Can you keep and use your own teeth for life?
The smart way to use the dentist

Chapter 4

[Tartar removal at the time of first medical examination]

The main purpose of scaling at the time of the first medical examination is to remove the tartar which is attached to the edge of the gum. Naturally, when tartar is removed so too will plaque and food residual. We also sometimes remove cement left from the time of forming the mould of a crown and pigmentation which is also attached to the surface of the tooth. Generally the removal is performed using a machine called an ultrasonic scaler. Depending on the clinic the removal may be done by hand. Plaque and pigmentation are removed by equipment called an air flow which sprays water and a salt like sodium carbonate by compressed air.

In order to remove tartar 30 minutes to 1 hour may be required. At my clinic for first time patients we spend plenty of time to thoroughly remove the tartar.
“Until now I have never experienced such thorough removal of tartar.”
“I thought the removal would be finished in 2-3 minutes.”
There is sometimes quite a surprised reaction from the patients.

A lot of tartar may in fact still remain in the difficult to access areas. That is to say that in the case of middle to advanced stage gingivitis it is best to assume that tartar remains. Therefore, in the case of those people who do not have tartar removed on a regular basis, tartar must be removed by a more powerful method.

Dentistry medical treatment
Table 2 The effectiveness of scaling and root planning of molars
Fleischer & Mellong:J.Pero,1989
There is the method of scaling which removes tartar from all over the jaws and scaling and root planning (SC & RP) which removes the tartar from the deep, hard to access areas after the patient has been anesthetized in the required section (block) of the mouth. According to the requirements of the insurance system of Japan, we divide the jaw into two upper and lower sides to perform scaling. After that we divided the total amount of teeth into six blocks to perform scaling and root planning. Furthermore, if it is necessary, a crown may be removed and tartar may be removed.

Obviously in the case where tartar is in a hard to access area it cannot completely be removed in one or two treatments. In spite of having performed scaling, when the condition of the gum is such that it is swollen, tartar almost certainly remains.

Once it is considered that all tartar has been removed, maintenance can begin. The main disposal at the time of maintenance is cleaning in the mouth by the air flow and easy scaling. We do not usually use anesthesia in this case.

[The change in the mouth by maintenance]

When you are tired, have you ever experienced a toothache? Moreover, after returning from travel when you brush your teeth, haven't you ever experienced a tooth smarting?

Don't you feel that the inside of your mouth ha a sticky feel to it? Have you ever experienced that even though dental medical treatment is finished two years later it is necessary to remove a dental nerve?

The pile of small inflammation which seems to heal up naturally and seems not to require treatment from a dentist will allow gingivitis of the last stage to appear around 50 years of age.

If scaling is performed, you will recognize that bleeding from the gum will decrease overtime compared with immediately after the first medical examination. Unlike the tartar removal at the time of the first medical examination when the gums were inflamed, scaling performed during maintenance is not accompanied by pain, and is completed faster.

If maintenance is continued for about ten years, the bad memories of having the nerve removed whenever visiting the dentist, or having a tooth extracted can be considered a thing of the distant past. You will lose the uneasiness for the future and will see the ray of sunshine for keeping your teeth. Maybe around 20 years later that hope will be replaced with firm belief.

[The problem of scaling]

I think that it is common in all medical acts that there is no medical treatment completely without any troubles or side effects. You must face this fact squarely and must not complain about loss by medical treatment. Please compare it with the loss at the time of not treating.

Although it is ideal that there is no loss, there are various problems also with scaling. Concern of wearing a tooth out or causing damage, a tooth smarting or the problem of gum pain actually exist sometimes due to scaling. These problems are not because of unnecessary violence or poor skill at scaling. It is a necessary result of performing thorough tartar removal which is the purpose of medical treatment. When having caused inflammation for tartar removal it is even more necessary to do a thorough job.

A dentist judges that it is necessary to perform scaling, when the possibility of these problems are fully understood. If the patient does not have this understanding it can result in spoiling the confidential relationship with the dentist. Now there is a focus on informed consent. I wish that people have at least a basic understanding of dental conditions as it relates to their health.

