Who Pluck the Teeth Out.. Who.. Huh...Hu

Friday, February 22, 2008

Dental Implants

Before explaining about it, for clear perspective just grab the free book INTRODUCING DENTAL IMPLANTS By John A. Hobkirk, Roger M. Watson, Lloyd J. J. Searson from link given in BOOKS FOR YOU (See besides) in this blog.

From Wikipedia definition, A dental implant is an artificial tooth root replacement and is used in prosthetic dentistry. There are several types of dental implants; the most widely accepted and successful is the osseointegrated implant, based on the discovery by Swedish Professor Per-Ingvar Brånemark that titanium can be successfully fused into bone when osteoblasts grow on and into the rough surface of the implanted titanium. This forms a structural and functional connection between the living bone and the implant. A variation on the implant procedure is the implant-supported bridge, or implant-supported denture.


A typical implant consists of a titanium screw (resembling a tooth root) with a roughened surface. This surface is treated either by plasma spraying, etching or sandblasting to increase the integration potential of the implant. An osteotomy or precision hole is carefully drilled into jawbone and the implant is installed in the osteotomy.
Implant surgery is typically performed as an outpatient under general anesthesia or with Local anesthesia by trained and certified clinicians including general dentists, oral surgeons, and periodontists. An increasing number of general or cosmetic dentists as well as prosthodontists are also placing implants in relatively simple cases. The most common treatment plan calls for several surgeries over a period of months, especially if bone augmentation (bone grafting) is needed to support implant placements. At the other end of the surgery scale, some patients can be implanted and restored in a single surgery, in a procedure labeled "immediate function" and "teeth in an hour."
A single implant procedure that involves an incision and "flapping" of the gum or gingiva (to expose the jawbone) takes about an hour, sometimes longer; multiple implants can be installed in a single surgical session lasting several hours. At the conclusion, the patient goes through a period of recovery, returns to consciousness and is sent home with a relative or friend.
Healing and integration of the implant(s) with jawbone occurs over several months in a process called osseointegration. At the appropriate time, the restorative or cosmetic dentist or prosthodontist uses the implant(s) to anchor crowns or a prosthetic restoration containing several "teeth". Since the implants supporting the restoration are integrated, which means they are biomechanically stable and strong, the patient is immediately able to masticate (chew) normally.
In an immediate function procedure, the gingiva is not flapped (Flapless). Instead, the surgeon removes a small plug of gingiva directly over the drilling site. The site is drilled and the implant is installed. Then a crown is immediately added. Patients are cautioned to give their new "teeth in an hour" ample healing/integration time (weeks or months) before attempting normal mastication.
There are different approaches to place dental implants after tooth extraction. The approaches are:
Immediate post-extraction implant placement.
Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
Late implantation (3 months after tooth extraction).
According to the timing of loading of dental implants, the procedure of loading could be classified into:
Immediate loading procedure.
Early loading (1 week to 12 weeks).
Staged loading (3-6 months).
Late loading (more than 6 months).
Most patients need the longer treatment plan, which has an excellent history going back many years. Before surgery, with the patient fully awake or during an earlier office visit, a prudent clinician planning mandibular implants will conduct a neurosensory examination to rule out altered sensation, thus setting a base line on nerve function. Also prior to surgery, a panoramic X-ray will be taken using a metal ball of known dimension so that calibrated measurements can be made from the image (to accurately locate "vital structures" such as nerves and the position of critical anatomical features such as the mental foramen, which is the transit point in the jawbone for the nerve which innervates the lip and chin).
At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid vital structures (in particular the inferior alveolar nerve or IAN within the mandible). A zone of safety, usually 2 mm, is the standard of care for avoiding vital structures like the IAN. When computed tomography (3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures, the zone of safety may be reduced to 1 mm through the use of computer-aided design of surgical guides.
Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.
Once properly torqued into the bone, a cover screw is placed on the implant, then the gingiva or gum is sutured over the site and allowed to heal for several months for osseointegration to occur between the titanium surface of the implant and jawbone.
After several months the implant is uncovered in another surgical procedure, usually under local anesthetic by the restorative dentist or prosthodontist, and a healing abutment and temporary crown is placed onto the implant. This encourages the gum to grow in the right scalloped shape to approximate a natural tooth's gums and allows assessment of the final aesthetics of the restored tooth. Once this has occurred a permanent crown will be fabricated and placed on the implant.
An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable. This can cut months off the treatment time and in some cases a prosthetic tooth can be attached to the implants at the same time as the surgery to place the dental implants.
In all of these approaches, computer-based guidance has thrust itself onto the treatment stage. Not only will 3D digital imagery yield critical treatment guidance, the digital data can be used to manufacture precision drilling guides, virtually eliminating surgical errors.

Complementary procedures

Sinus lifting is a common surgical intervention. The trained general dentist, oral surgeon, or periodontist thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance and as a result creates a better quality bone site for the implantation.
Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height -- which is very difficult to achieve -- is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth. If an implant is too shallow, chewing may cause a dangerous jawbone crack or full fracture.
Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or better cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.
A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bonelike substances (calcium sulfate with names like Regeneform; and hydroxyapatite or HA, which is the primary form of calcium found in bone). The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason.
Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity. Then the gingiva is carefully sutured over the site. Together with a course of internal antibiotics and external antibiotic mouth rinses, the graft site is allowed to heal (several months).
The clinician typically takes a new panoramic x-ray to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predicts success in the third dimension, depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam X-ray may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same X-ray data set can be employed for the preparation of computer-designed placement guides.
Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.


For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases, what must be addressed is the functional aspect of the final implant restoration, the final occlusion. How much force per area is being placed on the bone implant interface? Implant loads from chewing and parafunction can exceed the physio biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.
The restorative dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reversed engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist consults with the oral surgeon, trained general dentist, or periodontist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the surgeon's request, and are used as physical aids to treatment planning. If not supplied, the surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CAT scan to achieve the proper treatment plan.

Computer simulation software based on CAT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereo lithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. Software products like Materialise' SimPlant (simulated implant) use the digital data from a CAT scan (such as an iCAT or a NewTom) to provide extremely accurate simulations that are easily understood by patients. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides.

Success rates

Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and also to the patient's oral hygiene. Various studies have found the 5 year success rate of implants to be between 90-95%. Patients who smoke experience significantly poorer success rates.


Failure of a dental implant is often related to failure to osseointegrate correctly. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (after implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2mm a year thereafter.
Dental implants are not susceptible to dental caries but they can develop a periodontal condition called peri-implantitis. The cause may be infection that was introduced during surgery; or failure by the patient to follow correct oral hygiene routines. In either case, inflammation in the bone surrounding the implant causes bone loss (recession) which ultimately may lead to failure, often evidenced by the ability to "spin" an implant.
Peri-implantitis is often dealt with pre-emptively by clinicians who prescribe a course of antibiotics in the days prior to surgery; and post-surgically with another course of antibiotics and special oral rinses. Since peri-implantitis is generally easy to see on standard panoramic and periapical X-rays, prudent clinicians who suspect the problem will take an X-ray soon after surgery, and again at staged intervals post-operatively.
Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

There are no absolute contraindications to implant dentistry, however there are some systemic, behavioral and anatomic considerations that should be considered.
Particularly for mandibular (lower jaw) implants, especially in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN). The standard of care for mandibular implants calls for 3D or cone beam X-ray imaging (computer assisted tomography) because 3D enables precise measurements to 0.1mm, followed by precision treatment planning with computer-designed surgical guides.
Patients should be referred to an appropriate cone beam imaging center if 3D is not available in the implantologist's practice. Cone beam systems (brand names include iCAT, NewTom, Accu-i-Tomo and TeraRecon) have been widely available in developed nations since 2001 or earlier. Many hospitals have dental modules for their multi-slice CT systems, since the mid 1980's, for example the current GE Lightspeed and Philips Brilliance systems. And, companies who supply in-office X-ray systems are beginning to offer value-priced cone beam systems, such as the Planmeca Promax 3D, as clinicians fully recognize their utility as the gold standard and standard of care for certain cases in everyday use.
Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.
Lack of sufficient alveolar bone is another contraindication to the procedure. Typically, a preoperative in-office panoramic X-ray is taken to establish (with allowances for image distortion, a known problem with panoramic X-rays) in two dimensions (height and width) the amount of available bone. A bone graft or augmentation procedure, sometimes called guided bone regeneration may be performed and allowed to heal several months before implantation surgery. A new panoramic X-ray will help determine if the graft was successful.
This is an important step inasmuch as improved bone height is much more difficult to achieve than increased bone depth. For mandibular grafts, a 3D or cone beam X-ray enables measurement of bone height (top to bottom), width (left and right) and depth (front to back) to an accuracy of 0.1mm. The precision of cone beam has stimulated a new industry that produces computer-designed surgical guides based on the cone beam X-ray's digital data. These surgery aids are employed by implantologists to precisely locate and drill into the mandible and maxilla, and to avoid vital structures.
Uncontrolled type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.
There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.
The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may be advised to stop the administration prior to implant surgery, then resume several months later. But this protocol may not be necessary. As of January, 2008, an oral bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms." (JOMS, Volume 66, Issue 2, Ppgs 223-230).
The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health," (JADA, Vol. 137, page 1048, July 2006.) In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June, 2006. The overview may be read online at ada.org but it has now been superseded by a huge study -- encompassing over 700,000 cases -- entitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants. (JADA, January 2008, 139:23-30).
Bruxism (tooth clenching or grinding) is another contraindication. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient. Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night.
Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chin -- usually noticed after surgical anesthesia wears off -- is another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

Thursday, February 21, 2008

Oral Pathology

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Wednesday, February 20, 2008

Dental Technology

Thanks to new dental technologies, modern dentists can treat patients more quickly, more efficiently and more comfortably. Some technologies have eliminated the use of drilling. Other technologies allow dentists to make vast aesthetic improvements to a patient’s smile in half the normal time. And even more exciting are the developments that will enable patients to grow new teeth, perhaps permanently eradicating the need for drilling or filling!

Genetic Engineering May Grow New Teeth
The human genome project involves identifying the three billion chemical base pairs and 50,000 to 100,000 genes that are contained in the human genome (all of the genetic material that makes up a person). This information may help to prevent and cure diseases, and may also aid other scientists that seek to "grow" new teeth in the future. Mary MacDougall, Ph.D., associate dean, Dental School, University of Texas Health Science Center at San Antonio, says she, along with colleagues, has been studying the dynamics of tooth formation and conducting laboratory research to eventually grow human teeth. To understand the research, we need to know a little bit about the anatomy of the tooth. A tooth is hollow like our bones, and is composed of several layers. The outermost layer (above the gum line) is called the enamel. Enamel is the hardest and most mineralized substance in the body. Beneath the gum line a substance called cementum covers the tooth roots. Under the enamel and cementum is the dentin. Beneath the dentin is the dental pulp. The pulp is a vascular tissue composed of capillaries, larger blood vessels, connective tissue, nerve fibers and other cells. Dr. MacDougall's research uses genetically engineered mouse and human cell lines to form these three outer layers of the tooth, the enamel, cementum and dentin. The goal of the research is to grow teeth remotely in culture for transplantation or locally within the mouth itself. The benefits of this research would be incredible for people with missing teeth. Teeth that are lost due to extensive cavities, gum disease or accidents could be replaced with new, genetically created ones. Instead of having to wear dentures or rely on synthetic titanium implants, a person could have real, natural teeth either reimplanted or regrown in place of the missing ones. Although the practical applications of this research may be many years into the future, the idea of growing new teeth is an intriguing one. Just a few decades ago, dental implants also seemed like a far fetched way to replace missing teeth. Now, it is common practice in dentistry. Who knows what else will be common practice in dentistry just a few decades from now?

Keeping Dental Waterlines Clean
Dental unit waterlines supply the water used during dental treatment. The water is used most often in high-speed drills, the air-water syringe, and the Cavitron® (which cleans teeth and gums). Water both cools and helps clear away debris when a high-speed dental drill is preparing a tooth. The potential problem with the waterlines is that they become colonized with microorganisms, and develop a biofilm within the narrow tubing. This potential problem has been the subject of serious controversy over the last few years. The question is, is it much ado about nothing? Normal drinking water is usually allowed to have up to 500 colony forming units (CFU's) of bacteria per milliliter, but is often found to have many times that amount when entering homes due to colonization in the water pipes. Water found in drinking fountains, water coolers and presumably "pure" bottled water have been found to have thousands of CFU's per milliliter. A glass of water from a kitchen faucet sitting stagnant at room temperature is often teeming with bacteria due to microbial bursts that exponentially increase the numbers of bacteria. The amount of bacteria found in dental unit waterlines varies, depending on the methods used to reduce it. What most people want to know is, "What is the risk of contracting an infection from the water used in dental treatment?" The risk for getting an infection from the dental waterlines is probably very low, although nobody really knows for sure. People are exposed to potentially high concentrations of bacteria-laden water all of the time from many different sources, so specifically citing the dental waterlines is impossible. Also, modern dental techniques (e.g., high-speed evacuation of fluids; rubber barrier for treatment; having patients spit the water out during treatment; relatively few visits to the dentist for an average person each year) greatly limit the amount of water patients are exposed to during dental treatment. Research has shown that about 60 milliliters (2 oz.) of water is used for a typical dental visit, and more than 90 percent of that is usually removed (not ingested) using the above methods. It is also important to remember that the mouth and gastrointestinal tract contain millions of bacteria, many of which are both beneficial and necessary for life. Other bacteria, of course, are associated with infectious diseases and should be avoided. There might be a higher potential risk for a person with a weak immune system (e.g., those that have diseases like AIDS, severe and uncontrolled diabetes, or are being treated with chemotherapy for cancer) when they are exposed to any colonized water, including dental waterlines. The ADA does not cite any documented cases of people contracting dental infections from the waterlines. The second question people ask is "What methods can dentists take to reduce the bacteria used in dental treatment?" Dentists routinely take many measures to reduce the bacteria in dental water used during treatment: - Use of high-speed suction to remove water during treatment. - Having patients spit out excess water during treatment. - Use of a rubber barrier (rubber dam) for some procedures to prevent water from getting into the mouth in the first place. - Flushing out water from the dental lines for several minutes at the beginning of each day. - Running the drill for a half a minute after each use. - Having proper maintenance of the waterlines. Other procedures, such as the preparation of crowns (caps) and dental cleanings, cannot be done using a rubber barrier. Some companies have created products to reduce the bacteria in the waterlines. All of the options have limitations and take time and money to implement: - Using filters for the water. - Using chemicals to disinfect the dental lines (e.g., diluted bleach 1:10, glutaraldehyde, food grade ethyl, alcohol, chlorhexidine-based products). These chemicals may be more harmful than the bacteria if ingested. - Using a combination of ozone and silver ion catalyst to disinfect the dental lines. The manufacturers of dental units have known about this problem for years and have done nothing about it. Having waterlines supplying the dental unit is a design flaw that these manufacturers should have addressed, but did not. The ADA has encouraged the manufacturers to help solve the waterline problem and has made some suggestions, such as having an independent water supply for dental drills and other equipment. Dentists may need to take steps to address this potential problem while the public and organized dentistry is urged to put pressure on the manufacturers of dental units to solve the problem that they helped to create. There are some new products on the market that have tested well and may eliminate nearly all bacteria from the lines. In my office, I filter the water and use ozone, coupled with silver halide catalyst, to disinfect the dental lines. Dentists will continue to safeguard the well-being of their patients while encouraging the dental unit manufactures to create dental units that address the waterline issue. The ADA recommends that all water used in dental treatment have a maximum of 200 CFU's per milliliter (the standard used in kidney dialysis).

Lifesaving Equipment for the Dental Office
Part of every dentist’s training is what to do in a medical emergency. This is necessary because dentists are treating patients with potent anesthetics and are often doing surgical procedures (removing teeth, gum surgery, biopsies and root canals). Some patients are also coming to the dentist with a high degree of emotional stress or poor general health. All of these factors can increase the risk of a medical emergency in the dental office. One of the most dangerous types of emergency involves the cardiovascular system, especially heart attack and sudden cardiac arrest. Until recently, dentists could do precious little to treat these life-threatening emergencies in a typical office setting. Now, a relatively new device called an Automatic External Defibrillator (AED) is available that can often prevent death from sudden cardiac arrest (SCA). SCA is responsible for about 350,000 deaths each year. Unlike a heart attack where there are usually telling symptoms (e.g., chest pain, pain radiating to the left arm or nausea) and there is often time to get to the hospital for treatment, SCA strikes quickly and usually without warning. SCA is caused by an abnormal heart rhythm (often ventricular fibrillation), which causes the heart to quiver chaotically, unable to deliver the necessary oxygen to the body. Typically, the person loses consciousness in seconds. SCA can happen to anyone, at any age, and at any time, but increasing age and previous heart problems amplify the risk. When SCA occurs, the person will usually die in a few minutes unless the heart can be “shocked” into a normal rhythm. The AED can deliver this lifesaving shock in seconds and is considered preferable to the older defibrillators that were more cumbersome, required more training, and were more expensive. The speed at which the AED is applied is also of critical importance, because every minute that goes by after SCA occurs reduces the likelihood of preserving life by 10 percent. Here’s an overview of how the AED works. When a person suffers from SCA, you first call 911, and then quickly get the 4.5 pound AED and turn it on. From that point on, the device tells you what to do. You put the self-adhesive pads on the person’s bare chest and the AED “reads” the heart rhythm. If the device decides that the person will benefit from a shock, it says, “Shock advised, stay clear of the patient” and you push a button. In the majority of cases, one shock is all it will take to return the person’s heart to a normal rhythm and often help save a life. Finally, you monitor or assist (if necessary) the heartbeat and breathing as you wait for the ambulance to arrive. AED’s are turning up in many places, including airports, casinos, shopping centers, stadiums and in offices. An AED can be used by almost anyone, and requires almost no training. With its ease of use, obvious importance, and relatively low cost (less than four thousand dollars), there is little reason not to have one in the dental office. I would urge dentists, other health professionals, as well as other business owners to purchase an AED. Remember, the life you save could be your patient’s, your client’s, or even your own.

Air Abrasion Takes the Fear Out of Treating Cavities
Air abrasion is a relatively new technology used for treating cavities that can often eliminate the need for an anesthetic injection and the dental drill. Air abrasion works like a precise sandblaster, where tiny, harmless particles of aluminum oxide are propelled against the tooth, removing a cavity. Although the concept of air abrasion originated decades ago, only recently have advances in technology and modern dental filling materials sparked new interest in the method. You may be thinking, "No needle, no drill, this is too good to be true. How come every dentist in America isn't using air abrasion?" The reason is that air abrasion can only be used for a limited number of procedures, and its cost is relatively high. Air abrasion is primarily used for treating small to medium sized cavities, preparing teeth for protective dental sealants, and removing stains on the surface of the teeth. Air abrasion prepares teeth that are ideal for the placement of the white "resin" fillings, and is not often used with silver (amalgam) or most other dental materials. Air abrasion cannot be used for preparing crowns, shaping the roots during root canal therapy, gum treatment, removing soft decay found in deep cavities and other procedures preformed in the dental office. One of the advantages of treating cavities with air abrasion is the conservative nature of the procedure, where only a small amount of the tooth is removed at a time. A small to medium-sized cavity can usually be treated without anesthesia in minutes, silently (no disquieting whistle of the dental drill), and with little or no discomfort. There is a powdery residue after treatment, which is usually suctioned out or limited with the use of a rubber barrier, or dam, during treatment. Most patients find the powder residue less of a nuisance than the buildup of fluids that sometimes accompanies the use of a dental drill. In my office, I use air abrasion for patient treatment about 15-20 percent of the time. I have found that air abrasion is most useful with anxious patients and children. Patients that are fearful are relieved if their cavities can be treated painlessly and without a needle or drill. Children who are often apprehensive about many aspects of dental treatment are thrilled with the air abrasion alternative. Although air abrasion is not a panacea, it is certainly a useful addition to modern dental treatment, and a must for every dental office interested in patient comfort.

Micro-Abrasion: Comfort Dentistry
The 21st century has come to dentistry. Innovations for dental health, comfort and beauty abound. This includes advancements in lasers, tooth bleaching, porcelain veneers, implants and the types of filling materials used which greatly reduce sensitivity after placement. In this article I would like to enlighten you on a revolutionary process in restorative and preventive dentistry called micro-abrasion. This process of micro-abrasion is making dental visits better for adults and children, and, if diligently followed, will lessen the dental problems of our children later in life. Specifically, it will reduce the widespread need for root canals and crowns we see in the baby boomers and older. You will understand why most dental problems in adults are of the major variety and stem from teeth that were filled as youngsters. Here’s why I think this is the most exciting thing I've seen in my 20 years of dentistry: Early fillings to restore decayed teeth date back to the Phoenicians who pressed gold into teeth over 2000 years ago. Silver amalgam dates back to the Civil War era, and today, is still widely used due to its strength and wearability. The newest materials are tooth-colored resins (composites) and porcelains that are made to adhere to the tooth. The fact that they are "glued" to teeth makes them unique. These fillings, when of reasonable size, restore the tooth to its original strength, whereas silver amalgam tends to cause teeth to fracture over time. The reason for this is simple. Amalgam contains about 50 percent mercury. Mercury is used in thermometers because it expands and contracts as temperatures change. In the tooth the silver filling expands and contracts about three times as fast as the tooth structure it sits in. Also, amalgam is soft; it creeps and crawls under chewing forces. All this results in cracked teeth. The larger the filling the worse the problem. I would say that over 90 percent of the teeth that need crowns or root canals (major work) have had a silver filling in them. Mercury toxicity is also a worry of some people, but I believe this is insignificant. You get more mercury from your tuna sandwich than from your fillings. Yet, if you have a viable option that eliminates exposure - why not? The traditional amalgam filling requires that a sufficient amount of tooth structure be removed-healthy or not-to make the filling large enough to be strong. You must also use the dental drill to "undercut" healthy tooth structure in order to lock the filling in place. As dentists, we know that even if the decay is small you can't make the silver filling too shallow or narrow or it will break. All these requirements also weaken teeth. For the last eight months, I have been removing decay and restoring teeth with "micro-abrasion." Micro-abrasion is a fine stream of air and tiny sand particles that gently removes decay. This will never completely eliminate the drill, but when it is appropriate to use, micro-abrasion is far superior to drilling. The drill removes tooth and decay by spinning a drill bit (better called a bur) at 300,000-400,000 rpm. The flutes of the bur hit the tooth and cause microscopic cracking, heat and vibration. This all points to the need for numbing teeth. Micro-abrasion cleans the cavity like a small sandblaster with no cracking, heat, vibration, or, usually, numbing. Some patients report a cold sensation, but none ever ask to be numbed. Now you should be able to see how a minimally invaded micro-abraded tooth filled with a composite bonded restoration is the best way to maintain the structural integrity of a tooth for the years ahead. The most ideal use of micro-abrasion is treating decay in children's teeth. When you look at back teeth you notice they are loaded with fissures and pits on the biting surface that tend to gather brown stain. This is where teeth are most susceptible, as the fissures are too narrow to let in one toothbrush bristle, but plenty big for a stadium full of bacteria. These bacteria eat the foods we eat and excrete acids, which cause the fissures to deepen and turn into true decay. Stopping this process is the rationale for sealants. Sealants are liquid resins placed in tooth fissures optimally in the first two years after eruption. This resin is hardened, thus sealing the fissures and preventing bacteria from residing therein. The ages 6 and 12 years are key periods for sealants. Typically sealants are done by painting the fissure with a mild acid to roughen the surface just enough to hold the sealing resin. Researchers have found that as many as 60 percent of sealants done this way fail in too short a period. This is because the acid doesn't remove debris or bacteria that, inevitably, are hiding deep in the fissure. This is where micro-abrasion shines as it cleans all the crud out of the groove before the sealant is placed. Furthermore, as I am cleaning the debris out of the fissure, I can watch as I follow the stain down the crevice until it's entirely gone. Lo and behold, in many teeth we find the stain goes all the way to the underlying dentin, where it spreads rapidly. At that point the tooth is getting a needed filling instead of just a sealant. I never would have known the tooth was decayed unless I had used micro-abrasion. This scenario shows a common shortcoming of conventional sealants because it is easy to seal over decay that the dentist would not suspect to be under the fissure. Common sense tells us that the sealant won't stick to crud. By the way, the patient rarely knows I've gone from sealant to filling because microabrasion is so painless. This leads to my next related topic. Fluoride has dropped the decay rate in children's teeth greatly, but by no means has eliminated it. What fluoride has done is change the appearance of decay. The way fluoride works is to be incorporated in the tooth's enamel while it is forming deep in the jaws. Fluoride makes the enamel less soluble, like turning it from chalk to marble. This is why fluoride has reduced decay on the smooth surfaces of the tooth, but it has done nothing for the pits and fissures. By understanding the decay process in fissures as I described above, you can see why the result is that the hole in the top of the tooth is tiny, while the decay may be raging under the enamel. Those of us older than 25 years old may remember the dentist probing teeth and when the explorer "stuck" he'd found decay. Now, dark stains in the groove and, especially, a shadow under the enamel are more diagnostic. The stickiness is gone! Instead, a hard brown plug is present and it's difficult to tell stain from active decay. Fluoride has changed the look of decay! In my opinion, the only way to diagnose incipient decay in fissures is with micro-abrasion. As you may gather, micro-abrasion is excellent for pit and fissure decay in early stages. It makes a sealant that is second to none. It's also wonderful for removing old tooth-colored fillings. It's not recommended for removing metals such as old amalgams. Amalgam is actually too soft -- the sand particles hit it like mush. Neither could a dentist reduce a tooth for a crown using micro-abrasion. We also still use rotary drills to polish the resins, so the whine of the dental drill is not gone -- just a lot of the anxiety.

Futuristic Dental Procedures Are Already Here
Cutting edge research and high-tech gadgetry will dramatically change the way dental care is delivered in the next century, say dental researchers. "Dental offices already are becoming the scene of many new technologies that permit more complex and improved dental treatments," says Trucia Drummond, D.D.S., a general dentist. "Dentists love new gadgets -- anything that makes treatment easier for our patients." Dr. Drummond says intra-oral cameras are a classic example how technology can improve dental care. "A small wand with a miniature video camera is inserted into the patient's mouth, where it transmits a signal to a television monitor next to the dental chair," she says. "The dentist can use the image to explain a condition or procedure to the patient, or store it on a videocassette to track a particular condition over time." Many dentists have this equipment in their offices now, says Dr. Drummond. He lists some other advances that are on their way. - Lasers -- Already used for some soft tissue applications such as removing lesions, and for tooth whitening purposes, many dentists feel they will used to zap tooth decay, precluding the need for tooth restorations or fillings. - Digital Radiography -- This technology uses a tiny intra-oral sensor that replaces conventional X-ray film, sending images by wireless methods directly to a computer screen. They can be viewed immediately or stored on a hard drive. This technology greatly reduces patient exposure to radiation. - Kinetic Cavity Preparation -- Also called "air-abrasive technology," this procedure occurs when tiny aluminum particles are carried by a stream of air, spraying away decay without the sound of the drill, vibrations or local anesthetic. - Electronic Dental Anesthesia -- By attaching electrodes inside the mouth, the dentist can use electric pulses to alleviate nerve sensation during common restorative procedures. - Bonding and Adhesives -- These materials allow tooth and veneers, for example, a better fit, resulting in minimal drilling, greater strength, tighter seals, and more natural color blending with the tooth. - Dental Implants -- They have been used for 30 years, but now there are better ways of fastening dentures or a single tooth that may have been knocked out in an accident. Some implants stimulate bone to attach to the implant post, resulting in a stronger hold. - Computer Charting -- Manual charting will give way to computerization. Thanks to dental software packages, microphone headsets, electronic probes and light pens, dentists and hygienists are not hampered by paper or pencils during the dental examination.

New and Improved Dental Procedures
Many people avoid dental care because of bad experiences they have had. As a result, some people may not have seen a dentist for 15 or 20 years or more. What these people should know is that dentistry has been literally transformed in the last 10 years. The most notable and important changes have been in the science and technology used for the reduction of pain, improvement of root canal therapy, replacement of teeth with dental implants, and the revolution in cosmetic dentistry, specifically porcelain veneers and the white, resin fillings. One of the most important changes is the improvement in local anesthesia. Years ago, dentists used the local anesthetic Novocain, and many people still associate it with what the dentist uses for "the shot." Novocain is rarely used today because it causes a much higher incidence of allergic reactions. The most common anesthetics used in dentistry now are lidocaine, bupivacaine, mepivacaine, septocaine and others, which may still cause an allergic reaction. Septocaine, a recently approved anesthetic, may be stronger than the other local anesthetics and allows most dental procedures to be performed painlessly. In an effort to reduce discomfort during dental procedures, today's dentist can use either air abrasion or a dental laser. These modern devices enable dentists to treat many cavities without a needle or a dental drill. Some dental lasers can also treat the gums and do other more advanced procedures with less discomfort during and after the treatment. Perhaps one of the most improved dental procedures in recent years is also the most feared -- the root canal. New techniques have greatly reduced the time needed to perform a root canal, and also greatly limit the potential for discomfort. In almost all cases, root canal therapy can be effectively completed in just one visit. The average time needed to complete a root canal varies, but is usually between 30 and 60 minutes. This is possible because the new systems use nickel-titanium dental files that can be mounted on a slow speed dental drill. The older methods of performing root canal would involve the manual use of dental files that would often necessitate three grueling, one-hour visits. Modern methods and technology have greatly improved most dental treatment and may provide a pleasant surprise for those who have avoided dental care for many years.

