© 2020 Don A. Ducasse. No part of this book may be reproduced, distributed, modified, adapted or made available in any form—graphic, electronic or mechanical—without the prior written permission of the copyright holder, except in the case of brief quotations embodied in critical articles or reviews.

This publication is meant to complement your common sense, not substitute for it. It is also not a substitute for the advice of any of your personal or professional advisors.

ISBN: 978-1-7751101-1-8

Version 1.0

Published by Coach Press

A division of TMC Ltd.

Library and Archives Canada Cataloguing in Publication

Title: DONtistry 101 : let the tooth be told! / Dr. Don Ducasse.

Other titles: DONtistry one oh one | DONtistry one hundred and one

Names: Ducasse, Don, 1957- author.

Description: Version 1.0.

Identifiers: Canadiana 20200304178 | ISBN 9781775110118 (softcover)

Subjects: LCSH: Dentistry—Popular works. | LCSH: Teeth—Care and hygiene. | LCSH: Mouth—Care and hygiene.

Classification: LCC RK61 .D83 2020 | DDC 617.6—dc23

Book Design, Illustration and Cover Design: Andrej Klimo

Printed and bound in Canada

It Takes A Village…

In my wildest dreams, I would never have thought I could write a book; and I still couldn’t do so without the help and guidance of some friends. Riley Moynes has been my guide and mentor on this journey. Without him, there would be no book. Janice Barkham, my office manager deciphered and typed my handwritten notes. She always does her tasks impeccably, and makes me look good.

To the friends like Dave, Denis, Grant, Rosie, Vince and Wayne: Without your stories and pictures, the book would be empty and boring. Thank you for sharing.

They say it takes a village to raise a child, but it takes a host of angels to raise a dentist. Janice, Stephanie, Gillian, Soula and Erica are the angels who look after me. I have been blessed to have them by my side.

DEDICATED TO CINDY AND EMERSON

“No one cares how much you know until they know how much you care.”

Teddy Roosevelt

ACKNOWLEDGEMENTS

Recently, I read a book called The Happiness Advantage. The author Shawn Achor said his favourite part of writing the book was the acknowledgements section. As he wrote his acknowledgements, he was “humbled and excited, knowing every word in this book has been shaped by the people in my life.”

Mr. Achor recommended that “if you have never written an acknowledgement page, take an afternoon to do it, and you cannot help but be happy and humbled being reminded that we’re loved and that we do nothing alone.”

Thanks to Mr. Achor’s advice, here are my acknowledgements.

Thank you to Mrs. Dodsworth, my kindergarten teacher. One day, she sat our class in a circle and asked each of us what we wanted to do when we grew up. When it was my turn, I announced, “I’m going to be a dentist.” I’m sure Mrs. Dodsworth had no idea her simple, “getting-to-know-you” class exercise would have such a profound effect.

Thank you to all my other teachers in elementary and high school. You made school fun, so it never felt like work to me.

Thank you to Queen’s University for showing me that it’s possible to achieve anything you want. It just takes the right people and enough time.

Thank you to Xi Psi Phi dental fraternity. The camaraderie, antics, and friendships I made there kept me sane during the insanity of dental school at the University of Toronto.

Thank you, Dr. Ed Sonley, the Head of Clinics at U. of T. who, when I asked him what to do when I graduated, sagely replied, “Go where you want to be 25 years from now and don’t spend more than you make. You’ll be fine.”

Thank you, Dr. Phil Watson, head of Crown and Bridge at U. of T. Dr. Watson and an expert technician named Moon Choi ran a private practice, where they became famous for making world-class crowns and bridges. Upon graduation, I was invited by Dr. Watson to use Mr. Choi, and I still work with him today.

Thank you, Mr. Choi, for making my crowns and bridges with the same quality as Dr. Watson’s.

Thank you to my dental mentor and orthodontist, Dr. Eric Luks. Dr. Luks set a standard of excellence in everything he did, and I do my best to emulate his standards today. He gave me many pearls of wisdom to live by, and I’m eternally in his debt.

Thank you, Dr. Al Puskas, who in 1967 established the practice I now continue. It has been my honour to carry on his legacy at 91 Fifeshire Road, where we celebrated our 20th anniversary in 2020.

Thank you, Dr. Mark Lin, for teaching me to place dental implants and for teaching me to “Train my brain.”

Thank you, to the wonderful women I work with. Thank you, Janice and Stephanie, for doing a great job of handling the business aspects of our dental practice—allowing me to focus on dentistry. Thank you, Gillian and Soula, for keeping everyone’s mouth clean and healthy, so there’s less repair work for me to do—the best treatment is prevention. And when it’s necessary to perform dentistry, thank you, Erica, for your magic in making things go smoothly—I couldn’t do what I do without you by my side.

My office staff will all tell you that the most significant change in me and our practice occurred as a result of meeting Wayne Gretzky and the other pros at Wayne’s Fantasy Hockey Camp. Thank you, Wayne and the entire Gretzky family for inspiring me always to do my best. Thank you, Denis Savard, for being the personification of the reason for being a Chicago Blackhawks fan. Denis has the most passion, enthusiasm, and generosity of anyone I’ve ever met.

Thank you, Grant Fuhr and Curtis Joseph, for giving me useful goaltending tips; and while I’m talking about goaltending, I want to thank every teammate past, present, and future. Thank you all for letting me be your goalie, for standing there while you skated up and down the ice, working hard scoring goals, and even blocking the occasional shot. I especially thank everyone who played for the Toronto Buds; you guys are the best!

A few years ago, I was addressing a group of dental students, and one of them asked, “How many patients do you have?” I was taken aback by what I thought was an odd question. It was a moment reminiscent of the day my kindergarten teacher asked me what I wanted to do when I grew up. I gave the student’s question a moment to sink in and then replied, “None.” I explained that I have no patients, just two thousand friends who drop by regularly to catch up on the news, share some laughter, and improve their health.

For me, all of this would be meaningless without you, the reader of this acknowledgement. Without you and all the friends from Aaron to Zurita who drop by to improve their health, I’d be very lonely, bored, and sad.

To paraphrase The Beatles, “I get by with a ton of help from my friends.”

All of this is to say, Shawn Achor was correct. If you take the time to write your acknowledgements, you’ll be astounded by those who come to mind—I certainly was! In my case, I’m embarrassed that there are many more friends I should have mentioned. As Mr. Achor promised, I’m “happy and humbled being reminded that we’re loved, and that we do nothing alone.”

The Team: left to right Soula, Janice, Erica, Don, Stephanie, Gillian

WHY I WROTE THIS BOOK

I wrote this book for three reasons. First, it provides an opportunity to share my observations and some of the things I’ve learned during more than 35 years of practicing dentistry.

Second, it’s a means by which we can fulfil our Mission Statement, which states:

“Our commitment to our clients is to educate with integrity and honesty, all treatment options to achieve optimal health. We will provide this in an up-to-date environment respecting the client’s time and choices.”

It’s vital that you realize there might sometimes be a difference between what you need and what you (or your dentist) want. It’s my hope that this book will help to educate. Let the tooth be told!

Third, it’s a small personal celebration and a huge THANK YOU for allowing me to live my dream for all these years. You’re not a patient; you’re my friend and my neighbour.

I was born to be a dentist!

I am checking out the teeth of a family friend, Bill.

INTRODUCTION

As noted above, Mrs. Dodsworth, my kindergarten teacher, sat us in a circle and asked us one by one what we wanted to be when we grew up. It was one of those life-changing moments. I was going to grow up? I’d have to look after myself and be a responsible adult? It was the first time I ever thought about growing up, and I thought about it with all the openness, innocence, and honesty of a five-year-old.

Before it was my turn, some of the other pupils answered: “policeman,” “fireman,” “teacher,” and “nurse.” At that moment, when it was my turn, I blurted out that “I was going to be a dentist.”

I liked the idea of a job where I could help maintain and improve peoples’ health, but I didn’t like the idea of operating on patients like a medical surgeon, because their patients sometimes die.

Furthermore, I reasoned, because everybody has teeth, everybody needs a dentist, so it seemed like it would be a steady job where I could use my hands to create while helping people.

