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Blogs Written by Dr. Richard Janis

A Broken Front Tooth and the Psychology of the Smile

by Dr. Richard Janis on 04/30/17


Every dentist deals with emergencies on a regular basis. Some of them involve pain and infection and can affect your general health. Others may have no pain or swelling but may affect psychological health, such as when a front tooth breaks or is missing. Regardless of pain, this is a true dental emergency for most patients and that is what I want to focus on in this blog. When a front tooth breaks, I usually hear from the patient right away. We try to accommodate them as soon as possible because I understand that psychologically, almost no one wants to go around with a broken front tooth.  People feel especially attached to their anterior teeth because it is part of their smile. When it is changed in a negative way, it erodes their confidence. There are studies on the psychology of the smile and how a bad smile will create anxiety and cause people to avoid social events. A broken front tooth can amplify this affect further because it can create a sudden dramatic change in appearance. This may seem obvious to most people and certainly to dentists but over the years the extent of the anxiety this creates has surprised me. People are very self-conscious when something happens to one of their front teeth. I completely understand and would feel the same way.

When my sister was 8 years old, she fell and broke her front upper tooth. It was fixed but when she was a teenager she was in an accident and the tooth got knocked out completely. It was placed back in her mouth and lasted for some years but when she was in her late 20’s it started to loosen and the root resorbed. This was while she was living in another country and she was worried the tooth could fall out at any time. She was told the tooth needed to come out and she had a dental implant placed, which is still there after many years. However, while waiting for the implant to integrate into the bone and be restored, she had a gap where the tooth was and she needed to wear a flipper (a removable retainer with a fake tooth on it) for a period of a year. It worked out okay but created anxiety for her and other patients have told me this as well. My sister was traveling a lot and always worried that the flipper might break or that she would misplace it. My sister as well as other patients of mine have told me that when a front tooth is lost or about to be lost that it is not uncommon to have dreams about it. The good news is that we can almost always do some kind of a repair or fix, even if it is temporary. If a crown comes off, we can usually recement it, at least temporarily. If a tooth breaks, we can bond something on to restore it. If a denture tooth breaks, it can be repaired. If a tooth is beyond repair and needs to be removed, we can try to bond a fake tooth to the adjacent teeth. If this is not possible we can take an impression and make a retainer to fill the space with a fake tooth. This may take a day or so but we would always prioritize this type of treatment. Taking care of a front tooth emergency is one of the most rewarding parts of dentistry.


Is there any advantage to missing a front tooth? I can think of one. I once had a patient in the practice I worked in years ago in San Francisco who was a chess master involved in both online chess games as well as tournaments around the world. Just before a trip to play in a tournament, he broke a tooth. It was just behind his anterior teeth and was very visible when smiling. The tooth was fractured and needed to be removed. He elected not to have it replaced before his trip. I think he felt he didn’t have time and was going to look at treatment options in Eastern Europe, where he was going to play in the tournament. When he came home and I saw him months later, he still had not had it replaced. I talked to him about it. Chess is a game that is of course all skill and no luck. But players do try and get a psychological edge over their opponent. He was a big guy and when he smiled and showed his missing tooth, it gave him a fierce look, perhaps intimidating his opponent. The missing tooth might have helped him win the match!



The Flossing "Controversy"

by Dr. Richard Janis on 11/15/16

Dentistry is not often in the news but several months ago there were some stories about the lack of evidence for the benefits of flossing. It was reported that the recommendation to floss was dropped from the U.S. Dietary Guidelines this year, after having been recommended since 1979. An enterprising reporter wrote to the government and was told that there was just not much evidence for the benefits of flossing and that is why it was dropped.

Like everyone else, I was surprised at this as I had always accepted the benefits. The stories said there was no research showing the benefits of flossing. I don’t remember reading about any research when I was in dental school but it is just common sense that cleaning between the teeth would reduce the incidence of dental disease. My observations are just anecdotal, both with my personal experience and what I have seen in 25 years of dental practice. My personal experience is that I have a small cavity between two teeth in my mouth that has not progressed for over 25 years. I believe it is due to daily flossing. My personal observations are that my patients who floss regularly tend to have fewer cavities and less gum disease. 

I have had a number of patients ask me about the stories they had seen and what I thought of this issue. Of course, I continue to recommend flossing. You would have a hard time finding any dental professional saying that flossing is not beneficial, regardless of a lack of research.

I looked a little deeper into this topic and it turns out that there really is not a lot of research out there. There are short term studies showing that flossing reduces mild gum disease but no long-term data. Most of the studies are funded by industry and so there is more chance of bias. The studies that are out there do show that flossing results in a lowering of plaque. But there is no hard evidence that flossing prevents periodontitis, the most severe form of gum disease.

So the consensus is that the scientific evidence is weak, meaning in this case that there is just no proof that flossing helps prevent dental disease. One of the problems with doing large scale research of health care issues of this kind is that they must rely on self reporting of behavior, which is not always accurate.  Lack of research does not mean something does not work, however.  I recently received a newsletter about this issue from the National Institutes of Health, which is a part of the U.S. Department of Health and Human Services. I am going to quote what one of the researchers said: “The fact that there hasn’t been a huge population-based study of flossing doesn’t mean that flossing is not effective. It simply suggests that large studies are difficult and expensive to conduct when you’re monitoring health behaviors of any kind.”

The newsletter goes on to say that even though scientific evidence is lacking, there isn’t any harm in flossing and it is low cost so why not do it daily? I agree completely. I also believe that everyone who works in a dental office, having seen the benefits of flossing, would agree with that as well and that is enough for me to continue recommending it.

A Personal Project Completed

by Dr. Richard Janis on 07/25/16

I recently had the opportunity to complete a project that I started 7 years ago, when my mother passed away. My mother died in 2009 after a long battle with kidney cancer. She was treated for the last few years of her life at the City of Hope in Southern California, a wonderful center for cancer treatment.

Although my mother taught elementary school for over 30 years, her passion in life was art. She loved many forms of art including painting, drawing, sculpture, and ceramics and she studied all of them but was chiefly a painter of abstract art. Her art career spanned over 40 years, which included earning a master's degree and some time teaching art. She showed her work in galleries and art shows, mainly in Southern California, where she developed a good following of people who really admired her talent with colors and shapes. I have several of her paintings at my office and get many compliments on them. She was still doing art up until 6 months before she passed away.