New Technology Improves Dental Office Visits
In an effort to reduce discomfort during dental procedures, today’s dentist can use either air abrasion or a dental laser. These modern devices enable dentists to treat many cavities without a needle or a dental drill. Some people avoid dental treatment because of bad experiences they had in the past. An unpleasant incident can sometimes make a person stay away from dental care for many years. Over time and without care, teeth can break, become decayed and infected. Gum disease can erode bone in the jaw that supports the teeth, making them loose. Those who have not been to the dentist for a long time may not realize that, a trip to the dentist today is far better than it used to be. Dentists and their patients both benefit from new technology aimed at making treatment more tolerable, better looking and longer lasting. One of the most important changes in recent years is the improvement in local anesthesia -- what the dentist uses in the injection to get their patient numb. The most common anesthetics used in dentistry now are lidocaine, bupivacaine, mepivacaine, septocaine and others. Septocaine, a recently approved anesthetic, may be stronger than the other local anesthetics and allows most dental procedures to be performed painlessly. In an effort to reduce discomfort during dental procedures, today’s dentist can use either air abrasion or a dental laser. These modern devices enable dentists to treat many cavities without a needle or a dental drill. Some people may remember the unpleasant tasting material their dentist used to take an impression or mold of their mouth. New impression materials are actually flavored, an important step to help improve the experience of many dental procedures. Some people who have had “bondings” or tooth-colored fillings in the past may have been disappointed if they are discolored. Tooth-colored fillings used today are much better able to match and blend in with the tooth. These newer fillings rarely discolor, and can create a realistic and cosmetic result that lasts for many years. The procedure that has benefited most from new technology is porcelain veneers. Porcelain veneers are custom-made porcelain wafers that the dentist places over the fronts of the teeth to enhance their appearance and repair damage. They can be used to improve a wide variety of cosmetic dental problems. They can whiten stained or discolored teeth, close gaps between teeth, "correct" a crooked smile without the need for braces, repair chips and imperfections, and create a more attractive or youthful looking smile. This new generation of porcelain veneers are durable, beautiful and natural in appearance, and do not change in color over time. These are just a few of the advancements in dentistry over the last several years. Although the dental office is unlikely to make anyone’s list of favorite places, new techniques and materials vastly improve today’s trip to the dentist.

The Benefits of New Dental Technology
Technology is revolutionizing the dental office and is making dental care safer, more efficient and less fearful for the dental patient. "The intraoral camera is an excellent example," says Barry Freydberg, D.D.S., a general dentist. "The intraoral camera is a miniaturized camera that allows patients to view the inside of their own mouths live. It's a wonderful device and patients love it. It's a wonderful way to educate the patient because they can see what problems they have with their own eyes." Combined with imaging software, tooth defects can be corrected on the computer screen. "A patient can see their teeth straightened, a gap replaced by a new tooth, or see the results of tooth whitening," says Dr. Freydberg. "Patients can see how they look with a new smile. Plus imaging is a great diagnostic tool for the dentist." During his presentations, Dr. Freydberg will explain how intraoral cameras have value in a dental practice, plus he will discuss the following dental technology: - Digital Radiography -- "This technology involves a sensor wired directly to a computer," says Dr. Freydberg. "When placed in the mouth of a patient, it delivers digital images for diagnosis, much in the same manner as X-rays, but with much less radiation. It's much faster than X-rays too." - Management Software -- "We're seeing a lot of software that computerizes appointment books, insurance forms, clinical records and bookkeeping," says Dr. Freydberg. "Electronic clinical charts are tied to administrative records for easy updating of appointments and insurance forms." The new technology extends to the reception area. "Some dental offices have incorporated computers into their reception rooms that provide educational experiences for patients," says Dr. Freydberg. "If you touch the screen, you can learn about different types of treatments and how procedures are done. Better-educated patients are more likely to participate in their own care, creating a partnership of care." Computers and new computer-driven technology do not depersonalize the relationship between doctor and patient. "Quite the contrary," says Dr. Freydberg. "They allow more effective scheduling; they allow more personalized follow-up for treatment; they consolidate information; and they educate the patient. But the big plus is that they allow the dentist to provide better treatment. They are going to revolutionize dentistry and the sooner the better." Footnote

Dental X-Rays
X-rays are high-energy photons that have more energy and a shorter wavelength than ordinary visible light. They are called X-rays because Röentgen, the man who discovered them, didn't know what was going on or why. Ordinary light cannot pass through people because ordinary light does not have enough energy. Photons pass through substantial thickness of matter only if they have high enough energy. Some of the rays stay in the body. Some X-rays have to remain in the body because if no X-rays were absorbed, the image would come out white without any detail. The light and dark spots come from when you expose a photographic plate to X-rays. The plate starts off whitish, and when X-rays strike the plate, that section of the plate gets darker. In dental X-rays, metal fillings appear white because the metal is very dense. Bones appear lighter on the image because bone is denser than the rest of the body. Having X-rays taken a couple times a year is not harmful. However, your dentist will cover your body with a lead-lined apron to protect your body from unnecessary X-rays. Low doses of X-rays cause a negligible increase in the risk of cancer. However, dentists and their staff are exposed to X-rays several times each day, which is why they leave the room when they take an X-ray. You may also notice that the dental team wears a radiation badge, which measures the level of radiation to which they have been exposed. This is all part of your dental office's standard safety program. Finally, the doses of X-rays used in the dental office are very low. You are given just enough so that you dentist can see what is going on inside of you without jeopardizing your health. Remember, if you have any questions about X-rays, talk to your dentist. He or she will be happy to address your concerns.

Dental X-Rays and Digital Technology
Dental radiographs, or X-rays, are an important part of a thorough dental examination. A full set of X-rays (18) is usually required for patients who are new to a dental practice, or who need extensive treatment. Two to four follow-up or check-up X-rays called "bite-wings" are necessary every 6-18 months, depending on each individual patient’s needs. The most common questions concerning dental X-rays deal with: why they are needed, the amount of radiation exposure, the safety during pregnancy, and recently, the benefit of digital X-ray technology. Dental X-rays are important for many reasons. They can expose hidden dental decay; reveal a dental abscess, cyst or tumor; show impacted or extra teeth; and also help determine the condition of fillings, crowns, bridges and root canals. Dental X-rays can also reveal bone loss from periodontal (gum) disease, locate tarter buildup, find foreign bodies within the gum or bone, and see if there is enough bone for the placement of dental implants. These are just some of the many reasons why dentists rely on dental X-rays. Some people worry about their exposure to radiation during dental X-ray procedures. This is very understandable in light of the relatively high radiation of some medical X-rays. They may remember a doctor in the emergency room asking them or a female family member if they are pregnant because they need to take a chest X-ray or an upper gastrointestinal (GI) series. Patients who have had cancer may also have a heightened sense of awareness about the radiation that they are receiving at the dental office. Dentists are very concerned about minimizing the amount of radiation a patient receives at the dental office. That’s why we use special high-speed film, and cover patients with a lead apron during X-ray procedures. You will be happy to know that 18 dental X-rays deliver 56,000 times less radiation to an unborn child than an upper GI series, 800 times less radiation than a chest X-ray, and 40 times less radiation than a typical day of background radiation. Dental X-rays are both safe and effective, and can be used during pregnancy. One new dental technology involving dental X-rays is digital X-rays. They offer the advantage of an 80 percent reduction in radiation, no need for film or processing chemicals, production of a nearly instantaneously image, and the ability to use color contrast in the image. The main disadvantage is the cost. Digital X-ray units presently cost 3-5 times more than conventional units, and the quality of the image is not any better than film. The speed in which a dentist gets to see the image is about three seconds, but with fast developing chemicals, a conventional X-ray can be developed in about 15 seconds. The digital unit does reduce exposure to radiation, but the amount of radiation is so low that the benefit is very slight. Dental X-rays are an important tool in the diagnosis and treatment of dental problems. They do not, however, replace the need for a visual examination of the head, neck, TMJ and oral cavity. It is only with a combination of both the X-ray and the visual examination that the dentist can best treat his or her patients.

Panoramic X-Rays Show Dentists the “Big Picture”
Dental X-rays, also called radiographs, are an important tool for the dentist. The three most common types of dental X-rays are the bitewing, periapical and panoramic X-rays. Bitewing X-rays are those that are taken during most routine dental check-ups and are useful for revealing cavities between the teeth. Periapical X-rays show the entire tooth, including the roots, as well as the bone surrounding them. These X-rays are useful in helping to diagnose an abscessed tooth as well as periodontal (gum) disease. The third type of X-ray commonly used in dentistry -- the panoramic X-ray -- gives a broad overview of the entire mouth. This X-ray supplies information about the teeth, upper and lower jawbone, sinuses, and other hard and soft tissues of the head and neck. One advantage of the panoramic X-ray is its ease of use. Unlike other X-rays where the film is placed inside the patient’s mouth, the panoramic film is contained in a machine that moves around the patient's head. Some people may be familiar with the panoramic X-ray because it is usually taken when the wisdom teeth are being evaluated. The X-ray will also reveal deep cavities and gum disease, but it is not as precise as bitewing or periapical X-rays. The panoramic X-ray has many other applications, including evaluating patients with past or present TMJ or jaw joint problems; those who require full or partial removable dentures, dental implants, or braces; those who are at risk or suspected of having oral cancer or other tumors of the jaw, have impacted teeth (especially wisdom teeth) or have had any recent trauma to the face or teeth (e.g., can help identify a fractured jaw); and for those who cannot tolerate other types of films (severe gaggers). The panoramic X-ray can also identify some not so common problems, such as calcification within the carotid artery that may indicate the potential for a stroke. In one unusual situation, I can recall a patient who mentioned that he had suffered for years with recurrent sinus infections. I took a panoramic X-ray that revealed an infected tooth -- upside-down and stuck in his sinus! The panoramic X-ray is an important part of a thorough dental examination. I usually recommend a panoramic X-ray once every five to seven years for most patients. Although the panoramic X-ray does not provide as much detail when evaluating the teeth and gums as other dental X-rays, it can pick-up potential problems that the other X-rays cannot.

Using X-Rays to Diagnose Dental Problems
X-rays are a vital aspect to dental diagnosis and treatment. Many potentially injurious conditions would go undetected were it not for the regular utilization of X-rays. Modern X-ray film, equipment and technique make dental radiation safe and effective tools to ensure optimal dental health. For example, an X-ray of a patient who hasn't been to a dentist in two years can reveal a build-up of calculus and tartar. The calculus is visible on the X-ray as wisps or thorns projecting from the sides of the teeth underneath the gums where you cannot see them. These “thorns of calculus” are a major cause of puffy and bleeding gums (gingivitis), which leads to bone loss and periodontal disease. A dental prophylaxis (cleaning) can make your teeth brighter and squeaky clean once again! Necrotic Tooth -- A Tooth in Which the Pulp (Nerve Chamber) Has Died Though many teeth which die do not discolor, a dark purple area of a tooth seen on an X-ray indicates that the pulp of the tooth has died, likely due to a cavity or other trauma. Such a tooth needs root canal or other treatment in a timely manner to prevent extensive infection and abscess. Once a tooth has died, it tends to become brittle and will eventually break down without proper treatment from your dentist. Since the tooth has died, it may not feel sensitive to the patient and is often ignored. As a dentist, I routinely see patients who have broken off the entire crown of a necrotic tooth! Though the tooth may still be saved after it has broken off, unfavorable fractures may require extraction. A dark shadow around the root of a tooth indicates a tooth abscess (infection) or other pathology.

Why All the Fuss About Digital Radiography?
Each year dentists are bombarded with literally millions of dollars in paid advertising about digital radiography. Headlines you read might look like these: The Paperless Practice, Prepare for Real-Time Insurance Approval of Radiographs and Real Dentists Don’t Dip Anymore! The purpose of these ads is to entice you into spending large sums of money on the latest evolution in dental diagnostics. The facts are impressive: 1. There is a 90 percent reduction in the amount of radiation needed. 2. There is greater ease in storing each radiographic document in a permanent condition over the years, giving the dentist the ability to compare a sequence of the patient condition. 3. Making digital radiographs takes less time and has instant review capability by the doctor and the patient. 4. It is possible to use computer enhancement to better utilize the digital information for diagnosis. But, the biggest reason for using digital dental radiographic technology rests in your darkroom. The caustic chemicals used to develop and fix conventional radiographs are currently mixed with water to dilute them, and then flushed into the sewer systems all across America, but not for long. The Environmental Protection Administration is targeting dentistry to reduce, if not eliminate, dental office pollution that is beginning to tax our world’s water supply. Some people are even questioning patient saliva as a possible toxic material. So if you want to be really creative in your practice of dentistry, make the technological changes in your office before the Feds change the rules. If we clean up our own act based upon our care for the environment, then we set the standard. Would you want your children to drink the water from your dental office after having only been processed your city’s water purification? Not me!

Dental Problems

I advise all dentists to learn about the problems before treating patients.There are few people who have never had a dental problem. Dental problems can range from toothaches and tooth decay to cold sores, abscesses and dental phobias. In these sections, you can learn about causes, treatments and prevention of a variety of dental problems.Toothaches are a common dental problem, and can occur even if you’re diligent about oral care. However, what seems like a toothache is oftentimes mistaken for another condition, trigeminal neuralgia. Learn more about toothaches and neuralgia in the "Toothaches" section.Cold sores are another familiar dental problem, affecting about 80 percent of the American population. Although general physicians can help keep cold sores manageable, so can a dentist. In the "Cold Sores" section, learn what you can do to prevent outbreaks and what treatments are available.If dental phobia keeps you from visiting a dentist for dental problems, that’s a problem. The good news is there are many simple ways to overcome dental fears and phobias. Browse through the "Dental Phobias" section to learn how communication, relaxation, hypnosis and anesthesia can help you overcome dental fear.

Untreated Dental Abscess Can Be Dangerous

Regardless of the source, a swelling of the gum indicates a more serious infection. Have you ever had your gum swell from an infected tooth? Has anyone ever told you that the “poison” from the infection can kill you? Is this just an old wive’s tale, or is it the truth? To answer this question, we need to know a little more about dental infections, the potential risks, and how the dentist treats them. Dental abscesses are the result of a bacterial infection originating in the teeth or gums. If a tooth is the source of the infection, it is usually the result of an untreated cavity. A cavity is an infection caused by a combination of carbohydrate-containing foods and bacteria that live in our mouths. Although there are many different types of bacteria in our mouths, only a few are associated with cavities. When these bacteria find carbohydrates, they digest them and produce acid. The acid dissolves the hard enamel that forms the outer coating of our teeth. As the cavity progresses deeper into the tooth, it eventually infects the nerve and blood supply of the tooth contained within the pulp. At this point, pain increases, especially when eating or drinking cold or hot foods and beverages, or when biting down. In some cases, a dental abscess is caused by an infection of the gum. Bone loss from periodontal disease can cause a pocket or space to form between the tooth, gum and bone. When bacteria and other debris get into the pocket, an abscess can form. A dental abscess is treated in a number of ways, depending on the severity of the infection. If decay has caused the abscess, the tooth will require a root canal or will need to be removed. If the gum has caused the abscess, the gum will require a deep cleaning or surgical treatment, or the tooth may need to be removed. Regardless of the source, a swelling of the gum indicates a more serious infection. In many cases, a small incision into the gum is needed to drain the abscess. Antibiotics and pain medication are often required to further treat the abscess and relieve discomfort. So how dangerous is a dental abscess? It all depends on how soon the patient sees his or her dentist. If a person waits until the gum is so swollen that they have difficulty breathing or opening their mouth, the situation is very serious. It is not the “poison” of infection that makes the abscess deadly, but its growth that can choke off our ability to breathe. That is the type of dental abscess that can kill if left untreated.

Common Causes of Bad Breath (Halitosis)

About 85 percent of oral malodor (e.g., halitosis) originates in the mouth. Chronic bad breath can be caused by tooth decay, gum disease, oral cancer, digestive disorders or many other conditions. See a dentist to treat chronic bad breath. Occasional bad breath, however, is usually exacerbated by the food we eat. This transitory condition can be prevented if we understand how foods change the oral environment. Anaerobic bacteria in the mouth produce volatile sulfur compounds (VSCs). Onions, garlic and eggs are well known for their natural sulfur compounds. When milk spoils, bacteria convert lactose proteins and release amino acids that become odiferous VSCs. Drying agents, sugars, dense protein foods and acids are main food categories that stimulate oral bacteria to produce large amounts of sulfur. Drying Agents Although tobacco smoke is not a food, it will quickly dry out the mouth and cause bad breath. Alcohol is a common drying agent used in wine, beer and hard liquor. Surprisingly, alcohol is also used in most mouthwash. If you suffer from bad breath, do not use an alcohol-based mouth rinse. Sugars Most mints increase bad breath rather than prevent it. How can this be? The sugar is fuel for bacteria to produce more VSCs. Hard candy breath mints also contain a second type of sugar that is converted by bacteria into glycan strands. These strands make it easy for plaque to accumulate on teeth and gums. Individuals often have difficulty self-diagnosing bad breath because their brain suppresses self-produced odors. As long as there is a strong mint taste, we incorrectly assume that our breath is fresh. Actually, the opposite is true! Sugary candies, mints and chewing gum make the breath smell worse! Dense Proteins Milk, cheese, yogurt, ice cream and other diary products often cause halitosis. Many people are lactose intolerant. This means they cannot break down the lactose protein. These individuals are most prone to a buildup of VSCs. Other dense protein foods like beef, chicken, fish and beans cause similar breath problems. Acids Any increase in the acidity of the oral cavity beyond its healthy pH of 6.5 will cause bacteria to reproduce faster. Coffee breath is very common. Other acidic beverages like tomato and citrus juices also cause bad breath. If you need a caffeine boost, try tea since it is less acidic than coffee. Water is perhaps the best beverage to fight halitosis since it is neutral (pH 7) and prevents dry mouth. Conclusion In addition to diet, regular dental care and good oral hygiene prevent most cases of halitosis. Using a tongue scraper and dental floss are beneficial too.

Finding the Source of Bad Breath and Halitosis

Plagued by chronic bad breath? Chances are, you can blame it not on your diet, teeth or gums, but on your tongue. And the solution may be as simple as adding a daily tongue cleaning to your regular brushing and flossing routine. Depending on who is counting, 25 million to 85 million Americans have halitosis, an unpleasant, even repugnant odor emanating from their mouths that may cause others to recoil upon close contact or to stand at a distance during conversations. "Dragon mouth," or the fear of it, has Americans spending about $1 billion a year on mouthwashes, breath mints, sprays, drops, gums and other products that they hope will mask an obnoxious mouth odor. But experts say most of these expenditures are a waste, at best reducing bad breath for an hour. Everything from the foods people eat to the diseases they have can cause bad breath. Use of tobacco products commonly results in lingering mouth odor. But most cases of bad breath are temporary. After a person dines on garlic or raw onion, for example, volatile oils from these foods get into the blood and are exhaled through the lungs. And nearly everyone has unpleasant breath upon awakening in the morning. Other transient causes include a cold, sinus or bronchial infection, a respiratory allergy or use of a medication (for example, an antihistamine or decongestant) that dries the mouth. A small percentage of cases have a medical cause, like diabetes, chronic sinusitis or bronchitis, postnasal drip, a liver or kidney ailment, emphysema or Sjogren's syndrome, an autoimmune disorder that causes dry mouth. Contrary to popular belief, bad mouth odors do not originate in the stomach and are not caused by indigestion. A rotten or abscessed tooth can result in noxious mouth odors. But while advanced periodontal disease can contribute to bad breath, more typical degrees of gum disease are an unlikely cause, according to studies in Toronto and the University of Michigan in Ann Arbor. Dr. Erika H. De Boever at the University of Michigan School of Dentistry conducted a detailed study with Dr. Loesche that zeroed in on the overriding importance of the tongue in chronic halitosis that afflicts otherwise healthy people. The tongues of some people become coated with bacteria that ferment proteins, producing smelly gases like hydrogen sulfide (rotten egg odor), methylmercaptan, fatty acids and ammonia. Other people have what dentists call a "geographic tongue" with fissures and indentations that resemble a coastline, Dr. Loesche said. Anaerobic bacteria lodge in these crevices, where they ferment proteins and give off noxious odors. Dr. De Boever showed that daily tongue cleansing can virtually eliminate the problem in healthy people who have suffered with embarrassing halitosis for years despite careful oral hygiene, regular periodontal care and the routine use of breath fresheners. In the study, the 16 patients, who ranged in age from 14 to 71, were taught how to scrape their tongues -- reaching as far back as it is possible to go -- and were given a prescription antibacterial rinse, chlorhexadine gluconate, to use daily for a week. Their mouth odor disappeared along with the bacteria that were living on their tongues. While the rinse should not be used continuously because it can impair taste sensation, it can be used intermittently, she said. An alternative agent is chlorine dioxide, a powerful though unstable germicide that is used in water purification. Dr. John Richter, a periodontist who has treated more than 5,000 patients with halitosis, said chlorine dioxide had a triple-action effect in combating bad breath: it is a deodorant, it kills odor-causing bacteria and it reduces the amount of protein available for bacteria to ferment. Dr. Richard H. Price, a dentist affiliated with the Boston University Dental School, said daily tongue cleansing and the use of chlorine dioxide has enabled him to solve his own breath problem. He explained: "To be effective, you must scrape the very back of the tongue, which makes many people gag. But after a while you get used to it and you no longer gag."

Halitosis and Bad Breath

What Causes Bad Breath? Unpleasant oral odors are caused mainly by the gaseous sulfur-containing by-products from the bacterial breakdown of proteinaceous substrates, such as impacted food particles and sloughed off oral cellular debris. This process is most prominent on the back of the tongue. The tongue geography provides an excellent putrefactive habitat for the strains of microbes that are able to metabolize proteins as an energy source. In a healthy mouth these substrates are carried away by the saliva, swallowed and digested fast enough so that there is little chance for them to putrefy in the mouth and cause halitosis. Inflammation of mucosal tissues can cause cells to be shed at a faster rate than the saliva can cleanse. Bacterial action then hydrolyzes the proteins from these substrates to amino acids. The three sulfur-containing amino acids include methionine, cysteine and cystine -- the main precursors to volatile sulfur compounds. These gaseous substances, which are responsible for malodor, consist primarily of hydrogen sulfide, dimethyl sulfide, methyl mercaptan and sulfur dioxide. Volatile sulfur compounds are very toxic substances and can further damage already inflamed oral tissues. Why Should I Be Concerned? One of the early warning signs of periodontal (gum) disease is persistent bad breath or a bad taste in the mouth. Bad breath may also be the sign of a medical disorder, such as post-nasal drip, respiratory infection, diabetes, gastrointestinal, liver or kidney problems. What Types of Products Can Be Beneficial in Treating Halitosis? Tongue scrapers are very effective by removing the plaque coat that forms on the surface of the tongue. The tongue's surface contains crevices, which can trap dead cells and bacteria. It is generally believed that bad breath occurs most readily in the absence of oxygen. The plaque coat forms an anaerobic (without oxygen) environment, in which the bacteria may then release volatile sulfurous gases, the components of bad breath. Use of tongue scrapers to effectively remove the plaque coat can help to maintain a clean environment in the mouth. Oral rinses are one of the therapeutic approaches in the treatment of halitosis. However, knowledge and understanding of this condition is in its infancy, and there are presently only limited products on the market geared specifically to the eradication of oral malodor. In addition, there is a paucity of clinical trials to substantiate the efficacy of these products for the condition of halitosis. Certain mouth rinses can help to reduce oral malodor. However, most commercial mouth rinses provide a short-term effect by basically masking odors. Prevention of malodor that lasts beyond 30 minutes after rinsing is a result of the antiseptic compounds, but often these substances do not provide long-lasting effects. Most commercial mouth rinses contain alcohol, which can decrease the flow of saliva in the mouth. This dry mouth condition can induce a temporary oral malodor, similar to morning breath, a condition many people experience, caused by decreased saliva flow during the night. Healthy saliva flow is important as saliva lubricates and oxygenates the oral cavity, aids in digestion, acts as a buffering agent and provides antimicrobial properties. Finally, a chronic dry mouth condition (xerostomia) can be treated with an alcohol-free mouthwash and medications which stimulate the salivary gland to produce more fluid.

Halitosis: Causes and Treatments for Bad Breath

What Is Halitosis or Bad Breath? Halitosis is a condition of having offensive or bad breath. Nobody wants to have bad breath, and many consumers are in search of products -- including toothpaste, mouthwash and mints -- that promise a quick cure for halitosis and fresher-smelling breath. Bad breath is often self-perceived and there is no test or device to diagnose or measure the problem. Breath mints or mouthwash may freshen the breath short-term, but don't often get to the root of the problem. A common source of bad breath is the mouth and tongue. Therefore, a trip to the dentist is the first step to rule out any dental problems. What Causes Halitosis? There are many different reasons for having bad breath, including: - Decaying or Rotten Teeth -- Bacteria and acids in the mouth form a sticky deposit called dental plaque that clings to the teeth. If the plaque is not removed, the acids will destroy the tooth's enamel surface resulting in holes or cavities. If left untreated, tooth decay can result in a foul odor in the mouth. - Food Trapped in the Teeth or Tongue -- Bacteria and food particles can become lodged in the teeth or stuck on the papillae (small projections on the tongue), causing bad breath. It's important to brush and floss the teeth, and brush the tongue and back of it to remove food debris. Tongue scrapers are also available to help remove debris from the tongue. - Periodontal (Gum) Disease -- Pockets of plaque form between the teeth and gums -- causing inflammation and irritation to the gums. The constant inflammation can damage the ligament supporting the teeth and an infection can occur, eventually resulting in tooth loss. Gum disease can cause a bad taste in the mouth or halitosis. - Sinus Problems -- Infections in the sinus cavity can contribute to bad breath. - Xerostomia or “Dry Mouth” -- When there is decreased saliva in the mouth, for example, during the night, food and bacteria build up and can create odors. - Systemic Diseases -- Certain medical conditions, such as diabetes, lung problems, and kidney and stomach disorders may contribute to bad breath. - Odiferous Foods -- A diet rich in foods with strong odors, such as garlic and onions, is a surefire way to have bad breath. - Smoking -- Smoking cigarettes, cigars or a pipe can produce halitosis. - Menstruation -- Hormone changes in the body during menstruation may also cause bad breath. How Should It Be Treated? Good oral health care -- brushing the teeth and flossing -- will help reduce foul odors in the mouth. If you have chronic bad breath, visit your dentist, who can rule out dental problems such as decay or periodontal disease. The dentist may recommend that you visit your physician to determine if the problem is linked to a medical disorder. If bad breath is not related to a dental or medical condition, psychological problems may come into play. In rare cases, individuals become obsessed with body disorders. They may perceive that they have "bad breath," when in fact, they don't. Mouth Bacteria: The Good, the Bad and the Ugly
Dental problems, including broken teeth that trap food, infected teeth that abscess, and untreated periodontal (gum) disease are the most likely causes of bad breath. Bad breath is a sensitive subject, and can affect a person’s self esteem. There are many potential causes, but about 85 percent of the time, the mouth is the source. When the mouth is the cause of bad breath, food, oral habits and dental health should be examined first. Foods or beverages such as garlic, onions and coffee, and habits such as smoking and chewing tobacco can contribute to bad breath. Dental problems, including broken teeth that trap food, infected teeth that abscess, and untreated periodontal (gum) disease are the most likely causes of bad breath. Another potential source of bad breath is the type of bacteria in our mouths. A recent study reveals that certain bacteria may be associated with fresh and bad breath. If the teeth and gums are healthy, the tongue is the most likely cause of bad breath. The top back part of the tongue is a common and sometimes overlooked cause of bad breath. There is speculation that chronic postnasal drip that collects on the tongue becomes infiltrated with bacteria causing odor. Researchers from the Forsyth Institute and the University Of Michigan School Of Dentistry analyzed the type of bacteria found on people’s tongues. The small study showed that three types of bacteria -- streptococcus salivarius, rothia mucilaginosa and a strain of eubacterium -- were commonly associated with fresh breath. Six other types of bacteria were also found in people with bad breath. Tongue brushing and the use of a tongue-scraper can help remove bacteria associated with bad breath. Excellent oral hygiene -- brushing at least three times a day and flossing once a day -- is essential for optimal dental health and for fresh breath. Oral odors may be reduced by chewing sugarless gum and drinking water throughout the day to moisten the mouth. If odor persists after the teeth, gums, and tongue are clean and healthy, an antiseptic mouth rinse containing chlorhexidine gluconate can be prescribed. If none of these measures succeed, a medical doctor should be consulted to explore other potential causes. Bad breath is a sensitive topic that should be discussed with a dentist. As research continues, new treatments may be developed to directly target bacteria associated with bad breath. For now, a dentist can help to discover the most likely cause and help alleviate the problem.

Burning Tongue: An Unnerving Problem

Q: I recently had dental treatment (a temporary crown) and during the injection, I felt an electric shock on the left side of my tongue. Over the past 5 weeks, I have had a burning sensation on that same side of my tongue, like it was scalded with hot water. The dentist has put me on different vitamins and minerals, but nothing has helped. What should I do? A: It is not that unusual for a dental injection to cause the sensation of a mild electric shock when administered. This phenomenon occurs in roughly one out of 100 injections, when the needle passes directly through the nerve fiber, and is most common when anesthesia is required to numb the lower jaw. The nerves most commonly involved are the lingual nerve, which gives sensation to the tongue, and the sensory branch of the inferior alveolar nerve, which gives sensation to the lower teeth, jaw, gum and lip. In the vast majority of cases, the nerve is not damaged in any way from the injection, and in fact, the nerve is numbed so well that the dental procedure is usually completed painlessly. In rare instances, the nerve can be damaged by the needle (a condition called neuropraxia) and cause a wide variety of symptoms. The most common symptom of sensory nerve damage during a dental procedure is a prolonged feeling of numbness for weeks, months or longer after the injury. More minor nerve injuries can manifest in a tickling or burning sensation. Your situation leads me to suspect that you sustained a minor injury to your lingual nerve during the injection. The condition should clear up by itself over the next few weeks or months; unfortunately the vitamins your dentist prescribed will not be of any significant benefit. I would recommend that you consult an oral surgeon and possibly a neurologist to confirm that the damage is both minor and reversible.