In my mind, the dentist was the guy in town who worked in the little house on Main Street. Everybody knew him and trusted him. His clients weren’t just patients; they were his friends and neighbours. It seemed like the perfect job for me!

When I graduated from Keiller MacKay Collegiate Institute in Etobicoke, Ontario, I enrolled at Queen’s University in Kingston, Ontario, and earned a degree in Chemistry. If I’d known the system better, I’d probably have enrolled at Western, or U. of T. both of which have Faculties of Dentistry (Queen’s doesn’t).

But ignorance can be bliss sometimes, as it was for me. In Grade 13, a few friends and I took the day off school, and drove to Queen’s in Kingston. I loved the limestone buildings and the attendant sense of history. I loved seeing the specimens in the anatomy building. I could feel the school spirit; I imagined it as a place where the fans wore fur coats to football games in the fall, shouting “rah-rah, sis-boom-bah!”

Another reason I chose Queen’s was that the starting goalie on their hockey team was graduating, so there’d be a possible spot for me on the roster. I went to try-outs, and was invited by the team to be the third-string goalie, which meant I’d practice with the team but not dress or play unless there was an injury to one of the other goaltenders. As much as I loved hockey, I declined the offer—my primary goal in being there was to do well scholastically; to get into dental school.

Team Savard wins the inaugural Legends Cup in Chicago.

How Hockey Helped Get Me Into Dental School

Hockey has played a major role throughout my life. My first recollection goes back to a Saturday night in 1962, when I saw my first NHL game on an old black and white T.V. My parents were immigrants; my dad was born in India, then moved to England and the U.S. before settling in Canada. My mom was born in England and immigrated to Canada. We weren’t a hockey family at the time, so I had no home-town bias. It was the Chicago Blackhawks playing the Toronto Maple Leafs. The Leafs were dominant that night, but what really impressed me was the outstanding play of the Chicago goaltender, Glenn Hall, who, despite the loss, kept the Hawks in the game.

I remember how cool the Blackhawk logo looked—even on that grainy black and white T.V. That night, I became a Glenn Hall fan, a Blackhawk fan, and a goalie for life!

Fast forward ten years. I was 15 years old, and I’d saved enough money to buy my first custom goalie mask. In those days, mask makers would take an impression of your face. They would then use the impression to create a custom-fitting fibreglass mask by hand.

The mask was supposed to fit so snugly and securely that you wouldn’t need padding. The concept was that the perfect fit would distribute the force of the puck evenly over the entire area of your face, lessening the pain of impact. It worked, in theory anyway, but it still hurt, and you could still be cut or suffer a concussion.

The guy who took my impression was kind enough to teach me how to make masks, so I began making my own masks, and masks for others.

During my admissions interview at the Faculty of Dentistry, I had an opportunity to discuss my mask-making business. The interviewers asked me why I was leaving the business to enter dental school. I explained that the need for form-fitted custom masks was over now that Russian goalie Vladislav Tretiak had demonstrated that you didn’t need a tightly-fitted mask to see and stop the puck. His birdcage mask had metal wires in front of his eyes, but he’d proven that he could still see and stop pucks very effectively.

A collection of goalie masks made by Don in the 70’s

Tretiak’s birdcage mask was a game-changer for goalies, one that effectively solved the facial-protection issue. To this day, I’m convinced that this conversation, which seemed to be of great interest to some of the interview panel members (along with demonstrated excellent marks and good manual dexterity), was instrumental in my acceptance into dental school.

I graduated from the University of Toronto Faculty of Dentistry in 1983, and have been in private practice in Toronto ever since. It has been a wonderful experience that has fulfilled all my childhood hopes, dreams, and expectations.

It was on February 4th, 2000, that I moved my practice to 91 Fifeshire Road, my version of the little house on Main Street I’d imagined many years before.

Chapter 1

Your Mouth, Your Teeth, Your Smile

YOUR MOUTH

Every living organism or creature does three things: ingest, defecate, and replicate. Life is as simple as that. Creatures ingest and excrete, so the individual survives. Individuals replicate, so the species survives.

The bacteria in your mouth eat the food morsels that get trapped in all the nooks and crannies of your teeth and gums and excrete their waste. It’s that bacterial waste that infects your gums and dissolves your teeth, creating cavities.

Brushing and flossing do three things:

1.Remove the food from your mouth that the bacteria need to eat to survive.

2.Remove the bacterial waste products that damage your teeth and gums.

3.Remove or decrease the bacterial population to minimize the damage to your teeth and gums.

That’s why it’s so important to brush and floss immediately after every meal.

YOUR TEETH

Teeth are specialized skin cells. They start as cells of your ectoderm, the outer layer of early embryonic development. Fifty-two of these ectoderm cells will migrate into the mesoderm, the inside part of embryogenesis. While inside the mesoderm, these fifty-two cells will develop into the 20 baby teeth and 32 adult teeth that you get in your lifetime.

Baby teeth start to develop in your jaws at about the three month stage of in utero development. Adult teeth start to form in your jaws when you are three to six months of age.

Teeth develop from the crown (top) down. I tell people they “grow” the opposite direction from plants. We think of plants in the ground growing roots first, and then the flower. Teeth in the jaw grow the crown (flower) first and then their roots.

As the teeth develop and grow inside our jaws, they migrate back out to their positions as skin cells. Humans, like other mammals, develop two sets of teeth. The first set (called “baby” or “primary” teeth) typically start to appear at about six to eight months of age. Adult teeth begin to come in when we’re about six to eight years old.

The outside shell of your tooth’s crown—the enamel—is the hardest substance in the human body. Enamel can’t repair itself if damaged. That’s why you need to go to the dentist when you have a cavity.

Under the enamel is a much thicker layer of another hard, mineralized tissue called the dentin, which can renew or repair itself—to an extent.

At the center of the dentin is the fleshy pulp, which contains nerves and blood supply.

The teeth are among the most distinctive and long-lasting features of mammals. Because they’re so hard, teeth have been called readymade fossils. When the rest of you has turned to dust, the last physical trace of your existence on Earth may be a fossilized molar.

WHY DO WE NEED TEETH?

The primary function of human teeth is to break down items of food by cutting and crushing them in preparation for swallowing and digestion. Humans have four types of teeth: incisors (which cut the food), canines (which tear the food), premolars, and molars (which crush the food).

Our teeth are made of multiple tissues of varying density and hardness. The roots of teeth are connected to the jawbones by ligaments. As a result, teeth sway and flex in their sockets’ connection to the jawbones.

This movement gives your teeth the ability to bite with tremendous force without getting damaged. But anyone who’s had a broken or chipped tooth knows that accidents sometimes happen.

The second function of teeth, is that they’re used to communicate. When you flash a smile, you’re communicating your health, vitality, and state of mind. Straight white teeth and pink gums are an instant indication of good health. An inviting smile indicates to others that we’re engaging with them in a safe and friendly manner. On the other hand, when we snarl at people in anger, our display of strong, solid teeth tells others to beware.

We rarely use the third function of teeth anymore, which is as weapons. From a self-defense perspective, teeth were the nearest hard object you could use when dealing with conflict and enemies. Thankfully, we don’t bite each other anymore, though young children may still resort to this strategy when provoked.

Porcelain veneers by Don.

YOUR SMILE

I remember riding a motorcycle on the backroads of Goa, India, in 1992 and coming across locals who were working in the rice paddies. They would look stone-faced at us as we approached until I smiled at them. Every single time I did, the person would return a huge wonderful smile, many with missing teeth; but that didn’t matter nor deter from the joy of their smile. It’s a memory I’ve never forgotten.

So, when we smile at someone, it sends a signal that we’re friendly and mean them no harm.

From an evolutionary perspective, we’re drawn to those signals, going so far as to look and see whether a smile is “real” or “fake.” If eyes crinkle or smile along with the lips, then we perceive it as a genuine smile.

The next thing we look at in a smile is the teeth. Are they all there? Are they white? Are they straight? These traits tell us about the health and hygiene habits of the smiler. We’re attracted to clean and healthy, and put off by dirty and unhealthy.

That’s why there’s an emphasis in today’s society about cosmetic dentistry: because we all want to be attractive, desired, and even loved—it’s critical to our sense of self-confidence and well-being. It’s not surprising then that in surveys about attractiveness, the smile is almost always ranked the number one attraction.

