Acknowledgments

Editor-in-Chief
Michael Palmer, DMD

Contributing Editors
Nancy E. Hartrick, DDS
Jean Allen Martin, DDS

Book Committee
Tony Cascino, DDS
Bryce Chandler, DDS
Matt Falkenstein, DDS
Nancy E. Hartrick, DDS
Ken Hovden, DDS
Jamie LaViola, DDS
Ken LeVos, DDS
Jean Allen Martin, DDS
Doug McMaster, DDS
Andrew Mogelof, DDS
Michael Palmer, DMD (Chairman)
Sam Romano, DMD
Scott Rice, DDS, MBA
Deb Schwartz, DDS

Photography
All the photography within this book was graciously donated by graduates of the Kois Center who have the same passion for beautiful photography as they do for their profession.

Mark Benavides, DDS
Pat C. Beug, DDS
Dave Brown, DMD
Lloyd Fujimoto, DDS
Chris Mei, DDS
Michael Palmer, DMD

Design
Rob Warnick

The committee would like to extend its warm appreciation for the support given by the staff members at the Kois Center.

The concept of the coffee table book was developed by Dr. Sam Romano and his wife Terry.

The committee would like to thank Dr. John Kois for his relentless pursuit of excellence and his undying devotion to the education of dentists throughout the world.

Dedication

I would like to take this opportunity to thank all the individuals involved in making this book possible: the membership for their responses to our surveys, the committee members and their wonderful ideas, the Kois Center for their continuous and immediate support, and the photographers who unselfishly allowed us to use their work. I am truly appreciative to all of you. I also want to express my sincere appreciation to Rob Warnick, the graphic designer who made this book so beautiful to view and to Jean Martin and Nancy Hartrick whose tireless drive to get it right pushed me way beyond my own abilities and to a level that I never dreamed was possible. John’s familiar phrase, “None of us is smarter than all of us,” has taken on greater meaning and significance with the completion of this book.

To my children, Austin, Grant, and Carson who have been patient with me these past several months while preparing this book and my mother, Mary whose unconditional love has made all things possible, I am deeply grateful.

Finally, I would like to thank John Kois for seeing things in me that I did not see in myself. Your friendship and devotion are inspiring and humbling.

Sincerely,

Michael Palmer, DMD

Moving Forward.

This book was written to provide information about a special dental practice: the practice of a Kois- trained dentist. And it was written for you, the dental consumer, so you can become familiar with the concepts that your dentist will use to address your dental concerns.

Your dentist will gather all the necessary information to determine what treatment choices you may have. They will show you how the different risk groups fit together and influence each other in your mouth. You will see where your mouth is in the red risk zone and be offered strategies that move each category towards the green, or lower, risk.

No two mouths are identical. Each has unique needs and unique risks for dental disease. Thanks to their training, this dentist has the skill to understand what you need. They will develop a plan for your mouth: a plan that will fit together well, improve your oral health and lessen your risk for future dental problems.

A plan, from start to finish, that is defined by excellence.

How Long Will This Last?

What comes to mind when you hear that something is built to last? Maybe it is the Pyramids where huge stone blocks have endured the hot desert winds for 5,000 years, or perhaps you think of the finely honed walls at Machu Picchu— still standing after 600 years. Both of these famous landmarks were painstakingly constructed by people whose goal was perfection and longevity. They were carefully hand-built using the best tools available at the time in combination with traditional craftsmanship.

How long should my dental work last? While the durability of your dental work is influenced by your individual risk for dental disease in each of the four dental risk groups, your dentistry will last longest and have a much better prognosis when it is expertly created using the finest dental materials.

Your dentist learned these same timeless fundamentals at the Kois Center and employs them to design and craft your dentistry. They have learned techniques to create restorations that will perform for a long time and serve you well. These are restorations that are esthetically pleasing and function in a natural, comfortable manner. Since nothing lasts forever, they have planned ahead for the time when a repair may be needed so you can continue to smile and function for many years.

This is dentistry that is predictably long-lasting—clearly built to last.
  

Smile, Please!

The final area of oral health that your dentist evaluates is dentofacial, which examines smile characteristics and how your teeth look in your face. Kois-trained dentists understand this is the starting point for all esthetic dentistry. Your dentist has been trained to understand the elements that are necessary for a beautiful and healthy smile. Your risk is determined by how much your front teeth show in your happiest smile, the size and shape of the teeth, and their color. Your dentofacial risk is determined by all these components.

The dentofacial diagnosis helps you and your dentist select the appropriate treatment for your individual esthetic needs. Understanding a person’s dentofacial risk makes natural-looking, esthetic results more predictable. The materials that your dentist uses depend on how much tooth and gum are displayed when you smile. Smiles that “show everything” require materials that have a higher esthetic value but may not be the strongest. Those who show less may be able to use a material that is stronger with less need for cosmetic value. Many other decisions are also based on your dentofacial risk: Do the teeth need to first be moved into the right place so that conservative veneers are an option? Is tooth whitening alone enough? Is cosmetic gum surgery needed? Should the front teeth be longer or shorter?

