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Recognizing Body Dysmorphic Disorder in Cosmetic Dentistry
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Cosmetic dentists and surgeons see traits of Body Dysmorphic Disorder more than any other clinician. The way you handle these cases can put you at legal and financial risk. Find out what one cosmetic dentist advises.

Even the best dentist will never be able to make a body dysmorphic patient happy.

Dr. Michael Teitelbaum, owner and director at Briarcliff Center for Esthetic Dentistry, had an inkling that something was off about his patient’s behavior.

It started with the reason the patient came into Teitelbaum’s practice. Sure, many people had sat in the same chair to have their occlusions adjusted, but this case was different.

“He said that his life would be so much better if he could have the bite adjusted on not one side of his mouth, not a section of his mouth, but one particular corner of one tooth,” Teitelbaum recalled. “It was very unusual.”

The second red flag was the miles-long list of other clinicians the patient consulted prior to Teitelbaum, all of whom were unable to successfully treat the man.

“There was one clinician who lectures a lot and who I really respect, and he had been to him 17 times to have his bite adjusted. If this guy couldn’t satisfy him, then what were the odds that I could?” Teitelbaum said.

As it turns out, he couldn’t — no matter how flawless a procedure’s results, the patient’s apparent Body Dysmorphic Disorder (BDD) would never allow him to perceive any improvement.

Warning Signs, Preparation and How to Help

BDD, defined by a persistent and intrusive preoccupation with a minor or imagined defect in one’s appearance, occurs in roughly 3 percent of the population, according to a study. Cosmetic dentists and surgeons deal with these patients infrequently, but in higher numbers than other practitioners. And if those dentists aren’t prepared for BDD sufferers, legal and financial problems aren’t far off.

Patients with a BDD diagnosis cannot legally consent to cosmetic treatments like whitening or occlusion adjustment. Diagnosed or not, treating these patients is an exercise in futility.

“Ethically, it’s the wrong thing to do because the person has a psychiatric condition. It’s like trying to take advantage of someone who is drunk on a date — they’re not in control,” Teitelbaum said. “From a financial standpoint, it doesn’t pay to do the treatment because the patient is never going to be satisfied, and the dentist will have to redo the procedure.”

BDD patients don’t materialize often, but when they do, dentists need to be aware of the three common complaints that unite sufferers of this psychiatric condition.

Before pressing the patient about their fixations, it is crucial for the dentist’s legal protection that a trusted staff member, such as a receptionist or dental assistant, is present to witness the conversation. The number of people in the room must be kept to a minimum to secure patient confidentiality.

“If the person brings up that they can’t hold a job, can’t leave the house, and think about killing themselves, those are the three biggies,” Teitelbaum said. “There’s no reason to kill yourself because your teeth aren’t white enough. It’s not rational, and it requires diagnosis.”

Asking the right questions, the right way, is key to helping BDD sufferers, according to the study. When did the patient become aware of the problem? Why are they seeking treatment now, and how much does this problem consume their lives? If a patient is spending hours a day fixating on what most would consider a minor issue, that is not a patient a dentist should treat.

Most importantly, the dentist needs to put ego aside and accept that no matter what they do, they are never going to satisfy a person with BDD.

“It’s not anything a dentist should even try to fix on their own,” Teitelbaum warned. “It's very tricky, because dentists aren't great at referring to other practitioners in general, and it's extraordinarily difficult to refer someone to a psychiatrist. But that’s what you need to do, and you need to do it in a way that doesn’t offend the patient.”

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Painless Root Canal Alternatives
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July 18, 2003 - Nashville, Tenn. -- Painless root canal may sound like an oxymoron, but new techniques are making it a reality for many dental patients. One such technique involves avoiding the root canal altogether by sealing the exposed nerve with newly developed adhesives.

The procedure takes just one visit to the dentist and is much less expensive than a traditional root canal, but it is also controversial and not used as much as it should be, says New York dentist Michael Teitelbaum.

Teitelbaum tells WebMD that he believes 80% of people who need root canals are candidates for the alternative procedure but almost none are getting it, partly because few dentists know about it and partly because the failure rate with an earlier generation sealant was very high.

Teitelbaum spoke Friday at the annual meeting of the Academy of General Dentistry held here.