“When you’re smilin’, when you’re smilin’, the whole world smiles with you.”

Louis Armstrong song

When you smile, the feel-good hormones—dopamine, serotonin, and endorphins—are produced and released in your body. These chemicals play roles in making you feel happy and less depressed. They relax your body, and even lower your heart rate and blood pressure. Endorphins are also natural painkillers.

All of these reasons are why it’s so important to smile freely and often. People who are self-conscious about their smile, or who stifle a smile, or refuse to smile because of their poor teeth, are doing real, lasting damage to their bodies.

The easiest thing you can do to look your best is to smile. Quite simply, a smiling face is seen as more attractive than a non-smiling one.

Market Tools Inc. surveyed over 5,000 men and women. They discovered that regardless of sexual orientation, the first thing someone notices in a potential love interest is their smile. A Yale study by Marianne La France concluded, “Smiling is a way we connect with other people. People convey by their faces that they acknowledge us, that we’re alive, that we matter, and that we’re not objects to be dispensed with.” No wonder we all find smiles so appealing!

Grant Fuhr stops by the office

Chapter 2

Check-Ups

There are many procedures performed at my dental office—cleanings, fillings, crowns, implants, Invisalign, etc. But by far the most important thing we do is look and listen. I lump “look and listen” as one procedure because looking without listening is pointless, as is listening without looking.

Hygienists and dentists are trained to know the difference between healthy and unhealthy mouths. We use mirrors, magnification loupes, intra-oral cameras, and X-rays to look into that mysterious cavern known as your mouth.

We ask questions like, “Any pain?” “Any bleeding?” “Any changes since last time?” and we listen carefully to your answers. And then, like Sherlock Holmes, we put the pieces of the puzzle together to come up with the diagnosis. Only the correct diagnosis results in the correct treatment. “It’s elementary!”

One day, my friend and hockey teammate Dave was in the office for his regular check-up and cleaning. Christine, the hygienist that visit, noticed Dave had a small scaly patch on the left side of his lower lip. She asked him how long it had been there. Dave replied, “I don’t know … it comes and goes … nothing serious.”

That answer made Christine suspicious, and she recommended that Dave see an oral pathologist specialist.

Five months later, after hockey one night, Dave quietly mentioned to me that he’d made an appointment with the specialist. I asked him what he was talking about because I’d completely forgotten about it. He reminded me of Christine’s recommendation and admitted that he had only made the appointment to see the specialist because he had an upcoming appointment with us, and he didn’t want Christine to have to remind him again. It turned out that Dave did have a basal cell carcinoma on his lip. A doctor removed the lesion, and Dave has been healthy and cancer-free ever since.

That’s an example of why your check-up is so vitally important. As Yogi Berra famously said, “You can observe a lot by watching.”

Chapter 3

Cleaning

Early in my career, Vince became a patient. He was a young adult with a disability as well as being on medication—a drug called Dilantin—for epilepsy.

Dilantin has a side effect that makes gum tissue (gingiva) grow as a response to irritation caused by bacterial plaque. Vince’s teeth were essentially buried by his overgrown gums.

He wasn’t aware of the importance of brushing his teeth, and my dilemma was how to convince him to improve his oral hygiene habits. To put it in simple (and somewhat graphic) terms, I told Vince that our bodies are like tubes. Food goes in one end and out the other. I told Vince I was pretty sure he cleaned up every time “food comes out the other end.” He would need to clean up when food went in the front end too.

He got it right away, and began to brush his teeth after every meal. He never had gum problems again!

Your mouth is your most complicated orifice. Your tongue, gums, lips, cheeks, and teeth provide a vast array of hiding places for bacteria. As a result, your mouth has the greatest variety and number of bacteria than any other part of your body.

We immediately clean the “other” end when food passes, yet we aren’t all in the habit of cleaning our mouths immediately after food enters.

Sadly, the story isn’t so simple as “keep it clean, and you’ll have no problems.” There are so many factors involved—hygiene, diet, age, stress, genetics—and the latest, our microbiome.

The microbiome is “a community of microorganisms (such as bacteria, fungi, and viruses) that inhabit a particular environment, for example, the collection of microorganisms living on and in the human body.”

We can’t eliminate bacteria from our mouths. What we need is a balance of bacteria that is consistent with good health. That’s what we try to achieve when we clean your teeth and gums. If we can get your bacteria to live and work harmoniously, then you’re more likely to have healthy gums and teeth.

It’s unpredictable, however, with no guarantees, and can change suddenly. It’s like trying to cure or prevent a cold: you can eat well, drink plenty of water, get a good night’s sleep, have minimal stress, yet you still might get a cold.

Gum disease is the world’s most common disease, and it seems the more we learn about it, the more we realize how little we still know.

It’s not as simple as brushing and flossing and avoiding sugar, though that is still the best recommendation. We don’t know why gum disease can progress in clean mouths and why sometimes it doesn’t progress in dirty mouths.

What we do know, is that the progress of gum disease is a result of the complex reactions and interactions that occur in your mouth as a result of your bacterial microbiome, the food you eat, your immune response, your overall health, genetics, even who you kiss! That’s why treatment is so difficult to predict. Some people may need their teeth cleaned every one to two years, while others will need it every three months.

But how do we decide who needs what frequency? One key indicator is bleeding gums; that’s a sign of active, destructive gum disease. It means there’s inflammation, and inflammation can lead to infection. Generally, chronic inflammation and infection are painless, so you have to rely on your dentist or hygienist to recommend the frequency of your cleanings.

A dentist should never ask, “How many units (a unit refers to a 15-minute interval of time) of scaling are covered under your insurance plan?” In that case, the dentist is treating your plan, not your disease.

“Good health is having the right bacteria, at the right number, at the right place at the right time. Bad health is having the wrong bacteria, at the wrong number, at the wrong place, at the wrong time.”

Don Ducasse

Chapter 4

X-Rays

The comic book hero Superman has x-ray vision. His superpower allows him to see through walls and other structures to know what’s going on beneath the surface and behind the scenes. What a tremendous advantage for Superman!

That’s the same superpower advantage dentists have when we take an x-ray.

X-rays enable us to see inside your teeth and jawbones. We can see decay between your teeth and under your fillings. We can see adult teeth developing in children and teens. We can see if your tooth has an abscess that requires a root canal.

When we have to extract a tooth, it’s necessary to take an x-ray in advance, so we can see how many roots your tooth has, and how those roots are shaped and bend, so we know what direction to “pull.”

X-rays reveal the bone levels surrounding your teeth, critical for assessing gum disease. With a simple dental x-ray, we can find a multitude of cysts, tumors, and malformations in the jawbones and sinuses.

In short, x-rays are an essential tool for dentists to provide “super” treatment. But like any superpower, they must be used judiciously and with caution. Dental x-ray radiation doses are very low; when you get two check-up x-rays, the amount of radiation is about 0.02 MSV (micro-sieverts), which is about the same small amount of radiation you receive on a flight from Toronto to Regina.

The future of x-rays, which is already here, is CBCT (Cone Beam Computer Tomography) scans. Traditional x-rays give us a two-dimensional picture of the hard tissues such as teeth and bone, but don’t show the soft tissues such as cheek, tongue, or gums.

CBCT produces three-dimensional images of the hard and soft tissues which we can slice and view from any angle. With CBCT, we’re able to visualize the inside of every part of your mouth in every dimension, reducing the guesswork. This allows us to map out our treatments better and plan complicated surgeries, root canal treatments, implant placements, or even orthodontic evaluations.

Chapter 5

Fillings

When do you need a filling? You need one when there’s significant damage or loss of tooth structure caused by bacterial decay or breakage due to trauma.

Immediate or direct fillings can be done in one appointment. That’s the typical dental visit whereby the dentist drills and then fills: the one everyone is most familiar with.

The two most popular materials for direct fillings are silver amalgam and resin composite. Each filling material has its pros and cons (See Chart #1).

Silver amalgam fillings are the historical workhorse of dentistry; they’ve been used safely since 1895—only gold fillings have been around longer.

They’re easy to place in the tooth (practically fool-proof); they’re very durable, strong, and resist bacterial leakage. They’re less expensive than other materials such as gold, and they provide the best “bang for your buck.”

