When will my child loose his first tooth?

I get this question all the time:  When will my child's first baby tooth fall out?  The answer is that it varies form child to child.  There are a lot of children who are really excited to get a loose tooth.  Their friends are loosing theirs, why not them?




Generally, if a child got his first tooth at an early age as a baby, he will loose it at an earlier age as well.  If he got his first tooth a little late, then he will loose his first tooth later than most.

The typical age to loose the first baby tooth is 6 years of age.  About 90% of kids loose their first tooth at age five or six.

The first tooth to be lost is almost always one of the mandibular (bottom) front central incisors.

If you look at a chart of tooth exfoliation from the ADA, you will see they list the lower front central incisor as falling out around 6 to 7 years of age.  That's pretty normal, however, I see lots of 5 year old kids with their first loose tooth.  If I'm making a chart, I'm putting 5-6 rather than 6-7.  I see just a few children loosing their first tooth at age 4, and there are many that do not loose a tooth till age seven.  There are a few loosing a tooth age eight, but that's definitely on the late side.  They key is that it varies a lot.  Four is definitely early, seven or above is later than most, but it's all normal.  If you are not sure, ask your pediatric dentist if your child's eruption pattern is right on track.  Also, some baby teeth do not fall out till age 12 on average.

There are a few syndromes or medical reasons for delayed eruption, but that's pretty rare.

See here for something that happens often:

Permanent tooth coming in behind baby teeth

In case you were wondering , the first baby tooth usually comes in any where from 4 to 12 months of age; usually 6 months of age is average.  This varies a lot as well.

Data Analysis, or Gambling?

I just got back from a continuing education meeting which happened to be located in Las Vegas. I also watched the movie "21" which is based on the real life story of a group of MIT students who learned how to count cards and beat the casinos at blackjack.  They made millions.  They did not let the emotion of the moment influence their decisions.  They used simple math, counting the cards already dealt to increase their chances of a winning bet: data analysis and rather fast arithmetic.

How much of dentistry is pure data analytics and how much is gut instinct?  Well, there are two ways to look at it. First, is cold science, numbers, and analytical data analysis.  We do a clinical exam, we look at x-rays, perform diagnostic tests, ask questions.  We consult the published research.  In medicine and dentistry this might be likened to flow chart decision making, or to something called evidence based science.  We use experiments, data and facts to decide the most likely outcomes.  If we don't, we are just guessing.

Second, there is the theory that real world experience makes the difference, raw talent, esthetic sense, gut instinct.  This is actually backed up by the study that mastery comes about with many hours of practice, error, corrections, and well, experience.  The more you have done something, the better you are at accomplishing the task at the level of a master, the expert.

My analysis is that they both matter.  You have to make decisions based on real science and study of the available data.  Dentists spend four to ten years after college in graduate education and training in science and techniques. Then, there are years of continuing education classes after that.  Collect the facts, the data, analyze, compare, then decide, act.  The problem with dentistry and medicine is that there is always a lot of data that is not knowable, that is missing or not timely.  That is where experience comes into play.  That is, making decisions when you do not have all the data you would like to have.  Sometimes there is more than one appropriate option.  Whether we like it or not, there is a lot of emotion involved.  Sometimes you go on experience and gut instinct.  Count the cards if you can, but sometimes you develop senses that tell you the card count at a subconscious level.  I'd like to think going to the dentist is not a gamble, but as close to a sure thing as you can get.

How To Keep Your Child's Teeth Healthy

Here is an article based on an interview with Dr. Joel Berg, pediatric dentist and president of the American Academy of Pediatric Dentistry, discussing prevention of dental disease in children.  Basically, he lists five things: start dental visits early, eat healthy, care for baby teeth, model good habits, and make it fun.

Click the photo to link to the article:

The Cost Of Braces Is Going Up?

There are a lot of factors that go into the cost of providing braces.  First, and significantly, it is the diagnostic and technical expertise of the orthodontist.  Try doing braces yourself and you will not likely get the same result.  Secondly, it is the overhead of the orthodontic staff, facilities and associated office costs.  Finally, it is the actual hardware itself, that is, the brackets, wires, adhesives and attachments.  These items are often made of sophisticated metal alloys such as nickel titanium that are manufactured within precise tolerances.  There are laboratory fees as well for diagnostic models or services.  So, as the cost of salaries, health care coverage, utilities, and supplies go up, so does the cost of braces.

