Laura’s experience with Invisalign. Laura had suffered with headaches due aggravated by misalignment of her teeth. This misalignment resulted in unsightly premature wearing. With Invisalign and bonding Dr. Palmer restored Laura’s beautiful smile.

Joan had lost bone and was unable to secure a denture in place until she had met Dr. Palmer. Dr. Palmer placed mini dental implants which are ideal for areas of very narrow bone. Joan is now very satisfied with the comfort and retention of her denture.

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.