Glossodynia: Burning Mouth Syndrome

Glossodynia, commonly called burning of tongue or mouth, describes a sensation characterized by pain, stinging or itching of the oral mucous membrane. Glossodynia is divided into two types: With or without observable alteration of the tongue. The common observable signs are inflammed fungiform papillae or a slight, localized reddening due to trauma or atrophy of the filliform papillae and either localized or generalized lobulations and generalized redness. It may be associated with an altered taste. Numerous causes of glossodynia have been suggested, including systemic factors such as nutritional deficiencies and climacteric; local factors such as candidasis and denture trauma; xerosotomia; and psychogenic factors and sensory neuropathies (See Table 1). Etiologic Factors for Glossodynia Local Causes: - Candidiasis climacteric postmenopausal anxiety - Migratory glossitits diabetes depression - Lichen planus Sjogren’s Syndrome (xerostomia) cancerphobia - Trauma drug reactions (xerostomia) - Oral cancer deficiency states - Denture faults anemias (Iron, B12, Folic Acid) - Impression surface lingual artery atherosclerosis - Polished surface fheumatoid arthritis - Occlusal surface gastric disturbances, hyperacidity - Denture plaque xerostomia - Residual monomer hypothyroidism - Sensitivity to dental materials - Radiation therapy (xerostomia) - Periodontal diseases - Electrogalvanic discharge - Climacteric postmenopausal - Diabetes - Sjogren’s Syndrome (xerostomia) - Drug reactions (xerostomia) - Deficiency states - Anemias (Iron, B12, Folic Acid) - Lingual artery atherosclerosis - Rheumatoid arthritis - Gastric disturbances, hyperacidity - Xerostomia - Hypothroidism Psychological Causes - Anxiety - Depression - Cancerphobia The nutritional deficiencies which causes glossodynia are iron, vitamin B12 and folate deficiency. Glossodynia associated with iron deficiency occurs in 13% of cases. The iron deficiency is low in men (3%), as compared to non-pregnant women (10-30%), and pregnant women (10-60%). Because of glossitis and glossodynia in iron deficiency anemia, the patient may seek dental treatment. The dentist and patient must be aware of signs and symptoms to prevent serious neurological complications of this disease. Iron deficiency is not a disease, but a sign of disease, which is also associated with glossodynia. The high incidence of iron deficiency anemia in pregnancy is due to the increased demand for iron in second half of pregnancy; thus it’s more common in females than males. In postmenopausal women and adult males, the common cause of iron deficiency is gastrointestinal bleeding by non steroidal anti-inflammatory drugs and hookworm infection. The oral mucous membrane is sensitive and its integrity is maintained by complex interacting factors superimposed on localized stabilizing mechanism. The patients suffering from deficiency states are particularly susceptible to candida albicans infection. There is atrophy of tongue epithelium with resulting disturbance of underlying nerve resulting in taste disturbance and painful tongue. This change in sensitivity of tongue can be a diagnostic value in deficiency states. Iron deficiency anemia has an incidious onset with gradual fatigue, irritability, dizziness, palitation, breathlessness and headache. Glossodynia may be one of classic symptoms of iron deficiency anemia. These changes in metabolism of oral epithetial cells are due to minor variations in the quality of blood supply, which give rise to abnormalities of cell structure and kreatization pattern of oral epithelium resulting in the atrophy particularly of the filiform papillae of the tongue which may be almost completely lost. The atrophic changes in tongue may lead to ulceration and soreness, which, in many cases, affect the whole oral mucosa and lead to ulceration. In a small group of patients, the atrophic changes in the oral and pharyngeal mucosa may lead to widespread soreness and dysphagia which is associated with achlorhydria and is known as plymmer-vinson syndrome. There is angular chelitis and thrush and the patient may complain of disturbance of taste sensation due to atrophy of the tongue epithelium, with resulting disturbance of underlying nerve endings. The gastrointestinal complaints are anorexia, pyrosis, flatulence, nausea, belching and constipation which are commonly associated with iron deficiency anemia. In addition to the clinical features of the iron deficiency anemia , the laboratory findings are most supportive. The laboratory values have low mean corpuscular volumes; mean corpuscular hemoglobin; and mean corpuscular Hb concentration. Low-iron values would result in decrease serum iron, elevated total iron binding capacity and low ferritin. The oral examination of the patient shows atrophy of the tongue (anterior border) and paleness of the palate, which exclude neurotic glossodynia (in which no abnormality of tongue tissue can be seen). The recent data indicates that burning sensation may also result from deficiency of vitamin B1, B2, B6 and B12. The deficiency of vitamin B2 and B6 also produces greasy dermatitis of the face. In pernicious anemia, there may be generalized atrophy of the oral mucosa with ulceration as in iron deficiency anemia. The soreness of tongue is due to atrophic changes in the lingual papillae termed as “beefy red tongue.” The tongue often shows a shiny smooth appearance and may be painful and tender to hot or spicy foods. Glossodynia is a common symptom. The diagnosis can be made by RBC morphology and serum vitamin B12 level which can be resolved by vitamin B12 parenteral therapy. Folic acid such as vitamin B12 is involved with RNA and DNA metabolism. A deficiency of folic acid may lead to burning mouth angular cheilitis. The tongue shows varying degrees of papillary atrophy which progresses until the surface of tongue is smooth and shiny. The diagnosis is done by RBC morphology and serum folate level. Likewise, niacin deficiency causes generalized erythma of the oral mucous along with papillary atrophy. There is glossodynia. Diagnosis can be made by measurement of niacin level. It is treated with niacin and vitamin B-complex vitamins. Conclusion Glossodynia is a distressing symptom and before considering psychological of glossodynia all its local and systemic causes must be ruled out for definite diagnosis and treatment.

A General Overview of Cleft Lip and Cleft Palate

Cleft lip and cleft palate comprise the fourth most common birth defect in the United States. One of every 700 newborns is affected by cleft lip or cleft palate. A cleft lip is a separation of the two sides of the lip. The separation often includes the bones of the upper jaw or upper gum. A cleft palate is an opening in the roof of the mouth in which the two sides of the palate did not fuse, or join together, as the unborn baby was developing. Cleft lip and cleft palate can occur on one side (unilateral cleft lip or palate), or on both sides (bilateral cleft lip and palate). Because the lip and the palate develop separately, it is possible for the child to have a cleft lip, a cleft palate, or both cleft lip and cleft palate. Cleft lip and cleft palate are congenital defects, or birth defects, which occur very early in pregnancy. The majority of clefts appear to be due to a combination of genetics and environmental factors. The risks of recurrence of a cleft condition are dependent upon many factors, including the number of affected persons in the family, the closeness of affected relatives, the race and sex of all affected persons, and the severity of the clefts. A child born with a cleft frequently requires several different types of services, e.g., surgery, dental orthodontic care, and speech therapy -- all of which need to be provided in a coordinated manner over a period of years. This coordinated care is provided by interdisciplinary cleft palate/craniofacial teams comprised of professionals from a variety of health care disciplines who work together on the child's total rehabilitation.

Bone Grafting for Facial Clefts

Bone grafting in the dental ridge of the upper jaw (maxilla) is now a standard, reliable treatment for patients with facial clefts. Bone grafting is an operation that involves taking a small amount of bone from one place (usually the hip, head, ribs or leg) and placing it in the area of the cleft near the teeth. The procedure is employed to accomplish the following four goals: 1. To provide support for unerupted teeth and teeth next to the cleft. 2. To provide support for the lip and nose and to improve symmetry. 3. To form a continuous upper gum (alveolar) ridge, creating a more natural appearance and stability to the ridge. 4. To improve the stability of the front part of the roof of the mouth (premaxilla), if a bilateral cleft is present. Bone grafting is a useful procedure and is most successful in patients under 10 years of age and as early as 5 to 6 years of age, as the front incisor teeth are erupting. The overall erupting varies from child to child, but usually is completed between the ages of 10 and 12. If the bone graft is placed after the permanent teeth have erupted, it will be too late to achieve goal number one above, although it may be useful toward achieving the remaining three goals. Older patients may benefit from a bone graft, but have less chance of total success. If the patient is a smoker, has a systemic disease such as diabetes, or has poor oral hygiene, the risk that the graft may fail increases even more. Once the bone graft has been placed, there are three options that may be considered to replace any missing teeth in the area of the graft: 1. Moving adjacent teeth into the bone graft 2. Prosthetic replacement (dental bridge) 3. Dental metallic bone implants The best bone grafting options are best decided by dental specialists on a cleft palate team who can determine what the benefits and risks are for individual patients.

Choosing the Best Care for a Child with Cleft Lip or Palate

Throughout the United States there are many qualified health professionals caring for children with cleft lip and palate as well as other craniofacial anomalies. However, because these children frequently require a variety of services, which need to be provided in a coordinated manner over a period of years, you may want to search for an interdisciplinary team of specialists. The principal role of the interdisciplinary team is to provide integrated case management for your child, and to assure the quality and continuity of care and long-term follow-up. Here are some points to consider when selecting a team: The Number of Different Specialists Who Participate on the Team The more specialists participating on the team, the more likely every aspect of treatment can be considered during the team evaluation. The specific staff will be determined by the availability of qualified personnel and by the types of patients served by the team. When the team cannot provide all the services required by its patients, team members are responsible for making appropriate referrals, and for communicating with those to whom patients are referred. This arrangement will allow treatment plans to be coordinated and carried out in an efficient manner. Although not all patients will need each type of specialist, the team may include: - An audiologist who assesses hearing - A surgeon -- such as a plastic surgeon, an oral/maxillofacial surgeon, a craniofacial surgeon, or a neurosurgeon - A pediatric dentist or other dental specialist, such as a prosthodontist, who makes prosthetic devices for the mouth - An orthodontist who straightens the teeth and aligns the jaws - A geneticist who screens patients for craniofacial syndromes and helps parents and adult patients understand the chances of having more children with these conditions - A nurse who helps with feeding problems and provides ongoing supervision of the child's health - An otolaryngologist -- an "ear nose and throat" doctor, or "ENT" - A pediatrician to monitor overall health and development - A psychologist, social worker, or other mental health specialist to support the family and assess any adjustment problems - A speech-language pathologist who assesses not only speech but also feeding problems - Other necessary specialists who treat specific aspects of complex craniofacial anomalies When these specialists work together and with the family as an interdisciplinary team, treatment goals can be individualized for each child, and parents and health care providers can make the best choices for treatment by consulting with each other. Because growth is a significant factor in the ultimate outcome of treatment, the child must be assessed thoroughly and regularly by the team until young adulthood. “The Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Anomalies” document summarizes the current guidelines for team care endorsed by the American Cleft Palate-Craniofacial Association. By adhering to these guidelines, teams are promoting the best possible outcome for children born with clefts or other craniofacial birth defects. Qualifications of the Individual Members on the Team All the professionals on the team should be fully trained and appropriately certified and licensed. This issue may impact your insurance coverage, as well as the quality of care the team can deliver. Experience of the Team Each team must take responsibility for assuring that team members not only possess appropriate and current credentials but also have requisite experience in evaluation and treatment of patients with cleft lip/palate and other craniofacial anomalies. You should ask how often the team meets and approximately how many patients are seen at each meeting. You may also want to try to determine how long this group of professionals has been meeting as a team and also how much experience the various individual professionals have had. Location of the Team The distance of the team from your home may NOT be an important consideration in choosing a team. In general, the team will be seeing your child only periodically throughout his or her growing years. Usually routine treatment such as general dental care, orthodontics, speech therapy and pediatric care will be provided by professionals in your own community who will be in regular contact with professionals on the team. Your travel to a team will usually be limited to several trips a year or even once a year. Affiliation of the Team and Its Members You may want to ask if the team is listed with the American Cleft Palate-Craniofacial Association (ACPA) and how many of the individual members of the team are also members of ACPA. Staying current with recent developments in the field is one sign of a conscientious and concerned health care professional. You may also want to determine whether the team has any relationship to an established hospital, a medical school or a university. Facilities for diagnostic studies and treatment are often better with such an affiliation. Communication With the Team Your child may require care over a period of years, so you want to make sure you are comfortable communicating and working with the members of the team. Treatment recommendations should be communicated to you in writing as well as in face-to-face discussion. The team should assist you in locating parent-patient support groups and any other sources for services that are either not provided by the team itself or are better provided at the community level. For a list of to a cleft palate or craniofacial teams in your state or region, or for further information, you may contact the Cleft Palate Foundation. Cleft Palate: Researchers Getting Closer to Finding the Cause
Scientists at the University of Southern California have identified a genetic circuit that when broken causes cleft palate in newborn mice, according to a story in Dentistry Today. The critical points of the circuit represent genes and gene products that interact with each other to direct palate formation. The surge that caused the circuit to break in the mice was an environmental assault in the form of steroid hormones given to female mice during pregnancy. According to the study, which was partly supported by the National Institute of Dental Research, this is the first time a cause-and-effect scenario for cleft palate has been worked out at the molecular level. The findings may help define the genetic components of cleft palate in humans and explain the link of risk factors such as stress, smoking and certain medications that are known to elevate the level of steroids in the body. "Facial clefting disorders are among the most common human birth defects and occur in almost one in 2,000 live births," says Dr. Tina Jaskoll, one of the study's principal investigators. "The defects can range in severity from a relatively minor split uvula at the rear of the mouth to a cleft running the length of the hard and soft tissues forming the roof of the mouth." The more severe forms require surgery and are often associated with psychological and physical problems, she added. The investigators believe cleft palate results from a combination of genetic and environmental factors, but attempts to identify these components in human populations have proved inconclusive to this point. Dr. Michael Melnick, another of the study's principal investigators, believes the mouse model used in his team's study will provide the clues needed to unravel the mysteries of cleft palate. Currently, he cautioned, it is still premature to pinpoint the underlying causes of cleft palate in humans. "It is apparent from studying complex disorders, such as cleft palate, that simply identifying genetic differences between healthy and affected individuals is not enough to explain the cause of the disorder," says Dr. Melnick. "We must know what products are derived from the genes in question and what other genes and molecules are affected in the chain of events that lead to the formation of the palate."

Correcting Cleft Lip and Palate

Cleft lip and cleft palate are very common birth defects, affecting one in every 700 live births in the United States each year. A cleft lip results when the "lip edges" do not properly come together. A cleft palate is caused by incomplete fusion of the palate. Both are developmental deformities that occur in the first trimester of life: cleft lip in the sixth or seventh week in utero, and cleft palate in the eighth or ninth week in utero. Although the cause is unknown, there appears to be a genetic link, as the probability of a child having cleft lip or palate increases if parents or close relatives have the deformity. Cleft lip and cleft palate occur together in about half the cases, and in a quarter of the cases they each occur separately. Cleft lip and cleft palate can cause a child to have difficulty speaking, swallowing and breathing, suffer from frequent ear infections (otitis media), and have significant facial and dental deformity. Cleft lip and palate are also linked with disorders of the head and neck, extremities, genitalia or heart in about 20 percent of the cases. Cleft palate is also associated with Down’s syndrome and other genetic disorders. Cleft lip is usually surgically repaired in the first few months of a child’s life. Cleft palate is usually repaired later, from about six months to a year. Infants with a mild case of cleft lip will usually have no problems with feeding, while those with more severe clefts, especially involving the palate, will often have more difficulty. If there is difficulty swallowing, the infant’s palate can be temporary closed off with a device called an oral obturator. The dentist makes the obturator to block the opening in the palate and allow improved eating and swallowing prior to corrective surgery. As a resident at Mount Sinai Medical Center in New York, I had the opportunity to work with a cleft palate team. The cleft palate team consisted of dentists, including general, orthodontists and oral surgeons, social workers, speech pathologists, ear, nose and throat (ENT) physicians and plastic surgeons. Each member of the team concentrated on a different problem. The oral surgeons, ENTs or plastic surgeons would surgically correct the cleft lip or palate. The plastic surgeon would help remove disfiguring scars and improve the shape and contour of the face damaged by the clefts. Later, the general dentists would help to repair or replace missing or damaged teeth often found in cleft patients, and the orthodontists would assess the need for braces as the child matures. The speech pathologist helps the child develop a normal speaking voice, and tries to eliminate the nasal sound of some cleft patients. Last and certainly not least, the social worker deals with the emotional impact born by the child and the family. During my residency, I recall one occasion where I assisted our chief of oral surgery and an older surgeon, who was both a general and oral surgeon, in a cleft palate case. My chief asked the older surgeon what method he would use to stitch the palate, as he had always found it difficult. To our amazement, the older surgeon said that it’s much better to stitch the soft palate inside out. Later, my chief and I asked, "What about packing the sides of the surgical area?" "It’s not necessary," said the older surgeon confidently. That evening, and for the following week, we rounded on our patient and were impressed at how well the palate was healing. It was a great learning experience for me and my chief! Cleft lip and cleft palate are unfortunately a fairly common congenital disorder. Modern dental and medical team treatment can greatly reduce the physical and emotional scars associated with it.

Dental Care for Children with Cleft Lip and Palate

How Does Cleft Lip/Palate Affect the Teeth? A cleft of the lip, gum (alveolus), or palate in the front of the mouth can produce a variety of dental problems. These may involve the number, size, shape and position of both the baby teeth and the permanent teeth. The teeth most commonly affected by the clefting process are those in the area of the cleft -- primarily the lateral incisors. Clefts occur between the cuspid (eye tooth) and the lateral incisor. In some cases the lateral incisor may be entirely absent. In other cases there may be a "twinning" (twin = two) of the lateral incisor so that one is present on each side of the cleft. In other cases, the incisor or other teeth may be present, but may be poorly formed with an abnormally shaped crown or root. Finally, the teeth in the area of the cleft may be displaced, resulting in their erupting into abnormal positions. Occasionally, the central incisors on the cleft side may have some of the same problems as the lateral incisor. What Does This Mean for Future Dental Care? A child with a cleft lip and/or palate requires the same regular preventive and restorative care as the child without a cleft. However, since children with clefts may have special problems related to missing, malformed or malpositioned teeth, they require early evaluation by a dentist who is familiar with the needs of the child with a cleft. Early Dental Care With proper care, children born with a cleft lip or palate can have healthy teeth. This requires proper cleaning, good nutrition and fluoride treatment. Appropriate cleaning with a small, soft-bristled toothbrush should begin as soon as teeth erupt. Oral hygiene instructions and preventative counseling can be provided by a pediatric or general dentist. Many dentists recommend that the first dental visit be scheduled at about one year of age or even earlier if there are special dental problems. The early evaluation is usually provided through the cleft palate team. Routine dental care with a local dentist begins at about three years of age. The treatment recommended depends upon many factors. Some children require only preventative care while others will need fillings or removal of a tooth. Orthodontic Care The first orthodontic evaluation may be scheduled even before the child has any teeth. The purpose of this visit is to assess facial growth -- particularly the growth of the jaws. Later, as teeth begin to erupt, the orthodontist will make plans for the child's short and long-term dental needs. For example, if a child's upper teeth do not fit together properly with the lower teeth, the orthodontist may suggest an early period of treatment to correct the relationship of the upper jaw to the lower jaw. It is not unusual for this initial period of treatment to be followed by a long rest period when the orthodontist monitors facial growth and dental development. With the eruption of the permanent teeth, the final phase of orthodontics completes alignment of the teeth. Coordinated Dental-Surgical Care Coordination of treatment between the surgeon and dental specialist is important since several procedures may be completed during the same anesthesia. Restorations or dental extractions can be scheduled at the same time as other surgery. Coordination between the surgeon and the orthodontist becomes most important in the management of the bony defect in the upper jaw that may result from the cleft. Reconstruction of the cleft defect may be accomplished with a bone graft performed by the surgeon. The orthodontist may place an appliance on the teeth of the upper jaw to prepare for the bone graft. A retainer is usually placed after the bone graft until full braces are applied. When the child approaches adolescence, the orthodontist and the surgeon again coordinate their efforts if the teeth do not meet properly because the jaws are in abnormal positions. If the tooth relations cannot be made normal by orthodontics alone, a combined approach of orthodontics and surgical repositioning of the jaw is necessary. Such surgery is usually performed after the pubertal growth spurt is completed. Prosthodontic Care The maxillofacial prosthodontist is a dental specialist who makes artificial teeth and dental appliances to improve the appearance of individuals with cleft and to meet their functional requirements for eating and speaking. The prosthodontist may make a dental bridge to replace missing teeth. Oral appliances called "speech bulbs" or "palatal lifts" may help close the nose from the mouth so that speech will sound more normal. The prosthodontist must also coordinate treatment with the surgeon or the orthodontist to assure the best possible result. When a speech bulb or palatal lift is developed, the prosthodontist usually coordinates treatment with the speech pathologist. For the child or adult who wears one of these appliances, the care of the teeth holding the appliance is of particular importance. How Can I Get the Best Care for My Child? Children with cleft lip or palate require the coordinated services of a number of specialists. For this reason, many parents seek care for their child at a cleft palate or craniofacial treatment center. At such a center evaluation, treatment planning and care are provided by an experienced, multidisciplinary team composed of representatives from a variety of dental, medical and other health care specialties. Even if you do not have such a center locally, the care your child will receive in such a center may be well worth the inconvenience of traveling to another city. Parent and patient support groups are located throughout the country. You might want to join one to obtain support and practical help from others who share common problems. To obtain a list of cleft palate-craniofacial centers and parent or patient support groups in your region contact the Cleft Palate Foundation. Glossary of Terms Anesthesia - Drugs provided during a surgical or dental operation that put the child to sleep. Bony Defect - Area of missing bone, usually affecting the roof of the mouth in children with cleft palate. Dental Extraction - Dental procedures performed to remove damaged, malformed or malpositioned teeth. Dental Restoration - Dental procedures performed to repair or correct damaged, malformed or missing teeth. Multidisciplinary Team - A group of professionals who work together to help plan and carry out treatment for patients with cleft lip, cleft palate and related disorders. The group usually includes surgeons, dental specialists, speech pathologist and others who meet regularly to evaluate and discuss the patients under their care. Oral Hygiene - Care of the teeth and gums which is performed at home on a daily basis. This is performed first by the child's parent or guardian while the child is small, and eventually by the child under continued supervision of the parent or guardian. Orthodontic Care - Dental visits designed to move the teeth into better alignment with one another to improve chewing, oral hygiene and appearance. Preventative Dental Care - Regular dental visits during which teeth are checked for cavities and cleaned. Pubertal Growth Spurt - A period of rapid growth that normally occurs sometime between the ages of 10 and 16. The actual timing and length of this period of growth varies.

Replacing a Missing Tooth in a Cleft Palate Patient

Patients with a cleft lip and/or palate are often born with a missing tooth -- most often the lateral incisor (immediately next to the front central incisor). This may occur unilaterally or bilaterally, but special planning is needed to solve the functional and cosmetic problems the absence creates. Who will be involved in dealing with the missing tooth? Several dental specialists will be most important in planning treatment. Orthodontists align improperly placed teeth, while prosthodontists can replace missing teeth in a variety of ways. Oral and maxillofacial surgeons perform surgery to the teeth, mouth, and surrounding areas of the head and face. Coordinated planning by all specialists involved is necessary for the best result. What role does the orthodontist play in replacing a missing tooth? The large majority of patients with clefts will require full orthodontic treatment, especially if the cleft has passed through the tooth-bearing ridge. Goals of treatment will be to line up the teeth in the upper arch, create an arch form that is harmonious with the lower dental arch, and line up the midline of the upper arch with that of the lower arch. When a tooth is missing, the upper midline is usually shifted, so this must be corrected. A space is often opened up and maintained for later replacement of the missing lateral incisor. During orthodontic treatment, an artificial tooth may be attached to the orthodontic wire as a temporary replacement for the lateral incisor. When the braces are removed, a removable retainer with an artificial tooth serves to maintain the space, and improve speech and appearance until a definitive restoration is made. Is the missing tooth always replaced? In many instances, the space for the lateral incisor will be orthodontically or surgically closed by moving the canine forward into the space normally occupied by the lateral incisor. This will then require modification of the canine to make it appear as a lateral incisor. This may be accomplished by adding plastic or porcelain filling material or a porcelain crown to reshape its appearance. What options are available for permanent replacement of the lateral incisor? Treatment options for the permanent replacement of the lateral incisor depend upon whether or not the cleft has been repaired with a bone graft. In a non-grafted dental arch, there are two options for replacement: - First, a removable partial denture may be used to replace the missing tooth. While this option may be made to look acceptable, it has several disadvantages. The removable prosthesis must cover most of the palate for support. This may cause irritation on the roof of the mouth or at the gumline where it rests. Many patients also object to the extra bulk and removable nature of the partial denture and report that it feels unnatural. This type of prosthesis is best as a temporary replacement as described above. - The second option in a patient without a bone graft is a fixed bridge. The missing tooth is restored with an artificial one connected to crowns (caps) on teeth on each side of the left. Because there is loss of supporting bone at each tooth on either side of the cleft, two teeth on each side must usually be crowned to give adequate support to the bridge. This type of prosthesis is not removable. Its contours and appearance look and feel more natural than a removable partial denture. However, it does require grinding down the support teeth in order to crown them and connect them to the artificial tooth. Cleaning between the crowned teeth also becomes more difficult since they are connected. Can a fixed bridge be made immediately after braces? In a teenager or young adult, the nerves and blood vessels in the tooth pulps are rather large. Drilling down these teeth for crowns may expose the pulps and require root canal therapy. Therefore, this type of treatment must usually wait until adulthood when the pulps are smaller. What options are available for a patient who has had a bone graft? Bone grafting the cleft site in the upper jaw creates a more normal arch and eliminates special restorative considerations relative to the cleft. A conventional fixed bridge as described above may be used. In many cases, only one tooth on either side of the cleft needs to be crowned, since the graft has stabilized the arch and added bone. If the teeth that hold the bridge are not otherwise in need of restoration, a resin-bonded fixed bridge may be chosen. This type of bridge requires much less tooth reduction of adjacent teeth, and there is no danger of nerve involvement. A porcelain replacement tooth is held in place by metal extensions cemented to the backs of the adjacent teeth. This is a more conservative restoration with regards to tooth preparation but still requires connecting teeth together. The most natural, lifelike restoration for a patient with a bone graft is a single porcelain crown attached to an osseointegrated dental implant. This involves a surgical procedure where a titanium screw the size and shape of a tooth's root is inserted into the bone at the site of the missing tooth. It is covered by the gum for six months while the bone bonds to the implant surface. Then the implant is uncovered and an artificial tooth (crown) is attached. While this procedure does require minor surgery, it does not require cutting down or crowning any other teeth. Cleaning is also easier because the replacement tooth is not connected to any other teeth. This restoration does give the most natural result but does require that sufficient bone is present in order to hold the screw. Summary - Finding the best treatment for a missing tooth requires cooperation and planning among several specialists. - A variety of options for successful tooth replacement are available. - Patients with missing teeth, or their parents should thoroughly discuss treatment options with the multidisciplinary team before making a decision. A Few Words About Cold and Canker Sores
The intense heat of summer and the glare of the sun can cause problems for people who experience cold and canker sores. The same ultraviolet rays that cause sunburn can trigger an outbreak of cold sores. Scientists are not yet sure how UV rays promote cold sores, but they believe the rays are responsible for lowering the immune response of exposed skin cells. A recent study by the National Institute of Health may shed some light on UV rays and canker sores. In the study, the lips of 38 people with a history of canker sores were exposed to 80 minutes of UV light on two separate occasions. At one session, a sunscreen was applied to the participants' lips; in the second session, a placebo ointment was used. Without sunscreen, 71 percent of participants developed a cold sore within one week; with sunscreen, not one subject experienced an outbreak of cold sores. "Dentists have long advised patients to protect their lips by using protective lip balms, not just in the winter, but in the summer too," says Vicki Grandinetti, D.D.S., a general dentist who practices on Chicago's Northwest Side. "People who are very active during the summer should apply a sunscreen of at least 15 SPF or higher and they should reapply it frequently." Triclosan, an antimicrobial agent added to some toothpastes and mouth rinses, has been shown to have anti-inflammatory and analgesic effects that help ease the symptoms of canker sores. Researchers believe that when triclosan dissolves in the oral cavity, it stabilizes and protects cells from irritating agents and bacteria that may cause canker sores. Canker sores are small -- usually 1-2 mm -- and often characterized by white, painful, noncontagious, inflammatory lesions. They appear on the soft tissues and folds of the inner cheeks and lips, or the floor of the mouth. Though their cause is unknown, canker sores normally clear up on their own within 10-14 days. "If you're bothered by canker sores, try a mouth rinse or toothpaste that contains triclosan; the ingredients are always listed on the product's packaging," says Dr. Grandinetti. Dr. Grandinetti says that as much as 20 percent of Americans suffer from canker sores brought on by citrus fruits, spicy foods, mild tissue injury or stress factors. "Canker sores can be painful but generally are not a cause for concern," concludes Dr. Grandinetti. "However, if you have one or more persistent lesions that last longer than two weeks, and especially if they are not painful, schedule an appointment with a dentist for an evaluation."

Canker Sore Treatments: From Drugs to Diet

There is an oral paste has been shown to ease pain and speed healing of canker sores in healthy people and has been approved by the U.S. Food and Drug Administration. The drug is called Aphthasol®; its generic name is amlexanox. Researchers do not know how it works yet, although they believe it inhibits inflammation and offers protection as a wound covering. It should be applied four times daily and may sting or burn. Dentists or physicians can prescribe Aphthasol to patients who have recurring problems with canker sores. Canker sores are small -- usually 1 to 2 mm -- and often characterized by white, painful, non-contagious, inflammatory lesions. They appear on the soft tissues and folds of the inner cheeks and lips, or the floor of the mouth. Many factors are believed to cause canker sores or make them worse, including stress, food allergies, heredity, injury to the mouth, or use of a hard-bristled toothbrush. Dietary deficiencies of iron, folic acid or vitamin B-12 also are possible causes for canker sores. Canker sores normally clear up on their own within 10 to 14 days. Over-the-counter products containing lidocaine or benzocaine can relieve pain temporarily but do not promote healing. Triclosan, an antimicrobial agent added to some toothpastes and mouthrinses, has been shown to have anti-inflammatory and analgesic effects that help ease the symptoms of canker sores. Researchers believe that when triclosan dissolves in the oral cavity, it stabilizes and protects cells from irritating agents and bacteria that may cause canker sores. A study conducted in Norway suggests that sodium laurel sulfate, a detergent and foaming agent found in many toothpastes, can aggravate canker sores. Ingredients, including triclosan and sodium laurel sulfate, are listed on the toothpaste package. "We do not yet know how to prevent canker sores," explains Vicki Grandinetti, D.D.S., a general dentist. "Good oral hygiene and a balanced, nutritional diet may help significantly. Patients who are prone to canker sores probably should avoid heavily spiced foods, as well as citrus and other highly acidic foods, and be careful when brushing teeth." Dr. Grandinetti says that as many as 20 percent of Americans suffer from canker sores. "Canker sores can be painful but generally are not a cause for concern," she concludes. "However, if you have one or more persistent lesions that last longer than two weeks, and especially if they are not painful, schedule an appointment with a dentist for an evaluation."

