Fosamax Information Update

In recent articles I wrote about potential complications that Fosamax users could experience after dental extractions and oral surgery. We received numerous calls from concerned patients asking for more information. At a recent seminar more detailed information came out and thought it would be helpful and settling to provide new information on this topic.

In summary, those who have been treated for osteoporosis with oral Fosamax (or similar medication) for less than 3 years have very low risk concern about jaw bone death after dental extractions. Those who have been on oral therapy for more than 3 years are at higher risk. The risk has been estimated to be about 1:20,000.
Intravenous use of aredia or zometa for the treatment of cancer puts patients at a higher risk of jaw bone death after dental extractions than Fosamax. It is best to attempt noninvasive procedures rather than extractions when treating patients. If no other option is available then patients should be on long term antibiotic use with daily rinses of Peridex, an oral disinfectant.

It is best to have a comprehensive oral examination done before going on these medications to reduce your risk of future problems. For more information including the most current guidelines please call our office for a free report at (586)247-3500 or e-mail me at DrAntolak@TheGentleDentist.com.

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Categories: Drug Concerns

I have recently seen with friends of mine or patients who have become smoke free after  years of smoking and I see the positive effects this process has had on their lives.  I want to pass on some information for the Shelby Twp, Macomb county area people who read this blog and who are tired of the control that smoking has on your life.  To quit it usually takes a plan and commitment to stick to the plan for the changes to take place with any consistency. For those who smoke or live with a smoker I would like to expand on living a smoke free life in this month’s article. 
According to the American Heart Association, about 46 million American adults smoke cigarettes.  This breaks down to 23 percent of adult men and 19 percent of adult women. Most smokers are either actively trying to quit or want to quit. Since 1965, more than 49 percent of all adults who have ever smoked have quit. Leading a smoke free life: Smoking and using spit tobacco are  habits that significantly affect one’s health and well being. 
Why Quit?:
Cigarette smoking causes 87 percent of lung cancer deaths. Lung cancer is the leading cause of cancer death in both men and women. Smoking is also responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder.
Tobacco smoke contains thousands of chemical agents, including over 60 substances that are known to cause cancer.
According to the Surgeon General:  Cigarette and tobacco smoke, high blood cholesterol, high blood pressure, physical inactivity, obesity and diabetes are the six major independent risk factors for coronary heart disease that you can modify or control.

There are many oral conditions that are negatively affected by tobacco use which include:  periodontal disease, healing with dental implants, oral surgery and high risk for oral cancer.
The Good News:

  • After one year off cigarettes, the excess risk of coronary heart disease caused by smoking is reduced by half. After 15 years of abstinence, the risk is similar to that for people who’ve never smoked. 
  • In 5 to 15 years, the risk of stroke for ex-smokers returns to the level of those who’ve never smoked.
  • Male smokers who quit between ages 35 to 39 add an average of 5 years to their lives. Female quitters in this age group add 3 years. Men and women who quit at ages 65 to 69 increase their life expectancy by 1 year.

The Plan:
In any method used to be smoke free the person really needs to want to quit.  The motivation needs to come from within  rather than from an outside source such as a  spouse.  It needs to be done for yourself and as a result of your effort others will benefit. 

Both acupuncture and hypnotism can effective non-drug methods used to be tobacco free.  There is little scientific evidence that shows these methods are more effective than the use of pharmaceuticals.  For those patients who desire a more holistic approach these methods may be for you.

There are a number of pharmaceutical approaches used for a smoking cessation program.  These include nicotine replacement therapies such as nicotine gum or the patch, the use of zyban, an antidepressant, and a  smoking cessation aide called Chantix. I have current patients who have used Chantix with remarkable results.  According to Jonathan Foulds, the director of the Tobacco Independence Program, Chantix appears to target the nicotine receptors in the brain that are involved in producing the rewarding effects from smoking. Chantix is believed to work via two mechanisms:

1. Chantix binds to nicotine receptors and blocks them so that nicotine can no longer activate those receptors (an effect that pharmacologists sometimes call an antagonist effect). This means that when someone is trying to quit and they lapse and smoke a cigarette, they probably won,t get much satisfaction from smoking it, and will be less likely to smoke another. The take-home message for patients is that it still makes sense to select a target quit-date (day eight) and to try to quit smoking completely on that day. However, if you don’t immediately quit don’t give up on yourself or on the medicines. The evidence suggests that if you keep trying you will likely achieve abstinence, and that Chantix improves your chance s, so long as you keep trying and keep taking the medicine. On the other hand, it is important to be clear that the aim of the game is to quit completely, and it is better in the long run to throw away the cigarettes and get on with it.
 