Although my mother did sell her art, she was prolific and after she was gone we still had over 130 of her paintings, some sculptures, and hundreds of drawings and prints. My sisters and I had many pieces of her art so the question was: What should we do with the remaining art?


The City of Hope had been very wonderful to my mother and I decided to see if I could sell some of her art and donate all of the proceeds to them. The goal was to get her art out there for people to enjoy and at the same time raise some money for kidney cancer research. This was an ambitious project for me, a non-artist. I really did not know much about the art world, other than what I had learned from my mother. I had helped her at some art shows and got to learn a little about it that way.

The first thing I did was to get all of her art into storage in Southern California. I rented a U-Haul and my nephew helped me move all of the art. My mother had a website for her art but it didn’t have many of her paintings on it so I hired an art student to help me photograph the remaining art and I uploaded the photos of the remaining paintings. I contacted the City of Hope and they took some pieces for a fund-raising auction and I gave a painting to my mother’s oncologist and one to the nurse who cared for her. I wrote to auction houses, galleries and art dealers throughout Southern California. Some of the art dealers and gallery owners did like her work but they could not commit to anything. They explained to me that the art world was getting increasingly competitive and that they were constantly being inundated with requests from artists trying to sell and market their work. I realized this was going to be difficult. I constantly asked for advice and what I was told was that the best avenue for selling my mother’s art was to contact the people who had previously bought from her.
My mother had a mailing list of over 200 people who had bought her work or talked with her at one of her shows. I composed a letter to all of them, telling them of my mother’s death and explaining the project I was working on. I provided the link to her website and offered to deliver the paintings personally to anywhere in Southern California. I received many very nice letters and e-mails back. People told me stories about meeting my mother at art shows and it was very heartwarming. A number of people wanted to buy her work and I initially sold about 30 paintings this way, delivering them to the Los Angeles and San Diego areas. It was a fun experience for me to walk into people’s homes and see my mother’s art on their walls. I got to see how much people admired her and her art.
I continued this project for some years, always working on it when I made trips to Southern California. I continued to contact people from her mailing list who asked me to stay in touch and I was able to sell some more paintings this way. I wrote to hospitals, banks, cafes, hotels (anywhere I would see art) and asked them if they would display my mother’s art. Some expressed interest but told me that they were inundated with requests and had a waiting list of artist’s work to display. 

A few years ago I decided to donate her remaining art. I had exhausted my best avenues for selling it and I had raised thousands of dollars for research at the City of Hope. I wrote to art departments at colleges and universities and asked for advice. Most had no ideas but one suggested I try health care facilities and senior centers so I wrote to some in the Pasadena area, where the art was being stored. I was able to donate some paintings that way.  I would sometimes list the paintings for sale on craigslist before one of my trips and I sold a few that way.

Recently I realized that I still had around 60 paintings left as well as many drawings and prints. I wanted to complete this project. Listing the paintings for sale on craigslist had never brought about a big response. This time I decided to do something different. I posted an ad on the "free" section of craigslist. I was a little wary of doing this as I wanted my mother's art to go to people that would appreciate it. The "free" section is filled with things like old couches and computer monitors that people want to get rid of. Would I find people there that would appreciate original abstract art of the type my mother did?  

I placed the ad, showing just one painting and saying that I had some beautiful, original art to donate to those who would appreciate it. The response to just this one painting stunned me. Within just 2 days, over 50 people responded to my ad, many asking if they could come right away to see the art. I wrote back to everyone and sent them a link to the website, where they could see everything. This generated even more interest and I received many more e-mails about how much people admired my mother's art. I had a trip planned to Southern California where I could only be at the storage unit for one day and I set up some time for people to look at my mother's paintings. 

When I arrived in Pasadena, I first set aside time for a few people that had previously purchased my mother’s art. One woman came all the way from Phoenix and another from San Diego to choose some of my mother’s art.  I also gave some pieces to the director of a health care facility near Pasadena. After that, I met with people who had contacted me regarding the ad I placed. There were 15-20 people that came. One was a woman who wanted some paintings for a fundraiser for her father, who had just been diagnosed with cancer. Others came who had just moved into new homes and were looking for some original art. One man was an art instructor who wanted to use some of my mother’s art for his classes. What they all had in common was that they loved and appreciated my mother’s work. The people who came were of all ages and what I learned is that there is a real hunger for original art, even though many people cannot afford it. By the end of the day, all of the art was gone and some were disappointed that there was not more. I had found a place for all of my mother’s art and my project was completed.


I asked people to send me photos of my mother’s art when they had it up and many have done so.  Everyone who came on that day was very grateful for this donation of art. What they didn’t understand was that I was very grateful as well. Before my mother passed away, not wanting to burden me, she had told me to toss out her art after she was gone. I told her that I would not do that. Over 7 years I was able to sell and donate her remaining work to people who really appreciate it and I am very happy that I was able to end the project this way.

Dental Implants

by Dr. Richard Janis on 03/07/16

 Several years ago I wrote a blog about dental implants that was titled “Implants: The Game Changer in Dentistry.” I wanted to write a new blog about this because it is perhaps the fastest growing area of dentistry and one of the topics my office receives the most questions about. First, the reason implants are considered a game changer is because of how they have caused a dramatic change in the profession and how much they can improve patients’ lives. They can be compared to other advancements that have changed dentistry profoundly, things like anesthesia, fluoride, and x-rays.  Those innovations existed long before I entered the profession and game changer really describes them because it is hard to imagine dentistry without them.

The same can now be said with regard to implants. I learned about implants in school but almost no one, including the instructors, was doing them. In my first years of practice, I only restored a handful of implants but in the last 10 years, I have restored hundreds, including both large and small cases. Years ago most of my patients had heard little about dental implants and most did not know anyone that had one. Now it is rare that I find a patient who doesn’t know someone who has had a dental implant. In my own family, my father had dental implants even after the age of 80 and my younger sister had an implant in her 20s due to a childhood accident which caused her to lose a front tooth at a young age.

What are implants?  Dental implants are metal rods or posts made of titanium that are surgically placed in the bone.  Over a period of months they integrate into the jawbone and then they can be used to support a crown, bridge, or a denture.  The ability to integrate into bone is the development that makes them a game changer because now when a tooth is lost, there is a replacement that feels and functions like a natural tooth. When I ask one of my patients with an implant how their implant is doing, the response I usually get is, “I no longer even know it is there.”