Cosmetic risk reduction

Predictably improving a smile—and therefore reducing dentofacial risk—requires understanding where the teeth must be positioned in the face, how the teeth should be shaped for visual harmony, and if gum tissue contributes to the unfavorable appearance.

Crooked teeth may need to be placed in their proper position. Orthodontics or braces may be
necessary, although in some cases teeth may be restored esthetically to appear in better alignment. Creating harmony and balance between teeth and gum tissue on both sides may necessitate gum tissue alterations.

Your dentist’s training at the Kois Center and understanding of facial esthetics assures that you will receive the most predictable esthetic treatment options available, whether you seek a more youthful smile, cosmetic dentures, or the rebuilding of worn-down teeth.

My Teeth Are Worn!

Function/joint, bite and chewing surfaces

The key question in bite evaluation is “Can this person chew comfortably, with no pain and without tooth wear?” The chewing system is very complex and early signs of disease are subtle. Coordination among the two jaw joints, the chewing muscles and the teeth is necessary for healthy function. The long-term health of this system is dictated by the harmony among these three components and their ability to adapt to changes over time.

When the body cannot accommodate excessive force in the chewing system, the weakest link in the system will be affected. In some instances the jaw joints may become tender and, over time, can result in irreversible changes to the joint. Sometimes the muscles will be overworked, causing muscle pain and headaches. When the teeth are affected, they become loose or worn—teeth that are aging faster than the person.

Unfortunately, it can take years for some signs and symptoms to appear. Tooth wear, in particular, may not be noticed until significant loss of tooth structure has occurred, because the wear may be slow and tolerable in the early stages. If the disharmony can be caught soon enough though, extensive rebuilding treatments may be avoided.

Functional risk reduction

Due to the subtle nature of functional problems, it is essential that this risk be identified and managed at an early stage of the disharmony. A well-trained dentist can determine if the condition occurred in the past or is currently destructive. Once a proper diagnosis has been made, destructive patterns can be altered, often halting the ongoing breakdown.

The cause of the destructive patterns will be identified, then treated or managed to allow both teeth and dentistry to last as long as possible. Kois-trained dentists may use a removable appliance to determine how best to treat the excessive forces. Once the cause is determined, the risk for future wear or pain can be reduced by reshaping the teeth to correct the bite or possibly repositioning the teeth so the jaw joint, muscles, and teeth are in harmony. Final dentistry can then follow, in the newer, more comfortable position.

Some people squeeze, clench, or grind their teeth even with excellent tooth and jaw alignment. For most people with this condition, the greatest damage occurs during sleep. In this situation, risk reduction can be achieved by the use of a nighttime appliance to protect the teeth.

Not Another Cavity!

Biomechanics

Teeth can break down for many reasons. Although everyone is familiar with tooth decay, it is only one part in the determination of biomechanical risk. Decay has traditionally been considered a simple process caused when plaque (a bacterial colony) on the tooth surface was exposed to sugar. Over a period of time acids generated by the plaque weakened the enamel surface, eventually leading to a cavity. Today we realize that this process is much more complex and is actually affected by many other factors. Many prescription medications cause a decrease in salivary flow and dry mouth, which seriously compromises the body’s ability to flush the mouth of food and debris, buffer mouth acids, and remove plaque from the teeth. Some systemic diseases, like bulimia and gastroesophogeal reflux (GERD), increase mouth acidity, as do a wide variety of popular beverages. The acids literally melt away the tooth structure and can quickly and severely destroy the teeth.

The aging of our population and increased life span also increases the risk for tooth breakdown. Exposed root surfaces, more common as we age, are softer than enamel and therefore more cavity prone. Teeth are enduring eight and nine decades of chewing forces, thus making them more subject to wear, fracture and decay. Extensive prior dental work can result in weaker teeth, without adequate tooth structure to support needed restorations.

Individuals who have multiple areas of decay, large fillings, or have lost teeth in the past due to lack of tooth structure are at higher risk for future breakdown. These individuals may need further investigation to eliminate the cause of their susceptibility, including dietary monitoring, salivary flow examination, and acid level monitoring.

Biomechanical Risk Reduction

Once the risk level is known, a Kois-trained dentist will determine why the risk is elevated and develop a plan for eliminating or reducing the factors that may result in continued breakdown. Prevention of future decay may be accomplished by using the most effective forms of fluoride or anti-bacterial rinses. When consumption of sugary foods, soft drinks or other acidic beverages contributes to risk, dietary counseling and modification may be indicated. Management of systemic problems can be coordinated with an individual’s physician.