Amalgam may not be the best option in areas where appearance is important, and it may not be able to withstand stresses when only a small amount of the tooth structure remains. But it’s ideal as a restoration for hard-working back teeth. The average amalgam filling lasts 10-15 years, and I’ve seen many last over 50!

Amalgam’s negatives are the colour (it’s not white) and that it contains trace amounts of mercury. There’s always been concern about mercury as a poison, but to date, there’s never been a study or scientific proof that the minimal amount of mercury in a person’s filling has caused a health issue.

The other material used for direct fillings is resin composite, or what the public understands as “white fillings.” Resin composite is made of a tooth-coloured plastic resin that holds together small, hard particles of silica dioxide; the resin is the binding material that holds the hard particles together.

Tooth-coloured resin composite fillings may look better than the silver amalgam fillings, but they’re not as tough and durable.

The average composite filling lasts five to seven years, and the ingredients of the resin composite (such as Bis-GMA) are toxic, though there’s research and developments into newer resins which contain less of those toxins.

The greater challenge with resin fillings is that putting them in your tooth is very technique-sensitive. There can be no moisture of any type on your tooth during the procedure.

After we remove the tooth decay, we etch your tooth with an acid solution to roughen the surface. It’s this roughened surface that enables our glue to bond to your tooth. We place the bond on your tooth, and then place your white filling.

Any moisture that gets on your tooth between or during any of the steps will cause leakage which can result in new decay. Your mouth is a very wet area, and moisture control is difficult, so resin composites leak more than any of the other filling materials. That’s why white fillings can look good, but sometimes not last as long as we’d like.

Chart #1

AMALGAM

PROS

•Proven success

•Used for over 100 years

•Durable: Conservatively they last ten years and some last 30-50 years

•Economical

CONS

•Colour

•Some people with known metal allergies can’t tolerate amalgam

RESIN

PROS

•Colour

CONS

•The shortest lasting filling material, some estimates put them at lasting 5-7 years.

•More challenging to place in a tooth

•Longer time for patient in chair

If you think about it, the ideal repair material for your tooth would be exactly like your enamel and dentin. It would have all the same physical properties as your tooth. It would expand and contract as enamel and dentin do when you eat hot or cold things. Teeth flex and bend as you chew, so the material should be as flexible as teeth. Teeth rub against each other as you chew and grind, so the material needs to wear at the same rate as your enamel and dentin. Tooth material is non-poisonous and biocompatible, so the ideal filling material should be non-poisonous and biocompatible as well. Finally, the ideal filling would be the same colour as enamel and dentin.

With the exception of colour, the material that best meets all these criteria is gold alloy.

For the health-conscious, gold is the safest, most biocompatible filling material we have. Gold is an inert metal. It’s not toxic, and it doesn’t rust or corrode. Gold is the dental filling material that best matches the structural physical properties of enamel and dentin. It expands, contracts, and flexes, just like your tooth does. Gold has the same wearability as enamel, so it’s gentle to the tooth it grinds against. Gold may bend or dent or even get scratched, but it will never crack or chip, which is why gold fillings last so long.

Just like at the Olympics, gold is best!

The one physical property it fails at is colour. Gold is gold coloured, and not tooth coloured. Colour should probably be the least important physical property to mimic, yet the public views colour as the most important.

Porcelain (or ceramic) fillings are the newest materials, and were developed to satisfy the public’s desire for natural looking, tooth coloured restorations. Porcelain fillings are the best looking fillings by far. They can be custom coloured to match every tooth shade, and porcelain seals your tooth almost as well as gold. Its most significant advantage is its appearance. Porcelain fillings can last for up to 25 years.

Unfortunately, porcelain doesn’t match the other physical properties of enamel and dentin very well. Porcelain is abrasive to the tooth it chews against, so as it grinds against the opposing tooth, it wears the enamel of that tooth away. Porcelain doesn’t flex like teeth do, and as a result, porcelain fillings may crack or chip, which means they need to be replaced.

How Wayne Gretzky Changed My Life

My original business partner (a former classmate and roommate) destroyed our practice by putting us into receivership. I was one million dollars in debt with a young family to support.

Shortly after everything had happened, I was reading an article in the Toronto Star about a beer-league hockey player who was planning to attend the Inaugural Wayne Gretzky Fantasy Hockey Camp to be held in Phoenix, Arizona in 2002.

The price tag for a week of hockey with Wayne and other NHL alumni was $9,999.99 USD (in honour of his number 99).

I said to my wife, Cindy, “Imagine that! A guy who is as crappy a hockey player as me is going to play with Gretzky!” Her immediate response was, “You’ve always wanted to play with Wayne. You should do that too!”

I had to stop her right there and explain, “I’ve never said that. No one ever thinks, ‘I’ll go play hockey with Wayne one day.’”

I still remember the analogy that popped into my head. I told her, “No one ever says, ‘I’d like to have a cup of coffee with God one day. People just don’t think like that’”. But when your wife gives you the green light—well, maybe you better stop and ponder.

Anyway, I thought, “When you owe a million dollars, what’s another $9,999.99?”

There’s absolutely no doubt at all in my mind that if my ex-partner hadn’t created the economic hole I was in, I’d never have gone to Wayne’s hockey camp. Under normal circumstances, there could be no justification for the expense. But in retrospect, my ex-partner did me a huge favour. I went, and the experience brought incredible positive changes to my life.

Wayne, the other pros, and my fellow campers showed me that it’s OK to allow yourself to be successful. I’d always believed in myself, but I kept it to myself. Because of the camps, I renovated the office, invested in new technologies, and brought in practice management coaches to create the office and train the team I have today.

Chapter 6

Crowns

One of the most misleading terms coined by the dental profession is the term “crown.” Unfortunately, every filling we place in your tooth weakens the tooth. The more fillings in your tooth, or the bigger the filling, the weaker your remaining tooth structure becomes. That’s when you’ll hear the dentist utter the phrase, “Your tooth needs a crown.”

Personally, when I hear the word “crown,” I immediately think of the expensive decorative headpiece worn on special occasions by a king or queen, I don’t think “protection.” But maybe because I’m a hockey-playing Canadian, if the dentist said, “That tooth needs a helmet,” I’d understand the importance of what the dentist was telling me.

The simplest explanation is that a dentist will recommend a crown (helmet) when more than half of the original tooth structure is gone. This situation occurs after multiple fillings, large fillings, excessive decay, breakage due to trauma, or root canal treatment. A crown is not decorative—it’s an essential protective device that prevents your weakened tooth from further damage.

When a patient asks, “Don, when do I need a crown?” my honest answer is, “The day before you break your tooth beyond my ability to repair it.”

Chapter 7

Root Canals

Your teeth are like eggs or a Caramilk Bar, in that they’re hard on the outside with a soft gooey center. Just like living tissue flows in and out of every finger and toe to keep them as living, breathing parts of your body, the same living tissue flows in and out of every tooth to keep your tooth as a living, breathing part of your body too.

We all know that good circulation is key to good health. The problem with the design of teeth is that the blood flow in and out of your tooth is through a very tiny hole at the bottom of the root, leading to poor circulation.

If bacteria from decay enter your pulpal tissue, your immune system may not be able to get rid of them. The bacterial infection can destroy and cause death of the pulp tissue. When this happens, your tooth is considered “dead.”

The other way your tooth can “die” is from trauma. When your tooth gets hit, it can snap the blood vessels that enter through the tiny hole in the bottom of the root, cutting off your tooth’s circulation. As with the other parts of our body, when we cut off blood and oxygen, that part dies.

When your tooth dies from infection or trauma, the only option is to remove the infected, dead tissue. There are two ways to do this. One way is to extract the entire tooth from your mouth. The other is to remove the diseased tissue from the middle of your tooth, leaving the emptied shell of your tooth intact. Because the pulp chamber running down the middle of the root was thought to be like a canal, the hollowing out of a tooth became known as “root canal treatment.”

To hollow out your tooth, a dentist will drill a small hole through the chewing surface of your tooth until they locate the diseased tissue in the pulp chamber. They’ll then use a series of small flexible files and reamers to remove the diseased tissue entirely from the tooth—similar to how a plumber will use a roto-rooter to clean out a pipe.