Cold Sore Symptoms, Prevention and Treatment

Q: What is a cold sore? A: Cold sores -- small blisters filled with fluid that most often occur around the mouth area -- are referred to as herpes labialis or fever blisters. Herpes labialis is a painful and highly contagious condition that commonly affects the lips, mucous membranes, gums and skin around the mouth, but it can also spread to the fingers or eyes. An individual will break out with small bumps or blisters that eventually turn into scabs and go away. Cold sores are caused by herpes simplex virus type I. Genital herpes is caused by herpes simplex virus type II. An individual will generally break out with a cold sore within one or two weeks of direct contact with the virus. Stress, menstruation, exposure to the sun, an arid climate, trauma to the mouth area and poor diet can cause a cold sore. Some individuals are more susceptible to the virus, and may have repeated breakouts. Q: What are the symptoms? A: Symptoms include tingling, burning, itching, pain and tenderness in the area prior to the eruption of the blisters. An individual about to break out may have a headache, fever or flu-like symptoms. Q: How long do cold sores last? A: Once the blisters develop, they rupture and fluid drains out, forming a crusty sore. The cold sore -- which lasts seven to 10 days -- eventually goes away without scarring. There is an array of medications on the market designed to help alleviate the pain and promote healing, but most do not shorten the duration of the infection. Q: How do you prevent cold sores? A: During the early stages, the virus is extremely contagious. An individual, however, remains contagious until the sore crusts over. If an individual has a cold sore, do not share utensils or food with this person, and avoid kissing or sexual contact until the cold sore is gone. If you have a cold sore, wash your hands and avoid touching other areas of your body because the virus can spread very easily. For example, if you have a cut on your finger, the infection can be transmitted to that area. If the virus is spread to the eyes, it may cause ocular herpes, which can lead to blindness. Q: How do you treat cold sores? A: There are many different kinds of prescription and over-the-counter medications that include topical ointments, tablets and herbal remedies. Certain medications are prescribed to prevent future breakouts, while others may be used to help speed up the healing process. A healthcare professional can advise you on various treatment options. Ice may help with pain. The area should be kept as clean as possible. Q: When should you contact your physician or dentist? A: If you experience recurring cold sores, contact your physician or dentist who can diagnose the problem and recommend the best course of treatment.

Cold Sores: Healing Your Outbreak

For some people they are a simple annoyance, but for others they are a recurrent, painful and embarrassing event. Cold sores or fever blisters are usually caused by the Herpes simplex virus. About 75 percent of the population harbors the virus in their bodies and another 50 percent suffer from recurrent viral blisters. No one knows the exact reason for breakouts, but one common cause is stress -- either physical or emotional. When breakouts occur, it is important not to touch or break the blisters because of the possibility of spreading the virus. The virus infection can cause pain, tiredness and even mild depression in the blister or breakout stage. The treatment for cold sores until recently has been palliative in nature with no one remedy offering total relief. A product called Viroxyn® is available through dentists only. Viroxyn offers a one-dose treatment which stops the virus dead in its tracks. The medicine neutralizes the toxins released from the viral particles. It is the toxins that cause the pain, swelling and tissue destruction during the infection. It also stimulates the immune system and provides healing and relief in less than a day.

Skiers Should Watch Out for Cold Sores

While on the slopes, skiers need to take special precautions to protect their lips against cold sores, says a Chicago dentist. "Skiers need to constantly apply and reapply lip balm, ointments and even lipstick to decrease the chance of sun-induced cold sores," says Cheryl Watson-Lowry, D.D.S., a general dentist who practices on Chicago's South Side. "Skiers who are very active during the winter months should apply a sunscreen of at least 15 SPF or higher and they should reapply it frequently. Ski masks also are effective ways to block the elements and protect the lips. Lips are hard to protect because we constantly lick, rub or wipe them, which removes any protection and leaves them exposed to the wind, cold and the sun." Cold sores look like a small cluster of blisters and they occur on the gums, roof of the mouth, nose and lips. Unlike canker sores, they can be contagious because these inflammatory lesions are believed to be caused by the same virus that causes herpes. Cold sores tend to appear in the same place and usually clear up on their own within 10 to 14 days. The same ultraviolet rays that cause sunburn can trigger an outbreak of cold sores. Scientists and researchers are not yet sure how UV rays promote cold sores, but they believe the rays are responsible for lowering the immune response of exposed skin cells. Dr. Watson-Lowry says that as much as 20 percent of Americans suffer from cold sores brought on by weather, citrus fruits, spicy foods, mild tissue injury or stress factors. "Cold sores can be painful but are a cause for concern because they are contagious," says Dr. Watson-Lowry. "One solution for people who suffer from cold sores is to try a mouthrinse or toothpaste that contain triclosan, which is an antimicrobial agent with anti-inflammatory and analgesic effects that ease the symptoms. Researchers believe that when triclosan dissolves in the oral cavity, it stabilizes and protects cells from irritating agents and bacteria that might cause cold sores. Look for triclosan on the product's packaging." Dr. Watson-Lowry says that people who suffer from persistent cold sores should see their dentists for different treatment options. "If you have one or more persistent lesions that last longer than two weeks, especially if they are not painful, schedule an appointment with a dentist for an evaluation. Most people don't think to have their lips checked by a dentist, but it is entirely appropriate. Dentists are very familiar with this territory." Skiing vacations don't need to be interrupted with lips that are cracked, swollen, tender or covered with cold sores, says Dr. Watson-Lowry. "Protect your lips and spend your time worrying about breaking a leg," laughs Dr. Watson-Lowry

Treatment Options for Painful Canker Sores

Canker sores (aphthous ulcers or recurrent aphthous stomatitis) are painful mouth ulcer(s) that usually appear after a gradual burning or tingling sensation. Canker sores are usually found on the movable, non-keratinized (less protected) tissues in the mouth, including the inner surface of the lips, the cheeks, under the tongue, and back of the throat. You may remember the first time you experienced a canker sore and looked in your mouth to find a small (2-4 millimeter) white or yellow ulcer with a red halo around it. Canker sores usually occur in clusters of less than six, and tend to recur periodically in response to stress, during the menstrual cycle and hormonal changes, and from food allergies and dietary deficiencies (especially iron and vitamin B12). Canker sores can occasionally mimic other dental problems. Patients will sometimes come to my office thinking that they have an infected tooth or an abscess on their gum, and are surprised to discover that the cause is a canker sore. Canker sores usually cause pain for about four or five days, and generally completely resolve in 10-14 days. The cause of canker sores is unknown, but some researchers have speculated that there may be an inherited predisposition or defect in the immune system responsible for them. Small as these ulcers are, they seem to transmit a disproportionately large amount of pain. Treatment for canker sores is primarily centered on relieving the pain associated with them. Your dentist can prescribe a viscous 2 percent lidocaine rinse to be swished around the mouth every three hours to “numb” the canker sores and provide relief. The over-the-counter product Orabase®, which contains a protective barrier called carboxymethylcellulose, can be very effective in managing canker sores. In addition, your dentist can have the pharmacist add the mild steroid triamcinolone at 0.1 percent to the Orabase to improve its effectiveness. Canker sores can also be treated with chemical or physical cautery (searing of tissue). Chemical cautery can be accomplished with phenol-containing compounds and silver nitrate sticks, and physical cautery may be preformed with soft-tissue dental lasers or other heat-generating devices. In some cases, canker sores can occur in high numbers and cause severe and debilitating pain. In these cases, your dentist may consider prescribing an oral suspension of the drug tetracycline at 250 mg to be used four times a day for 10 days. The drug is to be held in the mouth for two to five minutes and then swallowed. Tetracycline should not be used for children under 10 because it can discolor developing teeth. For more serious cases of canker sores, the dentist can prescribe corticosteroids. A good choice is the drug dexamethasone, which is used topically as a solution that is rinsed and spit out twice a day for five days. A different corticosteroid called prednisone can be taken orally, in tablet form, starting at 40 milligrams per day and then tapered for 10 days. Severe pain can also be effectively managed by a combination of Benadryl®, Maalox® and Dyclone®, sometimes called “magic mouthwash.” The decision of how canker sores should be treated is up to you and your dentist. Many times, no treatment is needed. In more severe cases, however, it should be comforting to know that your dentist has a wide arsenal of remedies available to do battle with those pesky canker sores.

Causes and Treatment of Cracked Teeth

Q: Cracked teeth: How does it happen? A: When we crack or chip our teeth, we often blame it on eating the wrong foods, such as sticky candy or popcorn. But in fact, the food may not be entirely responsible for the fracture. Sticky candy may accelerate the crack, but the tooth may have fractured because of its weakened condition. For example, a tooth with a large existing restoration in it -- such as a filling or root canal -- is weaker than a tooth that has not been restored. There are a number of reasons why a tooth may crack, including tooth decay, trauma or injury, a weakened tooth structure, grinding of the teeth or a stress fracture. In some cases, the tooth simply can't withstand the strong muscles of the jaw and will fracture when an individual bites down on food. One way to protect the teeth from trauma is to wear a mouthguard during sports. Your dentist can fit you with a custom mouthguard. Taking proper care of the teeth and regular visits to the dentist will help keep your teeth in good shape. Q: What should you do if a tooth cracks? A: Cracking the tooth may be painful if the nerve is exposed, and the area may become tender. The Chicago Dental Society and the American Dental Association recommend that you rinse your mouth with warm water to clean the area and apply a cold compress to the mouth to reduce swelling. Call your dentist immediately. Q: How are cracked teeth repaired? A: The first step may be to buff down the tooth if it has a razor-sharp edge. Treatment may vary depending on where the tooth has fractured, how close it is to the nerve and the overall condition of the tooth. A cracked tooth may be repaired with a restorative material, such as silver alloy, gold, porcelain or plastic, a crown or overlay, or through a process called bonding, which includes applying porcelain or enamel to the fractured tooth. Your dentist will advise you on the best way to preserve the tooth. Q: What happens if you knock out a tooth? A: If a tooth is knocked out, retrieve it immediately. Hold the tooth by the crown and rinse off the root of the tooth if dirty. Do not scrub it or remove any tissue fragments. If possible, put the tooth back in the socket or in a container of milk or cool water. Call your dentist immediately.
Dentists Starting to See More Cracked Teeth
Dentists are noticing an increased number of patients who are coming to their offices with pain caused by cracks in their teeth. These patients often are "baby boomers" born in the 1950’s and early 1960’s who grew up before fluoridated water became the norm and before sugarless gum had been developed and marketed. They tend to have more cavities but have most of their teeth. "It's an interesting new area for dentists," explains Patrick Hann, D.D.S., a general dentist. "We are seeing patients who had fillings placed when they were children, but now these fillings are 30 years old. Like everything else, they have a life span and many have begun to deteriorate, causing teeth to crack." Anyone who lives long enough and keeps his or her own teeth may eventually have a tooth that cracks. People most prone to cracking a tooth are those who chew on hard objects such as pens, ice or unpopped popcorn kernels, and those who experience bruxism or toothgrinding, especially while sleeping. "The pain caused by a crack in a tooth is different from other toothache pain and different types of cracks may hurt in different ways," says Dr. Hann. "Toothache pain is a constant ache or you feel sharp pain every time you press on the tooth with your finger. Pain caused by a crack may hurt one time when you press on it but not the next time. It depends on the position of the crack. The tooth may be sensitive to heat or cold, especially cold. The pain may not be severe enough that you take an aspirin or miss school or work. If you have any of these symptoms, it's important to make a dental appointment right away. A minor crack often can be treated with a filling or a crown." A cracked tooth hurts because the soft inner tissue of the tooth, called the pulp, becomes pinched or irritated as the crack opens and closes. When chewing, pain may occur between bites. When pressure on the tooth is released, the crack comes together and pinches the nerve. Eventually the pulp will become damaged and a root canal procedure will be needed to save the tooth. If treatment is delayed for too long, the tooth may split and will be more difficult to treat successfully. Cracked teeth can be difficult to diagnose because the pain is elusive and variable. In addition, cracks are not visible on X-rays. Dentists use special illumination or magnification to find the crack. Dyes may be used to follow the course of the crack. Sometimes cracked teeth cannot be saved. Some cracked teeth will later cause problems after treatment because, unlike a broken bone, a fracture in a tooth doesn't actually heal. Even when a crown is placed on the tooth, a crack sometimes can continue to grow. In spite of this, dentists are successfully treating an increasing number of teeth that might have been lost only a few years ago. "Saving your natural tooth is always preferable to having it extracted and replaced," Dr. Hann says. "A patient may someday lose a badly cracked tooth, but in the meantime, treatment could make it last another 10 years. Most patients prefer to keep their natural teeth rather than have them extracted." Diagnosing and Treating Cracked Tooth Syndrome
Symptoms of cracked tooth syndrome include: - Pain while chewing - Hot and cold sensitivity - Pain when eating sweets - No evidence of a problem on X-rays - No dental decay present Teeth may crack when subjected to stress of chewing hard foods or ice, or by biting on unexpected hard objects. Teeth restored with silver fillings are most susceptible. The majority of cracked teeth can be treated by placement of a crown on the tooth. When the crown is placed on the tooth, the pain usually leaves immediately. Occasionally the tooth cracks into the nerve of the tooth. If pain persists after placement of the crown, you may have a crack into the nerve of that tooth. Please call your dentist, as this tooth may require a root canal. Suggestions will be made to help you maintain good oral health.

The Cracked Tooth Craze

A common tooth problem many face today, and even more will face in the future, is cracked tooth syndrome, or fractures of tooth cusps and weak enamel. Many patients come to me concerned about a small surface “crack” that they see, which is what we refer to as “crazing.” When I describe this in an exam, it does sound confusing. This is similar to the fine cracks you might see in the surface glaze of fine china, not necessarily a weakened part of the structure. These are often caused by the rapid and alternate exposure to hot and cold extremes. In teeth, these might come from a bite of ice cream followed by a sip of hot cocoa or coffee. The crazing is not the problem, but repeated cycling over the years can lead to weakening or deeper fracture lines forming between tooth and filling materials because of their different (technical term alert!) coefficients of thermal expansion. I know that's a big word, but it pretty much sums up why anyone who has his or her own teeth now is suffering from the broken tooth craze. The good news is, because almost all teeth in the 20th century were filled with silver amalgam, their owners still have them! The bad news is, because almost all teeth in the 20th century were filled with silver amalgam, their owners will suffer from some form of cracked tooth problem. Some other causes may be malocclusion with chronic clenching or grinding your teeth, a hard blow to the mouth leading to a crack or fractured tooth, or aging of heavily restored teeth that left them susceptible to cracking. One very common, yet easily preventable, type of tooth fracture is of a tooth that has had a root canal. A standard treatment recommendation that goes along with a root canal diagnosis is for a full crown after endodontic treatment to help protect the remaining susceptible crown and root from fracture. So, if you have an actual cracked tooth, then how do you know? This problem can be quite insidious, going undetected until it’s too late and a root splits, or causing nagging, slight symptoms for months or even years. If you have an area of your mouth where you get an "uncomfortable sensation" when you chew, or the tooth "feels weak," then you most likely have a cracked tooth. The pearl you found in your cereal this morning may be a sign (sorry, that's your buccal cusp from the upper left bicuspid, not a prize from the box). A crack often is not visible on the outer surface and accordingly, may not be apparent on an X-ray. Many cracked teeth may give no sign or symptoms. The gaping hole discovered by the tongue may be your first clue. Often, cracks are found when a filling is removed for another reason. Once discovered, a repair can be accomplished along with the treatment of the original problem. If you are lucky enough to have sudden sensitivity or pain (did he really say lucky?) to hot, cold, sweets, sticky or hard foods, and you can locate the exact spot, it will be helpful to the dentist in diagnosing this condition. If biting causes symptoms, and when you release the pressure, a sharp pain occurs as the crack closes; it can be very helpful in locating the offending cusp. Yes, I did say lucky. If you have a cracked tooth and it cannot be located, the result may be a fracture that gradually progresses into the root of the tooth. This will result in an unrestorable tooth that will have to be extracted and replaced, an obviously much more costly problem to treat. Diagnosing cracks and fractures can be puzzling at times. X-rays may reveal underlying decay or cracks in fillings, but rarely show the most common type of cracks. Incomplete cracks may only be revealed by removing a filling and viewing the tooth internally; you should be glad if your dentist recommends doing an assessment preparation. This may prevent the need for a later root canal or even worse, possible tooth removal. The crack lines may be vertical, horizontal or oblique, depending on the stresses applied to the tooth cusps. Teeth most likely to fracture usually have non-bonded, metal restorations. Many times, cracks may only be revealed by using magnification or light application and subsequent refraction. An intraoral camera is perfect for this method of detection. Sometimes, there is uncertainty as to whether it is a top or a bottom tooth, and on occasion, it is both a top and bottom tooth. There is no rule that says you can only have problems with one tooth at a time! Biting on a cotton swab or device designed to reproduce symptoms from pressure will help locate fractures intentionally. Disclosing dyes may be used to better show the origin and extent of a fracture line. If you are really lucky, you may have a dentist who will recognize that early detection and treatment is the best service that she can provide in dealing with the cracked tooth phenomenon. Stabilizing a symptomatic or weakened tooth with a bonded composite filling or a full crown will be the more favorable option and less likely lead to tooth loss or more extensive treatments. Again, the wait-and-see approach will only lead to more unfavorable and limited treatment options. During the last half-century, most dentists restored teeth rather than extracting them. In the next half-century, we will be dealing with preserving those retained and restored teeth, but that is a definite improvement over placing full dentures. The best news is that the next generation will not be dealing with the cracked tooth as much because we have preserved their teeth by preventing decay and the need for fillings to begin with

Dental Care for Traumatic Dental Injuries

Traumatic injuries to the natural teeth represent a common incidence of emergency room visits, and a perplexing problem for physicians, often untrained in the proper management of immediate dental care. After-hours emergency dental personnel may not be readily available quickly enough to prevent the unnecessary loss of traumatized anterior teeth. Completely Avulsed Teeth Adult teeth that have been partially or fully avulsed (luxated) from the mouth require urgent attention. Successful treatment is contingent on the time frame that lapses from the moment of impact to the time of re-implantation of teeth that are completely removed from their sockets. Treatment must commence prior to a visit to the dentist. If you have an avulsed tooth: - Gently rinse the tooth in tap water if grossly contaminated. - Do not attempt debridement of the tooth surface. - Replace the tooth within its socket with minimum pressure. - Remember that precise alignment is not as crucial as a quick response. - Obtain immediate dental care. If circumstances such as contaminated wounds, extensive injuries, or multiple tooth loss preclude re-implantation of the tooth, transport it the dental office in a container of milk, preferably cool temperature. The patient’s own saliva or water are secondary choices. Remember: Time is of the essence. Teeth re-implanted within the first hour have a significantly better prognosis. Professional treatment usually consists of approximate alignment of the tooth and light stabilization. Further trauma to the tooth and socket should be minimal. Splints are generally maintained for 7-10 days, with no biting force and diet instructions to avoid further disturbance. Root canal treatment is customarily performed two weeks after the injury to reduce the chance of unfavorable pulpal (nerve chamber) responses at a future date. An assessment of other facial and neurological injuries must always be considered, even if other injuries are not apparent. Lacerations that require sutures must be treated within 24 hours for ideal healing and minimum scar formation. Tetanus updates are often advisable for contaminated oral wounds, especially if a tooth has been re-implanted. Appropriate documentation may be necessary for legal and insurance considerations. Partially Avulsed Teeth A partially avulsed (subluxated) tooth -- one that has been loosened but not removed from its socket -- requires immediate care, though time is not quite as critical as for the total avulsion. The mouth should remain open sufficiently to avoid further disturbance to the loose tooth and immediate dental attention must be arranged. Do not attempt to forcibly reposition the tooth. The dentist will usually attempt to properly position the partially avulsed tooth, using minimal pressure. If more than an hour has lapsed, there may be a bleeding impediment within the socket to regain ideal placement. The tooth should be stabilized and biting forces removed. A partially avulsed tooth, incompletely repositioned, may be moved at a later time using orthodontic treatment. Fractures of Natural Teeth Management of fractures depends on the portion of the damaged tooth structure and require professional expertise. While time factors are not as critical as in the treatment of avulsed teeth, dental fractures may necessitate high priority attention, depending on the level of discomfort and cosmetic concerns. Traumatized teeth that exhibit momentary sensitivity to hot and cold do not generally command as much immediate attention as loose teeth, or those causing persistent pain. Treatment of dental fractures is dependent on many factors and often palliative, even temporary management is preferred. Pulpal damage assessment is complex and often not easily discernable at the time of the injury. Prevention The most predictable occurrence of dental injuries is sports related. Participants in contact sports should have an appropriate athletic appliance fabricated to avoid unnecessary tooth loss. The design of the mouth guard depends on the nature of the sport. Eye protection is of even greater importance, particularly in sports involving fast moving objects (even tennis balls may cause substantial ophthalmic injuries). Please note: This information is provided as a general guideline. It is not intended in place of follow up professional care. Should you require urgent care, consult your treating dentist for instructions on your particular situation.

Dental Emergencies Requiring Immediate Treatment

Swelling in the mouth or having a tooth knocked out of the socket are two serious dental emergencies that require prompt dental attention. Oral swelling is almost always caused by an infection of a tooth or the gums. Swelling that is caused by a tooth is the result of a deep cavity or trauma that causes bacteria to infect the tiny nerves and blood vessels within the tooth. Left untreated, the infection spreads, killing the tissues within the tooth and forming pus, the product of an abscess. The abscess looks for a way to spread, but because the tooth is hard and confining, it moves into the surrounding jawbone, and then to the cheek and near the gums. Untreated, the swelling can spread to the throat and become fatal if it prevents our ability to breathe. Swelling caused by an infected tooth will be treated with either root canal therapy, where the infected nerves and blood supply are removed from the tooth, or by extracting the tooth. In most cases, it is preferable to save the tooth with root canal therapy. If the swelling is hard, the dentist may make a small incision to drain the infection. Antibiotics may be prescribed as an adjunct to the dental treatment. A gum (periodontal) infection can cause swelling when plaque, a bacterial film that forms continuously around the teeth, and debris get trapped under the gum line. This almost always occurs in people with pre-existing gum disease, where the plaque and debris cannot be cleaned out. The dentist can clean under the gum line to treat swelling caused by a gum infection. If the tooth or teeth are loose in the area of the swelling, they may require extraction. In some cases, antibiotics may also be prescribed. Swelling can be very dangerous, and requires immediate attention. While you are waiting to go to the dentist, as well as after treatment, you can rinse with warm salt water (8 oz. of water with 1 tsp. of salt) every two hours to help bring the swelling down. You can take over-the-counter pain relievers such as ibuprofen (Advil®) or naproxen (Aleve®). Some topical ointments, such as Orajel® or others containing 10-20 percent benzocaine, can be helpful if rubbed over the swelling. If your dentist cannot see you within 24 hours, find a dentist who will, or go to a hospital emergency room. Having a tooth knocked out requires immediate action. First, find the tooth, hold it by the crown, and rinse it off with plain water, but do not scrub the root. Place the tooth carefully back into the tooth socket, if possible. Otherwise, place it in a cup of milk or inside your cheek like a lozenge. You must get to the dentist within half an hour to have a good chance of saving the tooth. The dentist will examine the site of injury and clean the tooth socket. The tooth will be replanted and joined to the surrounding teeth for 7-10 days for stability. If the tooth re-attaches to the jawbone, it will then require root canal therapy. Always remember that the use of a custom athletic mouth guard can greatly reduce the risk of having a tooth knocked out during sports participation.

Guidelines for a Knocked-Out Tooth

Well, it’s that time of the year again. The kids are back in school and the lazy days of summer are over. It’s also the time of year when many children become involved in contact sports. I am often asked by parents in my office, “What should I do if my child ever gets a tooth knocked out by trauma?” A typical scenario would be Johnny was playing soccer and got head-butted in the face. He fell down and when he got up he noticed bleeding from his nose and mouth. After wiping the blood from his mouth, he finds his tooth in his hand. What do you do? Luckily, your dentist can deal effectively with this kind of emergency. But he’ll need your help. Collect the tooth and immediately replace it in the socket at the site of the injury. Instruct your child to hold it in place with their thumb until you reach the dentist. This will keep the tooth in its natural environment and the opportunity for a successful re-implantation. If this is not possible, wrap the tooth in a wet cloth, or even better, place it in a cup of milk. Do not place the tooth in a dry paper towel or place it in any sports drink. Don’t linger! The chance for a successful treatment is best if the tooth is treated within the first 30 minutes after injury. After this window of time, successful re-implantation drops dramatically. Some parents rush their child to the dentist, but in their panic, forget the tooth. Don’t forget the tooth and don’t try to clean it yourself -- even if it looks horrible. What you think may be dirt, my actually be soft tissues that will help the healing process

Rescuing a Child’s Knocked-Out Tooth

It’s something every parent worries about. Your child comes back from the playground with a tooth knocked out after falling off the jungle gym. To complicate the situation, the accident occurs on a Sunday afternoon, and your family dentist is not in the office until Monday. The question is: What to do? Fortunately, there are some things that you can do to save a knocked-out tooth. The first thing to do is to find the tooth and immediately rinse it off, but do not scrub with plain or salt water. You should then try to determine if it is a baby or an adult tooth. Although this requires some instruction, there are general guidelines that can assist you. First, baby teeth are smaller and usually whiter than adult teeth. The age of the child is also important. If the child is under 5 years of age, the tooth is most likely a baby tooth and does not need to be saved. If the child is more than 12 years old, it is probably an adult tooth, and every effort should be made to preserve it. It is also important to know that the teeth most often knocked out are the upper two front teeth, directly in the middle of the mouth (the central incisors). These adult teeth usually come in when a child is 6 years old. If you are relatively sure it is an adult tooth, the best thing to do is place it back into the socket that it was knocked out of. Remember to hold the tooth by the crown, and gently guide the root into the socket. A good way to remember the correct orientation of the tooth is to match the surrounding teeth and remember that the part of the tooth that faces outward is rounded or convex (for a front tooth). The best hope for success is if the tooth is re-inserted within five minutes. You should then see your dentist as soon as possible. If you can get to your dentist within an hour, but are unable to re-insert the tooth into the socket, you should store the tooth in your child’s saliva or in cold milk. Your dentist will examine and clean the area of injury. The tooth will be re-inserted and then fastened for stability to the surrounding teeth for 7-10 days. If the tooth heals, it will then require root canal therapy. Unfortunately, if the tooth is not re-inserted into the socket within one hour of the accident, there is a high likelihood that the tooth will be lost. Although not practical for year-round use, I recommend that all children involved in contact sports wear a customized athletic mouthguard to prevent injury to the teeth and jaw.

What to Do During a Dental Emergency

A dental emergency is always a stressful situation, but it can become absolutely nerve-racking when your dentist is out of the office. Whether it’s late Saturday night and your dentist won’t be back in until Monday, or if your dentist is out of the office for several days, a dental emergency can be difficult to manage on your own. There are some basic things that you can do to prevent or cope with dental emergencies when they occur. The best way to handle a potential dental emergency is to avoid one from ever occurring in the first place. The most common dental emergency is pain or swelling from an infected tooth. In most cases, this does not happen suddenly, overnight. In general, a person has some degree of pain or discomfort for several days or even longer before they are in severe pain and in need of emergency dental care. The best advice is to go to the dentist at the first sign of any discomfort in the teeth or gums. Some people think that if they ignore a dental problem, it will go away -- but this is almost never the case. In nearly all situations, untreated dental problems become far worse over time, not better. There is also a benefit to treating a dental infection before it flares up, because then the dentist can manage it with maximum comfort to the patient. If a dental emergency does occur when your dentist is unavailable, there are several things that you can do. Pain in the teeth or gums can often be effectively handled with over-the-counter pain relievers such as ibuprophen (Advil®), naproxen (Aleve®), or acetaminophen (Tylenol®), to be taken as directed. Rinsing with warm salt water (a teaspoon of salt in eight ounces of water) can help temporarily relieve puffy or swollen cheeks and gums. Some-store bought products like Orajel® can also be effective in relieving minor soreness of the gums. If a tooth is broken, a piece of wax or even some soft chewing gum can cover a sharp edge until you can get to the dentist. Your dentist should also be available for advice if a dental emergency occurs. Most dentists wear a pager at all times so patients can reach them when out of the office. This gives dentist the ability to contact the pharmacy for antibiotics and pain medication should they feel that patients need them. If your dentist is going to be out of the office for more than a few days, he or she should have another dentist available to treat any dental emergencies that may occur.