It is not incorrect to worry about a tooth being damaged or wearing down due to performing scaling. However the tooth is not troubled by it. For the tooth to be completely worn down, I think that it will take over 100 years. Supposing that you worry about this wearing down and do not perform scaling, the reality of which a tooth will become useless in 50 to 60 years you need to compare.

Espacially, you need to rationalize about the pain at the time of the first scaling. It is because inflammation is so strong that such pain is felt. Therefore you must not feel that it is because tartar is being removed that you feel such pain. Since it is in fact a human that is performing the removal, the dentist is not necessarily pleased that the patient is feeling such pain. Naturally the dentist tries to limit the pain. Only rough tartar is removed when the inflammation is so intense. We consider treatment management that includes waiting until the inflammation has reduced and using anesthetics to continue the removal.

Since there is the possibility that a crown may separate from the tooth it is fixed to there are patients who want to avoid scaling. This view point leads to the receiving of problematic dentistry medical treatment. Certainly there is a risk that while tartar is being removed the crown may separate. It seems that there are some people who think that the dentist or the hygienist must have committed some mistake. This is a surprising misapprehension. During scaling the tooth is made to vibrate and the crown separates because it is in the state of which the cement is already destroyed or due to the fact that a cavity has formed. That is to say that I think that the crown separated because it was in the state of requiring some medical treatment. If the crown was functioning normally it would not have separated due to the vibration of the medical treatment. Rather since the crown separated detection of the problem can be made and a serious state can be avoided.

A typical complaint after medical treatment is that the teeth smart. If inflammation is intense then the degree to which the teeth will smart after treatment is very high. Tartar is the origin of various evils. However, tartar also plays the role of barricade to other problems. Since the tartar is removed forcibly it is natural that smarting occurs temporarily. Although temporary hypersensitivity is unavoidable, prolonged hypersensitivity is also a concern for us. After every medical treatment we apply medicine for hypersensitivity. Occasionally we prescribe a painkiller to reduce inflammation. Hypersensitivity usually recovers when the gum settles down. There is also the case where five years after beginning maintenance hypersensitivity no longer in a problem.

We sometimes hear the complaint of “the gum having become thin” or “the crevice between teeth having become large”. It is because the swollen gum has regained health and become tighter and thin as a result of performing scaling. I think that from an aesthetic point of view this retraction is not desirable. However the dental life of the teeth is reduced if a false, inflamed gum is allowed to exist. You need to judge and choose calmly the method to best regain the health and prolong the life of your teeth.

[Gingivitis medical treatment and insurance]

Probably, you have gained an understanding about the importance and effect of maintenance. But even if you wish for maintenance, not all clinics are happy to oblige. In order to perform maintenance the dentist has to submit notice to the insurance administration. Due to the fact that the checking of the submissions is extremely detailed, many dentists are hesitant to submit the notifications.

Moreover, in order to perform maintenance, I have to have the patient convinced of it's effect and necessity. In order to explain about the maintenance, the dentist therefore uses a lot of time and energy. Dentists also have hesitation to sparing the necessary time and performing informed consent in limited consultation hours. However as all dentists possess the skills to perform scaling, the number of clinics that perform maintenance will increase at the asking of patients.

Before April, 2002, monthly scaling was not accepted by the insurance system. Therefore, even if expected by the patient almost all dental clinics refused to do it. At that time the expense to the patient was high because the treatment was not covered by insurance.

Comments like “since there is a crack in your tooth, let's check it out every three months” have been made. In the past for treatment to be performed a space of three to six months was required so that for the purpose of the insurance system to could be stated that a new problem had been discovered and required treatment. Therefore at intervals of three to six months scaling could be performed. Although at the moment there does not seem to be much change from pre April, 2002, I expect that things will gradually change from now on.

On the other hand, there are also problems with the insurance rules. Although the patient requests “as recently my gums bleed so please remove the tartar” if inspection and notification is not submitted it is not covered by insurance. Even if tartar is clearly visible the patient must first undergo inspection. This is fine if the inspection is easy, the inspection is usually accompanied by pain and also is expensive. Nevertheless, inspection is required before shifting to tartar removal.

