Referrals
Why Do I Have to See a Specialist?
Often, we find that patients are frustrated by "having to go to another dentist." We do referrals in the best interest of the patient and do so often to meet the standard of care which we are expected to meet. "Standard of Care" is an esoteric concept that professionals use to determine whether a colleague has acted appropriately when rendering treatment for a given patient. When such a question arises, dental boards will poll respected clinicians in regard to what they would have done in a particular situation. If a majority of polled dentists indicate they would have acted differently, the dentist whose judgment is in question can be deemed to have committed malpractice because he was not within the "Standard of Care" of his peers.
Standard of Care is a regularly changing and evolving entity. Changing technology and changing dental techniques fuel this change. When referrals are made, we not only are attempting to meet Standard of Care for our liability concerns, but also to provide you with the best, most appropriate care possible.
When a referral is provided for you, we also attempt to refer to only those specialists we know and have a long-term relationship with. These are doctors we would use ourselves and with which our patients over the years have given us positive feedback on. Unfortunately, some dental plans and PPO plans require the use of specialists that we do not know or have a track record with. In these cases, we will usually inform you that we do not know this specialist. You will then need to make a decision on whether to use this provider. While we make suggestions on specialists, we never require a patient to see the specialist we suggest. You are always free to see any specialist of your choice and most board certified specialists have proven their mastery of their specialty to a board of their peers. If you have used a specialist in the past and wish to continue to use their services, know that we fully support your decision to do so.
Oral Maxillofacial Surgeons
Oral Maxillofacial Surgeons are an ADA recognized specialty in dentistry. These specialized dentists perform all types of surgery in and about the oral cavity. They have received post-doctoral training and have completed residency training at a hospital. Some Oral Maxillofacial Surgeons even have dual degrees--both a medical and dental degree. They work more than any other dental specialist in the hospital setting and are more adept at handling medically compromised patients.
As specialists, they can make a difficult extraction much easier for the patient. Using techniques and instruments that are highly specialized to their field, a root that may take a general dentist 45 minutes to extract, can be done in just minutes--with much less distress for the patient.
In addition to making the procedure more pleasant and tolerable for the patient, they also perform certain procedures that many General Dentists do not.
When we suspect you will require a surgical extraction, you will most likely be referred to this type of dental specialist, who will make this procedure more pleasant and faster. Surgical extractions require that bone be removed to extract the root. In such cases where bone is removed, this can leave a significant defect in the alveolar bone. At one time, it was routine to just let such surgical defects fill in as they would, resorb and then deal with the effects of the surgery afterwards. This could mean problematic sore spots under dentures, problems retaining dentures, an inability to place an implant at this site, or poor results with a bridge, should the patient ever desire these services.
Today, it is quickly becoming the standard of care to fill in these bone defects created by surgical extractions, with different types of bone grafting material. Doing so will allow the site to heal much better and the patient will end up with a well formed ridge that does not cause problems down the road.
We also routinely refer patients who will have multiple teeth extracted for their denture, especially if the patient has had a lot of bone loss secondary to gum disease. The uneven ridges in such patients can often pose problems under the denture--creating more sore spots and requiring a much longer period of time to adapt to the new prosthesis. Oral surgeons will routinely do a procedure called an alveoplasty on the ridge when extracting the teeth. This procedure smoothes, evens out and prepares the bone to hold a new denture once it heals.
Those patients requiring wisdom tooth extraction are also routinely sent to the oral surgeon, who has specialized imaging equipment to evaluate the risk of nerve damage that can associated with this type of surgery.
Oral and Maxillofacial Surgeons can also provide patients with concious sedation during their surgery for patients who are anxious, or with procedures that they deem more difficult for the patient. This type of sedation for patients usually causes the patient to have no recollection of the procedure and greatly improves the experience.
It is our intent to provide the best care for our patients. When we refer to an oral surgeon, we know that this is the best course of treatment for our patients considering the procedures they require.
Seeing a Periodontist
If you're found to be suffering from Periodontal Disease, and that disease has moved into the moderate or advanced stages, our office is likely to recommend that you see this type of dental specialist. Periodontists are ADA recognized specialists who treat the gums and the supporting bone of the teeth. They have post-doctoral Master's Degrees in their field of practice--providing them intensive experience in TREATING gum disease
In addition, this specialist is also consulted for other procedures such as implants, gingival grafting procedures and crown lengthening.