Recently, there is another factor, which will increase the cost of providing orthodontic treatment.  That is the new tax that is part of the new Obamacare health care plan.  There is a new 2.3% medical device tax.  Yes, that cost will likely add up to at least $175 more than the present fee.

Obamacare tax increases cost of braces

Problems With Multitasking

In My Book, I stress the importance in having the ability to deal with all the demands of being a dentist in a busy office.  There are so many things to think about in a short amount of time.  An intense surgical procedure, an anxious patient, a worrying parent, other waiting patients, scheduling problems, phone calls, etc., all happening all at once, can become overwhelming.  A real ability to multitask would be the ideal in handling a typical day in the office.  Multitasking is often thought of as doing many things at once or switching back and forth rapidly between tasks.  We sometimes fool ourselves that that we are more productive by this kind of multitasking.  There is some research that effective multitasking is not really possible.  Studies show even young sharp minds tend to loose  cognitive ability the more things they have to deal with, thereby reducing productivity.  Have you ever tried to carry on two phone conversations at the same time.  You cannot listen to both, only one at a time.  There was an exhibit at Disney World a few years back (it might still be there in the Hollywood Studios Park), where you would put on headphones and would listen to one story in one ear and another story in the other.  It was impossible to make sense of either.

Focusing on many things at one time, effectively, is not really possible.  The goal is to focus on only one or two things at a time.  There is a certain talent of being able to focus and concentrate effectively on just one thing, then moving to the next item and focusing on that, eliminating distractions as much as possible.  Reducing stress also increases productivity.  This can be difficult to manage.  It seems that it's not really multitasking you should be attempting to do, but prioritizing your focus and concentration.

Here are a few articles on the subject:

"We're always multitasking, and that's the problem"  --Britannica

"Multitasking Makes you Dumber" --Annie Murphy Paul

"Teaching kids to Concentrate"  --Annie Murphy Paul

"Why Multitasking Does Not Work" --Forbes

"You can only remember three or four things at a time"  --Business Insider

"Too much stress results in poor performance" --Business Insider

Dental Office Stakeout-Lessons in Customer Service

Dental offices would be wise to learn lessons in customer service from other industries.

Take "Restaurant Stakeout," a Food Network TV show, where restauranteur Willie Degel sets up hidden cameras in a restaurant to assess what is really going on when the owner is away.  Scenes such as rude waitresses, messed up orders, lazy employees, food fights and drinking on the job. Wow. Yes, much of the show is staged, but these kinds of things really happen in real restaurants and businesses.  Willie's advice and customer service philosophy is usually spot on for any field dealing with people.

As medical and dental professionals, much of our training and education was scientific and treatment oriented.  There was almost no attention given to human relations and certainly not how to run a business.  In addition, many in the medical and science related fields spent much of their time studying by themselves not developing social skills.

Recently, a physician posted on the blog KevinMD about how doctors can learn from working at Starbucks.  Yes, I have noticed physicians especially have lost touch with human relations, service (in the business sense), and personal relationships with patients.  It's not all their fault as much of medicine has drifted away from free market private practices sensitive to the patients concerns, to third party influenced businesses focused on volume and less and less time with patients.  They are running on a treadmill.  Dentistry has, for the most part, escaped much of this trap.  Patients still have the choice to go to the dentist down the street.

Probably a scenario closer to fact is the TV show "Airline" from a few years ago, where a camera followed around customer service employees from Southwest Airlines on any given problem ridden day.  These are higher stress, higher stakes, more emotional scenarios that cannot be fixed by just a complimentary cup of coffee and a smile.

Richard Branson says to set high expectations of great customer service for your staff, maintain your great reputation, and be the best in the market.  We try, but it is very difficult to master great customer service.  There are so many interactions, so many chances to succeed, or to fail.  There will always be those who will complain, or who are not satisfied.

It's not easy and I don't know anyone who does it all perfectly all the time.  I don't think setting up hidden cameras is critical, nor dramatic confrontations.  What is necessary is a constant attention to the customer (patient) experience.