Not only dental problems exist, but no matter of the skill and effort of the dentist, a portion of the effort must be made by the patient. How the administration tackles regulations for medical treatment cannot be disregarded. In order to have true national health and to spread maintenance, there are many regulations that are needed. Anyway I think it epoch-making that scaling at the time of maintenance can now be carried out by insurance.

[The interval of maintenance]

In my clinic, the next month's reservation is decided. To the patient who says “I'll call when I know when I am free “, I say “Even if you think you can't keep it ,please make the reservation now”. By human psychology, plans that are made that originally the person did not think that they would be able to keep, to the extent of what is humanly possible, the person usually tries to keep the appointment. Consequently, if the convenience of the appointed day is truly bad, they will change the reservation by telephone or visit the clinic on a day which is more convenient. Even if they do not come to that appointment or forget, they surely will visit the clinic the next month.

In the case of patients who do not have a reservation made, two or three months easily pass and they stop visiting the dentist. They will return to the conventional pattern of not going to the dentist until a problem is felt.

Even if there is a day which the teeth are not brushed something bad does not necessarily happen immediately. Even so, if one stops brushing one's teeth the environment in the mouth will become surprisingly bad. Similarly although it is not essential to perform scaling every month, if tartar is let to accumulate it will reach the stage where recovery is impossible.

According to the situation in the mouth, in the past my clinic accepted reservations for six months. However if these infrequent reservations were forgotten the patient lost teeth to the damage. Only two patients religiously continued the maintenance every three months for over ten years. However from the experience of disease reaching and advanced stage quickly and suddenly, they change to monthly reservations.

At present I am uncertain of the interval that is necessary for a positive result to be obtained. The correct interval will be known if the custom of performing maintenance periodically is put into place worldwide. I think that having removed tartar monthly for 20 years, my clinic is a good case example. Therefore, looking at the experience of my clinic a satisfactory result is achieved by maintenance every month. It is somewhat of a regret if in the future it is discovered that the optimal period is longer than a month.

Under the Japanese insurance system treatment every month is the basis. If a three moth interval opens then the first medical treatment inspection is compulsory. Therefore if three months are let to pass then before maintenance can be performed the inspection must take place.

To have maintenance performed every month does require some finance. If the expence of 30,000 yen per year throughout life is thought of as an investment in keeping the patient’s teeth, it is surely a good investment. Definitely I am sure that the happiness beyond this will be aquired.

[The mistaken usage of the insurance system]

In many foreign countries, all or most dentistry treatment is not covered by insurance. When it is recognized that a dental nerve should be removed and a crown fitted about 200,000 yen per tooth is needed.

On that point Japan is unusually cheap as it costs about 20,000 yen per tooth. Also under the insurance system about 30% charge, 6000 yen, is the burden to the patient. Setting aside that treatment in Japan is much cheaper compared with many foreign countries the Japanese public takes this for granted.

The medical treatment of removing the dental nerve and putting in a crown is such a negative one that it entraps the patient's future in darkness. I strongly hope that the insurance system is not misused in such a way.

In many foreign countries, this situation is avoided as individuals own initiative leads them to seek checkups. Consequently, they are able to maintain a better oral condition than Japanese people.

There are also countries were insurance can not be used at all for medical checkups or initial medical treatments. Therefore tens of thousands of yen must be paid. In spite of the high cost they understand the worth of seeking treatment. Since it is tens of thousands of yen, it is hard for them to afford maintenance even once a year. If the same amount of money is spent in Japan you can receive a monthly medical checkup.

If monthly medical checkups are continued from a young age the necessity for removing a nerve and putting in a crown will be almost zero. Also you can lead your whole life without fear of gingivitis. This will result in Japanese dentistry medical expense to fall to a tenth of its present state. I wish people would use the Japanese insurance system in order to maintain their health.

