Category Archives: Blog

Fluoride

Overview

Fluoride is controversial subject for many people. Many patients oppose the use of fluoride in any form. Fluoride is used in two different ways, 1) Systemic- taking in fluoride in drinking water whether it is added by the Public Health Department or occurs naturally 2) Topical- where it is applied directly on to the surface of the teeth. Research has shown however that drinking fluoridated water (.7-1.0 ppm) reduces tooth decay by up to 60%, with little proof of harmful side effects.

Systemic Fluoride

Systemic fluoride involves the introduction fluoride into the bloodstream through drinking water, at a level of seven tenths to one part per million – a level shown to significantly help prevent tooth decay. Fluoride joins with the enamel as it forms within the tooth bud (a sack within the jaw bone where the tooth grows) and helps prevent tooth decay by making the enamel more resistant to the acid made by bacteria.

If the water supply where you live does not contain fluoride, your doctor should supply the necessary concentration of fluoride, in a dietary supplement, for infants and toddlers. Once your child is old enough to start seeing a dentist, usually at about the age of two, your dentist or physician should monitor your child’s fluoride levels to prevent discoloration of enamel due to a higher than recommended fluoride intake (see Enamel Fluorosis).

Topical Fluoride

Topical fluoride is a gel, foam, or varnish applied to surface of the teeth. Use of topical fluoride should continue as long as you have teeth. It “soaks” into enamel, microscopic cracks and exposed root surfaces, further protecting against tooth decay. This is most important in later years, when many people experience a decline in saliva production. Topical fluoride does not cause enamel fluorosis once the enamel is fully formed.

From the Centers for Disease Control and Prevention:

There is some potential for developing enamel fluorosis when children consume fluoride during the time when teeth are forming under the gums (birth through age eight). Primary, or “baby,” teeth begin to develop at about the fourth month of gestation. Development of the “permanent” teeth begins at about the age of three to four months and continues to about 12-16 years of age. To help prevent both tooth decay and enamel fluorosis, the Centers for Disease Control and Prevention (CDC) recommends the following:

For parents:

Children younger than six have a poor swallowing reflex and tend to swallow much of the toothpaste on their brush, which can contribute to a child’s total fluoride intake. Therefore, as soon as the first tooth appears, begin cleaning by brushing without toothpaste with a small, soft-bristled toothbrush and plain water after each feeding. Begin using toothpaste with fluoride only when the child has reached two years of age, but only in pea-sized amounts. Use toothpaste with fluoride earlier if your child’s physician or dentist recommends it.

  • Do not brush your child’s teeth more than two times a day with fluoride toothpaste.
  • Apply no more than a pea-sized amount of toothpaste to the toothbrush.
  • Supervise your child’s tooth brushing, encouraging the child to spit out toothpaste rather than swallow it. Additional information is available online at the CDC.
  • If your child’s pediatrician or dentist prescribes a fluoride supplement (or a vitamin supplement that contains fluoride), ask him or her about any risk factors your child has for decay and the potential for enamel fluorosis. If you live in an area with fluoridated water, fluoride supplements are not needed.
  • You can use fluoridated water for preparing infant formula. However, if your baby is exclusively consuming infant formula reconstituted with fluoridated water, there is an increased potential for mild enamel fluorosis. Additional information can be found in a CDC fact sheet on infant formula @ CDC.org.

For health professionals:

  • Fluoride supplements can be prescribed for children at high risk of tooth decay whose primary drinking water has no or a low fluoride concentration. For children under age eight, weigh the risk for decay without fluoride supplements, the decay prevention offered by supplements, and the potential for enamel fluorosis.
  • Counsel parents and caregivers on the use of fluoride toothpaste by young children, especially those younger than two years old. Fluoride toothpaste is a cost-effective way to reduce the occurrence of tooth decay. However, because they do not have a well- developed swallowing reflex and may like the taste of the toothpaste, young children often swallow a large portion of it from their brush.

The prescription dose of fluoride supplements should be consistent with the standards established by the American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics.

Fluoride Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50 (RR-14):1–42. PMID 11521913. Lay summary: CDC, 2007-08-09.Up to 42% caries reduction

Fluoridation Basics
Water fluoridation prevents tooth decay mainly by providing teeth with frequent contact with low levels of fluoride throughout each day and throughout life. Even today, with other available sources of fluoride, studies show that water fluoridation reduces tooth decay by about 25 percent over a person’s lifetime.

 

Fillings

Overview

Silver filling with defective margins and a high probability of tooth decay under the filling

Silver filling with defective margins and a high probability of tooth decay under the filling

A filling is a dental procedure where material is used to replace tooth structure that has been lost due to tooth decay or a minor fracture. The filling restores lost tooth structure and re-establishes the contour of the tooth. Fillings are also referred to as “direct restorations” because the decay is removed, the tooth is prepared to receive the filling, and filling material is placed directly into the preparation, restoring the tooth to its original shape. There are three primary types of filling materials that are generally used today; silver amalgam, glass/plastic composite and glass ionomer. Though no longer as popular as in the past, some patients still ask for gold foil, a fourth material option.

Types of fillings

Amalgam (silver filling)

Amalgam restorations, or “silver fillings,” have been used to fill teeth for hundreds of years. Amalgam is composed of mercury and powdered metal called an alloy, which is made up primarily of silver, copper, tin, and zinc. This type of filling material is manufactured in a capsule with a membrane separating the mercury from the metals. When mixed (in a triturator or amalgamator), the membrane breaks and the material gains a thick, creamy consistency. The amalgam is placed in the preparation, condensed, burnished, and carved. The amalgam restoration is fully set in 24 hours.

When a tooth is prepared to receive an amalgam, the preparation needs to have retention grooves and be undercut in order to lock the filling into place. Therefore, in order to use amalgam to replace lost tooth structure, more tooth structure must be removed to be sure the filling will stay in place.

Advantages of amalgam restorations:

  1. Amalgam is cost-effective.
  2. Amalgam is strong and lasts a long time.
  3. The placement of amalgam is less technique-sensitive, making it the preferred restoration in situations where isolation of the tooth from blood or saliva is not possible.