Why are implants better than other alternatives for missing teeth? If a single tooth is lost, an implant can be used and when it becomes fused to the bone, a crown can be placed over it. The adjacent teeth will not be touched. A fixed bridge is also a way to replace a missing tooth but it involves grinding down adjacent teeth to support a missing tooth.  Those teeth used to support a bridge are now more susceptible to needing other treatment, including root canals. Before implants were common, I was doing many bridges every year. Now I only do them on rare occasions because an implant is usually better treatment. In replacing a single missing tooth, an implant is taking a one tooth problem and leaving it as a one tooth problem. A bridge is solving a one tooth problem but potentially creating a three teeth problem. Since implants are made of titanium, they can never decay. However, they are susceptible to periodontal disease just as natural teeth are.

Implants can also be used to support a denture or partial denture, providing much greater stability and retention. This procedure has, in my opinion, provided greater satisfaction for my patients than any other treatment I have done.

What about costs? Implant are not inexpensive and certainly cost more than other procedures. If an implant is done to replace a single tooth, the cost will generally be about 25-30% higher than the cost of a bridge.  However, even with the greater expense, I have yet to have a patient that regretted having a dental implant done.  It is the best procedure dentistry has for replacing a missing tooth and it is almost always the treatment that I recommend.






Dental Insurance

by Dr. Richard Janis on 11/10/15

Dentist ConcordWhile not the most interesting topic, our office gets enough questions about dental insurance that I wanted to write a blog about it. Insurance issues are confusing to patients and are among the most common questions we do receive. I am not an expert on the subject but my office manager, Melissa, is an expert and I consulted her about the most common concerns our patients have. She is always available for any questions from patients about insurance.

I do realize that dental treatment can be expensive and the lack of insurance is a main reason we hear about why people avoid going to the dentist (aside from the fact that they just don’t like going to the dentist). But lack of insurance should not keep people from the dentist. I understand that some people may be hesitant about beginning a large amount of dental work if they have no coverage. Most dental problems, however, are preventable and routine dental cleanings and exams are not expensive relative to the problems they help to prevent. In fact, routine dental cleanings and exams may be considered ”insurance” whether paid for out of pocket or not because they are the best way to prevent dental problems and large dental bills.                                                               Dentist Concord Ca

Dental insurance is not truly insurance and is not usually meant to cover all dental treatment costs, although some plans will cover preventive care at 100%. It is more of a defined benefit plan, not designed as much to cover major problems but more routine maintenance issues. In that respect, it differs from most other types of insurance, such as property, auto, and health, which are generally meant to protect you from catastrophic loss.  People buy property insurance because their house could burn down but they generally get dental insurance because they want help with dental bills that are not necessarily major expenses. Who pays for dental insurance premiums? Often it is an employer. If you have to pay for the coverage yourself outside of your work, it may or may not be worth the cost. It is important to look at what your premiums and copays are versus what you will pay for dental treatment.  It may be better to just pay out of pocket as there are usually not good individual plans but every situation is different based on premiums, copays, and what is covered by the insurance plan.

What about HMOs and PPOs? HMOs are a type of insurance that may appear to provide better coverage but have more exclusions and restrictions as you are not covered for dental treatment outside of a list of providers who accept the HMO type of insurance. PPOs are less restrictive than HMOs but also may limit you in your choice of providers based on the plan. They may also allow you to see any provider but in some cases will provide less benefits with an out of network provider than someone who is in network.

What about someone without dental insurance?  What options do they have? Many offices, including mine, offer a dental benefit plan that covers preventive care and offers a discount on dental treatment for those who join.  As far as obtaining an individual insurance plan, there are some plans but most do not provide good coverage and often the patient is better off paying out of pocket.
Although my view is admittedly biased as a health care provider, I strongly feel that even those without dental coverage should continue to seek preventive dental care and treat small problems before they become large ones.  Since so many dental problems are preventable that, in essence, is the best “insurance”.


The Dentist Goes To The Dentist

by Dr. Richard Janis on 08/03/15

Dentist Concord CaI had a gum tissue graft surgery done on me last fall. It was the first dental treatment I had needed for a while. It was done by a colleague of mine, Dr. Stephen Reid, an excellent periodontist that I have known for a long time.  The need for the treatment was that I have a lot of recession and the strong tissue needed to prevent further recession was missing on some teeth.  The procedure involved removing some tissue from the palate and placing it next to those teeth that have recession.  Dr. Reid did a couple of grafts on me more than 10 years ago and those have been very successful in preventing further recession and bone loss.

Not many people enjoy going to the dentist and I can't say that I am any different, especially if it involves palatal injections and palatal surgery.  But the procedure went very well and I had minimal pain.  My treatment caused me to reflect on how we are influenced by our experiences and how my experiences have affected my philosophy of practice as a dentist.

Growing up, I had no bad dental experiences (if I had, I am sure I would not have become a dentist).  My oral hygiene as a kid wasn't too great and I ate a lot of sweets. I had a few cavities but for the most part I was lucky and had little decay.  I went to the dentist regularly and had fluoride treatments.  How do I think luck played a role? Well, my teeth were straight and didn't have a lot of grooves in them, making them easier to clean and less prone to decay. When I got to dental school, we did tests for bacteria in our saliva and I was found to have little of the main bacteria known to cause decay. To me, that was another explanation for my lack of decay.

As an adult, my oral hygiene has been very good, at least since entering dental school.  Just before entering dental school, I went to a dentist, who found a cavity between my teeth.  He said it was small and was only in the enamel (the outer layer of the tooth).  He advised me to floss daily and said that if it progressed, the cavity would need to be filled.  Well, since that time, I have flossed nearly every day.  That tooth has been x-rayed many times and the cavity has not gotten larger, even though it has been over 25 years!  Small cavities between the teeth can become arrested and remineralize, if there is good oral hygiene.  I knew this and learned it in dental school but nothing is more powerful than your own experience, which has influenced me in the way I practice dentistry, causing me to be very conservative in my approach.

What about the recession and bone loss I have experienced?  Why didn't good oral hygiene prevent them? Dr. Reid believes that I am one of the people susceptible to the bacteria that can cause bone loss.  The treatment recommendation has been regular cleanings, good oral hygiene, antimicrobial rinses, and gum graft surgeries to prevent further recession. This has worked for me over the last 13+ years that I have seen Dr. Reid. My first grafts are over 12 years old and have prevented further recession.