The difference is that the plumber only cleans out the pipe to open it up, whereas the dentist, after cleaning out the pipe, fills the empty root canal with a soft rubber material called gutta percha, which seals your tooth. It’s the same idea as shoving a cork in a bottle of wine to seal it shut.

My friend Glenn Clark demonstrates that my mouthguards aren’t just for hockey.

So You Weren’t Wearing Your Mouthguard, NOW WHAT?

Everybody knows that elbows, pucks, hockey sticks, and occasionally fists can damage our beautiful smiles and teeth. But what should we do immediately at the time of injury? Let’s look at some typical scenarios.

You’re digging for the puck in the corner, and someone’s stick accidentally comes up and cuts you on the chin. You’re not hurt badly, but there’s blood.

Should you get stitches? Well, if it’s a scrape (like you did to your knee as a kid) then, no. If it’s a clean, sharp cut, less than .5cm deep, and you can bring the edges together and hold them in place with a band-aid, then, no.

However, if it’s a cut that doesn’t readily stop bleeding, or it’s over .5cm deep, or the edges are jagged and don’t come together well, then yes, you need stitches. They hold the wound together so it can heal, and help to minimize scarring.

Two games later, you’re in front of the net, and the puck deflects and hits you in the mouth. Luckily, it doesn’t re-open the wound on your chin, but you notice a piece of tooth in your mouth, and your tongue is suddenly aware of a sharp edge on your tooth.

Your first instinct is likely to spit out the broken piece. But don’t throw it away! It’s useful. With the new bonding or “glues” available in dentistry these days, it might be possible to reattach the broken piece. If not, the dentist can still use the broken piece as a guide for the shape of the filling required.

If possible, keep the broken piece in a glass of water to keep it hydrated. It will dry out if left overnight in the open.

While assessing the damage, check to see if any teeth are loose or have changed position using your tongue—which is excellent at detecting changes in your mouth. Another way to determine if a tooth has shifted is by gently and carefully closing your teeth together, and seeing if they all meet as they did before. If a tooth has moved, see if you can gently ease it back into its original position with your fingers, or by clenching your teeth carefully. Whenever a tooth is chipped or moved, it’s wise to see your dentist as soon as possible.

The very next week, as you’re racing towards the puck to prevent an icing call, you catch a rut in the ice and fall face first into the boards. When you open your eyes, you see your two front teeth lying on the ice in front of you. What should you do?

If you’re fully conscious and aware, the best place for your teeth is back in their sockets. First, gently remove any large debris or dirt from your teeth—do not scrape them! The fibres that hold your tooth in your jaw are called periodontal fibres, and if those fibres are accidentally removed, your teeth may not reattach.

To the best of your ability and as soon as possible—ideally within 30 minutes—gently push your teeth back into their sockets. The longer they’re out, the less the chance of successful reattachment.

If you’re unable to put your teeth back in the sockets, put them in a cold glass of milk and get to your dentist or the hospital immediately. If milk isn’t handy, put them in your mouth (don’t swallow them) or as a last resort, in a cold glass of water.

It’s important to see your dentist as soon as possible after your tooth has been knocked out or put back in for two reasons.

One is that your tooth will likely need root canal treatment. The other is that your tooth will need to be splinted or joined to its neighbours for one week to allow the periodontal fibres time to reattach your tooth to your jawbone. It’s the same idea as when the physician splints or puts a cast on broken bones to stabilize them while they heal.

When you return to action the following game, you’ll be much smarter, and you’ll probably be wearing a custom-fitted mouthguard from your dentist!

Chapter 8

Extractions

As with all illnesses, prevention or early treatment is the best medicine. That’s why we recommend regular check-ups and cleanings. It’s best to prevent tooth decay and gum disease or, at the very least, treat things when the treatment is minor, and a good outcome is predictable. However, despite the best efforts of the dentist and the patient, sometimes a tooth needs to be removed.

Dentists will extract a tooth when gum disease has destroyed the supporting bone, when the tooth is infected, or when there’s so much damage (due to decay or breakage) that there isn’t enough solid tooth structure remaining to support a large filling or a crown.

Regardless of the reason, an infected tooth must be removed because of the risk of the infection spreading to the rest of your body, especially to your brain. I always tell patients that if the infection would just affect the area around one tooth, it wouldn’t be such a problem; you’d just have a sore tooth. But science has proven that the bacteria enter your bloodstream and go on a rollercoaster ride throughout your body, which can lead to much bigger problems.

Compounding these problems is that (as I’ve mentioned earlier) your mouth is the dirtiest part of your body—it harbours the largest population, and more types of bacteria than are found anywhere else in the human body.

Tooth problems have plagued humanity since the dawn of civilization. The ancient Egyptian mummy Djed-maat-es-ankh, who died in the middle of the 9th century B.C. and currently resides at the Royal Ontario Museum in Toronto, is an example. C.T. scans revealed that she died a horrible and painful death from a brain infection caused by an abscessed upper left incisor. She was only in her 30s.

And it wasn’t that long ago that tooth problems were still a common way to die. Health records from London, England in the 1920s list brain infection from abscessed teeth as the third leading cause of death. In the past 100 years, improved dental care and antibiotics have significantly reduced the number of deaths due to dental disease. However, it’s still a factor, especially in heart attacks, strokes, and in diabetes control.

So, if you ever have a sore tooth, or notice a swelling of your gums, getting it treated, even if it means an extraction, could save your life.

Chapter 9

Missing Teeth

The evolutionary purpose of your teeth is to chew food efficiently. Chewing begins your digestive process. Chewing your food thoroughly is critical to maximizing the nutrition you obtain from it, and recent studies have shown that improperly chewed food decreases the absorption of the nutrients from your food and upsets your microbiome.

Would you miss a missing tooth? A saw that is missing a “tooth” can still cut wood, though it would take a little more effort and time. Similarly, if you have a missing tooth, you can still chew your food correctly, just with a bit more effort and time.

Of course, the more teeth you’re missing, the more difficult it is to chew your food. Just like when more “teeth” are missing from a saw, the more difficult it is to cut wood.

Your front teeth are called incisors. Incisor comes from the Latin word “incidere,” which means “to cut.” The word scissors are also derived from “incidere.” That’s an easy way to remember that your front teeth act as scissors to cut your food into manageable pieces. Your back teeth are called molars. Molar comes from the Latin word “molaris,” which means “grinder.” Back teeth act as smashers and hammers to grind your food to a pulp. It’s only by grinding your food to a pulp that you can best extract and absorb the nutrients to maintain maximum health. Healthy teeth mean a healthy you!

Your teeth come in different shapes and sizes because of their various jobs. Molars are big and wide for the heavy work of crushing your food. Despite their strength and design, molars are quite often damaged; they’re typically the first tooth lost. As you lose more back teeth (if they’re not replaced), you’ll begin to use your front teeth to chew.

AN ELEPHANT’S MISSING TEETH

An elephant’s migration to the “burial ground” is a result of the wearing out of their molars. Their fibrous diet destroys their molars slowly, and when they have no back teeth left, they head to a swamp area where the food is soft and mushy in a final effort to stay alive.

But remember, your front teeth are meant to cut your food like scissors, not smash your food to a pulp. Can you imagine the damage done to a pair of scissors if you used them as a hammer? If you use your incisors to chew your food, you’ll more quickly damage and wear down your front teeth. It’s sort of a lose-lose situation. Your life doesn’t change dramatically because of a single missing tooth, but, there’s no doubt your health will suffer as you lose teeth, especially if you don’t replace them.

The Importance of Chewing

Your stomach doesn’t have teeth, but the digestive process starts as soon as food enters your mouth. Immediately, enzymes in your saliva mix with and begin to break down your food as you chew it. The enzymes in your saliva prepare your food so your body can absorb the nutrients. Even with a full set of teeth, it’s recommended that you chew each bite of food a minimum of 30 times! The food should be completely liquified by your teeth before you swallow it—as if it went through a blender.

When you chew your food slowly, it increases the alkalinity of the food and reduces the acidity. The high acidity in poorly chewed food is what causes acid reflux, heartburn, and indigestion because you can’t efficiently digest improperly chewed food.