Periodontists treat gum disease, especially when it has cause significant bone loss and defects in the bone. They will often resort to bone surgery procedures in an attempt to manage more severe cases of Periodontitis. When such problems with the bone arise, some root surfaces cannot be cleaned with normal home care procedures such as brushing and flossing, and periodontal surgery can correct such problems and prevent tooth loss. New modalities of therapy involving lasers are also being employed in such practices.
We consider Periodontal Disease to be in the Early stage, when patients have 5 or 6 millimeter pockets and no radiographic evidence of angular bone defects exist. Such patients are usually treated successfully with non-surgical methods such as Scaling and Root Planing and Periodontal Maintenance. However, once patients move past this early stage of Periodontal Disease, further bone loss is inevitable should surgical methods not be employed.
Gum disease is a silent disease. It typically does not provide very many symptoms or much discomfort until it's in the latter stages. By this time it may be too late to even save the dentition. Early, prompt and appropriate treatment at the first signs of gum disease is always the way to go.
Should you be referred to a Periodontist, it does not automatically mean you'll require surgery. Today, many new procedures are being employed by this type of dental specialist--some which can help avoid or greatly delay the need for surgery.
Some patients who have been treated wit non-surgical gum therapy (Scaling and Root Planing) will not respond appropriately to therapy. If this should happen in your case, another round of Scaling and Root Planing may be suggest. If, we still then do not see improvement in the degree of inflammation and the reduction of pockets, you may also be referred to this type of dental specialist, to see if their specialized modalities may provide better results.
While few patients like being referred out from their general dentist for specialty care, failure to see a Periodontist promptly and when recommended, can mean the difference in maintaining your dentition for life, or being condemned to wearing denture in your future years.
Periodontitis is a complex, inflammatory disease process that must be controlled. Inflammation is a normal reaction to bacterial proteins that contact or invade our bodies. As the mouth has a constant load of bacteria, this means controlling the volume of that load is a daily fight. Effective home care is essential, and without this, even a Periodontist will be unable to get gum disease under control.
Seeing an Orthodontist
While our office does perform some limited orthodontic therapy for our patients, many patients who wish to have teeth straightened or crowding eliminated, will require a referral to this type of dental specialist.
Orthodontists work to move teeth and correct dental malocclusions.Dental malocclusions occur when the teeth do not meet as they would ideally. Children with dental malocclusions can have significant self-esteem problems and may not smile because they are ashamed of their teeth. Others can suffer from malocclusions that are so significant it effects speech and eating.
Orthodontists work largely with teens. This is a time in life when all the adult teeth have erupted, the bone is very susceptible to moving teeth and malocclusions first present themselves. It is a perfect time to move the teeth into a more acceptable and functional position.
Adult orthodontics, however, is quickly becoming a bigger part of the orthodontist's patient base. Many adults are electing orthodontic treatment later in life and new materials and methods can make tooth movement much less esthetically unpleasing as braces once were.
Our office monitors all our minor patients and suggests consultations with an orthodontist should the child exhibit a need for such services. If, however, you're an adult desiring this sort of therapy, please make this known to Dr. Titus, as we do not always recommend such treatment on adult patients--even if they could benefit from it.
Orthodontists not only employ mechanical means to move the teeth, they also can take certain measure to prevent crowding, promote bone growth and create space for the developing dentition. Usually, by the time a child has achieved the age of 8 and they are exhibiting signs of crowding, our office will make an orthodontic referral. This is a consultation to determine how much crowding is present and to evaluate if certain treatment is appropriate to minimize future crowding. Such things as palatal expansion and sequential extractions cannot wait until the teen years to be employed. Rarely will an 8 or 9 year old, being referred to an orthodontist, end up in braces right away. These are typically consultations to just evaluate the child's teeth, the degree of crowding and to evaluate if something need be done before the child hits puberty.
While orthodontic therapy isn't inexpensive, most orthodontic offices offer parents and adult patients easy financing terms where the therapy can be paid for over the course of treatment. Providing a child with an attractive smile and healthy teeth is a valuable gift which fosters, self-confidence, sociability and success in their future.