 

 It is exciting for us to team up with those who want to get control of their lives and finally be smoke free.  Give us a call at (586) 247-3500 or email me at DrAntolak@TheGentleDentist.com for more information on this or previous articles. Please submit questions you may have about dental related topics to the same address on the internet. If you would like to write us, out address is 15055 22 Mile #2,  Shelby Twp.  MI 48315.

Dr. Robert Antolak practices implant, cosmetic and general dentistry in a relaxed “homey” environment where you are  made to feel like family. 

Ask the Gentle Dentist-Bulimia and its affect on oral and systemic health

And Burning mouth syndrome

Bulimia or Bulimia nervosa is a psychological eating disorder that usually affects women starting in the teen years and continuing into adulthood.  Bulimia is a condition where a person overeats with large quantities of food. They usually feel that they cannot stop eating or control what and how much they eat.  To compensate for their overeating and potential weight gain they will then purge by self induced vomiting.  Over exercising and the use of laxatives is also common to avoid weight gain.  These women usually have an inaccurate view of their bodies and are influenced by the gaunt look that is popular in fashion and culture.

This disorder can exist in a constant cycle from a few times per week to even daily. Common problems that bulimics face is gastric reflux (heart burn), esophagus inflammation, dehydration, constipation and oral trauma from sticking a finger down the throat.

The upper front teeth are severely worn down due to the fact that strong acid from the stomach passes across the teeth surface, eroding the enamel from the teeth.  The wear is caused mostly by tooth brushing after one of these episodes as it microscopically breaks down the fragile matrix in the enamel.  Teeth can appear very thin, uneven and tattered on the edges.  They may even appear dark on the edges where light shines through them.

Treatment for bulimia consists of psychological therapy to help these people get over the habit and to create a better self image of themselves.

If they are in therapy we as dentists want to also stop the effect it has on the teeth.  I have made thin plastic trays like bleaching trays that go over the teeth.  The patient fills them with fluoridate to remineralize the teeth.  Porcelain dental veneers also help to rebuild the areas that have the erosion of enamel.

Bulimics are very quiet and discrete in what they do, but if you notice that the one you love seems to overeat and then dismiss themselves from the meal you might be direct and lovingly confront them.  Tell them that you noticed a change in their behavior and that you have concerns about their health.  The affected individual needs to know they are loved and matter.

A well informed and observant dentist can see the effects from constant purging when examining the teeth.  If you are making an appointment for the teenager you suspect to may be wise to discretely give the dentist a heads up to take notice if there are any changes in the appearance of the upper front teeth.  Many times the message is received more openly if it comes from a dentist or dental hygienist rather than from a family member. I have diagnosed a few young women who had this disorder and the way we handled it was critically important to letting the patient know the damage they are doing to their bodies and teeth and that they matter.  It really takes a lot of time to effectively talk to a practicing bulimic and not have them get defensive, yet get the message across.

If you suspect that your wife or daughter is practicing this, you can give me a call to discuss the situation.  We can be the objective observer and direct their treatment accordingly.  We have a psychologist we work with to help treat the bulimia.  Our phone number is 586-247-3500 or you can email me privately at DrAntolak@TheGentleDentist.com.

Question: I have had a burning tongue for the last 6 months or so and don’t know what to do about it.  I am a 60 year old female and wonder what it caused from.  Could you please provide some information for me to treat this irritating and painful situation

Answer: If you have a perfectly normal looking tongue, but as the day wears on, the burning sometimes seems to progress. You may even experience some tastes that have no apparent cause. If you are having these mysterious and irritating sensations, you may be suffering from burning tongue syndrome, also known as burning mouth.

Causes and Possible Solutions

Although burning tongue is not a common condition, sufferers are generally older women. Only about four or five percent of American adults suffer from it. It’s not known exactly what causes the condition, although there are many factors. In some cases, more than one cause may be at work.

