Bright Ideas

Six top NJ dentists discuss the challenges and joys of their profession.

There’s no doubt: Dentists get a bad rap. Even the president of the United States joined in the dental bashing this year. But most of the bad news about dentistry is old news. Today’s dentists have advanced tools and procedures that substantially improve the experience and the results for most patients. What’s more, the increasing emphasis on preventive care means fewer dental crises for all of us.

New Jersey Monthly assembled a panel of six of the state’s best dentists (click here to read their profiles) to talk about their profession. The six were chosen from among the 298 practitioners on this year’s Top Dentists list. They represent six of the nine specialties identified in the survey.

Our panelists are Dr. James M. Courey, a prosthodontist in Manalapan; Dr. Anthony Fasciano, an endodontist in Englewood Cliffs; Dr. Amy E. James, an orthodontist in Haddonfield; Dr. Jay S. Schuster, a general dentist in Morristown; Dr. Elisa J. Velazquez, a pediatric dentist in Toms River and Manahawkin; and Dr. Eric C. Weiss, a periodontist in Livingston.

In his 2010 State of the Union address, President Obama, in describing the bank bailout, said it was “about as popular as root canal.” As a dental practitioner, that must have hurt. How did you react to Obama’s statement?

Elisa VelaZquez: I don’t think he intended to use dentistry as a negative comparison, but it was careless.
Jay Schuster: Obama’s statement was a derogatory and unfair generalization.

James Courey: It certainly does not help ease people’s fear of pain associated with seeing the dentist. The fear of pain is one of the main reasons people fail to see a dentist until they have an emergency so severe that they are literally driven to seek professional help. The irony is that root-canal therapy saves thousands of natural teeth each year, making it more of a hero than a villain.

Anthony Fasciano: It is unfortunate that the misconception of root canal continues to haunt dentistry….The truth is root-canal treatment is most often a painless procedure. It may be true that the tooth hurts before treatment; however, people should be aware that root-canal therapy relieves pain, allowing for the maintenance of one’s natural tooth.

Amy James: Comments like that come with the territory. We don’t take it personally. Fortunately, I have chosen a specialty [orthodontics] well liked by most. It’s been my experience that patients look forward to their visits and are highly aware of their progress throughout treatment.

Eric Weiss:
The comment wasn’t hurtful, it was thoughtless. It propagates an inaccurate and negative perception and condones a lackadaisical attitude about the importance of dental care in general.

Obviously, root canal has an image problem. What other popular misconceptions are there about your field of dentistry?

James: I think the greatest misconception about my specialty is that orthodontic treatment—straightening teeth—will hurt, and that you always have sore teeth. With such amazing technology, this couldn’t be further from the truth. Brackets—or braces—have become so small that they are hardly noticeable to the lips—and the alloy metals used for the wires were [engineered] by NASA. Our specialty borrowed the engineering because the wires have memory and are light in force with long activation. That means greater comfort for the teeth and less frequent visits to the office.

VelaZquez: A major misconception is that baby teeth do not need to be fixed when they are decayed since they are only going to fall out. That is incorrect. If primary teeth are not restored, that can result in pain, infection, and space loss for the permanent teeth.

Schuster: Painful needles and loud drills. So many people put off going to the dentist for five or even ten years out of fear. At that point there is so much decay that major work is needed and could have been minimized by regular visits.

Courey: The myth I hear the most is that prosthodontists are glorified general dentists. While there is some overlap in the types of procedures offered by general dentists and prosthodontists, general dentists are trained in dental school to do procedures in everyday dentistry. Specialists are trained for three to four years after dental school to provide a higher standard of care and to treat the more challenging conditions. For instance, any dentist may extract a tooth or make a crown; however, oral surgeons are often consulted for difficult or multiple extractions, while a prosthodontist is consulted for multiple crowns or a major rehabilitation of the mouth.

Weiss: Firstly, there is the thought that bleeding gums are not a big concern. They are! If a person had bleeding anywhere else in their body they would race to the physician. Well, bleeding gums means there is inflammation and disease. There is much evidence now that there are strong relationships between inflammation in the mouth and many other serious medical conditions, such as diabetes, cardiovascular disease, and respiratory problems.

Another common misconception is about dental implants. People often believe that they must go without teeth for six months or more after the implant is placed before it can have a tooth attached to it. That is no longer accurate. Often a tooth can be extracted, a dental implant placed in its position, and a tooth attached to it at the same time.

How have new technologies improved results for the patient in recent years?

Velazquez: In our office, we use computers and computer software to chart and plan treatment for our patients. It makes the process and explanation of the needs for our patients easier and faster. Digital cameras also enable us to photograph conditions in a patient’s mouth as part of their dental record.
Dental bonding has improved dramatically in the past ten years. Resin materials and bonding agents are stronger and easier to perform. The curing process with LED curing lights has also accelerated the process of bonding…. Also, stronger and superior materials means being able to restore more complicated cases of rampant decay or malformation of the teeth.

Courey: One of the most important imaging and diagnostic breakthroughs in modern dentistry is the use of cone-beam computed tomography for implant-treatment planning. The CBCT provides 3-D images of the jaw, teeth, and vital structures with extraordinary accuracy and detail, making it the gold standard for patient care in implant dentistry. This marriage has resulted in success rates as high as 98 percent for today’s dental implants.

I am a big fan of digital radiographs. There is a significant decrease in radiation exposure; a significant decrease in the environmental impact, since dangerous chemicals are not needed to process the image; the image can be enhanced to aid in diagnosis; and the image can be stored indefinitely and easily exchanged between dentists and dental specialists. Visual enhancement through magnification with the use of a surgical microscope is a huge change for dentistry. It is basic; you can’t treat what you can’t see.