Poor digestion causes bloating, gas, and that fully-stuffed feeling. The larger chunks of unchewed food can putrefy in your intestines, creating more bacteria that may upset important balances in your microbiome, reducing the absorption level of the nutrients from your food. In the end, poor digestion can result in soggy stool and diarrhea.

So, chew your food slowly and thoroughly!

5 Reasons to Chew Your Food Slowly and Thoroughly

1.Chewing more can help you eat less.

2.Chewing more can make food taste better.

3.Chewing more can help digestion.

4.Chewing more can boost energy.

5.Chewing more can prevent choking.

DID YOU KNOW?

More than 5000 people died from choking in 2015, according to the U.S. National Safety Council.

Chapter 10

Dental Implants

In Sweden in 1952, a young orthopedic surgeon, Per-Ingvar Branemark, was studying blood flow in rabbits. In one experiment, he attached a titanium-housed optical component to a rabbit’s leg so that he could watch the blood microcirculation in the bone tissue. When it was time to remove the metal-framed device from the bone, Dr. Branemark found that the titanium had fused to the bone. The Latin word for “bony” is “osseus,” so he called the fusion with bone “osseointegration.”

As a result of this accidental discovery, Branemark said, “we changed the direction of our work to investigate the body’s ability to tolerate titanium.”

Because he was an orthopedic surgeon, Branemark’s plan was to use his discovery for knee and hip replacements. But there was a far greater number of people who were missing teeth than needed knee or hip surgery, so he redirected his efforts towards dental implants, even though he was not a dentist.

The first dental implants went to Mr. Gosta Larsson of Gothenburg, Sweden, in 1965. He was 34 years old at the time, and those very first implants lasted until his death at the age of 75 in 2006.

The second implant recipient was the taxi driver, Mr. Sven Johansson, who drove Mr. Larsson to the Branemark clinic. When Mr. Johannson found out why Mr. Larsson had gone to the Branemark clinic, he wanted implants too. Mr. Johansson’s implants lasted him until he was well into his 90s.

The second place to ever perform implant surgery was at the University of Toronto under the leadership of Dr. George Zarb. I was very fortunate to have been a student there at that exciting time. In 1982, Dr. Zarb created and hosted The Toronto Osseointegration Conference in Clinical Dentistry, during which he announced the availability of dental implants to the world.

A dental implant can be thought of as a titanium metal root that replaces a missing natural root, similar to how orthopedic surgeons can replace knees and hips with metal versions. It takes about three months for the bone to fuse with the titanium, and once we know the “osseointegration” has occurred, we can then attach a crown or denture to the implants.

The technology and surgical techniques have improved over the years to the point that now, dental implants are quite common and usually successful. When they emerged in the world of dentistry, there was hope that implants would be the “cure-all” of dental problems and disease, but that has not proven to be the case. As we experience failures over time, I think dentistry will likely follow the orthopedic surgical model. We’ll try every reasonable treatment to save and preserve your natural body part, and only resort to placing artificial parts such as implants, when all else has failed.

An implant is a titanium root to replace the lost natural tooth root.

Where Goalie Masks and Dentistry Intersect

A few years into my dental practice, because of my dental knowledge and experience in making goalie masks, I was invited to attend the first Canadian Standards Association (CSA) meetings about establishing the criteria for goalie mask safety.

The CSA wanted to develop minimum safety standards for goalie masks. At a minimum, it was decided that to be acceptable, a mask would be required to withstand the force needed to break the temporal bone—the thinnest bone in the human skull.

Of course, it wasn’t appropriate to break the temporal bones of living individuals for test purposes, so we used cadavers. Once we determined the needed force to break the temporal bone, we tested masks from different manufacturers to ensure that they met the established criteria, by firing pucks out of a rifle-type machine.

Jerry Wright, who at the time made most of the masks used by NHL goalies, had the best test results, and he has made all of the masks I’ve worn since then.

Porcelain veneers by Don.

Chapter 11

Cosmetic Dentistry

There are ten official specialties within the dental profession, cosmetic dentistry is not one of them. But in a sense, all dentists practice cosmetic dentistry—there’s never been a dentist who wanted to put in ugly fillings, crowns, or dentures. Even the ancient Egyptians filled their cavities with a white filling material made from crushed seashells.

It may help to think of the enamel in your teeth as being composed of popsicle stick-like crystals held together in Jello.

In 1955, Dr. Michael Buonocore at the Eastman Dental Center in Rochester first treated a tooth with acid. The acid dissolved the “Jello” a bit, without damaging the crystal sticks. After the acid treatment, he painted a bond onto the tooth, which flowed into the spaces around the crystals where the Jello had been.

When the bond set, it locked onto the tooth. This procedure revolutionized dentistry—cosmetic dentistry was born! Now, we can simply glue tooth-coloured filling materials onto teeth and make them look as white and perfect as the patient wants.

And though there’s no such specialty as “cosmetic dentistry,” every dentist calls themselves a cosmetic dentist as a means of self-promotion.

The two most used types of tooth-coloured materials each have their advantages and disadvantages. The most popular material is resin composite. It comes in different shades, which makes it possible for us to match it closely to the existing tooth colour. The newest resins, such as Omnichroma, have the chameleon-like ability to change colour to match the colour of your tooth. I find this improvement in resins to be quite exciting!

Resin composite comes as a soft putty, which gives the dentist time to place, shape, and sculpt the filling, to create the desired tooth shape. Once we have the ideal shape, we make the soft resin material hard by curing it with a bright light.

The advantage of composite resin is that we can do it in one appointment. The disadvantage is that it can sometimes be challenging to get an acceptable colour match, and the colour can change over time. However, composite resins usually look good for many years.

For the best esthetic results, porcelain veneers and crowns are the standards of care. Well-made porcelain restorations mimic the colour of natural tooth enamel, and are very durable, usually lasting over 20 years. The disadvantage of porcelain is that it requires two appointments with a dentist—it requires a dental technician to make the porcelain at their laboratory—so there’s a one to two week gap between appointments.

Porcelain veneers and crowns give dentists the ability to provide any patient with beautiful, long lasting restorations.

It’s important to realize that cosmetic dentistry does not only mean whitening, veneers, implants, or Invisalign.

I met Rosie over thirty years ago when her friend Linda dragged her into my dental office. Rosie grew up with a deep fear of the dentist. As a result, she’d never gone to a dentist in her life. Her teeth were badly decayed and broken; she never smiled because of how her teeth looked.

One of the greatest compliments I’ve ever received is that Rosie trusted me; she was able to overcome her fear and allow me to treat her. I saved the teeth that could be saved and removed those that couldn’t. Then I made a simple, inexpensive, removable acrylic partial denture to fill in the gaps of Rosie’s smile.

Six months later, Rosie returned for her check-up, and I almost didn’t recognize her. She came in with a beaming smile, had a new hairstyle, and was the most talkative I’d ever seen her. I had to ask her, “What happened?”

It turned out that her dream was to be a clown, but the state of her teeth held her back. But once she had her smile back, Rosie enrolled in Clown College. Professionally, she’s Winky the Clown, and she entertains at parties and Blue Jays games!

TEETH WHITENING

In general, people have always desired whiter teeth. There have always been dentists with home remedies or personal concoctions with which they would treat their patients, but teeth whitening was very much a small, cottage industry.

That dramatically changed in 1989 when Dr. Van Haywood of the University of North Carolina published the first scientific paper on the effects of 10% carbamide peroxide solution on teeth. He used custom-fitted trays worn in the patient’s mouth which contained the peroxide, so that the teeth could soak comfortably in the solution, while at the same time preventing it from going down the patient’s throat.

It’s important to realize that peroxide does not change the natural colour of your teeth, and does not turn them white. Dr. Haywood demonstrated that teeth could be made whiter by slowly (and it does take some time) using peroxide to dissolve and remove the stains embedded in your enamel as a result of the things you eat, drink, or smoke.

The enamel on our teeth seems solid as a rock, but microscopically, it’s porous. The colours in the things we eat, drink, and smoke are absorbed into the enamel, causing tooth discolouration, which can’t be treated with brushing, flossing, toothpaste, or rinses.