Dentistry, like medicine, is not an exact science.  Sometimes one treatment that works on one person will not work well for another.  I have seen a lot of things that have surprised me.  I have seen people move here from other countries as adults that have never seen a dentist  in their life and they have not had  a single cavity.  This is likely due to the lack of sugar in their diet when growing up.  I have also seen patients come every 3 months to the dentist only to continue to have decay, even when controlling their diet.  There are often multiple factors involved in causing dental problems, like teeth grinding or dry mouth caused by medications.  For the most part, however, we know how to control dental disease.  I wrote about some of this a few years ago in a blog I called “How to keep your dental bills low”. The last advice on the blog, visit your dentist and hygienist regularly, does sound self-serving but it is one thing guaranteed to lower your dental costs and dental problems over time.


The Cracked Tooth

by Dr. Richard Janis on 03/17/15

I am writing this blog because I have noticed an increase in the number of fractured and cracked teeth in my practice over the last 6-7 years as compared to the previous 15 or so years. Why is this? I don’t know for sure but there are likely multiple reasons for this, including old fillings, the type of restoration in the tooth, and teeth grinding- which I believe is the major cause of the increase.

 

I have researched this, even talking to a colleague of mine who is a root canal specialist.  Root canal specialists diagnose more fractures than other dentists as they utilize a microscope and have more advanced training. He says that everyone is seeing more fractures but the reasons for them are not documented in the research yet. It is becoming so prevalent that there is even a lecture at one of the dental meetings entitled, “Cracked Teeth. A Modern Epidemic?”

 

When teeth break, like in the below on the left, it is easy for us to see and make a diagnosis. However, cracked teeth without obvious signs are hard for even

experienced dentists to diagnose and it is a perplexing issue for many. I am talking about situations like the one in the photo on the right, where the patient has a shallow filling and no evidence of decay or fracture on the x-ray.

When I removed this filling due to pain, a fracture was seen and a root canal was needed because the pain did not go away, indicating a communication with the nerve of the tooth.  I suspected this beforehand because there was a small filling only and no decay. What else could be causing the pain? The diagnosis is often made by a process of elimination. X-rays rarely show a fracture. 

 

Actually, there are some other factors that could be causing the pain, including headaches, joint problems, and sinus issues. This is what makes the diagnosis difficult. Early diagnosis will often result in a better prognosis for the tooth. Many fractured teeth end up needing root canals or extraction. Sometimes doing a crown will prevent this but it is hard to know when to do one. We want to be sure that the pain is not arising from another source, such as mentioned above. Craze lines on the chewing surfaces of teeth can often be mistaken for other, more serious types of cracks and it would be a mistake to initiate treatment on all teeth with these as it would result in unnecessary treatment much of the time. I would want more evidence of a problem before beginning treatment.

 

What do I look for?  Well, most commonly a patient will report pain upon chewing, especially with tough, grainy foods and sharp pain when something cold touches the tooth.  Cracked teeth may have symptoms that range from slight to severe pain. Some people point the finger at old silver fillings, which corrode and are often thought to cause teeth to break but that is controversial because I have seen fillings last for more than 30 years without causing teeth to crack. On the other hand, most of the broken teeth that I see have an old silver filling in them. Removing an existing filling always results in the loss of additional tooth structure so you want to have a good reason for doing it.

 

These are some things that I can conclude about cracked teeth, along with preventive measures: 

 

1) If a tooth has a filling (especially an old one) and there is pain that is persistent, it is best to remove the filling and evaluate even if the filling looks fine in the clinical exam and on the x-ray. Sometimes we will find just a little decay and we can replace the filling and that is all that is needed. Sometimes I will see a crack that goes deep into the tooth, indicating the need for a root canal and crown. In the worst case scenario, the fracture extends down the root and the tooth will need to be removed.

 

2) Early treatment leads to the best prognosis for the tooth. If a tooth breaks, it should be evaluated fairly soon. Decay will not happen rapidly but if there is a crack in the tooth, it would be best to protect the tooth with a new restoration, possibly a crown.

 

3) If there is persistent pain on a tooth, particularly upon biting, it should be looked at. It may be something else, like a sinus infection, (especially if the patient recently had a cold) or a jaw joint problem. If the pain is mild, sometimes we can monitor the tooth. The nerve may become inflamed, but that inflammation may be reversible and the pain may go away. A fracture into the nerve will result in pain that will not subside, however, and  treatment will be necessary.

 

4) The most likely cause of an increase in tooth fractures is grinding of the teeth, thought to be caused by stress. People predominantly grind their teeth at night and I have witnessed how hard people can be on their teeth. A nightguard is recommended in those cases. Those who grind their teeth are more likely to create cracks in them but a nightguard can prevent the need for more extensive and expensive treatment, such as a root canal and crown, or even an extraction and implant. 

 

5) Evaluating a possible cracked tooth can be a challenge for any dentist. Other conditions can mimic tooth pain and it is important to be aware of that. This is an area in which there is an ovelap of medicine and dentistry. Many patients end up seeing both their physician and their dentist in order to find the source of their pain.  


This tooth below had no decay or filling but ended up with a fracture that extended down the root and needed to be extracted.

  

Power Brushes. Are They Really Better?

by Dr. Richard Janis on 11/04/14

  

Many patients have asked me over the years which power toothbrush I prefer or if I think power brushes are better than using a manual brush. It is a very important question because as most dental disease is preventable, if a power brush is more effective at removing plaque, then this should lead to less decay and less periodontal disease. While I generally have seen evidence of improved oral hygiene with the use of power brushes in my practice, I really wanted to review the research before writing a blog about this subject. The two main power brushes are the Oral-B, which uses a rotating-oscillating technology, and the Sonicare, which uses a sonic technology.

As part of my research, I contacted some hygienists who are very familiar with the studies done on power brushes. I received some valuable information and links to some very good research studies.  In addition, I looked at major dental websites to gather more information. Some of the research is sponsored by dental manufacturers and I didn’t want to rely on that alone. Other studies were done by independent organizations and universities.

What I found was interesting. Some studies showed that one particular power brush was superior to another power brush. Most studies I looked at did show that power brushes in general were more effective than manual brushes at reducing plaque and gingivitis. All of this I did expect to see. But I did find one study that claimed no difference between a power and manual brush. This study concluded that educating patients about proper brushing technique is the most important factor in improving oral hygiene, not the type of brush used. But that study is 10 years old and much has changed in the design and features of power brushes since that time.