Disadvantages of amalgam restorations:

  1. Amalgam is not tooth-colored, making it less desirable.
  2. Although amalgam can be bonded into the tooth with the use of a metallic bonding agent, tooth structure needs to be shaped through material removal to lock the filling into place.
  3. Because of mercury content, the use of amalgam has been controversial for decades, due to the effect of mercury content on humans.

Composite (white filling)

The left picture shows tooth decay on three teeth; on the left the teeth have been restored with bonded composite fillings.

The left picture shows tooth decay on three teeth; on the left the teeth have been restored with bonded composite fillings.

Composite restorations, or tooth-colored fillings, are composed of powdered glass and plastic resin. Manufactured in light-tight capsules, this material is completely mixed in shades designed to match your teeth. Composite is very light-sensitive and must be covered when not in use because it cures (hardens) in the presence of light.

The technique for placing a composite restoration is very specific and must be followed accurately. Decay is removed from the tooth, along with any loose, jagged enamel (called “loose enamel rods”). There is no need to remove any more tooth structure for retention of the filling, as is necessary for amalgam. The tooth is isolated or kept dry (possibly with the use of a rubber dam), and an acid etch solution is placed in and over the edges of the area of preparation for 10-15 seconds. After a thorough rinse, the preparation is left damp and an adhesive solution is placed, spread out with a stream of air and cured with a UV light. The composite material is then placed in the preparation and cured with a UV light. Composite material may be applied in layers, depending on the size of the preparation. The filling is then shaped and polished.

shutterstock_126059102

Advantages of composite restorations:

  1. Composite is tooth-colored.
  2. Composite is strong and durable.
  3. Composite requires removal of less tooth structure.
  4. Composite is bonded into place and believed to make the entire tooth stronger.

Disadvantages of composite restorations:

  1. Composite undergoes some shrinkage when cured and may need to be placed in layers, therefore requiring more time to complete treatment.
  2. This shrinkage makes such fillings more difficult to place (more technique-sensitive) and can result in extreme tooth sensitivity following placement.
  3. If the preparation is contaminated with blood or saliva during the filling process, the technician must repeat the entire procedure over, beginning with the acid etch. Blood and saliva contamination prevent the composite from bonding to the tooth and the tooth will present with recurrent decay in a short time.
  4. Composite is more expensive.

Glass ionomer (a white filling that releases fluoride)

Glass ionomer restorations are composed of glass and organic acid. Although they are tooth-colored, they are more matte or opaque than composite restorations. Glass ionomers may need to be light cured, or they may set by an acid/base reaction. Glass ionomer restorations release fluoride and are desirable when you have a higher risk of Tooth Decay.

Advantages of glass ionomer restorations:

  1. Glass ionomer is tooth-colored.
  2. Glass ionomer requires minimal tooth removal for placement.
  3. Glass ionomer releases fluoride, and the fluoride is “replenished” when you brush with a fluoride toothpaste or get fluoride treatment at the dentist.
  4. Glass ionomer does not require the bonding agents that composites require, making placement faster.
  5. Glass ionomer does not shrink the way composites can during the setting phase.

Disadvantages of glass ionomer restorations:

  1. Although they are tooth-colored, they do not polish as well as composite restorations.
  2. They are not as strong as composite restorations.
  3. They are about the same cost as composite restorations.

Gold foil (gold fillings)

Gold foil is mentioned only because, even though this type of filling has fallen out of use, there are a few individuals whose teeth still have gold foil as a filling material. Gold foil is manufactured with tiny, soft pieces of gold that are compressed (tapped) into the cavity preparation, carved, and polished.

Advantages of gold foil restorations:

  1. Gold is kind to the opposing teeth, creating the least amount of wear of any dental restorative material.
  2. Gold foil is strong and resists wear.

Disadvantages of gold foil restorations:

  1. Gold foil is not tooth-colored.
  2. Gold foil placement is time consuming.
  3. Depending on the market, gold foil can be expensive.

Indications for a filling

Fillings are indicated when you have lost less than half of the surface structure on the biting surface of the tooth, between the tips of the cusps. Once you lose a cusp or start placing fillings up the inclines of cusps, the strength of the tooth is compromised and a Crown or an Inlay/Onlay should be considered as the preferred means of restoration. Unfortunately, many patients cannot afford the preferred restoration, and many large fillings are placed as an alternative. Some of the problems that may occur when restorations that are too large are placed include, but may not be limited to:

  1. Weakness of the remaining tooth which may lead to a fracture.
  2. Reduction of tooth structure may cause the remaining tooth to flex when you bite down, causing pain.
  3. Overly of large fillings can irritate the pulp (nerve) and cause death of the tooth, requiring a Root Canal Treatment.
The silver filling and the composite or "white" filling; both teeth have recurring cavities and new fillings would be diagnosed had the teeth not been removed.

The silver filling and the composite or “white” filling; both teeth have recurring cavities and new fillings would be diagnosed had the teeth not been removed.

Sometimes fillings are simply replaced due to more decay around the existing filling (called “recurrent decay”). Sometimes silver fillings are fractured and cavity producing bacteria and sugar can seep down into the crack and under the filling, creating more decay; fractured fillings need to be replaced.

Tooth Sensitivity/Pain

Overview

Tooth sensitivity to cold can be from any one of a number of issues.

Tooth sensitivity to cold can be from any one of a number of issues.

Healthy teeth are usually not sensitive to temperature or the pressure of chewing. Teeth are considered sensitive if pain is experienced due to temperature, pressure, acidic foods or in the absence of chewing. Occasional aches or sensitivity is normal, after all teeth are connected to the central nervous system and some aches and pains are experienced throughout the body. Ongoing pain or sensitivity means something is wrong.