Sometimes the cause is as simple as irritation from various sources. One culprit may be your toothpaste or mouth rinse. To test this, switch toothpastes to a plain fluoride toothpaste, without any tartar-control or tooth-whitening ingredients. Also, stop using any mouth rinses except plain water or salt water. If you wear dentures or other oral appliances, they may be irritating to mouth tissues and contributing to burning mouth. If you suspect this, let us know right away so we can check them out and adjust them as necessary. Another source of irritation is acidic drinks, like soda pop, citrus, and tomato beverages. Try eliminating them from your diet, and see if your symptoms improve.

Certain hormone-related conditions can also be causes. Fluctuating hormone levels during menopause can lead to burning mouth, and the high blood sugar levels that occur with diabetes can also be irritating to oral tissues. Managing these conditions can sometimes help relieve burning mouth symptoms.

Another thing to consider is medications that you may have begun taking at about the time your symptoms began. Some drugs can cause burning tongue as a side effect.  Blood pressure medications,  antidepressants and diuretics can cause dry mouth, which can lead to a burning sensation. Talking with your physician about changing medications may do the trick.

There is some speculation that burning mouth syndrome is caused by damage or irritation to the nerves that control taste and sensation on the tongue and mouth. Some medications for controlling the nervous system, such as antidepressants, anticonvulsants, or pain medications, can help. Your physician may be able to prescribe these for you after a thorough exam.

Some people have experienced relief by rinsing their mouths with water and capsaicin (sometimes called capsicum). Capsaicin is the ingredient that makes hot peppers hot, and it’s used in pain-relief creams meant for treating nerve and muscle pain. You can try mixing about one part hot sauce with two or three parts water, rinsing your mouth with the mixture, and then spitting it out. Start by doing this every two or three hours for the first day or two, then tapering off to once or twice a day. Rinsing with this mixture will probably cause a burning sensation, and it’s thought that this burning temporarily interferes with the body chemicals that transmit pain messages. If you try this, though, be very careful. Once you get out the hot sauce and start working with it, don’t touch your nose or eyes until you’ve spit the mixture out and washed your hands thoroughly. Also, some people are sensitive to capsaicin, so if the burning is severe, stop using it immediately.

There are some other coping methods that may bring relief. If you drink alcoholic products or smoke, try to stop because these both irritate and dry out oral tissues. Avoid cinnamon and mint products. Chewing sugar-free gum or sucking on sugar-free candies or ice chips might also help. Vitamin deficiencies can be a contributing factor, so try taking a multivitamin supplement if you’re not doing that already.

If you’re suffering from burning in your mouth, let us know. We’ll want to check your mouth for sores, irritations, or other conditions that might be causing the pain. In some cases, we may want to work with your physician in determining the best course of treatment for you.

Dr. Antolak can be reached at DrAntolak@TheGentleDentist.com or call the office at (586)247-3500. If you have any questions that you would like answered you can do it also by writing at Ask The Dentist  15055 22 Mile #2, Shelby Twp. Michigan  48315 (Macomb County)

This article is from the Academy of General Dentistry newsletter that I get and thought it was valuable for men.

Now to answer the question—-Men are less likely than women to take care of their physical health and, according to surveys and studies, their oral health is equally ignored. Good oral health recently has been linked with longevity. Yet, one of the most common factors associated with infrequent dental checkups is just being male. Men are less likely than women to seek preventive dental care and often neglect their oral health for years, visiting a dentist only when a problem arises. When it comes to oral health, statistics show that the average man brushes his teeth 1.9 times a day and will lose 5.4 teeth by age 72. If he smokes, he can plan on losing 12 teeth by age 72. Men are also more likely to develop oral and throat cancer and periodontal (gum) disease 

Why is periodontal disease a problem?

 

Periodontal disease is a result of plaque, which hardens into a rough, porous substance called tartar. The acids produced and released by bacteria found in tartar irritate gums. These acids cause the breakdown of fibers that anchor the gums tightly to the teeth, creating periodontal pockets that fill with even more bacteria. Researchers have found a connection between gum disease and cardiovascular disease, which can place people at risk for heart attacks and strokes. See your dentist if you have any of these symptoms:

 

  • Bleeding gums during brushing
  • Red, swollen or tender gums
  • Persistent bad breath
  • Loose or separating teeth

 

Do you take medications?