Root canals are performed when bacteria, introduced through a cavity or crack, compromise the nerves located inside the tooth. The bacteria cause an infection, which eventually kills the nerves. But root canals can be avoided, Teitelbaum says, in cases where the nerves are not yet infected.

Instead of hollowing out the tooth and removing the pulp containing the nerves as is done in a root canal, the exposed nerve area is cleaned thoroughly and sealed.

"We now have bonding technology that allows us to seal over the nerve using the same liquid plastic that contact lenses are made of," he tells WebMD. "It hardens to form a hermetic seal that coats the nerve as well as the tooth."

Although the procedure, known as direct pulp capping, has been around for many decades, the use of traditional adhesives resulted in long-term failure rates as high as 80%. Teitelbaum says he has done around 200 direct pulp caps using the newer sealant, with a success rate of 92%.

"When this fails patients usually end up having a root canal, which they would have had anyway," Teitelbaum says. "Most of my patients don't see that as a very big downside."

Oral pain specialist Keith Yount, DDS, says the procedure is just one of many new strategies now being tried to simplify the treatment of diseased teeth.

"Right now root canal is going through a major evolution and we really don't have a handle on what will end up being the best treatment," the Raleigh, N.C. dentist tells WebMD. "It is premature to buy into one concept right now."

Kenneth Burrell, DDS, says direct pulp capping with the new materials could represent a significant advance, but that has not yet been proven.

"This is certainly the direction we would like to go in, but I would like to see controlled trials so that we know that it works," he tells WebMD.


A 'Dental Practice Hero' in the Fight Against Periodontal Disease
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After graduating from the University of Pennsylvania School of Dental Medicine, Dr. Michael Teitelbaum attended first a general practice residency, then the Prosthodontic specialty program at New York University where he was an Assistant Clinical Professor of Prosthodontics for 8 years. He now has a private practice in New York focused on prosthodontics and cosmetic dentistry and is very active in organized dentistry. 

He is a  published author, lectures on cosmetic dentistry and occlusion, and has received many awards throughout his career. Dr. Teitelbaum believes that a strong foundation is important for any restorative, prosthodontic, or cosmetic dental procedure, and a strong foundation begins with preventive dentistry. Here, he shares his philosophy on preventing and treating periodontal disease.


Q: Why do you believe it is important to proactively diagnose periodontal disease?

In my practice, every new patient is examined for periodontal disease, and I educate each patient on the importance of a healthy mouth. Periodontal disease is a progressive infection and if you can catch it in the beginning stages (when gums are just irritated and bleeding), you may be able to prevent progression by regular twice-a-year dental cleanings. If you catch it a little later when the perio pockets are just starting, you may be able to manage the disease with scaling and root planing and 90-day recall visits. Once you start seeing a lot of bone loss, that’s when it becomes so much more work to manage the disease.


Q: What do you believe is the appropriate protocol for diagnosing or treating periodontal disease?

We follow a protocol that works for most people. After a new patient thorough exam, which involves restorative charting, a full series of x-rays and perio probing, we normally recommend a hygiene visit for either gross debridement or a general hygiene appointment. If pocket depths are greater than 3mm, we generally do a scaling and root planing, and the hygienist educates the patient on how to brush and floss and gives the patient a water flosser. After a thorough exam, I bring each patient back for a separate consultation and explain the results. Although I’ll tell patients that surgery is an option, my philosophy is to be conservative. Research shows that people who are susceptible to periodontal disease should have their teeth cleaned every 90 days, so this is our first option. About 14-21 days after the scaling and root planing, we will recall the patient and re-probe their entire mouth. If nothing has changed, that’s when I’ll refer the patient to a periodontist. Luckily, in most cases there is usually some improvement (pocket depths are mostly less than 3mm). We may recommend treatment with minocycline for the few remaining deep pockets, and we can also prescribe minocycline in capsule form to be used with a water flosser if necessary. 


Q: What treatment hurdles do you encounter? 

The two biggest hurdles to successful periodontal treatment are patient acceptance and financing. It’s imperative that we get the patient to understand and appreciate that treatment is necessary to improve their overall health. That’s why a thorough exam and explanation is so important. When I first examine for periodontal disease, I show the patient a diagram and thoroughly explain pocket depth, attachment loss, and that normal healthy gums should not bleed. If a patient can truly see and understand there’s a problem, they are much more likely to follow through on the recommended treatment protocol. 
Financing is also an obstacle that stands in the way of treatment, and it’s important that dental practices offer flexible financial arrangements for patients so that they can overcome that hurdle. 