How it works

Sensitivity can be felt as an ‘all over’ sensation (generalized) or it can be felt in one specific area (localized). Since the covering of the tooth is enamel and enamel has no nerve connection, sensitivity or pain comes from the layer beneath the enamel known as dentin. Dentin is made up of tiny tubes that travel from under the enamel to the nerve chamber (see Parts of the Tooth). Whether it is hot, cold, acid, or pressure, the soft tissue moves toward the nerve, causing irritation, a signal is sent to the brain and the outcome is sensitivity/pain. Tooth decay allows acid, toxins and bacteria to travel through the dentinal tubules to the nerve. Sensitivity or pain is often caused by some type of break or opening in the enamel, exposing the dentin tubules and communicating with nerve chamber.

Causes of dentin exposure

Dentin exposure comes from any one of a number of problems:

  • Gum shrinkage exposing the neck of the tooth, where the root and crown of the tooth come together. In some people, this area is not completely fused, exposing the underlying dentin and creating sensitivity.
  • Cracks in the tooth exposing dentin. These cracks come from habits of chewing on ice, pens, pencils, or jaw breakers; the chronic grinding your teeth; trauma to the mouth; and/or the weakening of your tooth due to overly large fillings (see Cracked Tooth Syndrome).
  • Enamel wear from acid erosion or clenching and grinding, exposing dentin.
  • Notches at the neck of the tooth are called abfraction lesions. Abfraction lesions are caused by excessive force to your tooth. Teeth normally flex when loaded with pressure; forces that flex the tooth more than normal (clenching and grinding) cause the enamel to chip away at the gumline where enamel is thinner creating notches, leading to sensitivity.
  • Excessive brushing (toothbrush abrasion) with a medium or hard toothbrush causing gum tissue and the softer root structure (see Parts of the Tooth: Cementum) to be eroded away.
  • Excessive stress due to a filling or a crown that sits too high
  • A blow to your tooth causing a fracture in the enamel (see Cracked Tooth Syndrome).
  • A broken, fractured, or cracked filling
  • A tooth that is dying from deep decay or a past history of deep decay (see Root Canal Treatment (Endodontics)
  • Excessive amounts of bacterial plaque accumulated at the gum line in an area where the crown and root are not completely fused.
  • Tooth decay, especially as the decay becomes larger
  • Tooth whitening, especially long-term use of a whitening product
  • Sensitivity following a dental procedure, which is usually temporary
  • Excessive clenching and grinding, which pushes the tooth hard into the boney socket and irritates the bone, ligament, nerve, artery and vein (see Parts of the Tooth). This generally causes ‘all over’ sensitivity, especially to cold.

What can be done for tooth sensitivity?

Depending on the cause, tooth sensitivity can become a distressing, aggravating ailment. There are several possible remedies:

  • There are toothpastes that reduce sensitivity due to gum shrinkage and enamel wear. These toothpastes require repeated use to reduce and/or eliminate sensitivity.
  • Grinding of selected biting surfaces to remove high spots on teeth, crowns and fillings to improve the contact of or alignment between opposing teeth
  • Wear a night guard while sleeping
  • Use a soft toothbrush, never a medium or a hard brush. Thoroughly brush and floss your teeth daily to remove bacterial plaque; never “scrub” your teeth
  • Placing a crown covering the cracked tooth enamel
  • Professional desensitizers placed at the gum line and professional-strength fluoride treatments that help block the openings to the exposed dentin
  • Limiting the use of whitening products and/or using a desensitizer in the whitening tray between whitening sessions
  • Keeping regular Dental Exam appointments to ensure there is no active decay

Enamel Fluorosis

Overview

enamel_flourosis

Enamel fluorosis occurs when a higher than recommended concentration of fluoride is consumed during tooth development. There are varying degrees of  fluorosis demonstrating spots from white to black and in severe cases, severe pitting is apparent.  Over time the  involved teeth will chip and wear easier. From a cosmetic standpoint, this condition can cause embarrassment, loss of self-confidence and self-esteem problems.

Causes of enamel fluorosis

  1. When an individual receives greater than .7-1 ppm fluoride levels in their drinking water during tooth development.
  2. When children drink water with high natural levels of fluoride.
  3. Prescribing fluoride tablets for children with developing teeth without researching the amount of fluoride already in the drinking water.
  4. Ingestion of fluoridated toothpaste while consuming other sources of systemic fluoride.

Prevention of enamel fluorosis

  1. Know the concentration of fluoride in your community drinking water.
  2. Ask questions should your dentist and /or physician recommend prescribing a dietary source of fluoride.
  3. Never allow your children to swallow their toothpaste because toothpaste contains fluoride

Correcting enamel fluorosis

  1. In mild cases, spots can be removed from the enamel and white fillings can be placed.
  2. In children with more severe cases affecting the entire tooth, direct bonding (see Composite Veneers) will greatly improve cosmetics and self confidence.
  3. Once the patient has reached maturity, the affected teeth can be covered with Porcelain Crowns or Porcelain Veneers, a more permanent solution than direct bonding.

 

Dry Mouth

Overview

One of the biggest problems facing dentists and patients today is “dry mouth” (or xerostomia). Dry mouth occurs when saliva flow in the mouth is seriously diminished, leading to an increase in dental disease. One of the most common causes of dry mouth is the more than 1,200 commonly prescribed medicines that decrease saliva flow as a side effect. As baby boomers age and are prescribed medications with this side effect, their dental problems can become compounded (especially if they were born and raised in a community that didn’t fluoridate water when their teeth are developing).

Signs and symptoms

Dry mouth can occur as a result of taking medications, or from nervousness, stress, or other emotional upset. This is a normal body function, usually short-term and does not lead to any long-term problems with the mouth. Long-term cases of dry mouth will lead to sore, irritated oral soft tissue and an increased susceptibility to tooth decay, periodontal disease and other infections. As saliva decreases, the number of bacteria in the mouth increases.

Common symptoms include a dry, pasty feeling when you open or close your mouth; difficulty while chewing, swallowing, or speaking; an ongoing burning sensation; and/or a frequent need to sip water.

Patients who wear full dentures and suffer with dry mouth are less likely to be comfortable because saliva helps dentures adhere properly. Dry mouth can also result in painful denture sore spots, dry and cracked lips, and an overall increased risk of oral infection.