One of the things I always have wondered about is whether power brushes are as safe as manual brushes.  In other words, since so many people have recession of the gums as well as abrasion of the roots, would a power brush cause more damage to the gums and roots of the teeth?  The research shows that they do not.

There are some conclusions that I have made from looking at the research and my observations from over 20 years in practice:

1) Power brushes have been shown in multiple studies to be more efficient in the reduction of plaque and gingivitis when compared to manual brushes. For patients with dexterity issues, especially arthritis, the evidence is even more clear that a power brush works best.  A patient merely has to activate it and move it through the mouth and it will do the rest of the work.

2) Patients brush longer when using a power brush.  This is because most have a timer, which works to get people to brush for the recommended time of 2 minutes, which is needed to do adequate plaque removal.

3) Some brushes like the Oral-B have a pressure sensor, which lights up when too much brushing force is used. This is an excellent feature because it prevents damage to the gum tissue and roots.

4) Some patients prefer a manual brush. They find that the vibrations of a power brush can lead to sensitivity for them, something that goes away when switching to a manual brush. This is rare and I found no research on this subject.  A few of my patients have experienced this, however.

I personally prefer the Oral-B to the Sonicare because of the pressure sensor, which helps prevent over aggressive brushing, a very common problem.  But they are both excellent brushes and I would recommend just about any power brush that has a timer over a manual brush because it leads to longer brushing times, which in turn results in better dental health. 


What it means to do conservative dentistry

by Dr. Richard Janis on 07/05/14

Dentistry in the last 15 years has experienced nothing short of a revolution in terms of technology, materials,  and restorative options.  Some of it is not apparent to the patient, such as technologies used in the dental lab and bonding agents and materials that are much stronger.  What this has allowed, however, is for us to be able to be much more conservative in many situations.

One thing I noticed when I first got to dental school (and probably every other dental student did as well) was how much tooth structure needed to be removed in order to restore teeth.  You can see this in the first photo on the top right.  It truly amazed me that for even a small cavity, a large amount of tooth structure would often need to be removed.  This is because most of the fillings we were using didn’t bond to the tooth and so mechanical retention was needed.  That is something that has changed.  (See the photos below of the tooth colored filling with only minimal tooth structure removed.)

Even more surprising to me was when a crown was needed.  Posterior teeth have multiple cusps (peaks on the teeth that are used for chewing).  When one breaks, a filling is no longer a good option as it will not be strong enough to support the tooth.  So even when only one cusp would break on a molar tooth (which generally has four cusps), the whole tooth would need to be trimmed down for a crown, if an esthetic option was desired.  Of course, a conservative gold option has always been available but most people want something more cosmetic. 

A full crown often would seem to me to be too aggressive, especially when only a small part of the tooth would be broken. More tooth removal leads to greater risk of root canals or other dental problems.  But until fairly recently, we had no other good esthetic options.  Now we do, with partial crowns, porcelain onlays, and veneers.  These rely a lot more on bonding than mechanical retention.  But with newer, stronger materials and better bonding systems we can preserve a lot more of the tooth than we could before.  The photos above and below compare a full crown with a porcelain onlay (which only replaces the missing, broken or decayed portion of the tooth).

Another area that allows us to be more conservative is the use of dental implants when a tooth is lost.  I wrote a blog about this a while back (Implants: The Game Changer In Dentistry).  If a tooth is lost, an implant can be used to replace it and this remains a one tooth problem.  A bridge is also an option but it involves grinding down adjacent teeth and takes a one tooth problem and makes it a three tooth problem.  When adjacent teeth are involved and are trimmed down, they now become more at risk for other dental problems.  A bridge is definitely not a conservative option and I rarely recommend it over an implant.

Sometimes being aggressive with a treatment is needed, such as when more tooth structure needs to be removed for esthetic reasons or bonding is not possible in an area of the mouth.  But in most cases, it is best for the patient when we try to be conservative. Thanks to the advances in dentistry, this is now something we can achieve.

 

My Time At CDA Cares

by Dr. Richard Janis on 02/26/14

 In December, I participated in a dental charity event run by the California Dental Association.  As is often the case in these types of events, it was extremely rewarding.

CDA Cares is a charity event put on by the California Dental Association.  It was started a few years ago and is usually held twice a year, once in Northern California and once inSouthern California.   During the event, dentists, hygienists, dental assistants, lab technicians, and other volunteers provide free dental care to those in need over a two day period. Over the years, I have been involved with other charity events but nothing as well organized and productive as this one.  Obviously, as a dentist, I am aware of the tremendous unmet need for dental care and I was glad to have the opportunity to participate in this latest event.
dentist
The event was held at the Del Mar Fairgrounds north of San Diego. Over 1,700 volunteers, including 900 dental professionals, were involved in CDA Cares and provided care for over 2,200 patients over a two-day period.   It was divided into departments for oral surgery (the busiest section), fillings, preventive counseling, and a section for partials and dentures.  I am not sure how people signed up for care but there was a long line of people lined up the night before the event was to begin.  I helped out in the fillings and denture sections and also with Spanish translation.  The patients came from very diverse backgrounds.  That became apparent to me as soon as I arrived as they put out a call for a Somali translator (I don’t know if they ever found one).  Although oral surgery was the busiest, I feel the need was greatest in the area of preventive counseling and oral hygiene as so much of dental disease is preventable.

The energy of all the volunteers was fantastic and I met some great people.  The people I was able to treat were all very grateful.  They were mostly people who found themselves in unfortunate circumstances and unable to afford dentistry.  We made a partial denture for a man who worked in sales and lost his front tooth, which made it impossible for him to get another job.  We fixed two lower front teeth for a young lady who was unable to afford to fix them after breaking them during a grand mal epileptic seizure.

It was a great event, with several large rooms filled with dentists and other providers all working on patients.  Everybody had the same goal, which was to help as many people as possible and this was a wonderful experience.

Like most dentists, I am aware there is a problem for many people in obtaining dental care.  It can be costly and many in need are unable to afford it.  I don’t really have the answers as dental education and training are so expensive and the costs of a dental practice are so high.  But I know that events like CDA Cares can be a small part of the answer and I look forward to participating in future events.