 

Since men are more likely to suffer from heart attacks, they also are more likely to be on medications that can cause dry mouth. If you take medication for the heart or blood pressure, or if you take antidepressants, your salivary flow could be inhibited, increasing the risk for cavities. Saliva helps to reduce the cavity-causing bacteria found in your mouth.

 

Do you use tobacco?

 

If you smoke or chew, you have a greater risk for gum disease and oral cancer. Men are affected twice as often as women, and 95 percent of oral cancers occur in those over 40 years of age.

 

The most frequent oral cancer sites are the tongue, the floor of the mouth, soft palate tissues in back of the tongue, lips and gums. If not diagnosed and treated in its early stages, oral cancer can spread, leading to chronic pain, loss of function, irreparable facial and oral disfigurement following surgery and even death. More than 8,000 people die each year from oral and pharyngeal diseases. If you use tobacco, it is important to see a dentist frequently for cleanings and to ensure your mouth remains healthy. Your general dentist can perform a thorough screening for oral cancer.

 

Do you play sports?

 

If you participate in sports, you have a greater potential for trauma to your mouth and teeth. If you play contact sports, such as football, soccer, basketball and even baseball, it is important to use a mouthguard, which is a flexible appliance made of plastic that protects teeth from trauma. If you ride bicycles or motorcycles, wear a helmet.

 

Taking care of your teeth

 

To take better care of your oral health, it is important to floss daily, brush your teeth with fluoride toothpaste twice daily and visit your dentist at least twice a year for cleanings. Here are some tips to better dental health:

 

  • Use a soft-bristled toothbrush to reach every surface of each tooth. If the bristles on your toothbrush are bent or frayed, buy a new one.
  • Replace your toothbrush every three months or after you’ve been sick.
  • Choose a toothpaste with fluoride. This can reduce tooth decay by as much as 40 percent.
  • Brush properly. To clean the outside surfaces of your teeth, position the brush at a 45-degree angle where your gums and teeth meet. Gently move the brush in a circular motion using short, gentle strokes. To clean the inside surfaces of the upper and lower front teeth, hold the brush vertically. Make several gentle strokes over each tooth and its surrounding gum tissue. Spend at least three minutes brushing.
  • Floss properly. Gently insert floss between teeth using a back-and-forth motion. Do not force the floss or snap it into place. Curve the floss into a C-shape against one tooth and then the other.

Dr. Antolak treats his dental patients in a relaxed, friendly atmosphere where you are treated like a guest in the home.  His motto is to “relax while we take care of your smile”. He specializes in cosmetic dentistry, implant dentistry and general dentistry using sedation dentistry if necessary for his high fear patients. He has been treating patients for the past 21 years and is located in Shelby Township, Macomb county Michigan

 

Question: I had a toothache the other day and the dentist I saw said I need to have some teeth pulled since I haven’t been to visit a dentist in a long time.  After my stroke a couple of years ago my doctor placed me on blood thinners.   I am confused whether I need to stop using my blood thinners because the doctors are recommending different things.  My doctor says I need to stay on the thinners and this dentist I saw said I should stop taking them.  What should I do?

Answer:  I agree with your physician and would do what he recommends.

For maximum patient safety a blood test is needed before dental treatment is done to make sure prolonged bleeding won’t be a problem.  The INR readings need to be from 2-3 to safely treat the patient.

Assuming the INR readings are from 2-3;

  1. There is NO need to take patients off of their blood thinner medications for routine extractions, gum surgery, deep periodontal cleanings and regular cleanings.
  2. For some invasive treatments it may be necessary to take patients off of coumadin.  If so, they need to be taken off of the medication 4 days before the procedure and then have injections of heparin until the invasive dental treatment is performed.  All of this is monitored by their cardiologist or specialty department at the hospital.  Potential life threatening problems exist if patients are taken off of the coumadin and then restarted without special medications used.
  3. The dentist can use local agents such as thrombin gauze and sutures to enhance bleeding in areas where teeth are extracted.

This information is new and should be followed to treat patients most safely, preventing potential future strokes and heart attacks (thrombosis).

Extractions after a Stroke Explained by Michigan Dentist

If you have questions regarding Extractions after a Stroke, please call our office at 586-247-3500.