Common causes of dry mouth

Dry mouth was once considered a common symptom of aging; today, however, we associate it with certain prescribed medications and medical conditions. Some of these medical conditions include: radiation therapy for treatment of cancers to the head and neck (which can produce significant damage to the saliva glands), HIV/AIDS, Alzheimer’s, anemia, rheumatoid arthritis, diabetes, Parkinson’s disease, and cystic fibrosis, to name a few.

The main function of saliva

  1. Lubrication and binding: The mucus in saliva works in binding food that has been chewed so it can be swallowed without inflicting damage to the soft tissue lining of the throat. Saliva coats the mouth and throat so the food does not directly touch the epithelial cells of those tissues.
  2. Softens dry food: In order for food to be tasted, food must be dissolved and flavor released.
  3. Oral hygiene: The mouth is almost constantly flushed with saliva, which floats away food debris and keeps it relatively clean. The flow of saliva diminishes considerably during sleep, allowing populations of bacteria to build.
  4. Recalcification: As the acid-producing bacteria begin the process of tooth decay, ions in the saliva help to recalcify damaged enamel.

The main components of saliva include:

  • Water
  • Electrolytes:
    • Sodium
    • Potassium
    • Calcium
    •  Magnesium
    • Chloride
    • Bicarbonate
    •  Phosphate
    • Iodine
  • Mucus
  • Enzymes:
    • Amylase: starts the digestion of starch prior to swallowing
    • Lipase: starts the digestion of fat prior to swallowing
  • Anti-microbial enzymes that kill bacteria
  • Praline-rich proteins (helps in enamel formation, microbe killing, and lubrication)

Relieve dry mouth and protect yourself against an increase in disease

The best suggestions for dry mouth relief are:

  • Taking Over-the-Counter medications that help offset decreased saliva flow
  •  Mouthwashes that help offset decreased saliva flow
  • Increasing fluid intake
  • Chewing sugarless gum containing Xylitol
  • Sucking on ice chips
  • Breathing through your nose instead of your mouth
  • Regular moisturizing of lips
  • Sleeping with a humidifier

The best suggestions to protect you against an increase in tooth and gum disease:

  • Regular checkups for evaluation and treatment as a preventative measure.
  • Regular brushing and flossing.
  • Avoid salty foods.
  • Avoid dry food (crackers and chips).
  • Limiting sugar intake: limit sugar intake to after meals, as this is the time when you have the greatest saliva flow.
  • Avoid tobacco (most chewing tobacco contains sugar).
  • Avoid alcohol, caffeine, and carbonated beverages; all these decrease saliva production

Always carry a list of all your medications with you and supply this information to your dentist, who will review this list with you and discuss the associated conditions for which the medications have been prescribed. In some cases, a different drug can be provided or your dosage modified to help reduce or alleviate symptoms. Your regular doctor will often tell you if the drug they are prescribing will cause dry mouth, but rarely will explain the long term dental health consequences. Your dentist and pharmacist are your most reliable sources to help you deal with this problem.

Common medications causing dry mouth

There are well over a thousand medications that cause dry mouth. They include, but are not limited to:

  • Antidepressants
  • High blood pressure medications
  • Heart medications
  • Antihistamines
  • Decongestants
  • Iron supplements
  • Narcotic analgesics
  • Hormone replacement therapy

 

TMJ (Temporo-Mandibular Joint Dysfunction or TMD)

 

Overview

Pain in the face may be TMD, often referred to as "TMJ" by patients.

Pain in the face may be TMD, often referred to as “TMJ” by patients.

You may hear from time to time someone say “I’ve got TMJ.” TMJ is neither a disease, nor a disorder. The disorder they are often referring to is “TMJ Dysfunction,” or “TMD.”

TMJ stands for “temporo-mandibular joint.” It is the joint that controls the opening and closing of your mouth; with the temporal bone being above your ear, and the mandible: commonly referred to as the lower jaw. Where they come together is the temporo-mandibular joint.

TMJ Dysfunction (TMD) can range from simple tooth and muscle pain to more advanced problems involving the misalignment and degeneration of the temporo-mandibular joint. When you have pain or noise in your TMJ, something is out of place and your joint is not working properly. Healthy joints are pain-free and do not make any noise.

Joint noise can be a popping, clicking or grating noise, depending on the stage of dysfunction. The noises indicate that the pad between the bones is either out of place (popping and clicking) or completely gone (grating noise) and the patient is now bone on bone.

Causes, symptoms, and the progression of TMD

Clenching and grinding: problems without pain

Although there can be several causes contributing to TMD, one of the most common is Clenching and Grinding your Teeth (Bruxism) The medical term for grinding is bruxism. Some people have no pain following a night of bruxing and are completely unaware that they have developed this habit. Bruxers are usually told by a partner who has been awakened by an especially loud and intense episode.

The signs of wear are seen on molars that have become flat, shortened front teeth, and front that appear flat, chipped, thin, or indented. Your dentist can see the wear on your teeth, as the signs of bruxism are quite vivid to the experienced clinician.

While grinding occurs predominately during sleep, clenching can occur while sleeping or while awake. Your dentist may recommend a simple “nightguard” as the appliance of choice to prevent any further “wear and tear” to your teeth. A simple OTC nightguard is not recommended when there is pain or noise in your TMJ as a result of the bruxing habit.

Clenching and grinding: the onset of pain

Temporo-mandibular joint pain can be felt in the ear, in front of the ear and in the face muscles.

Temporo-mandibular joint pain can be felt in the ear, in front of the ear and in the face muscles.

The most common problem involving pain is myofacial pain or masticatory muscle disorder. Myofacial pain is pain in the muscles of the face. When simple Clenching or Grinding becomes a chronic problem and pain develops, patients may complain of “TMJ.” When questioned where they are experiencing the pain, they may put their hands on their cheeks and/or describe difficulty in opening and closing the mouth. This area is the masseter muscle (found on the side of the face from the cheekbone to the edge of the lower jaw), and it is one of the muscles of closure.