Is This Tooth Worth Saving?

by Dr. Richard Janis on 11/06/13

A common occurrence in my office is for someone to show up with a broken tooth. A question that I get asked a lot when a tooth breaks badly is, “Can this tooth be saved”? The answer is not always so simple. I have been doing this for over 20 years and my views have changed with the advent of predictable implant treatment. A better question is, “Is this tooth worth saving”? The answer is, “It depends”. Often, a tooth that is badly broken down can be saved with a root canal, crown build-up, and a crown. If the tooth has broken far below the gumline, then crown lengthening by a periodontist may also be needed to expose more tooth structure to support the crown.

However, another and often better option exists, and that is removal of the tooth and placement of an implant and crown. Of course, extraction and a bridge is also an option but for the purposes of this blog, I will discuss the best option, an implant and crown. A dental implant is a device made of titanium that is placed in the bone to replace the missing root. A crown is then placed on top of it. In the case where a tooth is badly broken down, this option will have a better prognosis. A root canal, build-up, and crown can be a good option and I have done many of them but I have also seen failures. Sometimes all of that is done and a few years down the road the patient comes in with a crown and tooth broken and not restorable. An extraction now has to be done and that, of course, is very frustrating and it has caused me to think long and hard about what is the best investment for my patient. So when is a tooth that is broken down worth saving? I believe if there is a good implant option, then a tooth is only worth saving if it has a better than fair prognosis. In other words, a good prognosis or better. How do I decide on the prognosis? Well, of course only time will tell if the decision was a good one but it is experience that allows me to decide.

I have been in my present office for almost 8 years and worked at the same place previously for over 15 years so that has given me the advantage of following-up and seeing what works and what doesn’t. A root canal, build-up and crown with periodontal surgery are sometimes what we might call “heroic measures” to save a tooth. Historically, that is what was done routinely, even if the prognosis was fair, because that was all we had other than extraction. Implants have brought a paradigm shift in dentistry and I rarely recommend heroic measures anymore. Dental implants are predictable and have a very good prognosis and that is why they are often the better option. Of course, there are exceptions, such as when the patient is unable to have an implant for medical reasons or if the tooth that breaks already has a root canal and the patient would be better served by just putting a crown on rather than having an extraction and an implant.

And what about the cost? A root canal, build-up of the tooth, and a crown can cost about 30% less than an extraction and an implant but if periodontal surgery is involved, the cost would be only 10-15% less. So cost is a consideration but I believe that the long-term prognosis should be the bigger consideration. An implant has a very good long-term prognosis. I am fond of saying that I have never had a patient regret the investment of having an implant done. I know that my patients are thinking of their improved quality of life and the long-term prognosis when they tell me that.

My Dad

by Dr. Richard Janis on 09/23/13

My Dad


My dad passed away peacefully in his sleep last month at the age of 87.  He had a great influence on my life and I miss him very much.  He was a veteran of World War II, fought in the Battle of Okinawa, and was training to be involved in the invasion of Japan, when the atomic bomb was dropped and the war ended.  He didn’t talk a whole lot about his experiences in the war but he always told me that he was certain he would have been killed in an invasion.  It made me realize how strongly random events can influence things, as I probably wouldn’t be here if an invasion had taken place.

When I was growing up, we did a lot of great things together, one of which was to go to a lot of baseball games as we shared a passion for the game.  My dad just missed seeing Babe Ruth but he saw all of the other great players of his era.  We attended hundreds of games together and it was always fun and interesting to talk with him about different aspects of the game.

We also went to a lot of great museums.  My dad would take me to museums of natural history, history, and science and it sparked my interest in those subjects.

My dad liked to take me to see movies and we saw some great ones, some that had a big impact on me.  One that I will never forget is a movie that he took me to when I was a teenager, “The Man Who Would Be King”, which is still my favorite.  He knew that it was a movie that would inspire me due to the great story of adventure.  For many years we would reminisce about that film and how much we enjoyed it.

My dad read to me when I was very young and reading is something I still love to do.  He got me interested in writers like Jack London and Mark Twain (still two of my favorites) and great adventure stories like “Mutiny on the Bounty.”  History, especially American history, was a passion that we both shared.  He was always giving me articles or books to read about the Civil War, World War II, or other interesting events in American history that we could talk about. 

My dad was a man of deep faith and became very spiritually oriented later in life.  Judaism became very important to him and gave him great comfort, direction, and a sense of peace.

Some years ago, my dad gave me a birthday card.  It was very simple and just said, “To the best of sons.”  I was lucky to have him as a dad.  I was inspired by his desire to be a perpetual student and always keep learning.  In the last year of his life, he read several books on history, which he recommended to me.  I plan on reading them and in my mind I’ll imagine talking to him and sharing ideas with him as we would always do.  I’ll imagine talking to him about baseball when I watch a game.  I miss him and there is an emptiness that is difficult to describe.  I know my dad would want me to keep learning new things and grow as a person.  This is what I intend to do.

 

 

 

 

 

 

 

 

 

 

 

Sleep Disordered Breathing

by Dr. Richard Janis on 09/16/13

Sleep disordered breathing (which includes snoring and obstructive sleep apnea among other more complex conditions) is very common and is estimated to affect more than 25 million Americans. Obstructive sleep apnea is a debilitating condition that is defined by episodes of stoppage of breathing or shallow breathing throughout the night. It is a situation in which air flow stops because the entire upper airway is blocked. Snoring is a condition that develops when air passes through an airway that is too small to allow unobstructed flow and it is often accompanied by shallow breathing that is tied to obstructive sleep apnea as well. In some cases, snoring presents without sleep apnea.

 

Snoring and sleep apnea are caused by the same thing: a narrow airway that collapses. Snoring may often lead to sleep apnea and can be a symptom. In fact, it is the most common symptom, followed by excessive daytime sleepiness and high blood pressure. Someone who snores should be evaluated for sleep apnea. What is the big deal about sleep apnea? Sleep apnea results in many episodes of breathing cessation at night. This greatly increases the risk of development of high blood pressure , heart attack and stroke and increases the risk of death if left untreated. The good news is that with treatment these risks decrease. When someone dies, sleep apnea is almost never listed as the cause of death, although it can be the underlying reason as severe derangements in our nervous system controls due to sleep apnea and lack of oxygen can cause an unstable heart rhythm and/or stoppage of the heart rhythm that can be lethal . It increases the risk of heart attack and stroke, more than any other factor, including smoking. It leads to daytime tiredness, which results in more accidents and reduced work production.

In short, it is a very serious problem.