Extractions after a Stroke Explained by Michigan Dentist

  
I ran across this consumer alert from the FDA and thought it would be good for you the consumer to be aware of this:

  The U.S. Food and Drug Administration on June 1 issued a warning to consumers to avoid using tubes of toothpaste labeled as made in China. The agency issued an import alert to prevent toothpaste containing the poisonous chemical diethylene glycol (DEG) from entering the country. DEG is used in antifreeze and as a solvent. The toothpastes that  have the ADA seal of approval are.  Cooldent Fluoride; Cooldent Spearmint; Cooldent ICE; Dr. Cool, Everfresh Toothpaste; Superdent Toothpaste; Clean Rite Toothpaste; Oralmax Extreme; Oral Bright Fresh Spearmint Flavor; Bright Max Peppermint Flavor; ShiR Fresh Mint Fluoride Paste; DentaPro; DentaKleen; and DentaKleen Junior. Manufacturers of these products are: Goldcredit International Enterprises Limited; Goldcredit International Trading Company Limited; and Suzhou City Jinmao Daily Chemicals Company Limited. The products typically are sold at low-cost, “bargain” retail outlets.
Please submit your questions or comments to me  DrAntolak@TheGentleDentist.com. call us at 586-247-3500 or stop in or office located at 15055 22 Mile #2 Shelby Twp. MI 48315
  

Fosamax update:( As it relates to dental surgery and necrotic jaw.)

For more information on this topic please visit our web site at www.TheGentleDentist.com and click In the News tab.  Under the drug concerns section you will find archived articles written on this subject. Because we had an overwhelming response for more information when the articles were first written, I felt it was important to add as current information became available.

I just attended an advanced implant grafting course in South Carolina a couple of weeks ago and some very current information was presented for patients who have been on medications to increase bone density secondary to osteoporosis and cancer therapy.

The body naturally deposits new bone (osteoblasts) and eats away old bone (osteoclasts) in regular healthy bone metabolism. The bisphosphonate medications actually make bone more dense, but at the expense of decreasing vascularity (blood supply) and inactivation of the bone cells called osteoclasts which are responsible to eat away the dead bone cells. Jaw bones are more susceptible to bone death after tooth extraction or other invasive dental procedure because jaw bone has the highest metabolism. Other bones in the body do not change over nearly as fast as the jaw bone does.

We now know that the bisphosphonate medications used intravenously to strengthen bones after breast cancer, prostate cancer and multiple mylenoma therapy affect the jaw bones the most.  These are commonly known as aredia and zometa. Oral medications used to treat osteoporosis such as fosamax don’t affect the bones to the extent the intravenous medications do. The key seems to be the duration of usage. If these medications are used for less than a 3 year duration the prognosis is good that they won’t have a problem. If it’s use is greater than 3 years there is more of a concern that jaw bone death could take place after dental surgery.

There are blood tests called CTX that can be performed to assess the relative safety of surgical procedures in patients who have been using the bisphosphonate drugs.  When using this information and bone density tests we can now assess the likeliness of potential future complications.

Of course the best way to prevent these major problems is to be proactive and inform your physician that you need a dental assessment before the treatment is started. It is much more prudent to remove teeth, place implants, or have oral surgery accomplished 4-8 weeks before you go on these medications.  For more information on the current protocol please call us at 586-247-3500

Fosamax and Severe Bone Infections

Beware Fosamax users!!!!!!!!!

Does someone you know have osteoporosis? If so, it is important to give them the following information:  It has been shown that patients having tooth extractions after being on FOSAMAX have the potential of developing severe bone infections.  This topic came up during recent internet discussions with fellow dentists.  Even though the Fosamax drug information insert states that “Rarely, patients have had jaw problems associated with delayed healing and infection, often following tooth extraction” it is believed that this side effect is more common than “rarely”.  The side effects of an extraction after the medicine is started can lead to gangrene or significant delayed healing.

Those patients who plan on being treated for the osteoporosis using this or other similar medications like this should have a thorough dental exam before starting the medication.  If there are teeth that are questionable or need extracting, this should be done before starting the medication.  Once the medicine is started, extracting teeth could be dangerous.  Even after being off of the medication it takes many years (10-20) for these negative healing effects to be broken down by the body.   I am not stating this for alarm, but it is intended to keep you, the reader informed.  It is highly suggested that your physician have a consultation with the dentist to determine the best course of treatment BEFORE these medications are prescribed.

Fosamax and Severe Bone Infections

If you have concerns about this you can call me at the office at (586)247-3500 to discuss your situation.