James: Computer-aided design and computer-aided manufacturing are being used to make appliances—braces, wires, palate expanders, etc.—more precise. These can rule out operator error, which then speeds efficiency and accuracy.

Our office is using a very specific new technology called Incognito. This is braces on the inside of your teeth and completely hidden or invisible. Each bracket is customized for each tooth for each patient; nothing is generic or interchangeable. Each wire is custom bent for each patient by a robotic arm in a lab. The results of treatment are superior.

Weiss: The most significant technological development relative to [periodontics] is the use of growth factors to engineer the regeneration of lost tissues. We can utilize various biologic agents to direct the differentiation of cells into specific tissue types. It’s really incredible! Also, the wide availability of low-dose radiation 3-D scanners now gives us the ability to much more accurately evaluate patients and diagnose problems. These cone-beam scanners also give us the ability to simulate dental-implant placement on a computer and then prefabricate surgical guides that allow us to do complex implant surgery in a minimally invasive manner.

What are the mistakes patients make in caring for their own teeth—or their children’s?

James: Most oral diseases—cavities, gum disease—could be eliminated in most people if they took their home care more seriously and were diligent about seeing their dentist for regular visits twice a year. I had a professor in dental school that always said, “Dentistry is not expensive, neglect is.”

Velazquez: Many parents make the mistake of not using fluoridated toothpaste when a child is receiving a multivitamin with fluoride. Or the flip side, parents have their children use fluoridated toothpaste but then do not give them the multivitamin with fluoride. The ideal course would be to have a systemic fluoride—the amount depending on the child’s age and the fluoride content in the town’s water supply—as well as a topical fluoride via a rinse or paste.

I also think a major mistake made by parents is not bringing the child to be examined early enough. The American Academy of Pediatric Dentistry advises children be examined for a caries assessment by age 1. Many children are not seen until age 4 or 5, and often the decay is so rampant, requiring the child to need extractions and extensive treatment.

Schuster: The biggest mistakes in caring for your or your children’s teeth are sports drinks and soda, which contain sugar and acid. Also, not brushing before bed.

Weiss: Not flossing daily is the single biggest mistake people make in caring for their own teeth. The oral cavity is rampant with bacteria. We all have various forms of oral bacteria in our mouths. These bacteria accumulate on the teeth as plaque. Brushing only cleans half the surfaces of teeth—it doesn’t clean the surfaces of teeth facing each other—and this is where periodontal disease usually starts. Mouth rinses, irrigation devices, etc., are all marketed to substitute for flossing, but they are not nearly as effective as flossing. And we know that, once plaque accumulates for more than 24 hours, it starts to change to a more harmful form. That is why we say, “Only floss the ones you want to keep”!

Courey: The biggest mistake people make is skipping their routine visits with their dentists and hygienists because “nothing hurts.” A hygiene appointment is not just a cleaning. Just as an ounce of prevention is worth a pound of cure—the best oral health investment a person can make is an appointment with their dentist and dental hygienist. People with healthy gums and teeth should visit their dentist’s office at least every six months.

Fasciano: Not following routine scheduled check-ups and not completing treatment. It is important for endodontically treated teeth to be restored back to form and function. Root-canal treatment without restoration of the tooth can lead to tooth fracture and tooth loss; therefore, it is imperative for a patient to seek treatment from their restorative dentist.

How do you think the Obama health-care plan will affect the practice of dentistry?

Schuster: If Obama institutes a health-care plan such as in England, it will not only be detrimental, but people will go to other countries for better treatment. I have patients from all over the world—Africa, Europe, Korea, and Australia—because they are offered inferior dental care at home.

Velazquez: In many countries with universal health care, the dental care and quality of dentistry declines. Choice is the only way to keep high standards and quality in health care.

How the Obama health-care plan will ultimately affect the practice of dentistry and oral health is unclear. The reduction in health-care flex spending allowances—from $5,000 to $2,500—will definitely impact patients’ ability to save and pay for needed dental treatment for themselves and their families.

What’s the best part of being a dentist?

The best part of being a dentist is when a patient grins from ear to ear and hugs me! Creating a healthy, beautiful smile can bring life-changing results.

Courey: The best part of being a prosthodontist is the variety of people who come into my life. I may see a child with a congenital tooth defect, a prom queen who wants whiter teeth, a cancer survivor who has earned a smile restoration, and a proud grandparent who needs their dentures adjusted, all in the same day.

Fasciano: As an endodontist, the best part is relieving pain for a patient. I enjoy taking an anxious, apprehensive patient out of pain and converting them to a calm, relaxed, pain-free root-canal advocate.

James: I love my career as an orthodontist because it’s a proactive specialty. People seek treatment to make their smile beautiful and/or make their teeth fit together ideally. The outcome is always great and people feel good about their investment. They have better function and aesthetics.

Weiss: The best part about being a periodontist is helping people become healthier—both dentally and medically. It sounds clichéd, but it’s the truth. I have helped diagnose many serious medical conditions in patients—such as diabetes, autoimmune disorders, cancer, etc.—by observing changes in the mouth. In doing so we have significantly improved the quality of their lives.

Velazquez: The best part of being a pediatric dentist is interacting with the children. Child behavior management is very challenging and rewarding. I remember meeting a 3-year-old little blonde girl who would scream upon entering the office. With patience and caring, I was able to develop a bond with her, and now she looks forward to her six-month visits. When she came in the other day, she gave me the best compliment and said she wished to be a dentist like me when she grows up.

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