When Your Family Doctor Should Call the Dentist

I recently had a patient come to my office for what she thought was a TMJ (jaw joint) problem. She complained that her pain was “mysterious” and would spontaneously occur every day or so. The pain was both intense and debilitating, radiating to the whole right side of her face. She had been to her family doctor, who suggested that she was having a TMJ problem, but not to go to the dentist for a “high-priced mouth splint.” Instead, he suggested that she purchase one herself at a sporting goods store. She followed her doctor’s advice, but got no relief from the store bought appliance. She then went back to her doctor, who sent her to an ear, nose and throat specialist (ENT physician). The ENT specialist thought she had a sinus infection and gave her various medications, including antibiotics, narcotic painkillers and decongestants. None of these therapies worked, however, so the specialist scheduled her for a CAT scan. Fortunately, her husband recommended that she see a dentist three days before the CAT scan was scheduled. She reluctantly agreed. When Debbie came into my office, she was understandably distraught. She had missed weeks of work due to the pain and medications she was taking, and her situation had not improved. When I evaluated her, I discovered that an infected tooth was the cause of all of her symptoms. I performed a root canal on the tooth, and within two days, all of her symptoms disappeared. She cancelled her appointment for the CAT scan, and is now back at work. I suspect that many of you reading this are surprised about what happened with Debbie. Her experience illustrates the importance why and when your family doctor should seek the opinion of a dentist for certain types of ailments. Unfortunately, the reason that a dentist was not consulted is because most medical doctors have little experience with dental problems. Medical doctors are generally not educated in medical school or in their residencies about dental diagnosis or treatment. This can cause many problems for patients, medical doctors and dentists. In Debbie’s case, her doctors were doing everything they could to help her, but simply did not know that a dental infection can cause all of the symptoms that she was experiencing. Medical doctors and patients should be aware that any pain or swelling in the mouth, face, head, neck, ear or sinus can be caused by a dental infection or other dental problem

Anxiety Relief From Your Oral Surgeon

A child wonders what the first day of school will be like. Someone is about to start a new job. A young couple is about to be married. Each of these situations is a classic anxiety producer. What they have in common is that each involves the unknown, and that's what anxiety is: The fear of an upcoming specific event that in all likelihood you've never before experienced. An upcoming visit to an oral and maxillofacial surgeon is another potential anxiety producer. In this case, the individual typically is most concerned with possible pain -- whether the procedure is going to hurt. Modern technology now makes it possible to perform complex surgery in the office with little or no discomfort. Knowing this should start to bring your anxiety level down to a minimum. Your oral and maxillofacial surgeon is not only a specialist in dealing with problems of the mouth, teeth and jaws, but is also experienced in dealing with the control of pain and anxiety. During years of hospital training, the oral and maxillofacial surgeon receives extensive schooling in medical and dental aspects of anesthesia. Your oral surgeon is thoroughly knowledgeable in pain and anxiety control and possessed extensive clinical experience in anesthesia techniques, from local anesthesia to sedation to general anesthesia. Putting Your Mind at Ease One of the things your oral and maxillofacial surgeon has been taught in terms of reducing anxiety is the importance of making the patient aware of what to expect during surgery. It's usually true: The more you know, the less you have to be anxious about. That's why beforehand, you'll review with your surgeon the type of anesthetic to be used, as well as what you will likely feel during the operation. Your oral and maxillofacial surgeon will answer any questions you may have about any facet of the operation. During surgery, one or more of the following can be used in controlling the pain and anxiety: local anesthesia, nitrous oxide-oxygen, intravenous sedation and general anesthesia. Commonly, patients describe their feelings during surgery as surprisingly pleasant, without a care in the world. After surgery, your oral and maxillofacial surgeon can prescribe a number of medications to make you as comfortable as possible when you get home. Suffice it to say that before, during and after surgery, your oral and maxillofacial surgeon truly shares your concern for your well-being. Beyond that though, your oral surgeon also has the training, knowledge and experience to make your visit as pleasant and as comfortable as it possibly can be.

Confessions of a Dental Coward

OK, you got me cold! I confess! Yes, I was a dental coward. I broke out in a cold sweat and cowered in the corner at the thought of plunking myself down in the dentist's chair and opening my mouth. Because of this, I pushed all thoughts of visiting a dentist out of my head for years, and as a result, the condition of my teeth became worse and worse. I know this is a terrible hackneyed cliché, but it all started as a young boy. Like most kids, I needed dental work and my parents took me to their dentist. I forget his name which, I'm sure, has been banished forever from my memory due to the horror of it all. Suffice to say, he was a butcher who had no regard for the comfort of his patients, and in fact, once told me that pain is all part of having your teeth worked on. His barbaric attitude and skills, coupled with the available dental equipment of that era, caused me great physical pain in his chair and great mental pain just thinking about being in his chair. When the work was finally over, I breathed a large sigh of relief, and although I didn't realize it at the time, my fear and avoidance of dentists was forever etched in my mind and I never again went near a dentist's office for decades. During this time, the condition of my teeth got progressively worse, both health wise and in appearance. I probably would have been condemned to remain a slave to my fears for life if a fortunate accident hadn't occurred. I broke a tooth in half on a piece of hard candy. How, you say, could this possibly be fortunate? I know … it sounds very strange. A few weeks later, the remaining half tooth fell out, leaving a noticeable gap in my upper front teeth. I had avoided smiling due to the appearance of my teeth before the accident. Now I stopped smiling altogether. I wrestled with my fear and finally sought the services of a dentist. Living in Seattle at the time, the dentist I picked was Dr. Reed. He was nearby and he was open on Saturday, which was important to me as I traveled a great deal on business during the week. With my heart in my throat, I timidly sat down in his chair for my initial examination fully believing that he was going to cause me unbearable pain. Dr. Reed concluded his examination -- with no pain -- and then, in consultation, told me what I needed. What I needed was massive and expensive. I went home to think about it, and decided I would endure the pain, face my fears and get it over with. Dr. Reed's staff scheduled me for a series of appointments and my ordeal began. Except, wait a minute, it wasn't at all the ordeal I'd expected! What's going on, here? Dr. Reed gave me an adequate amount of pain-numbing injections (and even those, he did with great care), carefully explained each procedure, and at all times, was extremely careful to ensure that I was comfortable and not in pain. I left my first appointment seriously doubting some of my deep-rooted convictions about dental work. As each appointment was completed, more of these fears went by the wayside. I began to really like Dr. Reed as both a dental professional and as a person. He had a great sense of humor and made me laugh. Imagine me laughing in the dental chair! Will wonders never cease? Once, I got to him with a little verbal joke I played on him. My appointments were quite long, so we would have occasional rest room breaks. Dental pain-numbing injections cause your speech to be quite slurred and almost unintelligible. Arising from the chair, on my way to the rest room, I covered my face and head with a nearby towel and in my greatly slurred speech announced, "I am not an animal." Dr. Reed and his assistant almost fell on the floor laughing. Yes, here I was laughing at and making jokes in the dentist's office. Once, during a particularly long appointment, I actually fell asleep in the dental chair and his assistant had to wake me up. My fear of dental work by that time was completely gone. As part of my needed work, Dr. Reed sent me to an oral surgeon, Dr. Cohen. Dr. Cohen was quite skilled in his work and was also quite funny, and in fact, did stand-up comedy as a sideline. I faced his work with no fear, thanks to Dr. Reed. Today, I have healthy, beautiful teeth. Yes, much of my mouth is bridge work, but they feel and act just as if I'd had them all my life. I have no toothache or mouth pain as I did in the past, and now I love to smile. I accomplished this with almost no real pain (during or after each appointment). OK, there was one bit of terrible pain when I got the bill. Ouch! My work was in the five-figure range and the first figure wasn't a one. Nevertheless, I feel it was some of the wisest money I've ever spent. If you've been putting off much needed dental work, I urge you to reconsider. While I was somewhat lucky in choosing a great dentist, I suggest you get referrals and other recommendations and pick your dentist carefully. You'll find there are many skillful and caring dentists from which to choose. Also, the dental equipment and techniques of today are vastly improved from what was available in years past. Grab your fear by the horns and face it. It's never been easier to do that than right now. I know that as well as anyone, and thanks to Dr. Reed and Dr. Cohen, I'm no longer a dental coward. The next person to say that could be you!

Controlling Anxiety and Fear in the Dental Office

For those with dental phobias, by far the most effective way to control fear and anxiety is the development of a trusting and caring personal relationship with their doctor and staff. My office is designed to look and feel more like a spa or boutique than a dental office. We constantly strive to create a warm, caring and cozy atmosphere, even down to elimination of that awful "dental office" smell. I find that earphones and movie glasses only interfere with the communication necessary for development of those relationships. I like to be in verbal and visual contact with my patients while treatment is in progress so that we can interact. Also, watching the eyes is the best way I've ever found to judge the emotional state of my patient. Local anesthesia is very effective when used in appropriate situations and appropriate amounts. I have developed many innovative means for the comfortable delivery of local anesthesia over the years. Foremost of these is the willingness to slow down and take the time necessary to be gentle. For new patients in need of immediate treatment or for those patients with unusually strong phobias, I have found the judicious use of a preoperative oral sedative or laughing gas to be an excellent solution. Conscientious dentists always remember: there is a person at the end of every root. Dental Fear and Anxiety in Children

Everyone knows that children are impressionable, and many people who avoid dental care as adults recall traumatic experiences at the dentist as children. Unfortunately, the absence of routine dental care can cause painful infections of the teeth and gums, broken and discolored teeth, and bad breath. Fear of the dentist is a major reason for dental neglect, and can almost always be avoided. The conduct of the dentist is directly related to the development of dental fear in children and adults. The past experience that causes the most fear is the memory of a dentist causing pain during treatment and then humiliating the person when they complained. The dentist saying denigrating things like, "This isn't hurting you," or "Stop being a baby" compound the painful experience at the dental office. Even though the pain from the treatment fades quickly, the insensitive comments made by the dentist continue to live on in the minds of the children and are often carried through to adulthood. There are several ways dentists can improve dental visits for children: - The dentist should be sensitive to the needs of each individual child. Patience and care during treatment will prevent anxiety in future visits. - Dentists should encourage parents to bring their children to the dentist by age two, or earlier if there is noticeable discoloration of the baby teeth or if the child is signaling pain. The sooner the child is seen, the less likely the child will have extensive dental problems. - If dental treatment is required, the dentist should usually start with the procedure that will be easiest for the child to tolerate. This allows the child to build confidence for future visits. - The dentist should avoid giving local anesthesia for simple fillings, if possible. Newer technologies, like air abrasion and lasers, can effectively remove decay in many cases, avoiding the fear-evoking needle and the prolonged feeling of numbness. - The dentist should consider conservative treatment for children’s baby teeth. Treatment that is less involved, takes less time, and causes less discomfort is also less likely to contribute to fear and avoidance of the dentist in the future. - Having a television in the treatment room with an age appropriate station will help children cope with the clinical setting of the dental office. A small toy after successful treatment gives the child something positive to associate with their dental visit. - Children who need extensive dental care or those that cannot be managed by the family dentist may best be treated by a specialist called a Pedodontist.

Dental Fear and Phobia

Does the sound of the dentist's drill make you cringe? Does the sight of the needle make you scared and nervous? If so, you're not alone. It has been estimated that more than half of all the people in the United States will never see a dentist for regular care. Fear of the dentist, or in more severe cases, dental phobia, is the main reason that many people avoid the dentist. And the problem with staying away from the dentist is that small problems soon require major dental treatment! Where did these fears originate? First of all, let's acknowledge that many people who are afraid of the dentist have a legitimate reason for their fear. Maybe they recall a traumatic experience when the dentist either caused them pain during treatment or embarrassed them by making light of their fears. These memories tend to be especially acute if the traumatic incident occurred during childhood. Vivid memories of the incident recur whenever the fearful person needs to go to a dentist. I have treated patients in their 70s and 80s who still fear dental treatment due to bad experiences they had as children. Modern dentists are well aware of the impact a negative dental experience can have on children, and fortunately, many of them have had training in child psychology. Using that background, they strive to make the early experiences with dentistry positive ones for children. The past experience that causes the most fear among patients is the memory of a dentist causing them pain during treatment and then humiliating them when they complained. These patients can remember the dentist saying things like, "This isn't hurting you," or "Stop being a baby." These denigrating remarks compound the painful experience at the dental office. Even though the pain from the treatment fades quickly, the insensitive comments made by the dentist continue to live on in the minds of the recipients of those unsympathetic comments. There are also large numbers of people who are "afraid of the dentist" or of certain dental procedures but have never actually had a bad experience at the dentist's office. These are people who have heard from others that dentistry is painful -- and they believe it! This type of learned fear is called vicarious learning and is quite common. Unfortunately, there is good reason for people to accept this premise on face value because it is sometimes reinforced by family and friends and also in the media. This is very similar to how we feel when we see a plane crash on the TV news. The vivid pictures and tragic personal stories stir our emotions. But, have you ever stopped to think that you rarely hear about the more than 20,000 safe take-offs and landings every day, or the incredible safety record of the airline industry? Likewise, few people share their successful dental experiences. Instead, research has shown that people are far more likely to share and embellish a negative dental experience. I know from years of treating patients the power of vicarious learning. Many times I have to suggest that a patient with a dental infection get a root canal to save a tooth. Right away, the fearful patient will say something like, "No way, put me to sleep and I'll have it pulled. I won't go through a root canal." When this happens, I ask them if they've ever had a root canal before, and if it was a bad experience. In most cases, the answer is no. I then ask them why they think it will be painful. They usually respond that they heard somewhere or from someone (a friend of a friend) that a root canal is painful. In addition, I sometimes hear fearful parents in my waiting room unknowingly establish with their children negative stereotypes regarding dental treatment. They might say things like, "Tell the dentist if he is hurting you," or "If you don't stop misbehaving, it will be your turn to go to the dentist next time," and other things that are likely to instill a fear of dentistry. Dentists and dental treatment are sometimes portrayed in a negative light in the media and in commercials we see on TV. We have all heard stories in the news about AIDS and dirty dental drills and water. Unfortunately, these stories are sometimes one-sided and can misrepresent the facts; this results in unnecessarily frightening people about the safety of dental treatment. Likewise, commercials often use the fear of dental treatment, especially root canals (the replacement of the tooth's pulp with an inert material) as the punishment in their contrived scenarios. People who fear the dentist will tend to hone in on negative stories regarding dentistry to help reinforce how they feel. I agree wholeheartedly with Burt Decker, author of You've Got to be Heard to Be Believed, when he says, "People make decisions based on emotion, and then justify them with facts." So, as you can see, fear can be a learned phenomenon. Fortunately, because fear can be learned, it can be unlearned as well. What are these fears about and how do you address them with your patients? The first step in overcoming any fear, including fear of the dentist, is to define the fear. Fear of the dentist involves everything from mild anxiety before or during a scheduled dental visit to high levels of stress and emotional discomfort, manifesting itself as nervousness, sweaty palms or tears. When the anxiety becomes so intense that the person will do anything to avoid going to the dentist, the fear becomes a phobia. Before you worry that your dental fears are approaching phobic levels, remember that fear or apprehension about dental treatment is a very common reaction. In fact, of the thousands of patients I've treated, the vast majority expressed at least some fear or anxiety before dental treatment. Even I, as a dentist, experience some anxiety before I am about to be treated by another dentist! Fear of the dentist is nothing to be ashamed of, and the good news is that fears and phobias about dental treatment can be overcome in most cases. People fear the dentist for a variety of reasons. I have found that the three most common fears are associated with: - The potential for pain during dental treatment - Fear of being scolded about the condition of their mouth - Fear of loss of control during dental treatment How can I overcome my fear of pain? The first step in overcoming fear of the dentist or dental treatment involves gathering accurate information to help you judge the veracity, or truth, of those fears. Knowledge can be a powerful weapon against fear. In fact, many people fear death because it is "the great unknown." A comforting component of many religions is the promise of heaven and other rewards in the afterlife. Although I cannot promise you that your dental experiences will be "heavenly," I can promise that it won't fall at the other end of the spectrum! Learning about how dentists deal with people's fears is a good starting point in alleviating a fear of the dentist, himself. Most people have at least some fear of pain or injury in life -- and that's a good thing. It prevents us from touching a hot stove (more than once) or driving a car into oncoming traffic. Fear is a protective and instinctive emotion that helps keep us safe. It should come as no surprise that when we are confronted with a situation or environment that we believe to be painful, we try to avoid it. Some people who avoid regular dental care do so because they believe that all dental treatment is painful. So what is the truth about dentistry and pain? I won't tell you that dental treatment is never painful -- on rare occasions, it is. But I will tell you that most of the time, dental treatment is either completely painless, or only slightly uncomfortable. And be reassured by the fact that most dentists are acutely aware of the impact of pain on their patients. Many dentists pride themselves on being "painless practitioners." A dentist who causes a patient pain will sometimes lose that person as a patient, and there is a good chance that the person will tell many others about the bad experience they had at Dr. So-and-So's office. Causing people pain during treatment is no way to build a dental practice and most dentists know that! How do dentists reduce or eliminate pain during dental treatment? Dentists have many ways of reducing discomfort during dental treatment. The first step dentists take is to evaluate the treatment required to decide if anesthesia, given as an injection, is needed. There are many dental procedures that can be done comfortably without anesthesia, using modern dental technology. For example, shallow cavities on the side or biting surface of the teeth can be treated with a dental laser or an air abrasion unit, a new device that emits a gentle spray of an air and powder mix that smooths away tooth decay. These devices can silently and painlessly treat cavities a high percentage of the time without anesthesia. If anesthesia is needed, strong topical anesthetic gels or patches are used to greatly reduce the discomfort associated with injections. Dentists also use very thin needles and inject the solution slowly to further reduce discomfort. The most important way a dentist reduces or eliminates discomfort during dental treatment is to make sure that the patient's mouth is as numb as possible during treatment. The approach I initially take is to begin treating the tooth very slowly. I will ask the patient, "Are you feeling this?" If the answer is “yes,” I either give them more anesthesia or wait a few minutes and test again. It takes some people's mouths a little longer to become numb. I recommend that you always signal your dentist to stop if you are having pain. If the dentist doesn't listen, you need to find a new one! What if I still feel pain after the anesthesia is given? In some instances, you may still feel varying degrees of pain even after everything feels numb. There are a few reasons for this, including inaccurate placement of the anesthesia; not enough time allowed for the anesthetic to work; or severe infection in the area interfering with the potency of the anesthesia. The dentist can remedy these situations by redirecting the anesthesia (or giving more); waiting longer before beginning treatment; postponing the treatment; and prescribing an antibiotic to reduce the infection. Another important issue is that different people have different thresholds for pain. I have had patients who have expressed genuine discomfort from a routine dental exam, and others who easily tolerated root canal or dental surgery without anesthesia (though I don't advise it). Over the years, I have discovered an interesting irony when treating fearful patients. The vast majority of these patients have a very high pain tolerance. When you think about it, it sort of makes sense. Fearful patients often avoid dental care and endure years of discomfort from their teeth. It seems likely that if they had a poor tolerance for pain, they would visit their dentist the moment a tooth became sensitive. Because of this, once a fearful patient develops trust with their dentist, the fear quickly evaporates. The fearful patient soon learns that dental treatment is not nearly as uncomfortable as the pain they go through every day with infected teeth. When I have patients who tell me they are afraid of the pain, I make them a promise. I say that I will not perform the procedure (whether extraction or root canal) if they are feeling pain -- plain and simple. On rare occasions, I will even reschedule the patient for a different day if the treatment cannot be comfortably completed. What can be done about pain after the treatment? Some dental procedures can cause discomfort after the anesthesia has worn off. Fearful patients are often concerned that they will be in pain following a dental procedure. These procedures include dental extractions (pulling teeth) and other minor dental surgery, root canal therapy, periodontal (gum) surgery and multiple dental fillings. Dentists are just as concerned with managing pain after treatment as they are during it. One of the first things dentists do is to make sure that they perform the procedure as gently as possible. A dentist with a forceful technique can put excessive pressure on the teeth and gums, which can cause greater discomfort later on. Dentists can also use anesthesia that lasts longer (bupivacaine) or give pain medication like ibuprophen (Advil® or Motrin®) prior to some procedures, because these measures have been shown to reduce pain after treatment. Dentists are also licensed to prescribe potent narcotic drugs that are highly effective in reducing or eliminating any discomfort after dental treatment. The final step the dentist can take is to call the patient at home after a potentially painful treatment. This is something that I have done for years. I like to see how my patient is doing, if the medication is working, or if the patient has any questions about the treatment. Some dentists do this, and I suspect more will in the future. Aside from being the right thing to do, research has shown that people's perception of pain is less when the dentist calls them at home to find out how they are doing. Most dentists realize that pain is a very subjective thing. What this means is that a person's emotions have a large impact on their perception of pain. For example, if a patient gets the feeling that the dentist is insensitive or lacks compassion, there is a good possibility that other concrete measures the dentist uses to reduce pain will be less than successful. On the other hand, a dentist who makes a worthy effort to reduce all discomfort associated with dental treatment, and empathizes with his or her patients, will have much better results. What if I'm afraid my dentist will scold or embarrass me? Some patients fear being chastised by the dentist for neglecting their mouths. They might nervously comment that "I know I should have come earlier" or "Is this the worst mouth you ever saw?" expecting the dentist to reprimand them like a disapproving father or a drill sergeant. It is no wonder that people with these preconceived notions fear going to the dentist. This fear seems to have originated years ago when some dentists thought they could "help" their patients by lecturing or insulting them. Most dentists today realize that this is a poor approach that ultimately backfires by either driving people away or building up a barrier of resentment. I look at it this way: The patient is coming to me for help. He or she has likely had bad dental experiences in the past; has been out of work; has lost his or her insurance; hasn't been educated about modern dental treatment; or is not particularly concerned about the comfort or appearance of their teeth. Whatever the reason, the important thing is that the person is coming in for dental care now. What should the dentist-patient relationship be like? Ideally, the role of the dentist is to understand what the patient's expectations are, improve their dental health, and then to educate them in how to avoid dental problems in the future. To achieve these goals, communication between the dentist and patient is of the utmost importance. People who seek dental care often come from vastly different educational, cultural and socioeconomic backgrounds. I have found that most dental patients fall into three main camps. Some are not interested in saving their teeth, and just want to have a tooth removed every now and then when they are in pain; others are highly motivated to preserve all of their teeth and want to keep them in the best condition possible; still other patients have never been educated about what modern dentistry can achieve but can become (with education) motivated to improve the comfort and appearance of their teeth. The bottom line is that most dentists do not browbeat their patients about the condition of their teeth. That may have been common years ago, but is not nearly as prevalent today. If you are worried about how a dentist will react to the condition of your mouth, try to remember that a dentist has seen everything from black and broken teeth to no teeth at all. Your teeth won't shock the dentist. If it does, or if your dentist insults you, find a new dentist. There are plenty of dentists out there who do care about helping their patients. What if I'm afraid of losing control during treatment? Some people who fear dental treatment are those who are used to being in control at home, work and in personal and professional relationships. In today's lingo, these people are sometimes referred to as "control freaks." Despite this negative label, these controlling people are often highly intelligent and very successful. For instance, you may have heard the statement that "doctors make the worst patients," but other professionals, including lawyers, teachers, engineers and high-level business executives could just as easily be put into this category. Although that statement is a generalization, it is accurate to say that some of these high-powered people can be difficult patients because they are accustomed to controlling their environment. When people who are used to being in a position of power are put into a situation where they must relinquish that power to their dentist, anxiety, confrontation and avoidance are the most common reactions. The first step in overcoming this fear is to tell the dentist that you want to know what he or she is doing and why. Ask your dentist to explain X-rays, show you your mouth with an intra-oral camera, give you handouts or in-office presentations, or any other information to help you have a more active role in your dental care. When you know what the dentist is doing and why, you will have a greater sense of control during the procedure. It is also important to ask the dentist how you should signal if you are having pain or any other uncomfortable sensation. Many dentists tell the patient to raise their hand if they are having pain, and the dentist will stop. I have had patients tell me that they had a dentist continue working on them even after they repeatedly raised their hands. This is not a dentist that you want treating you. It's a good idea to test your dentist -- even if you're not having pain -- to see if he or she will indeed stop. The dentist who follows through with that promise is what we call a "keeper." One technique I like to use is to let the patient have some input as to what procedure they want done first. Many times, there is no urgent need to have cavities on the left side of the mouth treated before those on the right side, or one crown (cap) done before another. I believe that it is perfectly appropriate for you to ask your dentist if you can have a particular procedure done first or last. If there is no urgent need, the dentist may comply with your wishes. Allowing you to help "call the shots" can be an effective way to reduce tension if a loss of control is your main source of anxiety. (Please note that some dental procedures must be done before others for your benefit. Your dentist should give you a good, jargon-free explanation to help you understand why). Whether you fear pain, being scolded or losing control, take heart with the knowledge that these fears can be overcome. The first step is to make an appointment with a dentist who has a reputation for being both skilled and compassionate. This appointment should be for consultation only, not treatment. Discuss your fears with the dentist. You should know in only a few moments if this dentist has what it takes to help you overcome your dental fears. Meanwhile, try some of these exercises designed to help relieve your dental fears.

Dental Phobia: Causes and Treatment
Dental phobia is a severe fear of the dentist that over time causes loss of teeth because of the patients' inability to go to the dentist and receive regular care. The heart of the matter is that dental phobia can rob patients of their self-esteem as they become embarrassed about the appearance of their teeth and withdraw from friends, coworkers and loved ones. Why do people hate and fear the dentist? Fear of the dentist is most commonly something that patients learn from traumatic personal dental experiences. If these experiences occur as a child and are accompanied by a real sense of panic, the resulting reaction to the dentist may become deep-seated, visceral and life-long. Such patients just don't feel safe in the dental chair. Patients’ recollection of their traumatic childhood experiences often includes being held down against their will, yelled at, pain and terror. A recent article in the Journal of the American Medical Association showed that people who suffer abuse as children may have life-long alterations in their response to stress. If a patient suffers from post traumatic stress disorder, the dental office may be just one of many situations where such patients feel unsafe. Patients who suffer from panic attacks associated with dental care will do anything not to have that awful feeling again. Sedation, which can block the panic response, can be particularly helpful for dental patients with anxiety attacks. Other patients may simply have difficulty getting numb after the dentist gives them an injection. If the patient is extremely anxious he or she may be sensitive to the slightest sensation because of the emotional component of their pain. Many patients may not be particularly anxious but still may feel pain during dental care because of anatomical reasons, the presence of infection or hypersensitivity of the tooth. Local anesthetics (Novocain®, Novocaine or Novacaine) used by dentists to numb the tooth or jaw may rarely cause patients to become excitable or anxious in large doses, especially in combination with epinephrine, a common additive. Newly developed injection techniques may help in these situations. Some patients suffer from a severe fear of needles, also known as needle phobia. As a result, people have trouble going to the dentist, medical doctors or even getting marriage licenses. A wide variety of techniques to help while at the dentist are available, such as anesthetic pads or gels administered without piercing the skin. Patients can also be sedated with an elixir or pill before any injection. What can patients do to deal with their fear? If you have a severe fear of the dentist, the most important thing is to recognize that there are people ready to help you. Take the time to find the right person. Take the time to communicate your feelings and concerns to your dentist. Make sure the treatment plan that you and your dentist have chosen reflects your cosmetic and long term oral health goals. Choose a quality office that is dedicated to a high level of care and patient satisfaction. Make sure the dentist you've chosen has the tools to care for you comfortably, and the patience and experience to guide you through the complete treatment plan. Consider relaxation and distraction techniques available by the dentist such as deep (diaphragmatic) breathing or headphones. Oral medications, such as a Valium® or something similar, can be used to help you relax and feel more comfortable during long procedures. Intravenous sedation or even general anesthesia may be best for very anxious patients who won't have dental procedures any other way. Patients who have a very sensitive gag reflex or a lot of trouble getting numb with dental injections can also benefit from intravenous sedation. Nitrous oxide (sweet air, laughing gas) also provides pain relief and distraction. Nitrous oxide does not relieve anxiety as well as Valium and its related medicines when taken orally or intravenously. All medications should be administered by dentists (called Dental Anesthesiologists, or sometimes Sleep Dentists) who are well trained and experienced for the best and safest experience. Sedation Dentistry, also called Sleep Dentistry, can be a beneficial way for patients to experience dental care without fear, pain or anxiety. Most importantly, it is possible for you to have your dental care in comfort.

Don’t Avoid the Dentist Because You Drool
One reason patients avoid trips to their dentists is because they are embarrassed about drooling during treatment, but dentists say this is a lame excuse. "Everybody pretty much drools, and it's true that some people drool more than others," says David Miller, D.D.S., a general dentist. "This is a non-issue for dentists. We see it all the time and if we were offended, we probably wouldn't be in this business." Dr. Miller says that dental procedures cause the mouth to be opened and closed frequently, stimulating the salivary glands. "We use a suction tube to control saliva because saliva makes it difficult to see and work," he says. "Too much saliva is like working under water." A patient's mouth needs to be dry for the dentist to complete many procedures. Many of the products dentists use such as adhesives, amalgams and bonding materials do not work effectively unless they are placed in a dry environment. To keep the mouth dry, dentists use cotton rolls, rubber dams, high-speed suction or a combination of all of these. In cases where patients excrete an excessive amount of saliva, dentists can use a medication that alleviates the problem. The medication lasts a short time but allows the dentist to work in a saliva-free environment. But the important thing to remember is that drooling in the dental chair is an ordinary occurrence. "I guess people simply do not like to look foolish and they think drooling is one of those things that embarrasses them," he says. "But it's just something that happens. Patients should not use drooling as an excuse to avoid dental care. To me, people look foolish when they have bad teeth due to lack of dental care and regular dental visits." Don’t Fear the Dentist Because of Bad Teeth
One all too common reason that people avoid going to the dentist is the fear that the dentist will scold them about the condition of their teeth. Some nervously say things like, "I know I should have come earlier," or "Is this the worst mouth you ever saw?" anticipating that the dentist is going to reprimand and demean them. It is no wonder that people with these preconceived notions dread going to the dentist. Sadly, patients usually develop this fear as a result of a misguided philosophy of some dentists who think they can “help” their patients by insulting them. Fortunately, most dentists realize that scolding their patients will ultimately backfire, because it tends to either drive people away or cause them to build up a barrier of resentment towards the dentist. I look at it this way: The patient is coming to me for help. He or she has likely had bad dental experiences in the past; was out of work or lost their insurance; was never educated about modern dental treatment; or is not particularly concerned about the comfort or appearance of their teeth. Whatever the reason, the important thing is that the person is coming in for dental care now. People who seek dental care often come from vastly different educational, cultural and economic environments. I have found that most dental patients fall into three primary groups: some are not interested in saving their teeth and just want to have a tooth removed every now and then when they are in pain; others are highly motivated to preserve all of their teeth and want to keep them in the best condition possible; and still other patients have never been educated about what modern dentistry can achieve, and become (with education) motivated to improve the comfort and appearance of their teeth. Ideally, the role of the dentist is to understand what each individual patient’s expectations are, improve their dental health, and then to educate him or her in how to avoid dental problems in the future. To achieve these goals, communication between the dentist and patient is of the utmost importance. If you are ashamed about the condition of your teeth, take heart in knowing that most dentists do not browbeat their patients. That may have been common years ago, but is not nearly as prevalent today. If you are still worried about how a dentist will react to your mouth, try to remember that a dentist has seen everything from black and broken teeth to no teeth at all. Your teeth won’t shock the dentist. If it does, or if your dentist insults you, find a new dentist. There are plenty of good dentists out there who do care about helping their patients

E-Mail: A Great Resource for the Fearful Patient

The Internet has caused a virtual explosion of information available to anyone with a computer and Internet access. The ready availability of information is helpful to fearful dental patients because they can find out about various dental procedures before their appointment. There is also another way that the Internet can help alleviate fear and anxiety associated with dental treatment. In many instances, prospective patients can contact a dentist prior to going to the office for an appointment. The anonymity of the Internet allows people to voice their fears or concerns from the comfort and security of their own homes. This anonymity, coupled with the increasing trend of dentists with Web sites and e-mail addresses, greatly facilitate the ability of apprehensive patients to “interview” dentists before meeting them face-to-face. Over the past few years, I have had the opportunity to correspond with many fearful patients through the Internet. Their messages have given me considerable insight into the anxiety many of these people have when going to the dentist. Consider this e-mail I just recently received: Hello Dr. I am a transplanted Philly person now living in Texas, and still have family in the Philly area and visit from time to time. It would really be heaven if you practiced down here, for I am the biggest coward in the world about going to the dentist. It is at the point where, whenever I even think about going for a cleaning, I feel that I am going to pass out. You can forget about the needle, too. Needless to say, I have a few bad teeth and a little gum pain every now and then. This message shows just how candid people tend to be when communicating over the Internet. Another advantage of corresponding by e-mail is that it can help apprehensive patients get at least some sense of the dentist’s personality or style, as well as address specific concerns. For instance, a patient can learn if the dentist uses nitrous oxide, sedation, air abrasion or other methods to ease anxiety or reduce pain. The Internet gives prospective patients the ability to communicate with a dentist before ever stepping foot in the office. Anxious patients should be encouraged to discuss their concerns to the dentist during the initial consultation, or before, via e-mail, if possible. The Internet can be a helpful tool for apprehensive patients so they can better prepare for what to expect when they visit the dentist.

