Audrey Sternberg

The high cost of living in the United States has many potential retirees considering a life outside of the United States. International locations that offer the best opportunities for retirement have high standards of living at the fraction of the cost of retiring stateside.

When considering an international move, healthcare, housing, food, transportation and utility costs are the most important factors for individuals to focus on. Indicators such as local currency stability and overall safety ensure retirees an easy transition and prosperous lifestyle.

Puerto Rico, a United States territory, barely makes the list since it does not qualify as an international location. However, the tax advantages offered to retirees paired with easy resettlement means this destination is hard to ignore. Puerto Rico differs from other locations in the US since residents do not pay federal income tax on their earnings. English is widely spoken in tourist areas, but a working knowledge of Spanish is helpful here. 

 reports depressed real estate values with lower home prices than several years ago. A home close to the ocean in popular San Juan can be found for around $100,000.

For potential expats intimidated by the prospects of underdeveloped infrastructure or lower standards of living, Portugal is Europe’s best inexpensive location for retirement. Beautifully situated along the Atlantic Coast, Portugal has the advantages of other Western European countries without the price. In fact, Portugal is a popular destination for medical tourism due to high quality standards and low costs, according to an article by 

. Taxation on income attributed to a pension is waived while wages, interest and capital gains are taxed at a reduced rate for seniors in retirement.

The unassuming South American country offers numerous benefits to senior citizens, both foreign and native alike. With discounts on utilities such as phone service, public transportation, electricity, water and airfare rates, coupled with Ecuador’s generous tax policies, retirees can live comfortably for less. The official currency is the American Dollar so retirees do not have to worry about fluctuations in the local currency. 

 says the cost of living in Ecuador could range anywhere from $12,000 to $24,000 per year — a considerable reduction when compared to retirement in the United States.

Malaysia is consistently sited as one of the best places for retirement in South Asia. Settlement is easy since crime rates are low, and English is widely understood. Apartments in the capital of Kuala Lumpur can be rented for around $500 per month, but in regional cities, like Batu Pahat, rental amounts can be under $200 according to an article by 

 in Malaysia is inexpensive without compromising quality. Many doctors are trained in the US, UK and Australia and are familiar with western standards of medicine.

Because of its close proximity to the US, Nicaragua tops the list as the best place for budget-conscious expats to call their new home. Flights from Miami to the capital of Managua take under 3 hours and run multiple times per day. Unlike neighboring Costa Rica, the country maintains affordable housing prices in the face of increasing tourism. Nicaragua’s landscape is the biggest draw since retirees can choose between beachfront locations or mountainous retreats. 

 reports homes on the beach can be found for under $100,000 while renting similar properties would cost between $400 and $500 per month. There is universal healthcare for citizens of Nicaragua, but expats are encouraged to purchase plans that afford them access to private medical care at the closest medical facility.

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The rising cost of living has forced many to delay retirement despite diligent preparation and disciplined savings. International retirement offers tax advantages and lower living costs to individuals who are tired of the daily grind.

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"Our aim is that the regenerative material would encourage the concept of minimally invasive dentistry" said Sherif Elsharkawy PhD, BDS, MSc, MFGDP RCSEng

Dentists frequently lament their inability to regrow enamel in cases where patients have suffered structural loss but have an otherwise healthy oral cavity. Fortunately, researchers have identified a new tactic for regenerating enamel and other hard tissues like bone that can help treat tooth decay and sensitivity.

The new development, known by researchers as a protein-mediated mineralization process and explored in a 

, shatters a ceiling that has loomed over the dental community for decades, and falls in line with the current trend of focusing on prevention, potentially arresting decay and erosion before it progresses.

In the study, researchers outline several uses for the material, ranging from prevention of dental caries to the treatment of dentinal hypersensitivity. One of the authors of the study, Sherif Elsharkawy PhD, BDS, MSc, MFGDP RCSEng, explained, “This protein-based material is not only capable to grow organized mineral that mimics dental enamel, but also it is highly resistant to acidic foods/drinks,” which differentiates it from current treatments like fluoride varnish and other desensitizing agents.

Efforts are underway to develop the technology to produce materials that mimic the natural enamel matrix. Thus far, the material has only been used to mineralize thin sections, but Elsharkawy thinks there is greater potential. “We are currently developing our platform to regenerate more complex dental defects by developing thicker 3D scaffolds that may become an attractive alternative to traditional fillings and crowns” he said in an interview with 

Although the new material won’t be readily available in the US market in the near future, it is important for dentists to be aware of the development and its conceivable affect to their business practices. An advantage of the new technology is its durability within the oral cavity. Resistance to the acidic nature of the oral cavity results in a reduced need for applications by a clinician. Offering patients a procedure that is less time consuming than previous treatments could introduce a lucrative method of production.