1.  Have a clean, well taken care of facility
2.  A welcoming friendly staff with a good attitude
3.  Appropriate attire
3.  Clear communication including diagnosis and proposed treatments
4.  Clear communication of financial arrangements and expectations
5.  Reasonable flexibility when things don't go just as expected
6.  Listening to patient concerns and getting feedback
7.  Systems in place for standard operating procedures and ways of doing things
8.  Realizing people are sometimes emotional and irrational
9.  Realizing you cannot please all of the people, all of the time
10. Have a medical or dental visit yourself-actually be the patient, you will remember what it's all about

Brushy Brushy

Ok, this is just so well done:

Just For Fun

Here are two brothers who give continuing education courses and have private general dentistry practices.  I saw them in Nashville last February.  This is a really funny and well done, albeit a little bit of a downer, version of Queen's Bohemian Rhapsody.  Enjoy.  The Madow brothers:

How To Study

With all the volume of material a dental or medical student has to remember, how do they do it?  Well, some do the "binge and purge" method, cramming the night before an exam, then forgetting most till the next time.  This is not a good way to really learn.  There is research that repetition over time helps retention.  Information studied one day, then reviewed again the next day or two is better retained.  Here is a reference article:

Psychology Today

The Way Doctors Learn

Dental Schools Like My Book

The University of Alabama School of Dentistry (UAB) just bought a bunch of my books.  I am pleased they find it of use.  If they think it is pretty good, perhaps you should get your copy:

Dental School: Preparation, Survival and Success- available on Amazon.

Here I am with Dean Reddy:

AAPD Launches A New Informational Website for Parents

The Academy of Pediatric Dentistry just launched a new website called mychildrensteeth.org

There looks to be a lot of good information there.  I'll see how it develops and report back here.  In the mean time click on the logo above to get the link.

Position Available for Pediatric Dentist

Alabama Pediatric Dental Associates and Orthodontics is looking for a Pediatric Dentist to join our group.  I don't usually blog post such an announcement, but with the great number of people viewing this blog, I am taking the liberty to spread the word here.

We are looking for both full time and flexible part time pediatric dentistry specialists.  If you are looking for a part time arrangement, we can discuss how you can be an integral part of our practice family. In addition, if you are looking for a full time position, we will interested in discussing your future with us as well.

We currently have five pediatric dentists and two orthodontists working in three very new office locations.  We have been very successful in attracting and retaining great doctors over the years.  Our group is one of the most well known and respected practices in the country; thus we can be, and are, very selective.  We are looking for quality applicants with excellent clinical skills and personality.  Our patients deserve a caring doctor with top notch abilities.  Experience in practice is preferred, but we will entertain new graduates as well.  This is for specialists in Pediatric Dentistry only.  We have an integrated management system which makes your day go smoothly and without the worries of running a practice all by yourself.  Please check us out and give us an opportunity to show you how great working with us can be.

Interested doctors can contact us here:
Office Manager
Alabama Pediatric Dental Associates and Orthodontics
4001 Balmoral Drive
Huntsville, Alabama 35801
256-539-7447
bob@cyberdentist.com
*Do not e-mail pediatric dentistry comments or questions, only inquiries about the pediatric dentist position.

Thumb Sucking

Although I have addressed the issue many times in other posts, I just realized I don't have a specific post on Thumb Sucking.  I hear all the time, "how do I get my child to stop sucking their thumb?"  Well, here is a rundown of some general advice that I give in the office. Basically, lots of kids suck either pacifiers, thumbs, or one or more fingers (digit sucking).  I will concentrate this post to thumb sucking as most information on pacifiers is here:  Pacifiers

What is going on:

1.  Pacifier and thumb habits in preschoolers are very common.  Kids find comfort in the habit.
2.  Sometimes these habits affect the teeth and jaws, sometimes they do not.
3.  There is often an associated habit that goes along with the primary habit.  For instance, a thumb sucker may hold a favorite blanket or twirl their hair.
4.  The habit tends to get worse when they are upset, tired, zoned out in front of the TV, or otherwise not occupied with other activities.
5.  The kinds of problems that involve teeth tend to fall into three categories:
     a.  Overbite, or protrusion of the upper front teeth, sometimes with the lower front teeth going backwards.
     b.  Open bite, or an opening of the front teeth to accommodate the thumb or pacifier.
     c.  A Posterior Crossbite or constriction of the upper arch resulting in the teeth shifting to one side or moving totally inside the lower arch.
6.  Anything in the front teeth, like overbites will tend to correct on their own once the habit is stopped--so long as it is in the primary dentition (no permanent teeth involved).  Posterior Crossbites do not tend to correct themselves and often need orthodontic correction.