When decisions are made to restore teeth, the biomechanical risk is minimized by conserving, or keeping, as much tooth structure as possible. Many new materials and techniques can be quite conservative. This minimizes trauma to the nerve inside the tooth, decreasing the chance that the tooth will need root canal treatment in the future. Sometimes, despite the best that dentistry has to offer, a tooth will simply be too weak to predictably restore and is best removed. Fortunately, dental implants offer a reliable replacement for missing teeth as they do not decay and can be part of a strategy to reduce the risk of future problems.

Got Bone?

Periodontal disease: gum and bone support for your teeth

Periodontal disease, commonly referred to as gum disease, is a chronic, often silently destructive disease. It is a complex disease initiated by certain types of bacteria that live below the gums and which, by using modern technology, can actually be identified! These bacteria can trigger a series of events that ultimately lead to the loss of bone around your teeth. If periodontal disease advances to the point where the patient’s teeth get loose or move, tooth loss may be the outcome.

It is very important at regular dental examinations that your mouth be examined for the pres-
ence of periodontal disease. Your dentist needs both accurate X-rays and precise measurements taken around your teeth to determine the level of health and bone support. Kois-trained dentists are passionate about understanding the science and susceptibility behind periodontal disease. They are using scientific breakthroughs in technology to diagnose and treat this disease. Armed with thorough, individual data collection, your dentist can explain whether periodontal disease is present in your mouth and if you are at risk for future periodontal disease. Other factors or risk modifiers like your family history, medical conditions, ethnicity, and smoking can also influence the response to the bacteria in your mouth. Your dentist will make recommendations to treat your disease and follow up with suggestions to help you avoid further breakdown.

The presence of untreated periodontal disease has also been linked to other conditions. Research shows a connection between periodontal disease and an increased risk of coronary artery disease, stroke, diabetes and pre-term, low birth weight babies. Improving your periodontal condition can have a positive affect on several other aspects of your health as well as improving the quality of your life for years to come.

Reducing your risk of gum destruction

Reducing your risk for future gum and bone loss is dependent on controlling the destructive bacteria in your mouth. Recommended treatments can be varied based on the findings by your dentist from their thorough evaluation and will be tailored to meet the needs of individual patients.

Tobacco use greatly increases the risk of periodontal disease; tobacco cessation strategies may be employed to help you quit smoking and thereby improve your prognosis. Consistent monitoring and maintenance of blood sugar will also have a positive effect in patients who have diabetes.

Your dentist has many treatment options, based on scientific evidence, to customize a plan that will help lower your risk of periodontal breakdown and help you maintain periodontal health.

“Those who do not remember the past are condemned to repeat it!” -George Santayana

Past dental disease and treatment is a very important and significant indicator of future dental health and disease concerns. After your dentist completes a thorough examination, they have an excellent understanding of your specific risk for future dental problems. Traditionally, a dentist would treat a cavity or a gum disease issue after it caused a problem or hurt. The standard model was to fix problems after they developed or caused symptoms. A different approach uses a risk assessment strategy.

This method takes you, specifically and individually, into account during the examination process in developing a plan to maintain or improve your dental condition. When you and your dentist understand that you may be likely to have a problem develop, special efforts can be made to focus on preventing that problem or catching it at a very early stage. Just as importantly, knowing that your particular risk of developing a dental disease is very low may help avoid unnecessary dental treatment.

Your dentist’s recommended treatment and preventive regimens will be based on exactly what you need—not some predetermined list that is applied to everyone. This is critical in designing dental care that will help you reduce your risk of future dental problems.

In an effort to clarify where you may be most at risk, the dentist will classify your risk as low, medium or high in each of the four dental risk groups using the dots green, yellow or red. Green is Good. Red is Bad.

What is my risk profile?

Your risk profile is actually a lifetime report card for your dental health. This is a summary of your mouth’s current condition and potential problems. Any area that does not have a green dot would be an area where you could be at risk for further problems.

How does my dentist do that: reduce my risk of future problems?

Your dentist will choose treatments that give you the best chance of keeping your smile, your teeth, and your oral health for your lifetime! Kois Center principles teach dentists how to fix one area of your mouth without harming a different area. For example, when a Kois-trained dentist fixes your smile, they will choose a method that does not harm your gums. When your dentist thinks about risk reduction, it means they are planning for the long term—your lifetime—instead of using techniques that only help your mouth for a few years.
  

The four dental risk groups

Everyone has heard of and recognizes the four food groups and the importance of a well-balanced diet. The Kois Center uses this concept to distinguish the four areas of the mouth that must be evaluated to develop a risk assessment, make a diagnosis and provide treatment recommendations for our patients. The four dental risk groups are Periodontal, Biomechanical, Functional and Dentofacial categories.

Periodontal:
Gums and Bone

Biomechanical:
Tooth Structure

Functional:
Jaw Joints, Muscles, Bite and Chewing Surfaces

Dentofacial:
Smile Characteristics