Neuromuscular headaches, often misdiagnosed as migraines, can also be a symptom of clenching. When questioned where they experience the pain of their headaches, patients’ hands often go directly to their temples, or the temporalis muscle, another muscle of closure.

A knowledgeable doctor of dentistry may recommend an appliance called a “flat-planed, canine-guided splint.” This type of nightguard allows the muscles to relax, prevents them from contracting fully, and protects the teeth. These appliances usually require a period of adjusting as the muscles relax over time.

Interferences

What may compound the problem of TMD are teeth that come together inappropriately. The biting surfaces of teeth are a series of hills and valleys termed cusps and fossae. The cusps have slopes, or inclines, from the cusp tip down into the valley, or fossa. If your teeth come together and a cusp tip hits on a slope or incline rather than in the fossa as you squeeze your teeth together, your teeth slide down these slopes in an effort to chew food. Biting on these slopes is called an interference; interferences can cause the muscles that operate the TMJ to fire antagonistically.

Initially, a splint may be worn for an extended period of time to allow the muscles of the joint to relax, allowing the joint to go into the proper position. This splint is constructed specifically for your mouth by a knowledgeable dentist with advanced training in TMD. This is usually followed by an adjustment of the teeth, with the goal of removing all interferences. An over-the-counter nightguard is an inappropriate device for the treatment of TMD.

If your teeth are coming together improperly, an occlusal adjustment (an adjustment to the biting surfaces of the teeth) may be required to eliminate any inappropriate movement of the mandible triggering the muscle pain. Reshaping of the enamel surface (usually less than 1 mm) may be performed, allowing the bite to stop in a fossa rather than on an incline.

In rare cases, a crown may be necessary to accomplish the proper positioning of the tooth, thereby removing the interferences. Braces (Orthodontics) can also provide the desired rearranging of the cusps and fossae.

Ongoing joint disease and degeneration

Other causes of TMD other than clenching, grinding, or interferences may include trauma to the face, fracture, dislocation, muscle inflammation, muscle spasm, arthritis, infection, and/or growth disorders. TMD itself can lead to a number of dental problems, including joint noise, joint pain, tooth pain, tooth fracture, tooth death, bone loss, bone hypertrophy, space development/tooth movement, tooth sensitivity, limited opening, receding gums, and more.

To summarize, this dysfunction can cause damage to teeth and surrounding structures, pain in the muscles of the face or can go well into five stages of breakdown, with Stage 5 demonstrating complete degeneration of the joint.

Pain in the TMJ is directly in front of or just inside and in front of the ear. Progressive TMD is a multifaceted disorder that can be debilitating and should only be treated by someone with advanced training in its evaluation, diagnosis, and treatment and/or a team of medical, dental, and psychology professionals.

The Mouth/Body Connection

If pain is experienced when chewing, it is not difficult to imagine how one would avoid diet of healthy, crunchy vegetables and nuts to softer, less nutritious foods. Over time, a poor diet can contribute to a number of illnesses, including diabetes and cancer. It is not difficult to see the relationship between diet and a healthy mouth.

 

Dental X-rays

Overview

This panorex x-ray is used for seeing all structures that support and surround the teeth including the TMJ, the bone of entire upper and lower jaw, sinuses and unerupted teeth. It is not used for up close detail of the teeth i.e. not for diagnosing decay.

This panorex x-ray is used for seeing all structures that support and surround the teeth including the TMJ, the bone of entire upper and lower jaw, sinuses and unerupted teeth. It is not used for up close detail of the teeth i.e. not for diagnosing decay.

Dental x-rays (radiographs,) whether taken digitally or with dental film, are a vital component in the prevention, diagnosis and treatment of dental disease. Without x-rays, proper dental treatment cannot be performed. Most states require dental x-rays be taken on a regular interval and State Dental Boards can dictate no treatment be performed without them. This is considered within the appropriate ‘Standard of Care’.

Routine Dental X-rays include

Full mouth x-rays

A series of 18 pictures showing root tips and areas between your teeth, this type of x-ray is good for showing close detail of each individual tooth. It allows views of the tooth from different angles, an important tool for diagnosing questionable areas. Understanding how to move the tube head or “camera,” and watching the image shift from x-ray to x-ray allows dentist to determine the location of areas of concern with a high degree of accuracy. Full mouth x-rays are taken every 3-7 years: every three years in the case of patients with a history of gum disease (periodontal disease); every five years on average; and every seven years for patients who have reached adulthood with little or no dental disease and immaculate oral hygiene.

This is a photo of full mouth x-rays. It shows details around the entire tooth. Dentists can also diagnose disease by watching how the decay/bone loss changes from picture to picture by understanding the movement of the image and the movement of the camera.

This is a photo of full mouth x-rays. It shows details around the entire tooth. Dentists can also diagnose disease by watching how the decay/bone loss changes from picture to picture by understanding the movement of the image and the movement of the camera.

Bitewing x-rays

This is a conventional bitewing x-ray that helps determine a number of issues necessary in a complete diagnosis such as fractures, tooth decay and bone level.

This is a conventional bitewing x-ray that helps determine a number of issues necessary in a complete diagnosis such as fractures, tooth decay and bone level.

These x-rays involve four pictures of the areas between the teeth. Bitewings help to determine the level of decay and bone between the teeth. For the average patient and non-flossers, it is recommended these be taken every year.

Vertical bitewings

This is a vertical bitewing x-ray used to see bone level. If this x-ray would have been taken the "conventional" way, the level of bone loss seen between the upper molars couldn't be seen.

This is a vertical bitewing x-ray used to see bone level. If this x-ray would have been taken the “conventional” way, the level of bone loss seen between the upper molars couldn’t be seen.

Routine x-rays taken once a year to detect tooth decay and monitor bone levels are termed “bitewing x-rays.” In situations where a patient has suffered bone loss, the bone level may not be viewed on traditional bitewing films. In this case, to view the bone, the films (taken in a horizontal position for routine visualization between the teeth) are turned and the x-rays taken with the film in a vertical position.