Referral to an Endodontist
Endodontists are dental specialists that work with the inner most portion of the tooth--the pulp. While they are mostly known for the root canal work they perform, these ADA recognized specialists render a variety of services--some which attempt to maintain the pulp. Endodontists are most often, however, involved with retaining teeth that have had bacteria enter into the pulp of the tooth. Endodontists have post-doctoral Master's Degrees in the practice of Endodontics from accredited dental schools, and have past board exams in their field.
Teeth with deep decay, cracks or severe wear allows bacteria to get in the pulp, and this causes inflammation and pain from the nerves within the pulp. Given enough time, such teeth will usually abscess, causing more subsequent pain, that then comes from nerves surrounding the root. Such abscessing teeths can cause serious, spreading infection in the soft tissues of the face.
Endodontics, or root canal therapy, is something our office offers to patients. In certain cases, however, you may be referred to this type of specialist for endodontic therapy.
Certain teeth, such as molars, have narrow, curved root canals and access to such is sometimes difficult. In addition, molars have 3 or more canals and each one must be treated successfully. Thus, molar endodontic therapy is technically more demanding, more time consuming and more difficult on the patient as they must remain with their mouth open wider for longer periods of time.
As such, completing this type of procedure quickly, accurately, comfortably and precisely is of prime importance. Endodontists, which do little other than this type of work, have their skills honed well and their practices geared to render such care. Other difficult to treat teeth, such as those with highly calcified canals, may also be better suited to be treated by an Endodontist, rather than your General Dentist.
Several longitudinal studies, conducted by major universities, also allude to the fact that molar endodontics performed by these dental specialists have a higher success rate over a five year study period.
All these factors cause many general dentists to refer their molar root canal therapy and other difficult root canal therapy to the Endodontist.
As most teeth that receive root canal therapy then need to be restored with a crown, we want the highest possible chances of success for the root canal therapy. Should an endodontic procedure fail after the crown is permanently cemented, it can mean having to drill through the chewing surface of the crown to perform a re-treatment--a highly undesirable situation. Providing the very best possibility of success for endodontic therapy is essential.
Dr. Titus will tell you when he feels its appropriate for you to see this type of dental specialist.
Does Your Child Need a Pedodontist?
Our practice loves kids, but we do limit the age of our patients to six years of age and up. From many years of practice, we recognize that children under this age often require extra time, specialized attention and certain modalities that are not easily rendered in the general dental practice setting.
While we use the age of six as a standard, some children older than this may not yet be ready for the delivery of dental care in a general practice. Anxiety with regard to injections and dental care in general, may cause a lack of cooperation out of fear. Some children cannot sit still or keep open as needed to render quality dental care, even if they are motivated to cooperate. In addition to these sorts of problems with rendering dental care to children, there can also be specific needs that are better corrected in a Pediatric dental practice.
Pedodontists are ADA recognized specialists that work specifically with children and sometimes with special need adults. They offer a wide variety of general dental services and many focused primarily on children. From orthodontics to routine cleanings, the Pedodontist can provide for all the needs of a child. In addition to these routine procedures, Pedodontists also use a variety of behavioral and pharmacological methods to overcome behavioral issues that are linked to a child's anxiety.
Some children may require sedation to have dental care rendered. State dental boards are very strict about sedating children and require conscious sedation permits for dental providers who which to do such. Pedodontists are usually permitted to render such sedation to the child patient. Employing such for the child can make a potentially anxiety provoking visit pleasant, or at least tolerable for the child.
It is our primary intent to foster positive dental experiences for the child patient so that they become good adult patients that do not harbor irrational fears towards dentistry in their adulthood. Fears from childhood dental experiences can create adults that avoid dental care altogether, a situation that will often result in the loss of the dentition prematurely. Poor childhood dental exeriences also produce patients that suffer long-term irrational fears with regard to dental care, even if they see a dentist in adulthood.
If your child exhibits significant fear and anxiety at their dental appointment and becomes uncooperative because of this fear, our office will most likely refer your child to a Pedodontist. Insurance plans will sometimes cover such a referral, but if a child has attained a certain age they may not. We strongly encourage parents--regardless of what insurance will pay for--to employ the services of a Pedodontist should your child exhibit this sort of fear of dentistry. Sometimes after just a few positive experiences at the Pedodontist -- with or without sedation -- it will give the child the positive experiences he or she needs to begin a using a general practice. It will be money well spent in rearing a child that does not fear dental visits in the future.