Dr. Haywood showed that peroxide, if held against the tooth for a sufficient length of time, could penetrate the enamel and remove unwanted colours. The original formula took many hours to be effective. Patients would be required to wear the trays in their mouths overnight while they slept, every night over a two or three week period.

Dr. Bill Dorfman, a famous Beverly Hills dentist, developed and brilliantly marketed his whitening product called (appropriately) NITE White. Dr. Dorfman had many Hollywood stars as patients. He appeared on numerous talk shows such as Oprah. As a result, his whitening product set the industry standard.

Some patients didn’t want to sleep with the trays in their mouths overnight, so Dr. Dorfman created a faster-acting formula he called Day White, which is now marketed as Zoom. Custom trays are still required, but with Zoom, you only need to wear them for 30-60 minutes at a time. You still need to wear them for that two to three week period to get the stains out, and to get your teeth their whitest.

Dr. Dorfman is the dentist who created the whitening and cosmetic boom in dentistry. In 2005, I was fortunate enough to spend a week with him at his practice in Beverly Hills. It was a fantastic experience, a wonderful opportunity to hone my craft, and to be honest, meeting all those celebrities was pretty great too!

Don in Beverly Hills with Dr. Bill Dorfman

Don and the Toronto Argonauts Cheerleaders

My interest in cosmetic dentistry led me to become the official cosmetic dentist of the Toronto Argonauts Cheerleaders and the Ann Sutherland Modelling Agency, one of Canada’s most prestigious agencies.

Chapter 12

Orthodontics

An extensive long-term dental study in Burlington, Ontario followed hundreds of children from 1960-1990. The children had their skulls and jaws x-rayed regularly to determine the growth rate of a child’s skull and jaws over time.

It was hoped that dentists could figure out who would need (or not need) orthodontic treatment and, more importantly, who could benefit from early orthodontic treatment. The theory was that if we knew what would happen to a child’s skull and jaws in advance, then we could prevent or fix the problem before it became a problem. We called this practice Early Interceptive Orthodontic Treatment.

The thought was that early treatment could take less time, cost less money, and prevent the need for braces during teenage years.

The study found that the growth rate of the skull and jaws of the general population has no bearing whatsoever on how an individual will grow.

The attempts to provide early treatment on 8-10 year olds to prevent problems as they grew into teenagers simply didn’t work consistently. Teenagers experiencing unpredicted growth still required braces, even after having gone through orthodontic treatment as a child. The result was that treatment times were longer, and costs increased.

Adult teeth are full-grown, but a six year old’s mouth and body are not. A lot of growth will occur in a six year old mouth and body before it’s full-grown. When the four front baby teeth fall out (around the age of six), they’re replaced by four, adult fully-grown teeth.

Try putting your adult sized foot in a six year old’s shoe. It would be a little tight, and your toes would be crooked. That’s what happens in a child’s mouth.

Luckily your child’s mouth is not like a shoe; it grows and gains space in two ways. The obvious way is that the jaw continues to grow in size as the child grows in size. So rather than the teeth fitting the jaw, the jawbone grows to fit the teeth.

The second way we gain space in the child’s mouth is always surprising to people. The back baby molars are not replaced by adult molars, but by smaller adult premolars when we’re around 10-12 years old. Adult premolars are the small teeth located between the incisors and molars, and are designed to both cut and chew.

When the larger baby molars fall out and are replaced by the smaller adult premolars, extra space is created for those large adult front teeth to spread out and straighten. When the child is around 12-15 years of age, and when all the adult teeth are in, we have a better idea as to whether orthodontic treatment may be required or not.

Note that I’m describing the average person here. There are many children with mis-sized, malformed, or malaligned jaws that do require early treatment, often involving oral surgery. But these are the exceptions, not the rule.

Another change taking place in orthodontics is that we’re paying more attention to the need to expand the patient’s airway to prevent breathing problems such as snoring and sleep apnea.

“Traditional” orthodontics used to involve removing four premolars to create the space needed to straighten crowded teeth. We didn’t realize at that time that we were inadvertently making airways smaller. When we removed the adult premolars and closed the space created by removing them, the jaw arch and airway space became smaller. I had teeth removed when I wore braces, and today I wear an anti-snoring appliance when I sleep to keep my airway open. (See Chapter 13 for more about sleep apnea.)

The new trend in orthodontics is not to remove teeth, but rather to gain the space needed by expanding the arch (making the jaw slightly bigger to accommodate the teeth) or shaving some of the teeth a little to make them smaller, so they can fit in the jaw without being crowded. We now know how important it is to keep the airway open, and we now know how sleep apnea can dramatically affect our health.

Blocked Airway

•Lower jaw relaxes and falls back.

•Tongue and palate relax and fall back to block airway.

Open Airway

•Lower jaw held forward by dental appliance.

•Tongue and palate relax BUT cannot fall back to block airway.

Chapter 13

Sleep Apnea

If you want to live healthier, happier, and longer, be sure to read this section!

Statistics tell us that about 25% of the population have Obstructive Sleep Apnea (OSA), yet 90% of people with OSA don’t know they have it. Researchers say OSA can take about 12 years off your life and causes more car accidents than drunk driving. Sleep is essential for tissue repair, memory formation, and hormone synthesis.

If you snore or stop breathing while sleeping, chances are that you have apnea. High blood pressure, heart disease, stroke, diabetes, gastric reflux, arthritis, headaches, and dementia are just some of the problems associated with apnea.

Here’s an easy test you can do in the mirror to see your Mallampati classification.

If you have a thick neck, small lower jaw, large scalloped tongue, grind your teeth, are overweight, or are a Mallampati Class III or IV, chances are you suffer from apnea, and are at greater risk of having health problems.

Obstructive Sleep Apnea occurs while you’re asleep. Your tongue relaxes and falls back against your soft palate and uvula, which in turn falls against the back of the throat, closing your airway and cutting off your oxygen supply. (See diagrams on page 78.)

Reggie White, NFL Hall of Famer, died in his sleep from a heart attack caused by sleep apnea at age 43. His widow Sara created and runs the Reggie White Sleep Disorders Foundation.

If you think of your airway as being like a garden hose, apnea occurs when your tongue and palate block the hose.

The good news is that obstructive sleep apnea can be helped by devices that keep the airway open while we sleep. The medical device used most often is called a Continuous Positive Airway Pressure (CPAP) machine. It essentially pumps air into you, gently inflating your airway and keeping it open like a balloon. The air pressure keeps your tongue and palate from collapsing against your throat.

As useful as they are, many people find CPAP machines cumbersome, even claustrophobic.

Part of dentistry’s great awakening is the development and increasing use of a dental device called a Mandibular Advancement Device (MAD)—an anti-snoring appliance you wear in your mouth to hold your lower jaw forward while you sleep. When your lower jaw is moved forward, your tongue is also moved forward, and your airway stays open. With a MAD in place, the tongue and palate cannot fall to the back of the throat and block your airway.

The MAD device takes some getting used to, but it’s possible to customize it to make it as comfortable as possible for the individual.

Because I have small jaws coupled with having had teeth extracted for orthodontic purposes, I snored. When they introduced Mandibular Advancement Devices over 30 years ago, I was one of the first to use them, and I’ve been making them for patients ever since.

The Cycles of Sleep

Stage 1:The start of the sleep cycle

Very light sleep

Easily awakened

Stage 2:Sound sleep

Less aware of your surroundings

Body temperature drops

Regular breathing and heart rate slows

Stage 3:Deepest, restorative sleep

Blood pressure drops

Breathing slows

Muscles relax

Increased blood supply to muscles

Tissue repair and growth occurs

Energy restored

Hormones released

Rapid Eye Movement (REM)

Occurs about every 90 minutes

Muscles are immobile and relaxed, except for

rapid eye movements

Energy provided to brain and body

Dreams occur

“Laugh and the whole world loves you; snore, and you sleep alone!”

Anthony Burgess

“We spend 36% of our lives sleeping; we should do it safely.”

Don Ducasse

Breathing is the most important thing you do to survive. Without oxygen, you’ll die in minutes.

The medical adage is:

You can live three weeks without food;

You can live three days without water;

BUT

You can only live three minutes without oxygen.