Periapical x-rays

A "periapical x-ray": peri means around and apical or apex is the tip of the root or around the tip of the root. This x-ray allows the dentist to see the entire tooth and details of surrounding structures. There are 14 of these x-rays in a full mouth set of x-rays.

A “periapical x-ray”: peri means around and apical or apex is the tip of the root or around the tip of the root. This x-ray allows the dentist to see the entire tooth and details of surrounding structures. There are 14 of these x-rays in a full mouth set of x-rays.

These x-rays show the whole tooth and area around the root of the tooth. There are 14 periapical views in full mouth set of x-rays. Occasionally, a patient comes in with a specific problem and is not due for a full mouth x-ray, but is in pain or having a specific problem. This is when one or two periapical x-rays are taken to determine the source of the pain. Often the dentist will use the existing full mouth x-rays and the new periapical x-ray for comparison to determine the proper course of treatment.

Panorex x-rays

This type of dental x-ray (see photo above in “overview”) aids in viewing a large area around teeth and surrounding structures. Dental professionals can see the TMJ, or temporomandibular joint (more specifically, the condyle and fossa and its general condition); the maxillary sinus; the canal where the nerve, artery and vein supplying the lower teeth and jaw and much more.  Oral surgeons often will only remove your teeth after a panorex x-ray is taken, allowing them to see the entire tooth and surrounding structures to determine how the tooth is positioned in the jaw.

Digital x-rays

Digital x-rays (digital radiography) require much less exposure to radiation and use a ‘sensor’ vs. dental film that has to be developed. The image is produced immediately and viewed on a computer.

Cephlometric x-rays

An adult cephlometric x-ray. In children, these are used to determine growth patterns and treatment planning.

An adult cephlometric x-ray. In children, these are used to determine growth patterns and treatment planning.

This is a side view of the head used in oral surgery and as a part of planning treatment for “braces” .

When you request that no x-rays be taken, we document that request and inform you that we cannot properly diagnose or treat any condition we cannot see. Decay can often be seen on front teeth by transmitting a dental light through the thinner front teeth and looking in a mirror placed behind the teeth. Decay cannot be seen between the back teeth without dental x-rays.

Requesting no x-rays would be considered an unsafe practice when:

  1. You have had a long absence between dental visits. Most dentists are conservative by nature and give you the benefit of the doubt when it comes to whether to watch an area or just fill the tooth. They will explain that you have areas that have begun to decay, that the progression of the tooth decay does not warrant filling the tooth at this time (because the decay is less than halfway through the enamel) but it needs to be kept clean (brush/floss) so the decay process can be halted. If you have taken a longer-than-recommended break from routine dental care, have been lax in your home care and regularly consume foods containing sugars, dental -rays are necessary. Saving money or worrying about radiation by foregoing x-rays could be a risky decision. You may need to spend more money in the future to repair a larger problem that could have been fixed when it was smaller and less expensive to repair.
  2. You have been diagnosed with periodontal disease and you are undergoing maintenance treatment. In this case, regular dental x-rays are of vital importance (full mouth x-rays every three years and bitewing x-rays every year).
  3. A “baby tooth” has significant decay. If the adult tooth that replaces it is not close to pushing out the “baby” tooth and erupting into the mouth, a filling is warranted. However, if the adult tooth is close to eruption, and the baby tooth is going to be lost soon, no filling is indicated. A decision cannot be made without dental x-rays.
  4. You were raised in an area without a fluoridated water supply.

Clenching and Grinding your Teeth (Bruxism)

Overview

Clenching occurs when you squeeze your teeth together over a sustained period of time. Grinding or bruxism, is the clenching of your teeth along with right-to-left and back and forth  movement of your lower jaw that rubs the teeth together.

Why does it happen?

Clenching and grinding are habits that can occur while sleeping, while awake, or both. Many patients are not even aware they are doing it. This habit may be a response to a number of life’s situations, such as:

  • Stress
  • Anxiety/worry
  • Concentration/deep thought
  • Athletic activity
  • Fear

Clenching and grinding: problems without pain

Indications of clenching and grinding: the biting surfaces are very flat with worn enamel and the roots on the lower second molar are fractured.

Indications of clenching and grinding: the biting surfaces are very flat with worn enamel and the roots on the lower second molar are fractured.

The medical term for grinding is bruxism. Some people have no pain following a night of bruxing and are completely unaware that they have developed this habit. Bruxers are usually told by a partner who has been awakened by an especially loud and intense episode.

The signs of wear are molars that have become flat, shortened front teeth, and front teeth that appear flat, chipped, thin, or indented. Your dentist can see the wear on your teeth, as the signs of bruxism are quite vivid. While grinding occurs predominately during sleep, clenching can occur while sleeping or awake. Your dentist may recommend a “nightguard” to prevent any further damage to your teeth.

Clenching and grinding: the onset of pain

When simple bruxism or clenching becomes a chronic problem and pain develops, patients may complain of “TMJ.” When questioned where they are experiencing the pain, they may put their hands on their cheeks and/or describe difficulty in opening and closing the mouth. This area is the masseter muscle (found on the side of the face from the cheekbone to the edge of the lower jaw), and it is one of the muscles that hold the mouth closed.

Neuromuscular headaches, often misdiagnosed as migraines, can also be a symptom of clenching. When questioned where they experience the pain of their headaches, patients’ hands often go directly to their temples.

Your dentist may once again recommend a night guard. This appliance prevents the full contraction of these muscles, reducing pain on awakening. (see TMJ/TMD.)

Cavities/Tooth Decay

Overview

The black area in the two front teeth is decay (adult.)

The black area in the two front teeth is decay (adult.)

Tooth decay is one of the most common diseases in the world. In the U.S. alone, more than 90% of all individuals will be affected by tooth decay at one time or another during their lifetime. It should be noted that tooth decay is also one of the most easily preventable diseases.

Tooth decay is the process by which bacteria in your mouth convert carbohydrates (such as sugar) to acid, which demineralizes, or dissolves tooth structure. There are two major bacteria that cause tooth demineralization: Streptococcus mutans and Lactobacilli. The demineralization happens in stages and, given time, creates holes in your teeth.