What to do about it:

1.  Ok, first, there is no magic cure or magic technique that always works to get kids to stop sucking pacifiers or thumbs.
2.  Almost all kids eventually stop the habit, sometimes sooner, sometimes much later, but you don't see too many 25 year old executives sucking their thumbs--at least in public.
3.  Most kids who suck a pacifier stop by the age of 3 and a half.
4.  Most kids who suck fingers or a thumb stop a little later, about 4 and a half years of age.
5.  Because thumb and digit habits tend to persist and seem to cause more adverse dental movements, I prefer a pacifier habit to a thumb.  Of course, the child usually decides what they like the best, not us.
6.  If a habit persists beyond a time where the parent feels uncomfortable or it's getting close to the time for permanent teeth to come in (around 5 years old), then you can try the following things:

     a.  Gentile reminders are usually the first step--not scolding- (that can make things worse).  Get them occupied with other activities or interests.
     b.  If you are seeing a general decrease in the amount of sucking, then you are on the right track.  Although, do not be surprised if things relapse a little if you move to a new house, have a new baby brother come along, or otherwise have a disruption in their normal routine.  Night time sucking is the last to go, and the most difficult to stop.
     c.  You can try that yucky stuff you paint on the thumb to inhibit sucking.  This tends to work better on older children.  Even then it only works about 10% of the time, but it's sometimes worth a try.  Here is a website for the stuff (which is yuckier than when we were kids): http://www.stopbitingnails.com
     d.  What if that does not work?  There are all kinds of things out there to prevent sucking, like things that you put over the thumb to inhibit the habit.  These things tend to work best if the child really wants to stop, but just needs a reminder from time to time.  One of the most interesting ideas I remember is to get a long sleeve tee shirt and sew the sleeve opening up.  The child wears this as a nightshirt.  These kinds of things can initiate a lot of angst on the child's part and are usually very frustrating unless the child really wants to stop.
     e.  There are good behavioral techniques I have seen speech pathologists use to get kids to stop.  Sometimes it seems like magic.  So, a dentist may refer you to one of these folks to give it a try.
     f.  Ok, if all that does not work, we dentists can make a thumb guard which is a dental appliance you attach in the mouth with orthodontic bands.  This child wears it all the time.  It usually has wire loops up behind the front teeth that inhibit the placement of the thumb the way the child likes.  It actually works most of the time.  The key is it is usually not used on preschoolers.  This is for kids who are into the permanent dentition, usually about 8 years old or older and is often followed by orthodontic treatment (braces).  Crossbites can be corrected with a simple orthodontic appliance.

Rising DAT scores

The DAT or Dental Admissions Test measures a dental school applicant's potential for success based on performance in several academic disciplines.  Here is a graph of the rising competitiveness of scores in recent years:

I cannot emphasize more how competitive it is to get into dental school these days.  You must have very good grades and very good DAT scores.  After research and studying recent trends and speaking to Deans of dental schools, I can say with confidence that it is harder to get into dental school than medical school.  I have heard of someone saying, "If I don't get into dental school, I can always fall back on medical school." Wow, how times have changed.  In fact, even since I wrote my book and alluded to the increasing application/acceptance ratio to dental schools these days, there has been an increase in the number of applications for the limited slots available.  There is a rapidly rising number of applicants and the quality of those applicants is rising very rapidly as well.

Read more in my book: "Dental School: Preparation, Survival and Success"

Get Those Requirements

In my book, Dental School, I mentioned the trials and difficulties of the dental school experience.  One thing I would like to bring out more is the relentless pursuit of "Requirements."  What do I mean?  Requirements are the need number of specific procedures you must accomplish to pass or to graduate.  These are things like a specific number of crowns, dentures, root canals, or two surface fillings you must complete.