Chapter 14

Infection Contro

Dentistry has always done an effective job of infection control. Standards have continually evolved and improved, along with our developing awareness of the continual dangers of infection.

Autoclave steam and pressure sterilization of instruments began back in the 1800s. In the 1960s, we started using chemicals such as glutaraldehyde to sterilize the tools that couldn’t go into an autoclave. Modern autoclaves are computer-controlled “pressure cookers” that sterilize every instrument—each instrument is sealed until opened for use with each specific patient.

At the time, we established these standards to prevent instruments used on one patient from infecting the next patient; there was no consideration at the time about the possibility of the patient infecting the dentist.

The AIDS epidemic of the early 1980s made it suddenly necessary to take steps to protect dental personnel. Very quickly, the routine use of safety glasses, masks, and gloves became the norm in dental offices.

Since then, sterilization protocols for instruments have continued to improve. Now everything is bagged and sealed to ensure it remains sterile until it’s needed for a patient, with processes designed to kill bacteria, fungi, and viruses that were considered surface contaminants caused by blood and saliva.

Studies done in the early 2000s concluded that most dental offices had relatively poor air quality. The air in those offices was contaminated by the aerosol sprays created when dentists and hygienists used their drills and cleaners on patients’ teeth. Then, in 2010, a Canadian company in Mississauga named Surgically Clean Air developed air filtration machines which remove bacteria, fungi and even viruses from the air. To ensure the safest possible air quality for our patients, I installed one of these in our office in 2017.

In order to eliminate the dangers of the spray that comes from your mouth when we work, we make your mouth as germ-free as possible before we begin. You’re familiar with that little cup of mouthwash we give you at the start of your appointment.

In 2020, molecular iodine (I2) mouth rinses were introduced for use in dentistry. Marketed as ioRinse, studies have shown molecular iodine to be the most effective antimicrobial agent available and safer than peroxide, alcohol or any other currently available mouth rinses. Not only does it work on the bacteria that cause tooth decay and gum disease, but it inactivates rhinovirus and coronavirus within 30 seconds.

Advantages of ioRinse

•Wide spectrum of kill—

⋅effective against bacteria that cause decay

⋅effective against bacteria that cause gum disease

⋅effective against coronavirus

•Rapid speed of kill

•No tissue irritation

•No harm to microbiome

•No side effects

•No bad taste

•No stain

•Safe, even for long term use

Just like AIDS changed dental office protocol overnight, COVID-19 will have the same effect. We can’t be content with merely sterilizing surfaces; we must sterilize the air too. Protecting patients and ourselves from airborne pathogens such as COVID-19 has raised the bar on health protocols in dental offices and everywhere.

I’m anticipating we will be adding full-coverage gowns over our scrubs, and full-face shields to complement our glasses, masks, and gloves as we move from surface sterilization to complete environmental sterilization.

This is the laser that may one day replace the drill.

Chapter 15

The Future of Dentistry

Dem Bones

toe bone connected to the foot bone

foot bone connected to the heel bone

heel bone connected to the ankle bone

ankle bone connected to the leg bone

leg bone connected to the knee bone

knee bone connected to the thigh bone

thigh bone connected to the hip bone

hip bone connected to the back bone

back bone connected to the shoulder bone

shoulder bone connected to the neck bone

neck bone connected to the head bone …

In this beloved old Gospel song first recorded in 1928, there’s no reference to the “mouth bone,” and no effort to connect it to the rest of the body, though I sure wish they did.

There’s increasing evidence that your mouth is not just an integral part of your body, but that it directly impacts the health of your entire body.

The new era of medicine, which is just in its infancy, is referred to as Integrative Medicine. Dr. Charles Whitney, a leader in this field, states, “It’s about empowering another person to create personal health. Health is not just the absence of disease. It’s a state of vitality where we have the energy, motivation, excitement, and hope of youth!”

Isabelle Simon, a leading Wellness Consultant and Certified Health Coach said, “Good health is a CHOICE, not a chance!”

Have you ever considered that food is medicine? It’s the medicine you put in your body that contains the ingredients for your optimal health (think about that the next time you have another donut).

At the same time as the development of Integrative Medicine, the future is bringing Integrative Dentistry to the forefront too. In this evolution, there will be a growing emphasis on The Four B’s: Bite, Bacteria, Breathing, and Body. This simple chart shows how the mouth is the gateway to oral and complete physical health.

Good Oral Health

Equals

Good General Health

Don Ducasse

HOW BITE, BACTERIA, AND BREATHING AFFECT THE BODY

The interdependence between medicine and dentistry has never been more apparent, and I trust that the future will bring closer working relationships between medicine and dentistry than ever before.

THE PAST AND THE FUTURE OF DENTISTRY AND MEDICINE

The Three Eras of Dentistry

1.Infectious Disease Dental Model 1900-1960

⋅Discovered that decay and gum disease are transmissible infectious bacterial diseases.

⋅Toothpaste and fluoride introduced.

⋅Learned to understand the causes of diseases, figuring out the problems.

2.Reactive Dental Model 1960-2000

⋅Technological advancements led to life changing procedures.

⋅Drilling and filling, implants.

⋅Veneers, Invisalign, whitening.

⋅Fixed the problem after the disease caused it.

3.Root Cause Dental Model 2000-present

⋅The objective is to understand cause and effect relationships regarding mouth and disease.

⋅The mouth affects diabetes, systemic inflammation, cardiovascular health, gastric reflux, stress, toxins, drug interaction, airway, breathing, sleep disorders.

⋅Treatment of the mouth affects the entire body.

⋅A healthy mouth contributes to overall health.

⋅Aim to prevent the disease from occurring.

The Three Eras of Medicine

1.Infectious Disease Medical Model 1900-1960

⋅Research and breakthroughs, understood bacterial and viral infections.

⋅Antibiotics and vaccines developed.

⋅Learned to understand the causes of diseases, figuring out the problems.

2.Reactive Medical Model 1960-2000

⋅Technological advancements led to life saving procedures.

⋅Heart surgeries, dialysis machines, transplants.

⋅Fixed the problem after the disease caused it.

3.Root Cause Medical Model 2000-present

⋅The objective is to understand cause and effect relationships regarding health and disease.

⋅Emphasis is on healthy life choices.

⋅Aim to prevent the disease from occurring.

CONCLUSION

In my life, I’ve always tried to live by the Golden Rule: “Do unto others what you would have them do unto you.” The design and culture of my practice is an effort to reflect that core value. Quite simply, I wanted to create a dental environment I would go to as a patient.

While my first practice was in its infancy, I worked part-time for an established dentist in a low-income neighbourhood where I’d lived as a child. One day he called me into his private office because I didn’t charge the full fee for a service I’d performed. He bluntly asked me, “What’s wrong with you? Would you rather have that nickel in his pocket or yours?”

My response was that that fellow needed that nickel. I left his practice because I’d rather sleep soundly at night, though it might mean fewer nickels in my pocket.

My practice continued to grow, and despite the dissolution of the partnership, I was able to move it and merge it with Dr. Puskas’ practice at 91 Fifeshire.

To help with the merger, we hired a professional practice management firm with whom we were completely “in sync” as to our intended outcomes. They worked with our team to develop a personality analysis of each of us, to help us work together more effectively—to know what makes each other “tick.”

We took part in team-building exercises. We created job flow systems and job descriptions, so each of us knew our responsibilities exactly, as well as the duties of other team members. All these years later, we continue to meet daily and monthly to keep everybody on track. In this kind of system, everyone can work with synergy; people are free to do their tasks at a high level, and each is empowered to do their best work for everyone’s benefit—patients and team members alike.

As I like to put it: “We’re the best, that do our best, for the best.” It might be a bit cheesy, but that’s what we do. We treat you the way we’d like to be treated if we were sitting in the dental chair. As a result, we attract people who value relationships, who are treated personally, not as numbers or objects in an assembly line.

And I think this purposely designed approach must be working. We have virtually no staff turnover; our team has been constant for years; our “newest” member has been with us for 13 years!

Our patients continue to refer colleagues, friends, and family to us. They value the approach we take to our practice and our interactions with our friends. We’re proud of our approach, and very grateful that it continues to meet with the approval and support of our patients.

I thank you with every ounce of my being.

Sincerely,