 

Plaque: the Primary Agent in Tooth Decay

Tooth decay in a child.

Tooth decay in a child.

Plaque is a highly organized colony of bacteria that forms on teeth, tongues, fillings, crowns, dentures, partials, and anything you place in your mouth for any period of time. This bacteria produces a glue-like substance that helps it to stick to everything and can only be removed by the mechanical action of brushing and flossing, and/or the use of a waterpik. If you are not flossing and/or the using a waterpik, you are only doing half the job of plaque removal. If you are not brushing correctly, you are only doing about a quarter of the job of plaque removal, which can lead to tooth decay and gum disease.

Plaque takes about 24 hours to fully mature in your mouth to a point where it can harm you. It will form on anything, even dentures. For example, if you take out all of your teeth and place a sterile penny on your tongue for 24 hours, when you remove the penny it will be coated with mature, highly organized bacterial plaque.

How does tooth decay occur?

This tooth decay has gone untreated and has invaded the nerve, artery and vein inside the tooth (pulp chamber.)

This tooth decay has gone untreated and has invaded the nerve, artery and vein inside the tooth (pulp chamber.)

Tooth decay occurs when four factors come together:

  • Plaque- or acid-producing bacteria
  • Sugar or any other readily fermentable carbohydrate
  • Tooth structure (any part of the tooth)
  • Time

Once sugar is taken into your mouth and dissolved, it takes about 20 seconds for bacteria to begin acid production. Given time, undisturbed bacteria can produce enough acid to dissolve any part of the tooth. There are progressive stages of tooth decay, and a complete breakdown of tooth structure does not happen immediately. The activity of the bacteria can be interrupted (by properly cleaning your teeth) and the decay is then stopped or “arrested.”

Fortunately, our body has a built-in protection that helps: your saliva contains natural biological agents that help neutralize acid and re-mineralize enamel (see Parts of a Tooth). This was discovered in the late 1970s, when radiation therapy to treat Hodgkin’s Lymphoma  shut down the salivary glands, causing the incidence of cavities to go up. This can also be seen in patients who take medications that decrease the production of saliva.

To compound the problem there is sugar in just about every processed food in the United States. Sugar is consumed in enormous quantities in this country. This is evident not just from the mouths of patients but by the nationwide obesity and diabetes statistics.

Tooth decay in early adolescence with both adult and "baby" teeth (mixed dentition.)

Tooth decay in early adolescence with both adult and “baby” teeth (mixed dentition.)

Children and teens are more cavity-prone because they may not have the knowledge, attention span, or the necessary coordination  to effectively remove plaque from their teeth. Children, especially boys, need help on a daily basis to completely remove bacteria from their teeth. As people age (65+ years), they re-enter a cavity-prone state because they naturally produce less saliva. Remember, saliva buffers acid and re-mineralizes enamel. There are thousands of medications that cause saliva production to decrease; as use of these medications increase so does the incidence of tooth decay.

How to Prevent Tooth Decay

Brushing

Ineffective brushing, regardless of its frequency, does little to prevent the process of tooth decay. Unless you are effectively removing plaque, every time you consume sugar, the acid produced by plaque will begin work to dissolve your teeth, creating cavities.

Instructions for brushing with a manual toothbrush:

  1. The toothbrush should not be dragged back and forth over the tooth surfaces; the focus should be on removal of bacterial plaque.
  2. You need to take your time: three to five minutes.
  3. Use a mirror and watch what you are doing.
  4. When brushing the upper back teeth on the cheek side, shift your jaw towards the side you are brushing, as it will give you more room to get behind the last tooth.
  5. Develop a system whereby you will reach all areas (e.g., start at the upper right and work your way around the upper arch, then move to the inside until you finish on the upper inside. Repeat on the lower teeth).
  6. Place the brush at a 45-degree angle; make sure your brush handle is parallel to the teeth you are cleaning and the tip of the handle is on the opposite side of your nose.
  7. To effectively brush your teeth on the inside, in the front, place the brush upright and parallel to the teeth, push either the head or heel of the brush against the teeth, and jiggle it in tiny up-and-down movements. Overlap each area you are cleaning with the previous area to avoid missing any teeth. Use a “jiggling” motion; circles tend to get too big, and rolling downward or upward does not clean under the gum tissue.

Instructions for brushing with a mechanical toothbrush:

There are three points that need to be stated about using a mechanical toothbrush versus a manual toothbrush:

  1. The mechanical vibration of this type of brush does all of the “jiggling” for you.
  2. It will clean your teeth better than a manual brush can.
  3. The instructions above still need to be followed, as the toothbrush is only as good as the technique of the person holding.

Flossing

Flossing is perhaps the issue least understood by patients. If you are not flossing, live, gooey bacteria are growing between your teeth and under your gums, causing odor, tooth decay, periodontal disease (gum disease), staining, and bleeding. Why? Cleansing foods such as apples, salads, and meat have the capability to remove and interrupt the activity of bacterial plaque when you eat; however, these foods do not get to the bacteria between your teeth and below the gum line. Dental floss is required to remove plaque effectively between your teeth.

If you find flossing difficult, there are many different types of floss and flossing aids that will assist you in thorough cleansing between your teeth.

If you thoroughly brush your teeth every day, removing all the bacterial plaque that your brush can reach, but you choose not to floss, you are leaving bacteria on 40% of your tooth surfaces.

Instructions for flossing:

  1. Wrap the floss around your middle fingers; do not tie up your index (pointing) fingers. You need your index fingers to control and manipulate the floss.
  2. Seesaw the floss only to get it between your teeth.
  3. Wrap the floss around one of the two teeth it is between in a C shape and rub the side of the tooth two or three times, gently bumping into the gum tissue. Then wrap the adjacent tooth and repeat the process. Do not “seesaw” on the gum tissue.
  4. Do not forget to floss behind the last tooth in your mouth; there is a good chance that your brush did not reach there.
  5. Flossing is nothing more than cleaning between your teeth where the brush cannot reach. You are washing the sides of the teeth, much like you wash your arm or leg in the shower.