Facing Your Dental Problems

People who avoid the dentist for many years may sometimes believe that their situation is hopeless. They may have pain, swelling, broken teeth or a variety of other dental conditions. Dental fear, phobia or financial limitations may compound the problem. In my experience, patients often overestimate the extent of their dental problems. A broken tooth on one side of the mouth and a lost filling on the other side can seem overwhelming, even though treatment could be relatively simple and require only a visit or two. Of course there are those who have multiple dental problems and will require comprehensive dental care. If you are concerned about the condition of your teeth, you should first see a dentist for a complete evaluation. The dentist should let you know what treatment is required, including: alternative treatment options; approximate number of visits; potential for discomfort; expected outcome of the treatment; and the treatment cost. If you have dental insurance, you may want to have your treatment proposal sent to the insurance company for a better estimate of how much of your treatment is covered. If you are not comfortable with the dentist or the office staff, you should consider getting a second opinion. In most cases, infected teeth (those requiring a root canal or extraction) and gums should be treated first. Deep cavities and teeth that require crowns and bridges should then be treated. Removable partial dentures should be treated next. Dental implant surgery can often be done in the preliminary stages of treatment because several months will be needed for them to heal prior to using them to replace teeth. Proper planning and sequencing of treatment is one of the most important aspects of dental care. In some cases, the amount of treatment may be extensive and beyond the financial reach for the patient. These patients should consider getting treatment performed at an area dental school or hospital based dental residency program. The cost of treatment in these programs is usually substantially lower than a private practice dentist, but it also takes much more time for treatment to be completed.

Fearful Patients Afraid to Lose Control

Some people who fear dental treatment are those who are used to being in control -- whether at home, at work or in personal and professional relationships. In today's lingo, these people are sometimes referred to as "control freaks." Despite this negative label, these controlling people are often highly intelligent and very successful. For instance, you may have heard the statement that "doctors make the worst patients," but other professionals, including lawyers, teachers, engineers and high-level business executives could just as easily be put into this category. Although that statement is a generalization, it is accurate to say that some of these high-powered people can be difficult patients because they are accustomed to controlling their environment. When people who are used to being in a position of power are put into a situation where they must relinquish that power to their dentist, anxiety, confrontation and avoidance are the most common reactions. The first step in overcoming this fear is to tell the dentist that you want to know what he or she is doing and why. Ask your dentist to explain X-rays; show you your mouth with an intra-oral camera; give you handouts or in-office presentations; or any other information to help you have a more active role in your dental care. When you know what the dentist is doing and why, you will have a greater sense of control during the procedure. It is also important to ask the dentist how you should signal if you are having pain or any other uncomfortable sensation. Many dentists tell their patients to raise their hand if they are having pain -- to signal them to stop. I have had patients tell me that they had a dentist continue working on them even after they repeatedly raised their hand. This is not a dentist that you want treating you. Rather, I would suggest that you test your dentist by raising your hand -- even if you're not having pain -- to see if he or she will indeed stop. The dentist who follows through with that promise is what we call a "keeper." One thing I like to do is to let my patients have some input as to what procedure they want done first. Many times, there is no urgent need to have cavities on the left side of the mouth treated before those on the right side, or one crown done before another. I believe that it is perfectly appropriate for you to ask your dentist if you can have a particular procedure done first or last. If there is no urgent need, the dentist may comply with your wishes. Allowing you to help "call the shots" can be an effective way to reduce your tension if a loss of control is your main source of anxiety. (Please note that some dental procedures must be done before others for your benefit. Your dentist should give you a good, jargon-free explanation to help you understand why.) Even if you have avoided dental care for years because you fear losing control, take heart with the knowledge that this fear can be overcome. The first step is to make an appointment with a dentist who has a reputation for being both skilled and compassionate. This appointment should be for consultation only, not treatment. Discuss how you feel with the dentist. In most cases, you should know in only a few moments if this dentist has what it takes to help you.

General Anesthesia and the Phobic Dental Patient
Some people are so fearful of the dentist that they avoid dental care at all costs. These patients are considered dental phobic and may sometimes require sedation or general anesthesia (being put to sleep) to have their dental treatment completed. Sedation and general anesthesia can be very useful for highly phobic patients, during advanced oral surgical procedures (e.g., removal of impacted wisdom teeth) and for those with certain physical and mental handicaps, but should be viewed as a last resort for most patients seeking general dental treatment. People with dental fears and phobias have many different reasons for their feelings. The vast majority will recall a past traumatic experience during a dental visit and others fear being confronted by a dentist about the condition of their mouths. Negative dental stories told by family, peers, on the evening news and in advertisements can compound the fear and anxiety that these patients have. People with dental fears and phobias may be difficult for a dentist to treat. These patients will often schedule and then cancel appointments, abuse over-the-counter medications and use any possible means to avoid dental treatment. Unfortunately, these patients put themselves at risk for serious dental infections, and often suffer from low self-esteem due to the appearance of their teeth. Although patients with dental fears and phobias may present a challenge for some dentists, I believe that most of these patients can be treated without general anesthesia or sedation. A dentist who is open, caring, and listens to their patient’s needs and fears can begin to effectively treat the anxious or phobic patient. The dentist can also employ new potent local anesthetics, air abrasion, nitrous oxide (laughing gas), relaxation techniques and many other methods to help a patient overcome their fears. General anesthesia and sedation are appropriate for patients receiving advanced oral surgical procedures and those with certain physical and mental handicaps, but should be reserved for only a small minority of highly phobic dental patients. General anesthesia and sedation are considered safe and effective, but cost more and may pose an increased health risk for some patients.

Overcoming Dental Fears: Difficulty Breathing

“I can’t breathe!” is probably one of the scariest feelings a human being can experience. When you’re anxious, panicky or phobic it can feel as if you can’t get enough oxygen; that the air around you is too warm or stuffy to be soothing; or that it’s impossible to take a deep, long, refreshing breath. When you get these feelings while your head is tilted back during a dental procedure, the discomfort is multiplied and often triggers terror. The single thought, “I can’t breathe,” sets up a vicious cycle of fear. In a mere three or four seconds, you can go from noticing what you perceive as an irregular breathing pattern to the conclusion, “I think I’m dying.” Each and every thought of danger adds to the cycle of fear. Each thought of danger heightens and prolongs your feelings of discomfort. The only authentic way to counteract thoughts of fear and danger is to replace them with more secure, factual thoughts. Here are a few facts you can bring to mind when you think you can’t breathe: If you are aware that you’re having some difficulty breathing, it means that you are thinking about what you’re feeling. The “I can’t breathe” may be a feeling, yet it is also a thought. If you really could not breathe, you would be unconscious, and it’s impossible to monitor your thoughts in that state. You have to be awake to be aware. If you’re aware, you’re awake! When you feel anxious, you may be holding your breath, which contributes to your feelings of distress, or you may be breathing shallow breaths. Both of these conditions can generate the impulse to gulp a large quantity of air in through your mouth. The antidote for a fear thought is a secure thought. Replace: “I can’t breathe” with “I can breathe,” or “It feels like I’m having some difficulty breathing, but I’ll be fine.” Squelch the thought of danger with “This feels scary, but I’m safe,” or, “This is distressing, upsetting and unpleasant, but it’s not dangerous.” Each threatening thought and each thought of danger has to be replaced -- one by one. What you’re doing in this process is changing your inner dialogue. Instead of continuing to think the scary thoughts, you’re replacing each one with a more accurate, safe thought. Choose one secure thought offered here or create your own and memorize it. Yes, commit it to memory, just like when you were back in school. What you’re doing is producing a new automatic response to the feeling. Trust me, I’ve used the same secure thoughts to neutralize my fear in dozens of different situations and with all kinds of disturbing and what I used to think were life-threatening, anxiety-related physical symptoms. With these types of cognitive replacement techniques, I’ve gone from having severe panic attacks, not being able to work and barely being able to drive to doing anything I choose to do. They work! I’m living, breathing proof that they do. Don’t expect immediate, total relief. Repeat the calming phrases in your mind several times until you feel yourself getting less tense. Repetition is the key. If you find your mind going back to even a hint of danger, start your mantra again. In fact, you may want to start the chant even before you feel any discomfort. As you’re sliding down into the chair, start telling yourself, “I can breathe, I can breathe.” It can help keep the scary thoughts from popping into your brain. We can only have a single thought in a single instant. It may feel as though several thoughts are crowding in at one time, but they’re not. Even though it feels like a steady stream, you can interrupt that stream with secure thoughts. You may also want to practice nasal breathing before your appointment. Consciously practice taking deep breaths through your nose with your mouth open, maybe even with your head tilted back as it would be in the dentist’s chair. The more you practice, the more adept you’ll be and comfortable you’ll feel. Another bonus is that deliberate attention to breathing in and out occupies the mind -- another method for taking your mind off the fear. Some of you may know that your difficulty breathing and other sensations are due to anxiety. If you’re not sure, do have your condition checked by a physician. If you only have difficulty breathing when you’re in a difficult situation, it’s probably anxiety-related. If you want to be 100 percent sure, discuss it with your doctor and have any tests that are suggested. Fears are real, and so are the physical sensations that come with them. What most people don’t realize is that they have the power to change their thoughts, and therefore change how they feel. Each and every one of our feelings comes from our thoughts.

Overcoming Dental Fears: Relaxation Techniques
Just relax -- easier said than done in most cases. If you’re one of those folks who can cocoon themselves behind a set of headphones and snuggle into the dentist’s chair, I applaud you. Not everyone can. If you don’t know if soothing music or your favorite lyrics will make you more relaxed during a procedure, sitting in the dentist’s chair is probably not the best initial place to test out the theory. If you’ve tried before and think the ritual is of no use in making you calmer, you may want to try again. Relaxation is somewhat of an art -- which means it is a learned skill. We aren’t born with relax buttons conveniently located at the base of our left ring fingers. But wouldn’t it be nice if we were equipped that way: The baby’s fussing? Teenager having a tantrum? Grandpa’s acting cranky? Feeling tense while the dentist is probing on a sensitive tooth? No problem! Reach over and press the button for instant comfort. Even though relax buttons are not part of our standard equipment, our minds are. With correct mind-control methods and practice, you can learn to be more at ease. Practice -- we’re mobile now because once upon a time, we stood on our feet and practiced moving them forward one step at a time. We can read the newspaper today because we practiced sounding out words, one at a time. Relaxation is like that too. If you want to be good at it, you have to practice it. Listening to music as a form of diversion is a good relaxation technique. The key is to focus, really focus, on the sounds coming into your ears. Listen so closely that you can identify the spaces between the notes, the pauses between the words in the lyrics. Do it long enough with the same tune, and you can find yourself knowing what notes come next, or hum it inside your head without making any external sound. Conscious listening is not always easy because we’ve got so much going on in our minds most of the time. As humans, we’re wired to take input from all of our senses, so it may seem challenging to concentrate on just one thing. We’ve all experienced fragmented focus: someone new is introduced to us and 21 seconds later we can’t remember her name. We’ve all had moments of intense focus. Confining your attention and being in your “own little world” is not limited to children; even as adults we do it. You miss something somebody said because you’re engrossed with what’s on TV. You turn on the radio to find out today’s weather forecast, and totally missed it because you were absorbed in looking for your keys, shoes or some other essential you need before heading out the door. You miss what was said during a meeting because you’re thinking of ideas to solve the problem that was just reported. These are examples of non-intentional lack-of-focus. Strange as it may sound, genuine relaxation requires intentional focus -- a change of focus. And it’s much more a mind activity than a body one. When you’re feeling tense or strained, I don’t recommend the technique of bringing a pleasant experience to mind. Why? Because we have very few purely pleasant experiences to draw from. Recall a vacation, and your mind is bound to wander from an awesome aspect to an awful one. Then, instead of having calming thoughts, you’ll find yourself with something different to help upset you. Having an old aggravation rise to the surface isn’t going to help you feel more at ease. It may have the opposite effect. You will be adding to your distress instead of subtracting from it. Sticking to more neutral thoughts is your best bet. One of the most effective ways to do this is to imagine yourself making an impartial report. No opinions, just facts. Most people are familiar with their vehicles, so the report you’re creating in your mind can go like this: I drive a 2000 Buick LeSabre -- it’s got four doors, four white-wall tires, beige exterior paint, beige leather seats, a split-bench seat in the front, automatic transmission and a gear shift on the steering column. Don’t stop there. Describe all the details of the dashboard: digital readout, radio and CD player? Is there a built-in cup holder? Where? What color is the carpeting? The floor mats? Are they fabric or a heavier synthetic material? How many seatbelts? How many windows? How many of the windows are stationary? How many can you open? Power or manual window and door lock controls? Where is the emergency flasher? If you don’t own a vehicle, recall the place where you live, or a specific room. The idea is to describe an item or a place in way that someone else could verify the facts. Not that they have to -- you’re going through the exercise for yourself. The only reason behind it is to shift your attention away from the thoughts that are stressing you out. Change your thoughts, and you will change the way you feel. You can’t simply drop thoughts or ideas. You must replace one thought with another until you, in your mind, have changed the subject. When you keep your mind busy thinking of neutral details or facts, it doesn’t leave room for the negative, agitating or disruptive thoughts to creep back in. You might think this replacement technique is too simple to be effective. I did too, until I used it to stop my panicky feeling from escalating into panic attacks. It works for severe tension, feeling a little on edge and any level in-between. Plus, it’s a lot more interesting than counting backwards from ten to one. Instead of allowing your thoughts to lead you, guide them. The result is you’ll feel a lot better when you do!

Take Control of Dental Anxiety

Have you ever noticed that the closer we get to an expected or scheduled event, the more worried we can get? That goes for happy as well as dreaded circumstances. Buying a car or your first house, events most people would label pleasant, can trigger as much worry as a less-than-joyful trip to the dentist. Webster’s II defines worry as to feel uneasy or troubled. Well, if you’re over the age of 12, that’s probably not news. We’ve all felt worried from time to time. There are lots of different outside triggers for worries: an exam at school, a meeting at work, personal finances, the economy. Sometimes they’re big worries, sometimes small. What some people would see as insignificant, someone else would view as all-important. What most, if not all, worries have in common is that they point to the future, what I like to call pre-viewing -- attempting to predict, view or guess what will happen. Perhaps a more accurate meaning for the term “worry” would be to reveal where worry comes from. I like to use “worry thoughts” instead of simply “worry” because the term targets the cause of the feeling. The one and only reason we feel fear or worry is because we’re thinking worry thoughts -- thoughts that contain some element of fear or danger. It’s impossible to feel calm, comfortable or at-ease while you’re thinking about fear. And, the opposite is just as true: You can’t think secure thoughts and feel troubled, insecure or worried. When we’re worried, upset or anxious there are really four separate components to that reaction: feelings, sensations, impulses and thoughts. Out of those four, we only have direct control of two of them: the thoughts and the impulses. So let’s imagine that it’s the evening before your scheduled appointment. If you’ve been busy at home or at work, you may have done pretty well in warding off the worry. Keeping busy has a way of pushing worry aside, although it doesn’t really resolve it. If you don’t take the time to examine and diffuse the worry thoughts, they will pop back into your mind, and cause that feeling of worry that Webster talks about. It’s a sure bet that most of your worries revolve around either “What if … ” or “I wonder … ,” two of the powerful fear producing statements (thoughts) we can think. When you feel worried, the key is to stop and listen to what you’re thinking, then replace those insecure, fear-filled, worry thoughts with more secure or realistic thoughts. And, if need be, do it one thought at a time. Here’s a sample of how that might work: - Worry Thought: What if I start feeling really pinned down in the chair? - Secure/Realistic Thought(s): I may feel trapped, but realistically I am not. I am not strapped down. I could get up if I need to or really want to. - Worry Thought: I don’t like feeling trapped. - Secure/Realistic Thought(s): This is just an uncomfortable feeling, and I will be able to get up eventually. I’m not stuck here forever. - Worry Thought: What if start gagging? - Secure/Realistic Thought(s): Well, gagging makes noise, and whoever is working on me will be to hear the sound and recognize that I’m having a problem. - Worry Thought: What if the novocaine doesn’t take? - Secure/Realistic Thought(s): If it doesn’t, I’ll feel it. Then I’ll tell them right away, and they can give me more. - Worry Thought: I worry about germs. I wonder if all those instruments are clean? - Secure/Realistic Thought(s): I am going to a reputable dentist who is careful about hygiene. They do sterilize all the equipment that reaches my mouth. For more generic fear thoughts like; “I wonder how long I’m going to have to sit there? I hope the sound of the drill doesn’t bother me too much,” or “What if I’m so nervous afterwards that I don’t think I can drive home?” tell yourself, “I don’t know.” You really don’t know! It’s interesting that most of us have been trained to think of “I don’t know” as a frightening thought, when in fact, it can be a very positive and secure statement. Think of it this way: If you don’t know the outcome, chances are that it could be a positive outcome. And realistically, worry isn’t going to change the outcome one bit. Worry can’t prevent anything from happening in the future. Remember, worry, the feeling, is caused by worry, the thoughts. That’s as true as 1+1 = 2. It always has been and always will be. One worry thought will create a miniature feeling of worry or concern. Repeated worry thoughts will cause more intense and more long-term worry feelings. If we want to change the feeling, we have to change the thought that’s producing it. The method is to catch the insecure worry thought and move it aside with more secure thought, each and every time one leaps into your mind. Use this technique and you’ll be able to keep your concern from spiraling into worry, no matter what the subject of your worry happens to be. The Truth About Dental Hypnosis
Hypnosis is used for more than just stage shows to make people laugh. By accessing the power of the subconscious mind, hypnosis can be used to help people overcome fears, accomplish weight loss, end bad habits such as smoking or nail biting, and reduce or eliminate pain. There are two areas where hypnosis can help in dental situations: fear of going to the dentist, or dental phobia, and having the mind eliminate pain when an anesthetic cannot be used. Before we talk specifically about these two areas, let us first look at hypnosis generally; what it does and how it works. Hypnosis has been practiced for many centuries. The word comes from the Greeks. Hypnosis has always been associated with sleep, but it really is a very deep state of relaxation. There are some myths about hypnosis which have made people either fear or shy away from it. The first myth is that only certain people can be hypnotized. This is not true; anyone can be hypnotized. We go in and out of hypnosis, a very natural state all the time. Watching television can put us in a hypnotic state. Sometimes when we drive home we don’t remember passing any lights or cars, and we are amazed that we got home! We were in a hypnotic state. The second myth is that you remember nothing under hypnosis. Again this is not true. You will remember everything that is said and occurs; that is how your subconscious protects you. The third myth is that the hynotherapist can get you to do anything he or she wants you to do. Not true. You will not do anything against your morals or values. Hypnosis is very safe and cannot have any harmful effects in any way. How does hypnosis work? When you go into that deep state of relaxation you have closed your conscious mind down and opened up your subconscious. In your subconscious state you are very open to suggestions and changes that you want to make in your life, gaining control over your own mind. With the help of a qualified hypnotherapist, you can either change those negative thoughts that stop you from achieving your goals, or end those phobias that interfere with your life. Some people have a fear of the dentist or a fear of what the dentist is going to do. These fears can stop us from getting the dental care that we need to take care of our teeth and have that beautiful smile. It can cause us not to see the dentist for years, missing simple things like a cleaning. Fears like this not only interfere with our needs, but they also can affect our health both mentally and physically. Through the use of hypnosis and with the help of a hypnotherapist, you can overcome this fear and others. Sometimes our fears come from something in the past or something we heard as a child. Under hypnosis one can get to the root of the fear and change it through hypnotherapy, visualizing and rehearsing a new behavior all while in hypnosis. It is time to stop having fears rule our lives. From fear of the dentist to fear of a shot or whatever fear we have, it can all be changed through hypnosis. Self-improvement and self-empowering is possible and available through a simple process that will enable you to take charge of your life. The second area where dental hypnosis can provide help relates to allergic reactions to any form of anesthetic that a dentist may use. This can create a great problem for people when dental work needs to be done. Once again, hypnosis can be of assistance. In Europe, operations and dental work have been done under hypnosis without an anesthetic. Hypnosis can help the individual take charge of his body and block out all feelings and pain to an area of the body. If you ever watched a person walk across hot coals without it hurting or burning, or a person walking on cut glass without causing pain or cuts, she or he was in a hypnotic state. In England, hypnosis has been used in dental operations for many years for patients with anesthetic allergies. Once again, with the help of a good hypnotherapist you can block out all pain to any area of your body. It puts you in control of your body. Hypnotherapy is short term therapy; in most cases five to ten sessions is enough. Very seldom will it go beyond ten. It is up to you as to how much work you want to put in on your own and how motivated you are. Hypnosis is a simple process that empowers you to take charge of your life, eliminate fears or take charge of pain and help you get the care you need, even with an allergy. Take charge of you life and empower yourself to make the changes you need or want. Make sure that the hypnotherapist is a state certified hypnotherapist. Get the help you need to make your visits to the dentist comfortable, enjoyable and pain free.

After years of avoiding the dentist due to dental fear, my teeth got progressively worse. There were more cavities. Teeth started crumbling away and breaking off at gum level. Abscesses were regular occurrences and often lasted for several days, swelling the side of my face. The constant pain was almost unbearable, but still my fears prevented me from seeking help. I would take painkillers like they were sweets but I could not go to the dentists because of my unconscious fears. I tried various ways to pull the offending teeth out to try to stop the pain -- failing miserably and making the situation worse. With a phobia the fear far outweighs the threat but the sufferer often has little control over their reactions. My rational thoughts told me that the pain I currently felt could not be anywhere near as bad as any pain I may experience having dental treatment. My unconscious mind did not agree and the fear won. It has been said, "When it hurts enough, people will go to the dentist." This certainly does not hold true if you are a dental phobic!! Now, not only were my fears stopping me from going to the dentist, I was also ashamed of the way my teeth looked. I thought that the dentist would never have seen teeth as bad as mine, and I knew from past experiences they would never understand. Once again they would rebuff me and make me feel small and dirty for the way I had let my teeth deteriorate. It is amazing how our minds work when we are limited by our own beliefs and lack of knowledge. For example, as several of my back teeth had broken at the gum level and the gums had swollen around them, I thought the only way to deal with the problem was to cut the gums open to get all the bits out. This did not help the situation at all and just served to re-enforce the fear which now controlled my life. Eating started to get to be a problem as well. It is difficult to chew food when the main biting teeth are rotting away. I would tend to chew on one side of my mouth until that caused pain. Then I would use the other side. Eventually that too would start to hurt. The only options open to me were to nibble in the middle, or only eat soft food, until the pain went away. I was always conscious about the state of my teeth. When speaking to people my hand would be strategically placed in front of my mouth to hide them. I also very rarely smiled, as this would reveal my teeth. So not only did I feel miserable, I also looked it. Frequently, I would have nightmares about teeth and often woke with broken bits of teeth in my mouth. The state of my teeth also prevented me from visiting a doctor, especially if I thought there was a remote chance he might want to look in my mouth. All of these factors compounded my fears, and of course I was the only one that felt this way. If you are unfortunate enough to suffer from dental phobia maybe you will know what I mean. The situation was getting progressively worse. Not only was my physical health suffering, but I had also lost my self-confidence and self-esteem, and had started to experience panic attacks. I was unable to see any way out and it was difficult to seek help because I was too ashamed of admitting to others how I felt. My life was so out of control, I felt isolated and alone. Eventually I came to the "crossroads" in my life and realized something must be done. I could not continue to suffer in this way. About a year previous to this I had read an article in the Derby Evening Telegraph about a dentist who had dealt with people just like me and I decided to see if he could help me. Now I thought was the time to regain control of my life. It was a difficult decision to make, but eventually it turned out to be one of the best things I could have done. I soon realized that not all dentists apprenticed to the Marquis De Sade. I had found one who did actually care and realized there was a person behind the teeth. I was treated with care and understanding, and was never made to feel small. My treatment was taken one step at a time, and I was never pushed beyond my limits. Slowly but surely, my treatment progressed and I started to feel better about myself. Every success I had helped to re-build my confidence. I began to understand just how much my own mind had distorted my thinking about dentists. How distorted was my thinking? Well: - Throughout all of my treatment I only experienced a slight pain once and that only lasted about one second. - The bits of tooth were the easiest to get out. My gums did not need to be cut. - The dentist had seen teeth worse than mine. - The dentist did not make me feel dirty, stupid or rebuff me for the state of my teeth. - I was not the only one who had such fears. In hindsight, I could have saved myself lots of pain, discomfort and suffering. I only hope this account of my own experiences provides hindsight for any other people who are experiencing similar problems and impetus to enable them to take the steps needed to beat "the fear." Please don’t let your lives be controlled by past experiences as I did. We all have the resources within us to enable us to find the right way to deal with our problem. It can be done and the fear really does far outweigh the threat in a big way. Once you face the fear, you can see it for what it is and defeat it.

Treating Dental Fear

Millions of people unnecessarily avoid dental care due to fear. Unfortunately, dental decay and gum disease do not simply disappear. As a consequence, many people suffer from dental maladies that could easily be avoided. Bad Dental Experiences People commonly blame bad childhood experiences at the dentist for their present anxiety about dental care. Psychologists have observed that it may take nine or more positive experiences to overcome one negative incident. But it can be done. The first step in managing dental fear is familiarization. The more you learn about a forthcoming experience, the less likely you will be anxious about it. Be frank with the dental staff. Talk about your concerns. Communications such as “I’m afraid of the drill,” “I’m a dental coward,“ or “Please, I need extra TLC,” will clear a pathway for an exchange of ideas. Most dentists are caring, empathetic people -- not the sadistic demons portrayed in Hollywood. They will listen to your fears. There are several options available for a tranquil dental appointment. For some patients, a comfortable setting, reassurance by the dentist or stereo headphones may be all that is required for relaxed dental treatment. Others may require more pronounced treatment modalities. Hypnosis Hypnosis is a suggestive technique that may produce a state of altered consciousness, opening the subject to the therapist’s behavioral or perceptive suggestions. This approach can easily include a state of relaxation. Once properly trained, individuals may later reproduce the relaxed state without the presence of the therapist. Nitrous Oxide and Conscious Sedation The American Dental Association defines conscious sedation as “a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command.” This may be accomplished with the use of a pre-treatment oral sedative, the inhalation of nitrous oxide, or a combination of both. The technique requires the use of a local anesthetic for most dental procedures. Some patients tolerate dentistry more easily by taking an oral pre-medication 30-60 minutes before the dental visit. The choice of a sedative depends upon the patient’s general health and other medications taken. The drawback to oral sedatives is that the level of sedation is difficult to manage and an escort is usually required. Nitrous oxide, or relative analgesia, is a safe, convenient agent for dental care in comfort. Also known as laughing gas, nitrous oxide is effective in producing a state of deep relaxation without the loss of consciousness. It wears off in a few minutes and the patient may drive home. Used by properly trained dental personnel, nitrous oxide is ideal for the dental environment. Some dentists prefer to prescribe anti-anxiety or sedative medications in combination with nitrous oxide. Intravenous (IV) Sedation Comprehensive control of pain and anxiety in dentistry is sometimes achieved by the intravenous introduction of anti-anxiety or sedative drugs. This technique produces a profound state of relaxation, without the loss of consciousness or compromising respiration. The technique is recommended for excessively anxious dental patients and an escort is always required. A local anesthetic is still needed for most dental procedures. While less convenient than conscious sedation, IV sedation’s predictable effects make it the method of choice for the highly fearful dental patient. General Anesthesia Outpatient oral surgery procedures or general dentistry for extremely apprehensive or handicapped dental patients may require the use of a general anesthetic. Oral and maxillofacial surgeon Dr. Ken Templeton states, “Modern technology now makes it possible to perform complex surgery in the office with little or no discomfort.” In an oral surgery or dental setting, general anesthesia characteristically produces a state of unconsciousness, short of impairing respiration. Special monitoring, supportive and resuscitative techniques are mandatory for patient safety. A local anesthetic is commonly used in conjunction with the administration of intravenous drugs. Recovery time is usually 20-40 minutes and an escort is necessary. Safety and Training The use of conscious or intravenous sedation and general anesthesia requires special university training and clinical experience. The 50 state boards of dentistry carefully regulate and license dental practitioners within their jurisdictions. Training requirements do vary. Offices must be specially equipped with emergency equipment and drugs, and in-office inspections are necessary for each dentist issued a permit. Dr. Stanley Malamed, Professor of Anesthesia and Medicine at the University of Southern California School of Dentistry, reports that dental IV sedation is a safe technique. "While any sedative technique carries a degree of risk, the drugs used and their slow delivery, accompanied by modern monitoring equipment, make IV sedation extremely safe.” Don’t Delay Necessary Dental Care Dr. Richard Gagne, who provides IV sedation for his patients, observes: “Comprehensive dentistry can save your teeth, improve your smile, and keep you looking youthful. However, the problems must be caught early and treated promptly. IV sedation can get you back to wonderfully healthy, attractive and pain-free teeth -- teeth of which you can be proud and will serve you for a lifetime.”