Q: For patients you treat with perio disease, how would you describe your patient mix? 

In my practice, I’ve found that the age of adults with periodontitis really varies. It can be a patient in her 30’s or one in his 70’s. It’s generally more common for me to diagnose perio disease in new patients who haven’t received regular dental care or who haven’t received good quality cleanings in the past. Just yesterday I saw a new patient in her 40’s who has horrible periodontal disease, some of the worst I’ve seen in a very long time. She had crooked teeth, loss of attachment, several pockets greater than 10mm (which is the length of my perio probe), and lots of bleeding. We still need to review her x-rays and come up with a treatment plan, but if we can save 2 or 3 teeth in each arch, we’ll probably recommend root canals and then an attachment overdenture or all-on-4 implants.


Less drilling and filling
Technologies that aim to stem the suffering
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By Jane Weaver | Health editor
msnbc.com | updated 9/30/2004 6:16:27 AM ET

At first, Laura Bienenfeld didn't pay much attention to the sharp pain she felt around the filling in one of her back teeth when she bit down on really hot or cold foods. Even though she's a dentist herself, she'd always had sensitive teeth and thought the new pain was part of the same old problem. But when she visited her own dentist to replace the silver mercury filling with new material, he discovered that a deep cavity had developed in the tooth and had reached the nerve.

Normally, Bienenfeld would need a root canal, a procedure that's been likened to living hell.

While there have been advances in the techniques used for treating diseased teeth over the last few decades, the fear of a bad root canal experience remains one of the leading causes of dental phobia. A root canal is generally performed when the pulp of a tooth becomes exposed or infected because of a cavity or crack, and at least 14 million of the procedures are done each year, according to the Academy of General Dentistry (AGD).

Some may say Bienenfeld was lucky. Because the nerve hadn't become infected, instead of getting a traditional root canal, which requires drilling into the tooth's crown to clean out the diseased pulp, Bienenfeld's New York dentist, Michael Teitelbaum (who is also her husband), used a newer technique called direct pulp capping that he says is faster, preserves more of the tooth and requires less time with the dreaded drill.

In a traditional root canal, a dentist removes the nerve, sterilizes the tooth canal and fills it with a rubber-like material to prevent future infection of the tooth. A substantial portion of the tooth is drilled away to fit a permanent porcelain or gold crown.

With direct pulp capping, if the nerve isn't infected, a dentist can clean out the bacteria from the cavity and cover the tooth with a resin seal over it so tight that "the nerve doesn't know whether it's a tooth or a bonding material," Teitelbaum says. Because the bonding material replaces the need for a crown, more of the tooth is preserved.

"It's not very widely used yet, but it should be," says the Briarcliff Manor, N.Y., dentist. "As long as the tooth isn't infected, about 90 percent of the time it'll heal."

For Bienenfeld, the direct capping procedure was as easy as getting a regular filling. You wouldn't expect her to criticize her husband, but she insists, "it worked out great."

Direct pulp capping has been around for several years, but newer, more effective bonding materials are helping make it a more viable alternative for root canals, dentists say.

"Most people appreciate having the option, the chance, of not having to have a root canal," says Teitelbaum.

'New paradigm'

To help take the bite out of going to the dentist, a growing number of dentists across the country are embracing options such as direct pulp capping and other new technologies that ease patient anxiety and reduce the pain associated with treating diseased and damaged teeth.

That's important because fear of pain is the reason 23 percent of people put off dental appointments, according to a 2003 American Dental Association (ADA) survey. And that can cause many people to ignore mouth pain to the point where a root canal or other major procedure becomes inevitable. But eliminate pain and over 41 percent of those fearful folks would be more likely to visit the dentist, the survey found.

Gadgets like lasers and air abrasion tools, along with advances in anesthesia, are part of "a new paradigm of being more conservative" and opting for minimally invasive dentistry, says Teitelbaum.

More sophisticated instruments and improved repair materials mean even a root canal isn't the agony-inducing experience it once was, some argue. "There are tons of patients coming out of offices saying, 'don't be afraid of root canals anymore,'" says Mac Edington, Nashville-based former president of the AGD.