Waterpik

If used properly, the waterpik (sometimes called a water brush or water flosser) can effectively remove the bacteria between the teeth.  Adding an antibacterial mouthwash to the water reservoir increases bacterial removal.

Fluoride

Although many patients feel fluoride is “bad” for human use, fluoride is undoubtedly one  of the most highly qualified, public successes in prevention of dental disease. Is it poisonous?  Yes, as is chlorine, medication, alcohol and even water if too much is consumed all at one time. Fluoridated water contains approximately .7-1.0 parts per million and when consumed while teeth are forming reduces tooth decay by as much as 60%.

Systemic Fluoride

Systemic fluoride is the dietary consumption of fluoride so that it gets into the body’s bloodstream. The fluoride ion is laid down as enamel forms within the tooth bud (the sack where the tooth forms within the jaw). This incorporation of fluoride into the enamel prevents tooth decay and/or makes it more difficult for the bacteria to dissolve the enamel.

If the water supply where you live does not contain fluoride, your doctor should prescribe the proper supplementation of fluoride for infants and toddlers. Once your child is old enough to start seeing a dentist, usually at about the age of two, your dentist will monitor your child’s fluoride intake. The supplementation of fluoride must be monitored by your dentist to prevent enamel fluorosis (the discoloration of enamel due to a higher than recommended intake of fluoride).

Topical Fluoride

Topical application of fluoride in a gel, foam, or varnish is used to soak the teeth. Use of topical fluoride should continue as long as you have teeth. Topical fluoride “soaks” into your enamel, microscopic cracks in your teeth, and exposed root surfaces, further protecting against tooth decay. This is most important in childhood (when brushing skills are immature) and later years, (when there is a decline in saliva production.) Topical application of fluoride does not cause enamel fluorosis. Once the enamel is calcified and the tooth has grown into the mouth, the topical application of fluoride cannot harm the tooth, it can only help.

Toothpaste

Toothpaste is not a necessary ingredient to home tooth care. In other words, the thorough removal of plaque is not dependent on having toothpaste. Although toothpaste creates a more pleasant experience while removing plaque, the most important ingredient in toothpaste is the topical fluoride it provides.

Mouthwash

Mouthwash, whether prescribed or over-the-counter, is not a substitute for brushing and flossing. There are mouthwashes that kill bacteria and improve gum (gingival) health; however, alone mouthwash does not do the whole job of cleaning teeth. It is a supplemental option designed to help kill or temporarily reduce the number of bacteria.

Sealants

Sealants are a composite material that is bonded to the enamel of the tooth, predominately on the biting surfaces of back teeth. They are designed to seal deep grooves, pits, and fissures, helping in the prevention of tooth decay. If you could see these grooves microscopically, you would be able to see that a toothbrush bristle cannot reach to the very base of the groove or pit where bacteria can thrive and create decay.

Sealants close the groove, thereby eliminating areas where the bacteria can gather and do  damage, undisturbed. The re-mineralizing properties of saliva cannot reach the base of these grooves as readily as it does the remainder of the tooth; therefore, the placement of sealants in childhood is encouraged as a preventive measure.

Xylitol

Products containing Xylitol will decrease the number of damaging bacteria.  Xylitol, interferes with bacterial metabolism, temporarily decreasing bacteria reproduction.

Antibiotics

Antibiotics control the overgrowth of, or infections caused by bacteria in the teeth and gums. They do not permanently kill the bacteria that each of us has acquired over the years since infancy. As an infant you acquire bacteria passing through the birth canal. When adults test a baby’s food for temperature, they pass on their bacteria. Kissing either people or pets, or when you share drinks, you share bacteria. These bacteria come to live in our mouths and number some 10 billion strong, by far more bacteria than on any other area on the body.

Tooth decay on the root surface (left) and on the biting surface (right.) There is a very high probability of decay under the silver filling as the margins of the filling are defective (lifting).

Tooth decay on the root surface (left) and on the biting surface (right.) There is a very high probability of decay under the silver filling as the margins of the filling are defective (lifting).

In short, antibiotics cannot rid your mouth of the bacteria you have acquired over time. However, antibiotics used for mouth infections or other systemic problems may alter your oral bacteria, in some cases, cause fungus to take over. Once the fungal infection is cured and medication discontinued, your acquired oral bacteria will return to their desired level.

Conversely, when antibiotics are taken for oral infections, fungus can grow out of control in other areas of the body i.e. antibiotics taken for tooth infections can cause vaginal yeast infections.

Fluoride Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50 (RR-14):1–42. PMID 11521913. Lay summary: CDC, 2007-08-09.Up to 42% caries reduction

Fluoridation Basics
Water fluoridation prevents tooth decay mainly by providing teeth with frequent contact with low levels of fluoride throughout each day and throughout life. Even today, with other available sources of fluoride, studies show that water fluoridation reduces tooth decay by about 25 percent over a person’s lifetime.

 

Canker Sores

Overview

Canker sores (apthous ulcers) are painful sores found inside the mouth. Some patients get canker sores all the time, while others only rarely or not at all.

What to look for

Canker sores appear as white or gray ulcerations with bright red borders and are always found inside the mouth, never on the outside lip area. Although the exact cause is still unknown, both viruses and bacteria have been suggested as a cause.

They can appear following trauma, anxiety, excitement, stress, bacterial plaque on a tooth that rubs against the soft tissue of the inner lip or cheek, or acidic foods. Allergies may even play a role in the outbreak of this painful condition.

Canker sores make any movement of the mouth painful. Eating, playing a musical instrument, even talking can be affected by these ulcers. They tend to be more painful early in the morning and late into the evening. Canker sores are not contagious or precancerous and usually heal spontaneously in 7-10 days; recurrent outbreaks are common.

There are medications that can be placed by your dentist that will typically stop the ongoing pain. The treatment is uncomfortable, but will stop the day to day pain immediately.

Dental lasers are a much more comfortable treatment; lasers are highly effective in eliminating pain and shortening the healing process.

There are over-the-counter medications that contain topical anesthetic that will temporarily lessen the pain.