What You Hear Can Make You Fear

It should come as no surprise that fear is one of the most common obstacles for some people to overcome when going to the dentist. In some cases, a person may have had a bad experience in the past, and then avoids their much-needed dental care because of it. In other cases, however, a person can become "afraid of the dentist" or of certain dental procedures without ever actually having had a bad experience at the dentist's office. These are people who have heard from others that all dentistry is painful -- and they believe it! This type of learned fear is called “vicarious learning” and it is both common and detrimental. Unfortunately, there is apparently good reason for people to accept these negative dental stereotypes, because they may be reinforced by family, friends and in the media. For instance, think for a moment about how you feel when you see a plane crash on the TV news. The vivid pictures and tragic personal stories stir our emotions. But have you ever stopped to think that you rarely hear about the more than 20,000 safe take offs and landings every day, or the incredible safety record of the airline industry? Likewise, few people share their successful dental experiences. Instead, research has shown that people are far more likely to share and embellish a negative dental experience. I know from years of treating patients the power of vicarious learning. There are times when I have to suggest that a patient with a dental infection get a root canal (the replacement of an infected tooth's pulp with an inert material) to save their tooth. Right away, the fearful patient will say something like, "No way, put me to sleep and I'll have it pulled. I won't go through a root canal." When this happens, I ask them if they've ever had a root canal before, and if it was a bad experience. In most cases, the answer is no. I then ask them why they think it will be painful. They usually respond that they heard somewhere or from someone that a root canal is painful. In addition, I sometimes hear fearful parents in my waiting room unknowingly establish negative stereotypes regarding dental treatment with their children. They might say things like, "Tell the dentist if he is hurting you," or "If you don't stop misbehaving, it will be your turn to go to the dentist next time," and other things that are likely to instill a fear of dentistry. Dentists and dental treatment are sometimes portrayed in a negative light in the media and in commercials we see on TV. We have all heard stories in the news about AIDS, mercury fillings, dirty dental drills and water. Unfortunately, these stories are often one-sided and can misrepresent the facts. Likewise, commercials sometimes use the fear of dental treatment -- especially root canals -- as the punishment in their contrived scenarios. Burt Decker, author of You've Got to Be Believed to Be Heard,” wrote, "People make decisions based on emotion, and then try to justify them with facts." That, it seems, is the reason people who fear the dentist will tend to hone in on these negative dental stories and why these stories have such a powerful and damaging impact. These examples help to illustrate that fear is usually a learned phenomenon, and because it is learned, it can be unlearned as well. A good place to start in overcoming a fear of the dentist and dentistry is with a dentist who listens to your fears. With time, and a dentist you can trust, your fears will disappear.

Medications That May Cause Xerostomia (Dry Mouth)

Xerostomia, also known as dry mouth, is a contributing factor to gum disease, rapidly progressing cavities, and bad breath. Frequently, I examine patients who develop numerous cavities within just a few months due to recently developed dry mouth! Below is a partial list of medications which have been known to cause dry mouth. Salivary gland dysfunction, smoking, dehydration, and other factors may also cause xerostomia. Ask your dentist or physician if you are concerned about this condition. Remember, this is only a partial list and if you feel you are taking any medications which are causing dry mouth and compromising your oral health, please consult your doctor. There may be alternative medications or oral hygiene methods!

Sjogren’s Syndrome: Diagnosis and Treatment

General Information Sjogren’s syndrome is an autoimmune disease in which the body's immune system mistakenly attacks its own moisture producing glands. Sjogren’s is one of the most prevalent autoimmune disorders, striking as many as 2-4 million Americans. Nine out of ten patients are women. The average age of onset is late 40’s, although Sjogren's occurs in all age groups in both women and men. The hallmark symptoms are dry eyes and dry mouth. Sjogren’s can also cause dryness of the skin, nose and vagina. Sjogren's also may affect other organs, such as the kidney, GI tract, blood vessels, lung, liver, pancreas and the central nervous system. Many patients experience debilitating fatigue and joint pain. Symptoms can plateau, worsen, or go into remission. While some people experience mild symptoms, others suffer debilitating symptoms that greatly impair their quality of life. When Sjogren’s syndrome occurs alone and no other connective tissue disease is present, it is called “Primary Sjogren’s.” When Sjogren’s syndrome is accompanied by a connective tissue disease, such as rheumatoid arthritis, lupus or scleroderma, it is called “Secondary Sjogren’s.” The term “secondary” in no way implies that Sjogren’s syndrome is less important than the other co-morbid illness. Approximately half of people with Sjogren's have Primary, and the other half have Secondary Sjogren's. Diagnosis Early diagnosis and treatment are important for preventing complications. Nevertheless, it sometimes takes a Sjogren's patient two years to get this diagnosis. Sjogren's symptoms may mimic other diseases, such as lupus, multiple sclerosis or rheumatoid arthritis. Furthermore, dryness can occur for other reasons, such as a side effect of medication like antidepressants or high-blood pressure medication. Rheumatology is the medical specialty that has primary responsibility for diagnosing and managing Sjogren's syndrome. Ophthalmologists and dentists are also specialists who diagnose symptoms associated with Sjogren's. Once Sjogren’s syndrome is suspected, the rheumatologist will take a medical history and do a series of blood tests to confirm the diagnosis. The rheumatologist will also refer the patient to an ophthalmologist for further tests, and to an oral pathologist for additional procedures. The following list includes some of the blood tests that the rheumatologist will order: ANA (Anti-Nuclear Antibody) -- ANAs are a group of antibodies that react against normal components of a cell nucleus. They are present in a variety of autoimmune diseases, so the test is not disease specific. About 70% of Sjogren’s patients have a positive ANA test result. SSA and SSB -- The antibodies SSA (or RO) and SSB (or LA) are often found in Sjogren’s syndrome; 70% of patients are positive for SSA and 40% are positive for SSB. RF (Rheumatoid Factor) -- This antibody test is indicative of a rheumatic disease, but like the ANA test, is not specific to Sjogren's syndrome. In Sjogren’s patients, 60-70% have a positive RF. ESR (Erythrocyte Sedimentation Rate) -- This test measures inflammation. An elevated ESR can indicate an inflammatory disorder, including autoimmune and connective tissue diseases, like Sjogren's syndrome. IGs (Immunoglobulins) -- Immunoglobulins are normal blood proteins. They are usually elevated in Sjogren’s. The following are tests that the ophthalmologists will perform to test for dry eye: - Schirmer Test -- Small pieces of filter paper are placed between the lower eyelid and eyeball. The amount of wetting in five minutes gives a rough estimate of tear production. - Rose Bengal and Lissamine Green -- These dyes are used to observe abnormal cells on the surface of the eye. - Slit-Lamp Exam -- This test provides an indication of the volume of tears by magnifying the eye and viewing it in its resting state. The amount of tears is then examined. The dentist or oral pathologist will perform the following tests: - Parotid Gland Flow -- This test is a quantitative measure of the amount of saliva produced over a certain period of time. - Salivary Scintigraphy -- This test measures salivary gland function by injecting radioactive material into the salivary glands. - Sialography -- This is an X-ray of the salivary-duct system taken after a radiologically sensitive dye is injected. - Lip Biopsy -- This test is used to confirm lymphocytic infiltration of the minor salivary glands. An incision of approximately two centimeters is made on the inside surface of the lower lip. Minor salivary glands are removed and examined under the microscope. Treatment While there is no known cure for Sjogren’s syndrome, many problems can be treated symptomatically with over-the-counter and prescription medications. Other helpful tips for coping with Sjogren's symptoms are also available from the Sjogren's Syndrome Foundation. Over-the-counter moisture replacement therapies are available to ease the symptoms of dryness. These include preservative-free artificial tears, artificial saliva, unscented skin lotions, saline nasal sprays and vaginal lubricants. The Sjogren’s Syndrome Foundation maintains an updated list of these products. The Foundation also offers tips for daily living in “The New Sjogren’s Syndrome Handbook” and in its “Moisture Seekers” newsletter. Two prescription medications, Salagen® (pilocarpine hydrochloride) and Evoxac™ (cevimeline), are available to treat the dry mouth associated with Sjogren's. Depending on the nature and severity of symptoms, other medications include non-steroidal anti-inflammatory drugs (NSAIDs), steroids and immunosuppressive drugs. There are also non-medication strategies for dealing with the various symptoms of Sjogren's syndrome. “The New Sjogren's Syndrome Handbook” contains a chapter covering many helpful ideas. The “Moisture Seekers” newsletter is also a great source of helpful hints. Athletic Mouthguards

Do Dentists Recommend Mouthguards? Yes.

The Academy for Sports Dentistry recommends that male and female athletes in any sport -- including football, basketball, softball and soccer -- wear a custom-fitted mouthguard made by a dentist. The advantages of wearing a mouthguard are that the device can protect the jawbone, teeth, lips and cheeks from injury. Thicker mouthguards can also help absorb shock, and in certain circumstances, may help prevent a concussion. Custom-fitted appliances are designed for the upper teeth and are comfortable to wear. The Academy's position is that for mouthguards to be effective, they need to be "properly fitted and properly worn." If this is done, an athlete should be able to fully participate in the sport. Are Mouthguards Mandated for Sports? According to the Academy, mouthguards are mandated in every state for high school football, hockey, men's lacrosse, field hockey and boxing. Some states also have mandated the appliance for other sports. There are a growing number of youngsters competing in sports. The number of female athletes has increased ten-fold since 1972. Mouthguards have proven to be an effective device in protecting the upper front teeth, which are most often injured during sports. What Types of Mouthguards Are Available? There are three different types of mouthguards available for the consumer: - Over-the-counter mouthguards are pre-made, inexpensive and available in stores. Dentists do not recommend them because they are often uncomfortable and don't fit properly. - Boil and bite mouthguards are available in stores and are fitted to an individual's mouth. Also inexpensive, they are customized by dropping the device into hot water and molding it to the mouth. The drawback to this mouthguard is that a person may get burned by hot water and they don't always fit properly. - Custom mouthguards are only available from a dentist. They are the only protective mouthpieces recommended by the academy. Custom mouthguards are the most expensive of the three options, but fit the best because a dentist takes a mold of the athlete's mouth. They generally last about one year in young adults. Can Individuals With Braces Wear a Mouthguard? Mouthguards are very effective in protecting the teeth and oral tissue in individuals who wear braces. They are also recommended for individuals who wear partials or dentures. Individuals who wear a partial or dentures should not wear them during sports because they could swallow it and asphyxiate, or it could crack in the mouth. Rather, a custom mouthguard is developed to fill in the spaces of the partial or denture. How Do You Obtain a Custom Mouthguard? Most dentists will make custom-fitted mouthguards in the office. Talk with your dentist about the sports you participate in and how a custom mouthguard can meet your needs.

Athletic Mouthguards and Children

Q: What is an athletic mouthguard? A: Athletic mouthguards are made of a soft pliable rubber. They are custom-fitted in the mouth or on a plaster model to cover the upper teeth. Q: What is the importance of wearing mouthguards? A: Mouthguards should be a part of every athlete's uniform. They are as important as knee pads, helmets and other athletic protective equipment. They protect the teeth, lips, gums and tongue. They also can prevent children from concussions and jaw fractures. Many organized sports require mouthguards to prevent injury to children. The majority of trauma to the mouth occur when athletes do not wear mouthguards, especially in unorganized sports activities. Q: When should my child wear a mouthguard? A: Whenever he or she participates in an athletic activity with a risk of a fall, or an injury to the mouth or head by other players and sports equipment. This includes football, baseball, basketball, soccer, hockey and skateboarding. Many people think that heavy contact sports like football and hockey are the most damaging to the teeth, but almost half of sports-caused mouth injuries occur while playing basketball and baseball. Also, studies show that many traumatic injuries occur when children participate in unsupervised sports in the gym or playground. Q: What type of mouthguard should I get for my child? A: Choose a mouthguard that your child can wear comfortably. If a mouthguard is not comfortable or makes it difficult for him or her to talk during sports, your child will not wear it. There are three different types of mouthguards. Preformed or "boil-and-bite" mouthguards are found in sports and department stores. There is a range in their comfort, protection and price. Second are professionally- fitted mouthguards. They are formed in the patient's mouth by a pediatric dentist, and are reasonably priced. The last are customized mouth guards which are laboratory fabricated and provided through a pediatric dentist. They cost more, but are the most comfortable and can be more effective in preventing oro-facial injuries and concussions. Your dentist can provide you with additional information on choosing the best mouthguard for your child. Athletic Mouthguards Protect Children Who Play Sports
Wouldn't it be great if mouthguards were all the rage this year? They'd be seen on all the runways, from skateboarding parks to organized team sports. The ADA has assembled quite a list of sports for which mouthguards are recommended: acrobatics, bandy, baseball, basketball, bicycling, boxing, equestrian events, field events, field hockey, football, gymnastics, handball, ice hockey, in-line skating, lacrosse, martial arts, racquetball, rugby, shot putting, skateboarding, skiing, skydiving, soccer, softball, squash, surfing, volleyball, water polo, weight lifting and wrestling. In addition, boxing, football, ice hockey, men's lacrosse and women's field hockey actually require mouth protection according to their governing bodies. There are two major goals in wearing a mouthguard for active play. One is to protect teeth against the impact of an object or body part. The second is to protect against concussions. A crushing blow from an elbow or implement transferred through the mandible and into the skull can cause severe damage, not just broken teeth but a concussion that can have long-lasting consequences. Responsibility Children, for the most part, follow the rules set out by sports organizations. They wear the gear set out by the regulations committee. If mouthguards are required and donned by all the other participants, they'll be worn. It's better if the sports committees make the rules than some outside "ruler" like insurance companies. High school football, for instance, has strict penalties for players who do not wear their protective gear, including properly fitted mouth guards. Penalties such as loss of time-outs or worse are available for officials to use, yet they are hesitant to use those penalties. Officials that do not enforce these rules are sending the wrong message. The decision to wear a mouthguard is made for children by their parents and the coaches, and enforced by officials in organized play. But what about unorganized play? Taking a second look at the list provided by the ADA we find that synchronized swimming is the only sport not on the list. Interestingly, age is not addressed. Store-bought mouthguards are easy to chew through and they grow longer with chewing, causing an uncomfortable choking sensation. This acute sensation renders the wearer totally distracted by the gag reflex and ineffective on the playing field. In order to be worn, a mouth guard must be comfortable. Properly fitted mouthguards are recommended for all activities that require gear. They come in fun colors, with team logos or animal designs. Parents that are active should be encouraged to wear mouth protection during their sporting activities. Parents are role models for their children and their children's friends. Wearing protective gear, from rain coats to mouthguards, is a marvelous, no-time commitment way to show kids that safety is all the rage.

Mouthguards Protect Against Dental Injuries

Youth sports, organized or random, can be harmful to children. Without the proper precautions, children are at risk for a number of injuries. Kids and balls, skates, bats, bikes, trampolines, ballet, pools, floor exercises, gymnastics, whether inside or outside, risk injury. Most can be prevented without too much trouble. Aside from teaching proper body mechanics, we protect children with body armor of all kinds. When your kid goes out for sports, organized or otherwise, is he well protected? One piece of equipment has had a controversial existence since coming onto the scene in 1913. It protects against concussions, yet is only required in five sports. It is the mouthguard. The American Dental Association recommends wearing customized mouthguards for these activities: acrobatics, basketball, boxing, field hockey, football, gymnastics, handball, ice hockey, lacrosse, martial arts, racquetball, roller hockey, rugby, shot putting, skateboarding, skiing, skydiving, soccer, squash, surfing, volleyball, water polo, weightlifting and wrestling. There is an irrational lack of perceived need for mouthguards in sports that cause the most injuries to the mouth and face: baseball, basketball and soccer. The perceived need for girls in these sports is less than for boys, even though girls suffer the same number of traumas. Customized mouth protection, most obviously, protects against broken teeth. Less obvious is protection against wear on teeth during lifting and jarring sports. Mouthguards also protect against concussion. Keeping the teeth separated with a uniform amount of plastic throughout the dentition opens the distance between the jawbone and the skull. With a mouthguard in place, the plastic will absorb the majority of shock from a blow. Without it, the impact will travel through the jawbone, forcing it to collide into the skull, resulting in a concussion. Who Should Monitor Wearing? It comes down to everyone. Once informed, parents can be an important ally to coaches and officials as well as a role model to their children. First, by supplying the child with a custom-fit mouthguard. Second, a parent can be a role model by wearing one during activities such as rollerblading, softball or weight training. Coaches are THE decision-makers on this topic. The decision to wear mouth protection for practice as well as competition is critical. It turns out that the coach's insistence on mouthguard use is the most important factor to influence the kids to wear their gear. Officials, in organized team sports, have the authority to penalize a team that presents a player without mouth protection. This penalty can range from yardage loss to eliminating a time out. Without the officials' use of these penalties, parents and coaches lose their momentum. Working together, parents, coaches and officials can insure this important safety measure becomes the status quo. What About the Kids? Often when mouthguards are suggested but not mandated, parents get the easiest thing they can find. Usually it's a “boil and bite” variety, some of which cover the upper and lower teeth, fully and together. The players complain because that design doesn't fit well and limits speech and breathing. Considering the sustained running involved in basketball or soccer, this is unacceptable as a safety device. Custom-made mouthguards are far superior. Any dentist can make one. However, a dentist that sees many athletes has an insight to the game that other dentists may not. For the girl or boy active in sports over their school career, a new appliance will need to be made periodically as they grow. Today mouthguards can be made to look super cool with wild colors and designs. Soon they will become as prevalent as the helmets the kids wear without self-conscienceness these days.

Mouthguards: An Important Part of the Uniform
The potential for sports-related injuries is an unfortunate fact of life for today's athletes and even the part-time athlete or weekend warrior. Dental and facial injuries generally include broken, displaced, or knocked out teeth (especially the front teeth), lacerations or tears of the lips, broken jaws, and damage to the TMJ or jaw-joint. A blow to the chin or other part of the head can give rise to a concussion, an injury to the brain that can cause loss of consciousness, dizziness, or more severe complications. Evaluation and treatment of medical injuries, such as stabilization of all vital functions is the top priority after a sports-related injury, and should be rendered by the team medical doctor or in the emergency room. Dental injuries should be treated as soon as possible. Teeth that are knocked out should be gently cleaned off, but not scrubbed, placed back into the socket or a cup of milk, and you should see your dentist in less than 45 minutes, if possible. Dentist prescribed, custom-made mouthguards are essential for the prevention of painful and costly sports-related dental and facial injuries, as well as concussions. In fact, an important study by the American Dental Association confirms that 31 percent of high school basketball players suffered from some form of dental or facial trauma during their careers if they did not wear a mouthguard. Only 4.2 percent of basketball players reported that they wore a mouthguard at the time of injury, proving a seven-fold improvement of protection. Despite these encouraging statistics, more than 2 million teeth will be knocked out every year, many from athletes who do not wear protective mouthguards. Well-fitted, custom-made mouthguards are essential for most sports, especially those that are high contact, such as boxing, football, martial arts, kickboxing, wrestling and street or ice hockey. They are also appropriate for soccer, basketball, baseball, softball, rollerblading, skateboarding and mountain biking. Not all mouthguards, however, are created equal. Store-bought, stock and boil-and-bite mouthguards provide some protection at low cost, but they are usually uncomfortable, ill-fitting, and can make talking or breathing difficult. It is for this reason that many athletes, including professional football players, do not wear mouthguards. The next time you watch Monday Night Football, keep your eyes on the quarterback. They usually do not wear mouthguards because it interferes with their audibles, huddle instructions and snap counts. For this reason, professional, amateur, and recreational athletes alike, should wear dentist-prescribed custom mouthguards. The procedure for making mouthguards is simple. The dentist takes impressions (molds) of your mouth and has you bite on a piece of wax. Models of your mouth are sent to a lab, and then the mouthguard is made. The best type of mouthguard, in my opinion, is composed of layered, heat and pressure laminated ethyl vinyl acetate (EVA). They come in a variety of different layers and colors. They are strong, comfortable, and allow for easy speaking and breathing, but do cost more than those that are store-bought. You should discuss mouthguards with your dentist if you, your spouse or children are involved in athletic activity. Ask your dentist if he or she has experience making custom mouthguards, or is a member of the Academy of Sports Dentistry. Remember that the cost of a custom mouthguard is far less than for rebuilding or replacing unprotected teeth. Using Nightguards for Tooth Grinding (Bruxism)
Bruxism, commonly know as tooth grinding, is the clenching together of the bottom and upper jaw accompanied by the grinding of the bottom and upper jaw and followed by the grinding of the lower set of teeth with the upper set. This behavior will remove critical portions of healthy enamel from the chewing surfaces of your teeth and may cause facial pain. People who grind and clench their teeth are called bruxers. They unintentionally bite down too hard at inappropriate times, such as when you sleep, especially in the early part of the night. During sleep, the biting force -- the force at which the jaws clench together -- can be up to six times greater than the pressure during waking hours. Bruxing is like clinching your two fists and holding them tightly against each other for eight hours. This behavior would cause you to end up with sore hands, arms and shoulders. Well, this same thing happens to your jaw muscles. Bruxism is a force that is far more destructive to teeth than caries because your teeth are worn down so much that their enamel is rubbed off, exposing the inside of the tooth called dentin. This exposed dentin will become sensitive. About one in four people suffer from at least one of the following: - Pain or discomfort often around the ears and when yawning or chewing - Tenderness of the jaw muscles - Clicking, locking or popping in the jaw - Jaw muscle contraction, spasms or cramping - Jaw clenching or teeth grinding, severe or very loud - Headaches and neck aches - Ringing in the ears - Tooth indentations on the tongue - Fractures of teeth and fillings, especially on the front teeth, due to the high pressure - Teeth sensitive to cold, pressure and other stimuli As bruxism can be a subconscious behavior that you do not realize is happening, symptoms might not be present. Complications - Damage to teeth - May awaken sleep partner - Worsening of TMJ dysfunction and dental disorders - Limitation or difficulty in jaw movement, jaw locks when opened or closed - The tips of the teeth wear flat - Tooth sensitivity and mobility Causes - Emotional stress - Personalities characterized by aggression, controlling, precision, nervousness, competitiveness or people who have time urgency and achievement compulsion - Malocclusion (teeth that are not aligned properly) - Jaw, head or neck injury - Diseases such as arthritis or missing teeth Treatment: The goal is to change behaviors in order to relieve symptoms. Nightguard - Learning how to rest the tongue, teeth and lips properly. The tongue should rest upward with teeth apart and lips shut to help relieve the discomfort. - Learn to control bad habits, such as chewing on ice or chewing fingernails or pens. - Chewing gum much of the day increases the wear and tear on the joint, giving little opportunity for your jaw to recover between meals. - If you chew habitually only on one side of your mouth, you concentrate all the pressure on one side rather than equally on both sides of your mouth. You need to learn to chew evenly -- left vs. right. - Clenching and grinding can be consciously suppressed. - Treat symptoms first with cold packs and as pain and spasms resolve, try hot packs for a half hour at least twice daily. - Nonsteroidal anti-inflammatory agents (ibuprofen, Naprosyn®, Tylenol®, Aleve®) and even aspirin are very effective for reducing inflammation in joints, and are recommended before bed and upon waking. - Most importantly, the joint should be placed at rest by eating a soft diet and avoiding hard, chewy or sticky foods. - Mouth exercises to improve mouth opening, e.g., slow opening and closing, stretching the muscles to their extent then relaxing them. - Relaxation or stress management techniques. A nightguard, which takes the punishment that your teeth would normally endure during bruxism, minimizes the damage from grinding your teeth. A nightguard is a thin transparent horseshoe-shaped retainer-like appliance made of hard plastic that has shallow borders for good tooth alignment and ideal bite relationship. This splint is worn between the top and bottom teeth and does not allow the teeth to interlock, which absorbs the force of the clenching and grinding to reduce joint irritation and inflammation. It takes two simple appointments. At the first appointment, an accurate impression of your upper and lower teeth will be made. These impressions are used to create models of your teeth. A bite record may be taken. These items are used to form a customized heat-processed hard plastic nightguard. At the second appointment, the nightguard will be fitted and adjustments made. The lifespan of a nightguard is 3-10 years. It can protect you from the symptoms of teeth grinding if you wear it regularly, which can even lead to a better night’s sleep for you and your partner! An In-Depth Look at Sleep Apnea
What is a sleep apnea problem? Actually, sleep apnea is one of several related conditions which include snoring, obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS). These conditions have all been successfully treated with mandibular advancement procedures (either dental devices or jaw/chin advancement surgery). OSA, UARS and snoring, to a lesser degree, are essentially due to collapse of the airway (total or partial) during sleep, and each can be severe enough to induce frequent sleep state changes. These sleep state changes can deprive the individual of adequate deep sleep and induce daytime sleepiness (hypersomnolence). Of course, the most common affliction associated with snoring is the disturbance in the bed partner's sleep, although snorers clearly have a greater likelihood of having OSA. UARS is an intermittent partial collapse of the airway that produces labored breathing. The more serious of the three conditions is OSA since it produces an intermittent complete airway collapse during sleep. Why should I be concerned? OSA is associated with increased mortality. The research indicates the risk is for individuals with moderate to severe OSA and another pulmonary or cardiac disorder (e.g. asthma, emphysema, and angina). In a routine patient, however, the main reason treatment is sought is because OSA has a major impact on their life style due to the daytime hypersomnolence it causes. What dental procedures can be used to treat sleep apnea and snoring? Nasal CPAP is the principal non-dental treatment for these disorders. For the moderate to severe apnea sufferer, this treatment is very effective but often is not used by patients because it is inconvenient to attach the mask each night and sleep with it in place (Kribbs, 1993). Surgical solutions which involve the throat only have a significant failure rate (Scher 1996). In recent years, for the mild to moderate OSA patient, several good studies have shown the dental devices which advance the mandible as a very successful device to treat SDB. These devices are usually two full arch acrylic devices which cover all of the mandibular and maxillary teeth and are then attached together in such a way as to hold the jaw in a forward position. Although the degree of advancement varies between designs, it has been proposed that at least a 50 percent or greater movement is necessary to achieve success of the device. In 1989, Clark proposed that at least a 75 percent advancement is necessary. The advantage of the mandibular positioner is that it maintains a continuous, forward tongue position throughout the night and is designed so oral breathing is still possible if the nasal passage is blocked. Why does a mandibular advancement work? There are two basic theories which can be advanced to explain how a mandibular advancement works. The first and most prevalent theory is that the mandibular advancement works by increasing the airway caliber, thus making the airway's resistance to collapse with negative pressure produced by inspiration. The second theory is that there is a stretch-induced activation of the pharyngeal motor system where the device and this motor activation provides enough stiffness to the system to prevent collapse of the airway. At this time it is impossible to know which theory is more correct. An issue which researchers must consider is that the passive shape of the airway may not be the critical factor in prediction of OSA development at all. Instead the issue may be how collapsible the airway is when placed under negative pressure (inspiration). Assessing the later will require a completely different methodology than radiographic or MRI based images.

Dentists Say Breathing Strips Probably Won't Help Snorers

Most patients who turn to breathing strips as a cure for snoring are doing little but wasting money, say most dentists and physicians who work with sleep apnea and its related disorders. Made popular by professional athletes, these adhesive strips press down on the bridge of the nose and pull the nostrils open, without decongestants or antihistamines. Packaged in 10-strip and 30-strip packs, they sell for about 50 cents each. "Breathing strips may open the upper airways, but snoring originates in the lower airway and they have absolutely no effect on this area," says Sheldon Seidman, D.D.S., a general dentist. "The strips do not address the vibrations that occur from excess tissue in the upper throat." CNS of Bloomington, Minnesota, sold $86 million of the strips in 1996, but flat U.S. sales and inventory problems in foreign countries depressed revenue to $67 million in 1997. The U.S. Food and Drug Administration first approved CNS to market the product for general improvement in nasal breathing. Later, the administration approved the product for relief from snoring, nasal congestion and a deviated septum, a problem in the nose cartilage that can obstruct breathing. "Most people snore because of vibration of tissue in the throat, palate and uvula -- not due to problems in the nose," says Dr. Seidman. "The vast majority of patients who try them come back to the office and say they had no effect on their snoring." Several other types of appliances are recommended by dentists and physicians to combat snoring. Some recommend breathing masks in which snorers wear continuous positive airway pressure (CPAP) masks while sleeping. The mask blows a continuous stream of air through the nose, keeping passages open. Also recommended are plastic mouthpieces that pull the lower jaw forward a number of millimeters and locks it forward while patients sleep. Some devices are specially fitted to hold the tongue in place throughout the night. Behavior modification is the first step recommended by professionals, including losing weight, smoking cessation, avoiding alcohol consumption before going to bed, and not sleeping as much in the supine position (on the back), where air passages can become blocked. Surgical procedures are more frequently performed to relieve patients of their snoring habits. In severe cases, airflow to the lungs is completely blocked for up to 90 seconds at a time. The resulting oxygen deprivation increases the risk of hypertension, coronary heart disease and stroke. Other problems include early morning headaches, impaired concentration and impotence. Snoring is believed to cause a poor night's rest, which means the next day is sluggish and sometimes non-productive. Some research suggests that people who snore are more prone to become involved in traffic accidents.