It always seemed in my experience and in those with whom I talk to, that it was difficult to get these done in a reasonable time frame.  What if the patient you have acquired or been assigned needs three fillings, one root canal and one crown?  That's great, but you need to do a periodontal surgery crown lengthening and a post and core buildup prior to the crown.  Moreover, the only thing you really need as far as requirements is the crown.  In some schools you have to get all the necessary work done on the patient, much like in the real world.  In some other situations, you may be able to have someone else do the root canal and surgery, then you do the crown, but that can take a while before you get it done.

The thing I want to emphasize is the drive to get the requirements.  It's not always easy.  Some schools are having a more difficult time getting patients as more and more are treated by private practitioners.  I know some pediatric residents that do only one or two premed (sedation) cases prior to graduation.  In practice I do one or two sedation cases a day.  Experience is an important part of developing and perfecting a skill.  The more you do the more you know how to deal with the little variations in each case.  Requirements are just the way schools have of making sure a dental student gets at least some basic minimal experience before awarding a degree.

10,000 HOURS

Malcolm Gladwell, in his book "Outliers", puts forward a well researched observation regarding the topic of skill and mastery.  He states that it takes approximately 10,000 hours of concentrated activity to become a master or expert.  He gives examples of concert pianists, sports figures, computer programmers and even The Beatles, who spent many a weekend performing and refining their music and performance skills in clubs well before becoming known to the wider world.  How long is 10,000 hours?  Ten thousand hours comes to working 8 hours a day 5 days a week for at least 5 years.

How does this apply to dentistry?  The art and science of the dental profession certainly falls within the definition of something that is difficult and complex, not only intellectually in diagnosis, knowledge and assessment, but the use of physically demanding and precise surgical techniques.  While there is a certain amount of innate talent and certainly compassion involved, the true mastery takes a long time to develop.

In Pediatric Dentistry, it pretty much takes at least that long.  A new graduate knows a lot, but has not yet mastered the art of the profession.  In fact, in dentistry, we call it dental "practice" because you are really never done learning and improving.

I am humbled that, although I have gone well past the magic number of hours, I still am refining, learning, and relearning how to practice with a certain degree of mastery.  In fact, I think the rule for dealing with children (and their parents) on a daily basis should be closer to 20,000 hours, or maybe a lifetime!

So, if a dentist with many years of experience takes a look and says he is concerned or offers an opinion, you might be well advised to listen.

"Outliers" by Malcolm Gladwell

Dental School is Exactly Like This

Dental School is Exactly Like This.  Ok, well, maybe not exactly.  Still, dental school was certainly an awesome experience.  I'm sure we could have made such a great video in our day if we had the technology.  In fact, weirder things than this are know to happen.  Hat tip to UNLV School of Dental Medicine.

Buy my book on Dental School click here.

Double click the youtube video for option of full screen.

Social Media, Everyone Is Doing It?

The most recent buzz in dentistry is Social Media.

I get all kinds of inquiries from dentists who want to know how to write a blog, how to set up a Facebook page.  They want the newest thing, they do not want to fall behind and loose market share.  Still, I think there is a problem.  First, there is the problem of over-saturation, of dilution; everyone's doing it.  The second concern is that most dentists know dentistry, but they have no idea how to use the tools of Social Media.  They all have a web page, Facebook and Twitter accounts, but rely on someone else, or no one at all, to actualy run the pages, post the comments and photos because they have totally missed the point.  It's a dead end for them.  It's useless.

You know there was a time when almost no dentist even had a web page.  Advertising, as it existed just a few years ago was yellow page ads.  In my college economics class, before I was even in dentistry, I asked my professor about something I had noticed.  Some dentists were beginning to advertise.  It was frowned upon for dentists to advertise back then.  It was unprofessional.  Really, this was a pervasive attitude.  It was allowed, but you had to put all kinds of disclaimers in any announcement.  The only thing you were "allowed" to do was announcing the opening of your practice in the local paper and later on, your retirement.  Now, there were a few dentists back then who were beginning to put "ads" in the yellow pages.  These were fairly minimal things; a quarter of a page max.  These dentists enjoyed what you might expect from the increased visibility, an increase in business.