Dentistry medical treatment
Fig. 21 Mr M 29 years old at the time of the first medical examination. Male
He visited the clinic due to pain in the second molar of the upper right hand side and lower right hand side. I explained that it was also necessary to treat cavities found in the lower left side. However, he stopped visiting the clinic when the medical treatment of the chief complaint was completed.
Dentistry medical treatment
Fig. 22 Mr M Seven months later.
This time, he complained about the pain from the second molar of the lower left side and hence visited the clinic. Finally the lower left molar needed to have the nerve removed.
Mr M 29 years old at the time of the first medical examination. Male (Fig.21-22)
He visited the clinic due to pain in the second molar of the upper and lower right-hand side. The lower side second molar were the point of focus having in the past had the nerve removed. In the case of the upper right hand second molar, as there is a deep cavity that has already reached the nerve it was necessary to remove the nerve. The lower left second molar was also in a dangerous state by then. Although I explained that the medical treatment of these teeth was also urgent, when the pain from the chief complaint was taken care of he stopped visiting the clinic. Seven months later, he appealed against pain in the lower left teeth and visited the clinic again. The reason was that the cavity had advanced and it had reached the nerve. It had developed to the worst case where the nerve had to be taken, and surely bore intense pain that had to be endured through the treatment.

If he had treated the lower left second molars at the time of the first medical examination, I think that preservation of the nerve of the tooth was possible with 90% probability. Let's apply this case with the medical treatment expense of many foreign countries. While treatment at the time of first medical treatment would have cost him 10,000 yen because it was left by the time it was treated the cost would have blown out to 200,000 yen. Furthermore, expenses of 200,000 yen would be needed at every re-medical treatment from now on, and he will have the infinite hell of needing the nerve removed.

In Japan, since the insurance institution is substantial, the patient can have medical treatment performed at expense of only about 6000 yen. However, since a possibility that the medical treatment will cause trouble in the future is high, they must be left feeling uneasy. There are problems with the insurance institution system and also with the dentist's technology for treatment. Hence patients have concerns about the dental system.

Misusage of the insurance system will sacrifice teeth. Furthermore, we need to be aware of the fact that the misusage leads to the accelerated breakdown of the insurance system.

[Are Japanese teeth the worst in the world?]

The insurance institution of Japan has the highest coverage of dentistry medical treatment in the world. Moreover, the level of skill of Japanese dentists is also in the world's highest level. In spite of this, to say that the condition of Japanese teeth are the worst in the world is not an overstatement.

There are problems with the insurance institution and the dentist's performance however I will discuss these problems at another time. Setting aside general abnormalities, in order to protect one's tooth now, we need to practice effective self-measures for protecting using the system and medical level to maximum extent.

[The secret of confidence]

The secret which I strongly recommend to you is maintenance centering on monthly scaling. I gather data, such as every person's chart and Roentgen rays in one file and save them altogether. For the patient who visits the clinic for the first time in ten years I take out the old file and add the new data to his bundle. About all patients, whenever I have the opportunity, I compare the medical treatment histories with Roentgen rays and think about the result of the medical treatment.

From the data I feel that there are some results of satisfactory progress but also unsatisfactory progress as well as patients who are located in the middle. Although I have attended to medical treatments with absolute confidence, I also know what results and limits that exist. From this knowledge I draw the conclusion and have optimum confidence in that regular treatment is the best method.


“We need only to go to a dentist every month and have the tartar removed.”
Though it is such a simple practice can you believe that it is possible to stop teeth rotting and hence keep the usage of them throughout life?

About 50% of people do not believe, even it is explained that the dreamlike wish can be obtained simply. If I ,the dentist, talk about it I come off sounding like a miller who draws water to his own mill. On that point, when talking to a patient who has actually experienced maintenance, I think that my message is fairly persuasive.

My clinic which was once full of patients with serious dental problems has changed recently to a quiet atmosphere like a salon. The reason is that the patients introduced by friends increase in number. They are patients who hope for maintenance from the beginning. If this atmosphere spreads all over Japan, “a healthy dental kingdom” will definitely be realized.