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Question:  I have a tremendous amount of fear when it comes to going to the dentist.  It has gotten to the point where I have to go and don’t know what to do.  Help!!!!

Answer:  You and many other patients come in to see us with this exact problem.  Past experiences at the dentist have literally paralyzed patients and then put off appointments for years.  These bad and usually very traumatic experiences can stay with people for decades.  In fact I saw a patient the other day who was in his 80’s and he could remember every detail of a visit when he was a child that kept him from visiting the dentist for over 60 years.

Modern dentistry has responded to this problem to make visits much more comfortable.  For example, we use sedation or dream dentistry to put people in a state where they have no memory of their procedure and are very relaxed when they get to the office.  It also allows for them to get many procedures done at one visit so they don’t have to continually return to our office.  Another option is to watch a movie on our virtual reality glasses.  Dental procedures fly by while you watch your favorite movie.

It is obviously critical to have procedures pain free.  Anesthetics properly administered do a wonderful job in controlling pain and therefore anxiety. Using topical anesthetic before the injection eliminates the “prick” from an injection.

Because fear comes from a loss of control it is vital that you are in complete control of the procedure and have a way of stopping your dentist if you need a break or are in pain.

It is also very helpful if all of your questions are answered when you need additional information.  Anxiety arises from fear of the unknown and when you are expecting pain the anxiety even heightens even more.

I, and other modern dentists, take the time to know our patients to the point where they feel comfortable because it is like seeing an old friend.  These relationships are important and can’t be stressed enough.

Please don’t let your bad experiences affect your present condition.  Modern dentistry emphasizes prevention over all other things so do yourself a favor and don’t delay this any longer.  You will be amazed at how easy and user friendly dental care can be.  Also don’t be embarrassed if you haven’t been to a dentist in years and are afraid of past judgments from the dentist.  A modern dentist will help you look forward to your future care and would never lecture you.

Question:
I read your article on the use of Fosamax and have concerns about the use.  My wife uses a similar drug for osteoporosis.  What should I do?  What is your reference and what other medications act like this.  Thank you for informing the public about these risks as now I feel more informed.

Thank You,
Henry B.

Answer:
Dear Mr. B.,
You are not the only person who expressed concern about the use of these drugs.  There is a class of drugs called Bisphosphonates they fall under the brand names such as Fosamax, Aredia, Boniva, Zometa, Didronel, Skelid & Actonel.

My source for the article is from May/June edition of The Academy of General Dentistry (the authority journal for the general dentist).  I have also created a link where the original position is taken from the following web site address:   http://www.agd.org/media/2006/june/treatment.asp.

If you don’t have access to the internet and would like to have a free copy, simply call our office at (586)247-3500 for your copy of the article.

We have received numerous calls in response to the article and am happy to pass along the information when it becomes available.

Question:
I saw an interview with you over the local cable news station about some contest to win a free computer.  My grandson is a great kid and does some great things at his church.  What does he have to do to enter this contest?

Answer:
You are referring to our “Do A Good Deed” Contest.  To enter, your grandson needs get on the computer, go to www.AntolakDentistry.com and click on the Good Deed logo.  Then he would a brief paragraph or two about what he as done to make a positive difference in his community.  There are a few questions on the form that need to be completed and his entry will be completed and ready to be submitted.  He could also fax us his entry at 586.247.1211, or send it to our office at:15055 22 Mile Rd. Suite 2 Shelby Twp. Michigan 48315.

This is a refreshing program that I hope will cause kids to step out of their comfort zone and be kind to another person.  There are so many dark and negative things we constantly hear about in the news and in our society. I am hoping to make a small impact towards the positive actions a person can make.  This contest also provides an opportunity for our youth to spend some time reflecting upon their kindness and/or good deed.

It will be my pleasure to present a new computer at their school to a well deserving child.   Our current contest winner will be selected October 15, so it is a little late to enter the ongoing contest.   We are accepting new entries now for our next computer so please pass this along to his parents so they can provide some encouragement to write it down and enter.  Our next contest will be targeted for February.  I look forward to receiving your grandson’s entry, it sounds as if you are very proud of him.

To Submit your questions please e-mail me at DrAntolak@TheGentleDentist.com, fax us at 586.247.3500 or write us.  Thank You,  Robert Antolak DDS

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