I asked my economics professor, what happens when more and more dentists advertise too.  You know,  just to keep up and compete?  He said the first adopters would reap the most bang for the buck.  Once it spread and most if not all were doing the same thing, the benefit would diminish.  Everyone would be back to square one, but with a higher monthly bill for advertising.

These days we do not advertise, we do "marketing".  It's more accepted to put your practice name out there on billboards, TV ads, etc.  There is a reduced stigma.  There is nothing wrong about telling people what you do and where you are located and educating people about your profession.  There is still a concern about deceiving the public, about presenting oneself as something you are not.  For instance, a general dentist saying he does braces is one thing, but saying or implying he is a specialist, an orthodontist, is unethical and in most states illegal.

So, what is the newest thing in marketing? -Social Media.  Dentists are being advised to not only have a webpage, but a business Facebook page, a locations page, a Twitter account and a Blog.  This is good as these are modern vehicles for not only information, but interaction and education. I love it. I started this blog in 2006 and had a Twitter account before most even had heard of it much less understood what it was.  Still, I wonder as more and more dentists get on the bandwagon of "Social Media" that a dilution effect will ensue.  This time perhaps not, at least for those who know how to actually use Social Media.  It is so sad that there are so many physicians and dentists who hire someone to establish their webpage, set up their blog and Facebook Page.  Then they just sit back and expect it all just to run itself like the yellow pages of old.  This is so off the mark.  You have to actually engage, interact, update and communicate on these sites.  It just doesn't work without that level of energy, interaction, and caring.  You can't take the Social out of Social Media.

So, Facebook, Twitter, videos, and blogs are all things that can help a practice grow and thrive in the 21st century.  The key is actually knowing how to use these new tools properly.

What Is Your Favorite Toothpaste?

What is your favorite toothpaste?  Which toothpaste is the best?  Most all toothpastes have the same amount of fluoride.  The ones that do not are those few marketed as natural, or the ones made for babies and toddlers that are sometimes called something like "tooth and gum cleanser."  You will find that fluoridated toothpastes are recommended for adults and children two years and older.  Even then I recommend only a very small bit of toothpaste on the brush so if a child swallows it (which they will do) then its just a little bit and will cause no real problem. Other than fluoride though, it's all about the other stuff, the whitener, Triclosan, the tarter control, the appearance and of course the taste.  Really none of the effects of toothpaste are more important than the fluoride.  The ADA seal is to attest to the fluoride content.  That's the stuff that helps prevent cavities.

So, which toothpaste is the best?  For the children I see in our practice, the one I recommend to them is the one they like the best; the one they are motivated to use.  It's all about the marketing, sparkles, smell and taste.  Some kids, usually very young ones, don't like any kind of toothpaste.  Hey, you can still clean the teeth with the brush and floss, but the advantage of the fluoride is not there.  Most toothpastes marketed to children have the same fluoride content (1000 ppm) as adult toothpastes, but often have bubblegum or other flavors that appeal to children--and sparkles!  Adults like the minty flavors more.

So, which one do you like the best?  What is your favorite toothpaste?  I like Colgate Total enamel strength stripe and the Crest Pro-Health For Me Minty Breeze.  It's not that these are any better than others, it's just the awesome taste, sort of a mild mint that I prefer.  It often comes down to what you like.  If you do find something you like, it's ok to try something different from time to time just to keep it interesting.

Dental Schools Are Opening All Over The Place

In response to rising demand for a dental education back in the late 1970s and early 1980s there was a large increase in the number of dental students matriculating in dental schools across the nation.  Some of this was due to federal funding increasing the number of slots available.  After a while, this led to what some called an oversupply of practicing dentists leading to a wave of unforeseen changes in the business of dentistry, namely the introduction of managed care dental plans and increased competition.

In time the cost to the schools of providing a dental school education began to rise and some, mainly private, schools began to close; schools like Northwestern, Georgetown and Emory.  

Recently there has been an increase in the number of schools opening or planing to open across the country.  I do not know what long term effect this may have.  It will be interesting to see what happens and how this might affect dental school admissions and graduates.  One planned school at the University of Central Florida has been put on hold. I do hope these new programs will provide a great educational experience and not just become a profit center for the parent organization with little actual training or education for the students.

More information on Dental School can be found in my new book.

See my previous post on dental school admissions applications vs. the slots available