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.
|
| Table 2 The effectiveness of scaling and root planning of molars
|
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.
 |
| 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. |
 |
| 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. |
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.
[Conclusion]
“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.