Good-bye to the drill?

Perhaps nothing causes more anxiety than the high-pitched, whining sound of the drill. "The noise of the drill, that's the perception of pain to people," says Edington.

But now drill-haters can get some relief from dental lasers. While the instruments have been used in dentistry for more than 20 years, primarily for gum disease and cosmetic bleaching, only in the last few years have they advanced to where they can be used to cut teeth, remove decay and cut bone.

The Academy of Laser Dentistry (ALD) says this offers several advantages: the need for local anesthesia is reduced, bleeding is minimized, swelling is controlled, and there is less post-operative discomfort.

All of this is cause for patient celebration. But the devices, along with training, can top $50,000. So the use of lasers is a slow-growing trend, with only about 1,100 practicing members of the ALD out of an estimated 170,000 dentists nationwide.

Furthermore, dental lasers are not good for deep cavities as yet and there are concerns that accidents could damage teeth, dentists caution.

"We're just in the beginning stages of using them on hard surfaces of the teeth," says Kimberly Harms, an advisor the ADA and a practicing dentist in Farmington, Minn. "It looks hopeful, but we have to make sure they're going to be safe and effective."

Still, dentists who use lasers can promise their patients bloodless, painless surgeries, giving them an edge over those waving drills and other scary surgical tools. And recently, some dentists have begun using lasers in root canal treatments.

Another advance is air abrasion, also called microdentistry, in which a little machine can sandblast away a small cavity. The idea is to treat the decay as early as possible, usually making anesthesia unnecessary. Air abrasion is often used on children.

"It's a little gritty, but most patients prefer it to a drill," says Harms. "You can do it without pain."

Easier shots

What if you're in need of serious tooth repair and can't avoid the needle, the jab in the jaw to numb your gums? Anesthesia experts say there's no more need to dread the shot.

"For many people the thought of having an injection in the mouth is worse than the actual shot," says Joel Weaver, a dental anesthesiology specialist at Ohio State University. "Sometimes dentists fear that patients want to get the shot over as quickly as possible, so they inject as quickly as possible, but that can cause more pain than when done slowly."

For the dentists who worry about needle-shy patients, there's a computerized injection system called "The Wand," a small needle which looks like a pen and is controlled by a foot pedal. The system allows a dentist to inject more slowly in order to minimize discomfort.

"The Wand injects the local anesthetic at a precise rate so that its much less painful when the dentist uses it," says Weaver.

And for people who don't like going home with a numb mouth, early research shows promise for reversible anesthetics, he says.

Beyond the advancements in technology, the real way to achieve pain-free dentistry is to develop more communication with patients and give them a sense of control over what happens to them in the chair, says Harms.

"There's more focus on taking care of the patient attached to the teeth," she says. "No technology can take the place of a trusting relationship."


Small gifts for vets make a large impact for everyone
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By Alli Filan and Christopher Dawson, CNN
November 11, 2010 11:50 a.m. EST

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(CNN) How does a dentist thank the troops? By sending them lots and lots of comforting candy.

Dentist Michael Teitelbaum was looking for a way to help his young patients avoid cavities, when he came up with a campaign that would also benefit our soldiers' sweet tooth.

After every Halloween he offers a candy buyback, where candy-sharing children receive a dollar coin for every pound of candy they bring in for overseas troops.

This November, he has already received about 200 pounds of candy. In eight years of Teitelbaum's candy buyback program, he has collected over 2,000 pounds.

Teitelbaum chuckled when considering the children's surprising generosity.

"The kids that are quick to give up their candy have the Halloween bags that have been clearly picked clean of their favorite treats," Teitelbaum said.

He helps those children struggling to give up their Halloween haul with a certificate of patriotism, a picture, and of course, the dollar coins.

The soldiers, Teitelbaum said, give away much of the candy to the children in Iraq and Afghanistan, who have never tasted American sweets. But he has also received letters that the troops devour a lot of it themselves, and want more.

"Over there they really don't get to celebrate Halloween or other holidays," Teitelbaum said, "so it gives them a little taste of home."

See the candy donations pile up, on CNN iReport.

Have you helped make a positive impact for our Veterans? Share your story with iReport and Impact Your World.