What causes sleep apnea? Weight gain is one factor. Your genetics play a role and anatomy of the face and oral cavity are other factors that can contribute to the development of sleep apnea. Childhood obesity and nasal allergies can cause anatomical changes in a school age child or teenager that result in sleep apnea as an adult and need to be addressed. There are also many other factors that can cause an obstructed upper airway, both medically and dentally related. These are best discussed with a physician and dentist who work in the area of sleep disordered breathing. What are treatments for sleep apnea and snoring? For mild and sometimes moderate cases, a dental appliance can be a very good option. It opens the bite and moves the jaw forward, resulting in a more open airway. Palatal expansion, particularly in teenagers, can result in benefits beyond orthodontic issues. It can greatly reduce the risk of developing sleep apnea. For severe cases, the gold standard is a C-PAP (Continuous Positive Airway Pressure) machine. This works by pushing continuous air pressure through the nose and into the throat. This pushes back the tongue and other tissues and opens the airway. The C-PAP machine works wells but some patients find it difficult to use. In those cases, a dental appliance that opens the airway is a good alternative. Surgical options also can be used in rare circumstances, mainly in people with certain facial abnormalities.

Anyone suffering from sleep disordered breathing should be evaluated by a sleep specialist. Getting treatment for sleep apnea will improve your health, life expectancy, relationships, and work productivity.

Oral Appliance

 

CPAP

Implants: The Game Changer in Dentistry

by Dr. Richard Janis on 09/16/13

“A game changer.” “One of the best things to ever happen in dentistry.” I have been to many dental courses about implants and these are some of the things I have heard from leaders in the field about dental implants. I tend to agree. I have been practicing for over 20 years and implants more than anything else have allowed us to improve the quality of our patients’ lives.

What are implants? Simply put, they are a titanium rod or post that is surgically placed in the bone. Over a period of months, the implant integrates into the bone, a truly revolutionary development. After the integration, an abutment or post and then a crown are placed on the implant and this is stable. The crown will look just like any other crown and most patients say that they function so normally that they lose awareness that they even have an implant.

Implants are the best way to replace a missing tooth and their advantages are numerous. They can never decay as they are made of titanium. They can restore chewing function without damaging the teeth next to them. A bridge is also a way to replace a missing tooth by grinding down the adjacent teeth and creating a framework that will include a replacement for the missing tooth. However, this is in most cases not desirable as the adjacent teeth become more susceptible to decay, the potential need for a root canal, and periodontal disease. The beauty of an implant is that the adjacent teeth are not touched at all. Although implants cannot decay, they can develop periodontal disease and patients are cautioned to maintain their normal oral hygiene with them.

To replace a missing tooth, an implant costs about 25-30% more than a 3 unit bridge. Insurance will sometimes pay for part of the implant. Insurance companies are starting to see that it is cost effective to pay for an implant because there is no risk of harming the adjacent teeth, unlike a bridge, which may lead to more costly treatment later. Of course, if more implants are needed, the cost differential between them and a bridge goes up but I would still recommend implants. I have yet to have a patient regret doing implants.

Another use for implants is to stabilize a loose denture. In most cases, a full lower denture lacks retention, due to the bone resorption of the lower jaw. Very few people are satisfied with their lower denture but that has changed with implants. The placement of two implants in the lower jaw can dramatically increase retention in a lower denture. In fact, I don’t think there is another procedure in all of dentistry that can give a greater increase in quality of life because it allows a patient to chew and function in a way that they could not before.

Age is rarely a factor in doing implants. I have had young patients who never developed certain permanent teeth get implants in their 20s and I have had patients in their 80s get them and be very satisfied. I urge anyone who is thinking of replacing any missing teeth to consider dental implants.

Porcelain Onlays: Why They Might Be The Right Fit For You

by Dr. Richard Janis on 09/09/13

The advancement of dental materials and bonding techniques have allowed us to offer patients restorations that we could not reliably offer in the past.  Porcelain onlays are an example of that.  A porcelain onlay is sometimes also referred to as a partial crown.  It is a porcelain restoration that restores one or more of the cusps of the tooth but doesn’t cover the whole tooth like a crown.

When one or more cusps of a tooth break, a filling is no longer sufficient to restore that tooth and protect it from fracture.  Something stronger is needed.  Traditionally, crowns have been done.  While a crown is good treatment, it involves the removal of a lot of tooth structure.  If only one or two cusps have broken, an onlay is usually better treatment because it preserves more of the tooth structure.  It fits into the tooth like a puzzle piece and is bonded to the tooth. 

Many times patients will ask about replacing large silver fillings that are breaking down.  In the past, the only esthetic options were a porcelain fused to metal or all porcelain crown, which require a lot of tooth removal.  Of course, gold onlays are an excellent choice and have been around for a long time but they are usually rejected for esthetic reasons.  A porcelain onlay allows us to provide a durable, esthetic option that will only require the removal of the old silver filling and any stained, decayed or fractured tooth structure.  Often, a lot of tooth structure will be preserved, unlike a crown.  This provides many advantages.  Since much of the margin of the onlay is above the gums, it is easier to clean, leading to less decay and gum disease.  Also, since less tooth structure is removed, there is a reduced chance of damaging the nerve which would require the need for a root canal.  In addition, if any decay does develop around the onlay, it will usually be easier to detect and repair than it would be around a crown.

Although onlays do have less retention than a crown, with good bonding and adjustment of the bite, they rarely come off or break.  Overall, their advantages over a crown are many.  If you should have the cusp of a tooth or a filling break, you should ask your dentist if a porcelain onlay is right for you.

Please note the before onlay and after onlay pictures below:


How To Keep Your Dental Bills Low

by Dr. Richard Janis on 09/09/13

Everyone wants a healthy mouth, a nice smile, and to keep their dental bills low.  There are many things to be aware of, beyond the traditional brushing and flossing, that can be beneficial to those who wish to keep their teeth for a lifetime and their dental bills low.  Let’s review them, starting with brushing and flossing:

1)Brushing

Yes, everyone knows about this and hopefully everyone is doing it daily.  However, not everyone uses the correct technique or brushes for the right amount of time.  The American Dental Association recommends brushing for a full 2 minutes, something many people are not doing.  An electric or power toothbrush is a great idea but if you get one, make sure it has a timer on it so you know how long you are brushing.  An electric brush does most of the work and you just need to move the brush head from tooth to tooth for the recommended amount of time.  With a manual brush, you should angle the brush at a 45 degree angle towards the gum and use a back and forth or up and down motion.  Do this on the inner and outer surfaces of the tooth and then brush the chewing surface as well.  Brush at least twice a day and divide the mouth into 4 quadrants (upper right, lower right, lower left, upper left) and each quadrant should be brushed for at least 30 seconds, to give 2 minutes in total.  Toothbrushes (or brush heads for electric brushes) should be changed every 3-4 months or when the bristles become splayed.  A soft toothbrush is recommended as a harder brush may damage the root surface if there is any recession.