As the material develops to replace larger portions of tooth enamel, patients could be offered an alternative to traditional restorations, like ceramic crowns. Elsharkawy sees this as an advantage. “In this context, our aim is that the regenerative material would encourage the concept of minimally invasive dentistry, while keeping patients and dentists away from dental problems associated to the restorative cycle,” he said. Elsharkawy assured the public that the aim is not to completely do away with traditional treatments but to supplement the dental repertoire in cases where it could be advantageous for the patient’s oral health.

Clinical trials are forecasted to continue for two to three years into the future. The goal is to develop the technology for homecare therapies as well as professional treatments.

The study was performed by Elsharkawy, Alvaro Mata BSc, MSc, Deng et al. at Queen Mary University of London. Mata credits the group as “focused on developing functional and practical regenerative materials by integrating molecular design, bioengineering, and medicine.”

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Researchers are earnestly developing an innovative tactic for regenerating hard tissues, like bone and enamel, that could prove instrumental in the fight against sensitivity, decay and  erosion.

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“Most root canals can be performed [by an endodontist] in one visit under an hour at the highest possible level” says Dr. Rico Short of Apex Enododontics in Smyrna, GA

Teeth with periapical pathology and root canal involvement have always been a thorn in the side of general dentists. On one hand, treating the compromised tooth might create revenue for the office and grow the patient’s loyalty towards their successful practitioner. But on the other hand, a failed procedure could leave the patient with pain and result in a lower level of trust between in their dentist.

 conducted by de Gregorio et al. for the 

Journal of the American Dental Association

, endodontists are more likely to use methods that are up to date for their root canal therapy procedures, whereas general dentists utilize 

, such as protocols on irrigation adjuncts.

Dr. Rico Short, owner of Apex Endodontics in Smyrna, GA and a clinical professor at Medical College of Georgia and Meharry Medical College, thinks patients are better off seeking the care of a specialist for root canal procedures. “An endodontist has at least 2 years in specialized training after dental school in root canal therapy” Short said. He referenced 

 in May 2016 that compared outcomes of root canal treatment for endodontists versus other providers. The results suggested that, “there was a significantly higher success rate for root canals performed by endodontists versus general dentists at year 5 for molars and year 10 for all tooth types,” he said.

While it may be difficult to refer a patient with legitimately needed treatment, there is strong reason to rely on endodontic expertise:

Many clients in the office are loyal to their team of dental providers and may be hesitant to go elsewhere for care. However, reassurance and a positive referral can increase a patient’s respect for the expertise and judgement of their general dentist. An endodontist will have state-of-the-art equipment specifically designed for treating root canal therapies that may not be present in the general office, such as specialized microscopes and cone beam computed tomography (CBCT) imaging systems. Even patients with little dental knowledge will pick up on these advances and feel more confident with their prescribed treatment. “Most root canals can be performed in one visit under an hour at the highest possible level” Short explained, adding that a positive endodontic experience usually correlates with overall patient satisfaction and a reduction in fear of future treatments.

Reduce the Possibility of Lost Chairside Time

Most general dentists will allocate one to two hours towards a root canal procedure to allow for proper excavation, radiographic updates and the subsequent temporary restoration. In the event of a procedure failure, the patient will either need to undergo an extraction, possibly by an oral surgeon, or require an endodontic referral on an emergency basis. In Short’s experience, most case failures “are usually due to missed canals, inadequate cleaning and shaping of canals, or procedural errors such as perforations”. An incomplete procedure does not generate income for the office, and it takes significant practitioner time and office resources. Getting in front of the issue by initially referring to a specialist can mitigate some of these office emergencies and reduce the possibility of disruption to both the office’s and patient’s schedules.

Increase the Likelihood of Providing the Proper Dental Restoration

While sending away a root canal may seem like a loss of income, a patient’s treatment does not end at the endo office. That patient will need to return to their general dentist for outstanding restorative treatments that need rendering, as well as proper monitoring and follow-up. Such appointments will generate revenue for the office, especially when treating a complex molar case. Following a smooth chain of treatment from the specialist to the general dentist will reaffirm the patient’s confidence in their chosen practitioner.

A dentist’s office can be a scary place for many patients, so they often look for an “out,” or some reason to abandon their prescribed treatments and maintenance. Experiencing a traumatic tooth loss as a result of a botched root canal therapy can be just the thing that brings those fears to life for a patient, and pushes them away for good. While the primary dentist overseeing their health cannot reverse periapical pathology, steering the patient towards the proper course of treatment with the highest likelihood of success will help them maintain their dedication as a reliable client, and make them feel good about coming back to your office.

It is important to treat every case of endodontic involvement individually to conclude the correct course of action for the patient. While some single-canaled anterior teeth may prove to be a seamless procedure for the general dentist, the infection of several canals may be better suited for a specialist. An unwavering focus on patient wellbeing should drive the decision-making process and will help determine if the time and resources are worth the economic risk. It is up to the individual practitioner to decide if their skillset, equipment, staff and the patient are suitable for in-office treatment or an endodontic referral.

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Endodontic treatment of teeth is one of the most complex procedures that falls under the umbrella of general dentistry. Understanding when it is appropriate to refer to a specialist could save the general dentistry office serious time, money and stress in the long run.