Patriotism on Pleasantville Road
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Posted by: Barbara Nackman - Posted in Briarcliff Manor on Jul 02, 2010
You often see flags waving on the Fourth of July and lots of red, white and blue.
But here in Briarcliff Manor, a local dentist has gone a step further.
Dr. Michael Teitelbaum got an idea last night to put a sign on the lawn of his office saying "Honk for Liberty."

honk

"It suddenly occurred to me. I wanted to do something a little different," he explained.
Teitelbaum's office is called The Briarcliff Center for Esthetic Dentistry and it's at 1312 Pleasantville Road. He said he usually hangs up a large flag, but this year he couldn't find it so he set out to come up with an alternative. By 11 a.m. he said he planted the signs and the horns began honking.

An observant passerby noticed the sign and sent up the above photo to share.Teitelbaum is seeing patients today and as a special treat in honor of the holiday he is handing out small American flags. And in case that is not enough patriotism, he is wearing all-American colors -- a white shirt, dark blue slacks and a flag tie, he says.

Happy Fourth of July!

"It's the Fourth of July and we are celebrating liberty, now that's patriotic," he said.


Read Dr. T's answers in this exclusive ASK THE EXPERT section!

Dr. T. in the Journal News' LoHud.Com showing off his patriotism!

Patriotism on Pleasantville Road
Posted by: Barbara Nackman - Posted in Briarcliff Manor on Jul 02, 2010
You often see flags waving on the Fourth of July and lots of red, white and blue.
But here in Briarcliff Manor, a local dentist has gone a step further.
Dr. Michael Teitelbaum got an idea last night to put a sign on the lawn of his office saying "Honk for Liberty."

"It suddenly occurred to me. I wanted to do something a little different," he explained.
Teitelbaum's office is called The Briarcliff Center for Esthetic Dentistry and it's at 1312 Pleasantville Road.
He said he usually hangs up a large flag, but this year he couldn't find it so he set out to come up with an alternative. By 11 a.m. he said he planted the signs and the horns began honking.
An observant passerby noticed the sign and sent up the above photo to share.
Teitelbaum is seeing patients today and as a special treat in honor of the holiday he is handing out small American flags. And in case that is not enough patriotism, he is wearing all-American colors -- a white shirt, dark blue slacks and a flag tie, he says.
Happy Fourth of July!
"It's the Fourth of July and we are celebrating liberty, now that's patriotic," he said.
Photo Caption: IMG01061
Tags: Briarcliff Manor, Dr. Michael Teitelbaum

LOCAL DENTIST CELEBRATES 41st MOON ANNIVERSARY
BRIARCLIFF MANOR (July 20, 2010) - July 20, 2010 marks the 40th anniversary of Neil Armstrong's immortal first step on the moon, and to commemorate the event local dentist Dr. Michael Teitelbaum will continue his tradition of giving out popcorn ball "moons" to everyone who comes in to his Briarcliff Manor DentistSpa office.
"Ever since my daughter learned to make Rice Krispy Treats, we've used the recipe to make 'moons' out of popcorn balls to give to my patients to celebrate one of mankind's greatest accomplishments," said the Briarcliff cosmetic dentist.
For "Moon Day" this year, the 41st anniversary of the fulfillment of JFK's lunar dream, Dr. Teitelbaum decided to open the fun to everyone and give out popcorn moon balls to anyone who comes in to his Briarcliff Manor office.
For further information call the office at 914-941-2000, or go to www.DentistSpa.com. The office will be open from 8:30am until 6:00pm on July 20th.

Among other charitable endeavors, Dr. Teitelbaum also volunteers his services restoring smiles of battered women through the "Give Back a Smile" program, donates teeth bleaching treatments for local charity fundraisers, collects Halloween candy to send overseas to our troops, and annually gives money from smile whitening to Garth Brooks' childrens' charity through the "Give Back A Smile" Program.
Dr. Teitelbaum graduated from the University of Pennsylvania School of Dentistry in 1989, received his Fellowship in the Academy of General Dentistry in 2001, and has been practicing dentistry in Briarcliff Manor, NY since 1990. Dr. Teitelbaum is a director of the Westchester Academy of Restorative Dentistry, Founding Vice-President of the Empire State Academy of Cosmetic Dentistry, and a member of the American Dental Association and the NY State Dental Association. He is the Director of the Briarcliff's DentistSpa Center for Esthetic Dentistry.

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