2) Flossing

Most people do not like to floss, but it is the best way to remove plaque between the teeth, thereby helping to prevent decay and gum disease.  Take a piece of floss 18-24 inches and wrap it around your fingers.  Then slide it down
one surface of each tooth and try to make the letter C as you slide the floss up and down.  Floss aids and floss picks are fine for those who prefer to use them or for those with arthritis or dexterity issues.  Don’t forget to floss behind the last tooth in each arch.

3) Nightguards

For those who grind their teeth, some type of nightguard is necessary to protect the teeth and reduce pain in the joint if there is any.  Bruxism, or grinding of the teeth, is a very destructive oral habit.  It can lead to very extensive, and very expensive, dental work because usually all of the teeth are worn down and it is not possible to restore them just one at a time, leading to possible crowns on all or most of the teeth.  An over the counter nightguard can be tried if there is no pain in the joint, but they are less comfortable.  If that doesn’t work or it leads to other problems,  a custom nightguard should be made by your dentist.  A soft custom nightguard may cost $150-$300 and a hard laboratory nightguard between $400-$800.  Whatever the cost is, it is far less than would be needed to restore the teeth when they are worn down by bruxism.

4) Dry mouth

Dry mouth is very destructive and should be alleviated if possible, both for comfort and to prevent dental decay.  There are hundreds of medications that can cause dry mouth and it is very uncomfortable for many patients.  You  can first try talking to your physician to see if there is an alternative medication that doesn’t cause dry mouth.  If that is not possible, then there are things that can be done to improve your oral health.  Special rinses and gels made by Biotene and others can be found at the pharmacy and alleviate symptoms of dry mouth.  The reason dry mouth can be so destructive is that saliva acts as a lubricant to rinse plaque off of teeth.  When there is less saliva, the plaque adheres to the teeth and this leads to more decay.  Some simple measures that can be done are to keep your mouth moist by always having a water bottle with you and sucking on sugarless candies or chewing sugarless gum.  However, it is not good to chew gum for long periods if you have problems with the jaw joint.  If you have gum recession or a lot of crowns, ask your dentist for a prescription for a high fluoride toothpaste or other supplemental fluoride products that can help prevent the decay that is more likely to occur.

5)  Soft toothbrush

I recommend a soft toothbrush for my patients.   Enamel is quite hard but if the root is exposed due to recession, the tooth structure that is exposed is dentin, not enamel.  Dentin is softer than enamel, more prone to decay and sensitivity, and can be more easily abraded with a hard toothbrush.  For that reason, I recommend a soft toothbrush.

6) Whitening

It seems just about everyone wants whiter teeth.  Teeth can be stained form coffee, tea, tobacco, etc., or internally from medications or too much fluoride when the teeth are forming in the bone.  The least expensive way to bleach is with white strips which can be bought over the counter at the pharmacy or at Costco.  These are often effective but have certain limitations.  If the teeth are not straight, it will be harder to fit the white strips over the teeth properly, which may lead to uneven bleaching.   Dental providers  may have some more powerful white strips that are available only through dental offices.  They will be more expensive than store bought strips but less expensive than other methods of bleaching.  The next step up is to try custom tray bleaching that is available from dental offices.  This will usually work better than white strips because the trays will adapt to the teeth very well and patients will use them for about 3 weeks and then do touch up treatment as needed.  For those who want instant results, there is in-office whitening, with results in 1-2 hours in the dental office.  The instant whitening will give the same results as the tray bleaching but in 1-2 hours instead of 3 weeks.  Many patients are now opting for the in-office instant whitening in combination with the trays for the best possible results.  With any whitening treatment, the bleaching should be stopped if sensitivity develops.  Also, patients need to know that no bleaching system will work on fillings or crowns and that they many need to be replaced if the shade is now different from the teeth.

7) Orthodontics

I hesitated to put this in because this is about keeping your dental bills low and braces are not inexpensive.  However, if you have crooked teeth, you will lower your dental bills significantly over your lifetime by straightening them, even with the expense of braces.  That is because braces are more than about just improving your smile, although that is a significant reason to get them.  People with crooked teeth often get more decay and gum disease, leading to possible fillings, crowns, root canals, deep cleanings and even periodontal surgery and extractions.  Why is this?  Straight teeth are simply easier to clean as they attract less plaque and tartar, which results in fewer dental problems.  If you are wary of a long commitment to braces, often traditional or invisible braces can be done over a shorter term (6-9 months).  This may not result in a perfect bite but will straighten the teeth, leading to easier and better oral hygiene.  While not appropriate for every situation, invisible braces have a few advantages over traditional braces in that they can be removed for oral hygiene and for meals.

8) Visit your dentist regularly

Yes, it is self-serving to say this but the truth is that this, along with good oral hygiene, are the two biggest factors in good dental health and in keeping your dental bills low.  Although a great deal of good information is available on the internet, your best sources for dental information are your dentist and hygienist.  The simple fact is that almost all dental disease is preventable and regular visits to your dentist and hygienist will definitely lower any dental bills over the long run through prevention and treatment of problems when they are small.  As an example, if you have a small cavity or chipped tooth that you do not address early on, it can lead to the need for a crown and possibly a root canal later on that could end up costing five or ten times what the original filling would have cost.  That is why, even if you do not have dental insurance, it is important to still go for your cleanings and dental check-ups.  Doing so is guaranteed to lower your dental costs over time.  In addition, your dentist will conduct an oral cancer exam and may be able to talk with you about other important issues, such as oral appliances for the treatment of snoring and sleep apnea.  For those without dental insurance, many dentists offer dental discount plans that will make any dental services, particularly preventive services, more affordable.  Be sure to ask your dentist about any ways that can improve your dental health and at the same time keep your dental bills low

dentist
1949 Parkside Dr, Concord, CA 94519 | email: dr.richardjanis@gmail.com     | call: (925) 689-4020 - Dentist Concord CA