Snoring & Sleep Apnea

A number of appliances and treatments exist today to treat snoring and sleep apnea disorders. The graphic demonstrates how the airway increases with a forward-positioned mandible, thereby decreasing the vibrations of soft tissue, which cause snoring and also increasing the pathway for oxygen. Some dental offices provide dental appliances that can help maintain this optimal position comfortably without surgery! Sleep apnea is a serious health condition for many people, and our office will work with you and your physician to address your concerns. If you feel you could benefit from this treatment, please contact your dentist for a consultation or for more information on local area sleep clinics.
Snoring Remedy: The Silent Nite™ Device
It is estimated that more than 80 million people in North America snore while sleeping. While snorers often do not seem to suffer from snoring themselves (excluding Sleep Apnea Disorder), their spouses and children are often repeatedly disturbed during their sleep cycles. Unfortunately, snoring can produce tensions and even animosity among family members if left untreated. Today however, thanks to extensive research and documented effectiveness, we can prescribe an affordable, custom made snoring prevention device called Silent Nite™. What Causes Snoring? During sleep, the muscles and soft tissues in the throat and mouth relax, making the breathing airway smaller. This decrease in the airway space increases the velocity of air flowing through the airway during breathing. As the velocity of required air is increased in the constricted space, soft tissues like the soft palate and the uvula vibrate. These vibrations of the soft tissues in the mouth and throat result in what is called noisy breathing or generally referred to as snoring. It should also be noted that sleep studies have shown that excess body weight, heavy alcohol consumption and other sedatives have been shown to increase the severity of snoring. A relaxed and collapsed airway produces soft tissue vibrations during breathing, which results in snoring. Surgical techniques to remove respiration pairing structures such as uvula, enlarged tonsils and adenoids have been among the many attempted snoring remedies. These soft tissue surgical procedures have shown only moderate success rates (e.g., 20 to 40 percent). At certain levels of severity, complete blockage of the airway space by the soft tissues and the tongue can occur. This is called Obstructive Sleep Apnea if the period of asphyxiation lasts longer than 10 seconds. For the majority of snorers, however, the most affordable, non-invasive, comfortable and effective snoring solution remains a dentist-prescribed oral snoring preventative device, such as Silent Nite. How Does Silent Nite Prevent Snoring? Snoring research has also shown that custom fabricated dental devices worn at night that move the lower jaw into a forward position increase the three dimensional space in the airway tube which reduces air velocity and soft tissue vibration. By increasing the volumetric capacity of the airway and preventing soft tissue vibrations, snoring is eliminated. In clinical research studies, these dentist-prescribed oral devices have exhibited initial snoring prevention success rates of 70 to 100 percent. With a Silent Nite device the airway remains open, allowing easier breathing and preventing snoring. The Silent Nite device positions the lower jaw into a forward position by means of special connectors that are attached to transparent flexible upper and lower forms. The forms are custom laminated with heat and pressure to the dentist’s model of the mouth. The fit is excellent and comfortable. Breathing Is Easier With a Silent Nite Silent Nite devices do not interfere with breathing through the mouth. Even in cases of congested nasal passages, the device prevents snoring and allows uninhibited oral breathing. Small movements of the jaw (temporomandibular joint or TMJ) are possible while wearing a Silent Nite device. This movement potential helps minimize stiffness in the joints of the jaw in the morning. The Silent Nite device may leave a slight sensation of the jaws being out of alignment upon wakening. This feeling is due to lymphatic fluid-build up in the jaw joint that occurs overnight and will rapidly subside in minutes. Silent Nite devices help promote deeper, more restful sleep by preventing snoring. The custom design of the Silent Nite will insure comfort and effectiveness. More restful sleep may be in your future. We have a simple take-home checklist that, when filled out with your partner, will help determine the exact design of your Silent Nite. Ask us for a copy and fill it out tonight. We will be able to advise you whether this device could help you or your loved ones obtain better, more healthful sleep.

Silent Nite™Causes of SnoringHow Does Silent Nite Prevent SnoringSilent Nite™ Device

Somnoplasty: Snore No More!

Most snoring is caused by the soft tissue of the palate vibrating violently as the sleeper breathes in. Snoring can be violently and alarmingly loud. The one who snores will often completely deny and scoff at their spouse when told that they snore because their snoring, strangely enough, does not wake them up. Of course, the non-snoring spouse can put noise "stopple" in their ears. However the noise of snoring can be so overpowering that not even that preventive measure helps. In my case, my wife had an ear infection earlier in life that prevented her from stuffing her ears with anything. My snoring was getting progressively worse not withstanding the fact that I was wearing a snoring device that had been 85 percent effective for the past 10 years. Then, I heard about a new procedure called somnoplasty which was a technically new, minimally invasive, non-surgical, in-office approach to the snoring problem with a relatively high success rate. Compared to the surgical approaches, somnoplasty seemed like a breeze and that is exactly what it turned out to be. Prior to the Procedure Dr. Dan Arick examines mouth, palate and throat to determine the suitability of the patient for the procedure using the Mallampiti classification for the seriousness of the airway obstruction. Dr. Arick prescribes two medicines to begin the day of and prior to the somnoplasty office procedure: 1. Steroid pills to prevent or minimize swelling -- methylprednisolone (4mg tabs) taken according to special instructions on pack. 2. Antibiotic -- cephalexin 500 mg caps. Somnoplasty Procedure The procedure was carried out at 4:00 p.m. as outlined below. In my case, the local anesthesia wore off in about three hours and my throat (toward the back of my mouth) began to hurt, especially upon swallowing, so much so that I took two Advil® ibuprofen to relieve it. I would describe that pain on a scale of 1-10 as a five. An hour later the pain receded. Just before going to sleep I took one Darvocet® non-narcotic analgesic. My snoring was so loud that I awakened myself -- something that my wife usually does for me. But this time she was away. I slept on pillows with my head raised 45 degrees. I had worn an anti-snoring device before the procedure, so I put that back in my mouth and it helped. I awoke with no pain and continued taking my antibiotic and steroid medicines. I was more aware of some difficulty, but only mildly uncomfortable, swallowing during the day. Dr. Arick and a nurse will check to see that patients are comfortable and prepared to have the somnoplasty procedure. Dr. Arick will establish his method of allowing you to signal him that you are comfortable during the procedure. The nurse assistant prepares the standard settings on the somnoplasty machine for the delivery of the proper energy and temperature to the soft tissue of the palate, which is about the size of a large bread box. She attaches your new sterile hand piece (energy-delivering apparatus) to the machine, and then attaches electrical grounding tape to the skin on your lower back. The doctor or nurse then gently sprays the back of mouth with topical anesthetic to prevent or minimize the discomfort of the anesthetic injections you’ll receive. The doctor will use a special bending tool to shape the power delivery tip on the handpiece to the exact shape of your palate. Dr Arick tests the anesthesia, and then painlessly inserts the tip of the handpiece into the middle of the soft palate, going up to and slightly into the uvula delivering a painless stimulus to the tissues for about one minute. Finally, the doctor will painlessly withdraw the tip from your mouth. He does the same on the right and left side of the soft palate. The somnoplasty procedure is now completed. The nurse will remove the electrical grounding tape from the back and check to see if the patient is comfortable. You will leave the office about 45 minutes after arriving. Post-Somnoplasty Treatment Instructions (for Patient) 1. You may experience a sore throat for 1-5 days. You can take Advil®, Motrin® or Tylenol® for relief. 2. The anesthesia takes about two hours to wear off. Then you will begin to experience pain or soreness. Sucking on icy cold water, liquids or flavored ice popsicles can bring temporary relief. Dairy products such as ice cream are not recommended because they may increase mucous production. Be cautious not to consume hot liquids until the anesthesia wears off -- you may unwittingly scald your mouth. 3. You may experience a full feeling in the back of your mouth and throat. It is caused by the uvula (the part that dangles at the back of your palate) becoming longer and swelling, and lying on the far back of your tongue. The feeling will fade in 24-48 hours as the uvula begins to normalize and shrink. 4. If you experience swelling that concerns you, call the doctor’s office. 5. You should sleep while propped up at a 45 degree angle the first night. You even may try a reclining chair. 6. You may experience a temporary change in your voice after the procedure -- maybe even for a few days after. It will return to normal. 7. Snoring is usually worse during the first week. 8. During the second week, snoring may become high-pitched. You and your spouse may begin to notice brief periods when your snoring is noticeably diminished. 9. Snoring will usually begin to diminish between the fourth and eighth week post-procedure. If you do not show significant improvement by 6-10 weeks, the somnoplasty procedure can be repeated until your snoring is controlled. The Snoring Solution
Snoring may be many things, but it is no laughing matter. The problem is manifold throughout the free and not-so-free world. In fact, some experts contend that Asians are affected in a more severe way than Americans or Europeans. Apparently, the facial structure of Asians is such that the snoring problem is magnified. An estimated 45 percent of the population snores occasionally. Thirty percent of those over 30 snore, rising to 40 percent in middle age. Fifty percent of men and 40 percent of women snore. Even one of my cats snores, and the first time I heard it I woke up in fright, thinking there was a strange man in my bed. Snoring can cause great bedroom distress, leading as many as 80 percent of couples to end up sleeping in different rooms -- no rest for the weary and no recipe, needless to say, for a good marriage or relationship. The social ramifications of snoring make it a serious subject. Snoring is often a symptom of obstructive sleep apnea, a sleep disorder that is potentially life threatening. Why do people snore, an awake and annoyed observer might ask? Well, snoring arises when the passage of air between the nose and throat is blocked, inhibiting normal breathing. Airflow vibrates across the soft palate tissue, which becomes relaxed during sleep. It can be brought on by alcohol, smoking, sleeping pills, blocked nose, sinusitis, enlarged tonsils, deformities in the nasal pathway and excess body weight. Obese middle-aged or older men and overweight menopausal women may start to snore. Some snorers produce the noise all night long and they do it every single night. Others snore only when they first go to sleep. The pattern varies with each individual. Added to all of this is the irritating reality that most snorers don’t even know they snore! Almost 85 percent of snorers exceed 38 decibels of sound, which is equivalent to the noise of light highway traffic. The average volume of snorers is 60 decibels, about as loud as normal speech, but really loud snorers can reach 80 to 82 decibels, the level of a loud yell. The record is 90 decibels (but whatever award was given for such a dubious honor should have been bestowed to the winner’s sleeping partner instead). Men tend to snore more loudly than women do, although no one seems to know why. Among the female population, statistics indicate that women who snore are significantly shorter and heavier than women who don’t, with a greater incidence of nasal problems. There is now scientific evidence provided by The Mayo Clinic that snoring has a very negative impact on the non-snoring bedmate. These poor souls lose an average of one hour’s sleep per night. Researchers also discovered that non-snorers wake up, at least briefly, more than 20 times per hour during the night. This produces fragmented sleep. The study also revealed that the sleep of the non-snorers is so disturbed that they may very well have a sleep disorder all their own. These bedmates end up irritated and sleep-deprived, which in turn affects mood, concentration, judgment and occasional thoughts of murder in the first, second and third degrees. What can be done about this? There are hundreds of possible solutions to the snoring problem, but not all remedies are for all people. One must become their own Ralph Nader, so to speak, and discover which is the best solution for them. American scientists claim they have developed a cheap pain-free injection that will make people stop snoring forever. Snoreplasty, as it is called, involves injecting a chemical called tetradecyl sulphate into the fleshy soft palate at the back of the throat. The snoreplasty technique destroys some of the soft palate tissues and forms scar tissue, which stiffens the palate to reduce vibration. The procedure, which was developed at the Walter Reed Army Medical Center in Maryland, can reduce the loudness of snoring from 11 decibels to two. It is still new and controversial, and even though most patients tested have had no relapses, I would still wait until more testing reveals all there is to know about its repercussions -- you could wind up with other parts of your body snoring instead of your nose and mouth. Lifestyle changes may afford a better solution to the problem. All the usual vices worsen snoring: alcohol, smoking, overeating, under exercising and caffeine. (I know … how will you live? Still, one has to balance addictions with needs and wants.) If you wish to keep smoking, drinking and overeating, you might try sleeping on your back. Some say pillows and strap-on devices can help a great deal. Some claim to have had success with homeopathic remedies, which are available in health stores and on the Internet. Other remedies include throat sprays, nasal dilation, mouth breathing correction, mouthpiece devices and CPAP (continuous positive airways pressure). Throat sprays coat the soft tissues of the throat in lubricating oils, allowing the air to move more freely and lessening the noisy vibration. Techniques for nasal dilation include adhesive strips which hold open the airways of your nose; plastic devices to hold open your nostrils; and sprays that reduce congestion or the swelling of nasal tissues. Many people would snore less if they would just learn to change the way they breathe; that is, learn to breathe through the nose. One must look into the products that will shut one’s mouth, possibly alleviating the level of town gossip in the process. Dentists can help here, by providing custom-fitted devices that pull the lower jaw or tongue forward, thereby creating enough space in the throat to prevent breathing obstruction. Continuous positive airways pressure is machinery, which blows air through your nose via a mask, preventing disruption of breathing and eliminating snoring. Which is the best solution? Check them all out carefully (when you are awake) and do research on each one. The Internet is a vast library of information and resources, limited only by the boundaries of one’s key search words. Get second, third and even fourth opinions before considering surgery. Don’t wait too long though. Hell hath no fury like the wrath of a non-snoring bed partner.

A Guide to Periodontal (Gum) Disease

Periodontal disease, or periodontitis (formerly known as "pyorrhea"), is one of the most prevalent diseases known to medicine. It is responsible for 80 percent of the extractions performed on adults over 30. Often characterized by a slow, insidious and often pain-free onset, periodontitis may progress undiagnosed and untreated until extensive damage has occurred in the bony apparatus of the jawbones that support the teeth. Ironically, like other dental disease, periodontitis is both preventable and treatable. With contemporary life expectancies extending well into the 80’s and beyond, there should be substantial motivation to invest in one’s teeth -- a lifetime of dental health is certainly an attainable goal! Dr. Keith Robinson recently published the first volume in an “anthology on aging.” Using tongue-in-cheek humor, Growing Older With Your Teeth … or Something Like Them, depicts the image of a beautiful, healthy smile opposing dentures in a glass. The message is clear: The choice is yours! In its early stages, periodontal disease is known as gingivitis, or inflammation of the gums. Gingivitis occurs in 98 percent of the population, even children. The primary cause of gingivitis is the accumulation of plaque around the teeth. Plaque is a sticky film composed of food debris, minerals from saliva and bacteria indigenous to the mouth. The bacteria produce acidic toxins that cause tooth decay and irritation of the gum tissue. Left unattended, calcium deposits form tartar (calculus) that attracts a further buildup of plaque. As tartar accumulates beneath the gum tissue (subgingival calculus), the inflammatory process slowly causes destruction of the periodontal attachment -- the fibrous connection that secures the tooth to the bone. Over time, the supporting bone resorbs (shrinks), teeth loosen, drift, become infected and even fall out in advanced cases of periodontitis (as depicted in this clinical photo). Unquestionably, the primary cause of periodontitis is inadequate oral hygiene. Familial histories of poor dental health are commonly found; however, it is more often explained by the incidence of poor oral hygiene practices within families than a discernible hereditary pattern. Other factors that may influence the progress or extent of periodontal disease include: - Diet and vitamin deficiency - Cooked or crowded teeth - Malocclusion - Heredity - Tobacco and alcohol - Bruxism (habitual grinding or clenching of teeth) - Hormones - Systemic disease such as diabetes Scrupulous oral hygiene practices and frequent dental exams offer the best defense against periodontitis and other dental disease. Plaque may easily be removed by the judicious use of tooth brushing and flossing techniques. As it takes approximately 24 hours for bacteria to colonize within plaque, dental hygiene practices should be done at a minimum of once a day -- preferably twice -- ideally after every meal. Regular dental checkups include a prophylaxis (cleaning) and a periodontal exam to identify potential problems in early stages. Personal oral hygiene must include the regular use of dental floss since most tooth decay and periodontal disease occur between the teeth. Hard tooth brushing does not compensate for lack of flossing. Many dental hygienists have advised patients: “It’s not necessary to floss all your teeth -- only the ones you wish to save.” The early warning signs of moderate to advanced periodontal disease include: - Swollen or bleeding gums - Recession of gum tissue - Spaces between the teeth - Loose teeth - Persistent dental aches - Bad breath Periodontal treatment may necessitate scaling and root planing -- removing plaque and calculus and smoothing the root surfaces below the gum level. Prescription mouth rinses may be used as an adjunct to improved hygiene techniques. In many cases of early gum disease, scaling, root planing and proper daily cleaning achieve a satisfactory result. More advanced cases may require surgical intervention, which may involve recontouring of the gums, and removing crusty, tenacious calculus. The supporting tissues are often repositioned to facilitate good oral hygiene. Periodontal detection and treatment begins with the general dentist, who may choose to refer the patient to a periodontist (specialist in periodontics). Patients should bear in mind that there is no absolute cure for periodontal disease -- the maintenance of periodontal health depends on a team approach -- the most important being the patient. Dentists and dental hygienists cannot do for the patient what he must manage by himself -- the daily routine. A regular oral hygiene regimen is critical for patients who want to maintain positive results of periodontal therapy. Patients should visit the dentist every 2-4 months (depending on the patient) for scaling, root planing and periodic evaluations. Customarily accepted hygiene practices include brushing at least twice a day and daily flossing. Manual soft nylon bristle brushes are the most dependable and least expensive. Electric brushes are also an acceptable option, but don't reach any further into the pocket than manual brushes. Water irrigating devices (such as Waterpik™) may be helpful, especially in patients with fixed bridgework. Proxy brushes (small, narrow brushes) are an effective means to clean between recesses in the teeth. Wooden toothpicks and rubber tips should only be used if recommended by your dentist.

Acute Necrotizing Ulcerative Gingivitis

Acute Necrotizing Ulcerative Gingivitis (ANUG) is a severe inflammation of the gingiva (gums), characterized by swollen gums, the formation of ulcers, sloughing of dead tissue, intense pain, fever and foul breath. The disease was formerly known as “trench mouth” because it was prevalent in soldiers fighting in the trenches in WWI. Originally thought to be contagious for the same reason, the cause of ANUG is poor oral hygiene, deficient nutrition and emotional stress. The soldiers in crowded conditions commonly experienced these maladies, giving rise to the misconception. ANUG, also called Vincent’s angina or Vincent’s stomatitis after the French physician Henri Vincent (1862-1950), is not contagious. The immediate treatment goal is to provide relief from pain. Removal of the soft film of food debris and oral bacteria (plaque) is attained with oral irrigation, antibacterial mouth rinses and dental hygiene instruction. In severe cases, antibiotics may be prescribed. Gentle debridement of the hard deposits of calculus (tartar) from the teeth and soft tissues is usually followed by more rigorous scaling, often with a local anesthetic. Sometimes it is necessary to scrape the inflamed surface tissue to restore gingival health. With the dissemination of dental hygiene education in industrial nations, ANUG is rarely encountered today. It is more commonly seen among indigent populations with little or no access to dental care. On occasion, even well-educated people, under conditions of hardship or duress, and those suffering from severe medical disorders or immune deficiencies may experience an underlying gingivitis (inflamed, bleeding gums) worsen into ANUG in a matter of days. A bout of ANUG may be accompanied by cold sores on the lips or aphthous ulcers of the oral mucosa. Naturally, prevention is the best means to avoid this painful condition. Regular tooth brushing, flossing and professional check-ups will inhibit ANUG and other dental disease.

Calcium Helps Prevent Gum Disease

Most people know that calcium is an important mineral that helps keep our bones strong. Ninety-nine percent of the calcium in the body is stored in the bones and teeth; the remaining one percent circulates in the bloodstream and is necessary for muscles to contract, blood to clot and nerves to carry their messages. Calcium intake is well known for its ability to help prevent the damaging effects of osteoporosis, but may also help limit bone loss around the tooth roots caused by periodontal (gum) disease. Gum disease is caused by plaque, a bacterial film that continuously forms on the teeth and gums. Over time, gum disease can cause bad breath, puffy and bleeding gums, loose teeth, and teeth that fall out. There are many contributing factors that can increase the risk and severity of gum disease. These factors include: heredity; those who have medical problems that affect the immune system, such as leukemia, diabetes or AIDS; medical conditions or treatments that reduce the flow of saliva, such as Sjogren Syndrome; dysfunction or removal of the salivary glands, those who have undergone cancer chemotherapy or radiation, or who take any of the hundreds of prescription drugs that can cause dry mouth; and habits such as smoking, poor oral hygiene, emotional stress and malnutrition. One new risk factor, low calcium intake, should also be considered to potentially contribute to gum disease. A recent study revealed that woman who had low dietary calcium intake (2-499 mg/day) had a 54 percent increase in the risk of developing gum disease. Women with moderate calcium intake (500-799 mg/day) had a 27 percent increase in risk. Men did not show any change in the severity of gum disease with low calcium intake. The most important ways to prevent gum disease are with regular brushing and flossing as well as professional dental cleanings at least twice a year. Women should also be sure to eat a balanced diet that has a sufficient supply of calcium. Good sources of calcium can be found in milk, yogurt, cheese, dark green vegetables, nuts, grains, beans, canned salmon and sardines.

Diabetics Are at Risk for Dental Infections

Diabetes is a disease that affects the way your body uses food. There are two types. Type 1 is referred to as insulin dependent or immune-mediated diabetes, and is caused by the inability of the pancreas to produce insulin. Insulin is necessary for the vast number of blood cells in our body to use glucose, a sugar that helps sustain life. Type 2 is often referred to as non-insulin dependent or adult-onset diabetes and is the much more common form, occurring in roughly 90 percent of the cases. With Type 2 diabetes, your body does not make enough insulin or cannot properly use it. Your physician has most likely informed you of the complications of untreated or poorly controlled diabetes, which include kidney failure, gangrene or possible amputation of the legs and feet, blindness, or stroke. As dentists, we are mainly concerned with the effects on the gums and immune system. Gum (periodontal) disease is generally more common and more severe in patients with diabetes. This is because blood cells in the gums and jawbone that protect us from infection are not as effective. This means that the diabetic needs to work more diligently on oral hygiene, brushing, and flossing, as well as make sure the disease is as controlled as possible. If you have a dental infection, and require either a root canal or need to have a tooth removed, there are some important things for you to remember. Make sure you eat your normal breakfast before you go to the dentist. If you are taking insulin, take your normal dosage unless your dentist and physician have agreed to alter the dosage. If you have not eaten and are in pain, or feel a high degree of stress prior to a dental procedure, this can cause your blood sugar to drop. By eating (we use the expression "keep them sweet") and taking the proper amount of insulin, you reduce the potentially dangerous complication of hypoglycemia (low blood sugar). Diabetics, especially poorly controlled diabetics, are at an increased risk for infection -- that includes potential complications from dental infections. If your diabetes is under poor control, and your blood sugar is very high, dental surgical procedures may need to be delayed until you are under better control. In some cases, you may need to take antibiotics prior to certain dental treatments to reduce the risk of infection.

Genetic Marker Discovered for Periodontal Disease

Researchers have identified a genetic marker that may increase a person's risk of developing severe periodontal disease by as much as six-fold, according to a study in the Journal of Clinical Periodontology. A research team at Medical Science Systems Inc., a Newport Beach-based biotechnology company, discovered that as much as one-third of the U.S. population may carry the marker, which is associated with increased gum inflammation. Periodontal diseases result from a bacterial infection of gums and bone surrounding the teeth. Once these bacteria take hold, the body releases a series of chemicals to fight them. This reaction, called an inflammatory response, can result in red and swollen gums, easy bleeding during brushing or flossing, bone loss, and many other symptoms. If too many of these chemicals are released, the inflammation can be severe, resulting in advanced loss of gum and bone structure and increased risk of tooth loss. The study identified patients who, when infected with the disease-causing bacteria, are at risk of releasing too many of these chemicals. Researchers reported the genotype identified in the study occurred in 29.1 percent of northern European Caucasian subjects of unknown periodontal disease status and no other known medical conditions. It is anticipated that preliminary data from other ethnic populations will yield similar results. "This is the first time a genetic factor has been identified for a common disease that affects such a large segment of the population," said Kenneth Kornman, D.D.S., Ph.D., lead researcher who discussed his team's findings in Dentistry Today. "This information is also one of the first times a genetic test has the potential to be used as a preventive measure to identify people before they show signs of the disease and get them in for early preventive treatment."

Guide to Gum Disease (Periodontal Disease)

I know what you are thinking -- you are thinking, "Yuck! I don't want to know about gum disease!" That's exactly what I thought when I first heard the topic. What's amazing is that zillions of people are affected by this disease and may not even know it! It really is an interesting topic once you get into it, and you can save yourself a bunch of trouble if you know how gum disease works so you can avoid it. It also seems like the average American adult sees something like a hundred ads every day talking about gingivitis. Why is that? It's because periodontal disease -- AKA gum disease or pyorrhea -- is a bacterial infection affecting an estimated 56 million Americans, and is about as widespread as the common cold! Three out of four Americans will suffer from some form of gum disease in their lifetime. Given that it is so widespread, it's funny that you don't really hear about it as a kid -- the whole focus with children is on cavities. Nonetheless, gum disease can become a real problem for adults! How Do Gums Become Infected? Gum disease is caused by plaque, a bacterial film that continuously forms around the teeth. Plaque is responsible for sore, puffy and bleeding gums, bad breath, loose teeth, and teeth that fall out. It is the main reason that people lose their teeth. Until recently, the prospect of losing one's teeth was the main thing a person suffering from gum disease had to worry about. Now, a building body of research has discovered possible links between gum disease and heart disease, heart attack, stroke, respiratory problems, and low-birth weight babies. Bacterial plaque infects the gums (gingival tissues) when our brushing and flossing does not remove it. Plaque is composed of bacteria that can cause destruction to the gums, connective tissue, and bone that joins our teeth to the jaw. In the healthy mouth, there are hundreds of types of bacteria that naturally live there. Like most bacteria, they have names that defy pronunciation. Most of the inhabitants of our mouth are harmless members of the streptococcus and actinomyces species, and are largely gram-positive bacteria. In a patient with gum disease, we see increasing numbers of bacteria, including spirochetes, bacteroides gingivalis and intermedius, fusobacterium nucleatum, eikenella corrodens, wolinella recta, and others. These bacteria are mainly gram-negative and anaerobic. What this means is that many of the bacteria associated with gum disease can survive without oxygen, which makes sense because they are wreaking havoc with our jawbone deep under the gumline. Gum disease causes bone loss because these harmful bacteria in our mouths force our bodies to defend against them. The chain reaction that follows goes something like this: - The bacteria produce toxins and enzymes under the gum line, causing a chronic infection. - This infection causes the immune system to kick in. The body releases chemical substances called cytokines. - The cytokines, in turn, cause a cascade of reactions within the gum and surrounding tissue. - One of the substances released is a family of enzymes known as matrix metalloproteinases (MMPs). - One of the MMP’s is collagenase, an enzyme that breaks down gum and bone. - The loss of gum and bone causes the formation of a periodontal pocket. The dentist can measure these pockets with a small probe to determine the extent of the disease. How Does a Dentist Diagnose Gum Disease? Gum disease is diagnosed by both clinical (hands-on) and radiographic (X-ray) examinations. During a clinical exam, the dentist uses an instrument called a probe to measure the gums. A probe is like a small metal ruler using millimeter increments. The dentist probes the gum around the tooth and takes a series of measurements -- usually six. If the gum bleeds when the dentist gently probes it, this often indicates the presence of gum disease. Visual examination of a person with gum disease may reveal red, puffy, swollen or receding gums. Large deposits of plaque and calculus (tartar) are often visible in people with gum disease -- especially those who have not seen a dentist in years. The teeth may be mobile, that is, the dentist is able to move the tooth a millimeter or two within the socket. A healthy tooth will not budge! The dentist may detect pus when putting gentle pressure on a puffy area of the gums. Foul mouth odor (bad breath) is also commonly associated gum disease. X-rays are also helpful in the diagnosis of gum disease. The dentist will usually require a full mouth series of X-rays (18 films) to document the approximate level of the bone around the teeth. Dentists often take a full mouth series of X-rays even if the patient does not have gum disease to serve as a baseline for future use. Bone loss appearing on the X-ray can be uniform (horizontal bone loss), uneven (vertical bone loss), or a combination of both. There are several stages of gum disease. In most cases, gum disease begins as gingivitis, an inflammation of the gums. People with gingivitis have red, puffy gums that often bleed after brushing their teeth. They may wake up and have blood on their pillow in the morning. Ironically, some people whose gums bleed after brushing decide to brush less or avoid brushing out of fear -- this avoidance of brushing often leads to more advanced gum disease. The first non-reversible stage of the disease is early periodontal disease. Early periodontal disease is confirmed when the dentist can probe a periodontal pocket depth of four or five millimeters (healthy gums measure one to three millimeters). Moderate periodontal disease has five to seven millimeter probe readings, and advanced periodontal disease is generally any probe reading greater than seven millimeters. As the disease progresses from early to advanced, the gums will often become more swollen and inflamed, the teeth may become loose, and people who wear partial dentures may notice a change in how they fit. The dentist will often be able to probe between the tooth roots (furcation) in people with moderate or advanced periodontal disease. All three stages of periodontal disease commonly affect adults. One rare form of gum disease affects children, at or slightly before adolescence. It is called juvenile periodontitis, and is characterized by bone loss around the child's front teeth (central incisors) and first molars. How Will I Know if I Have Gum Disease? In the vast majority of cases, periodontal disease is completely painless. Except for occasional bleeding while tooth brushing and puffy gums, most people have no idea that they have gum disease. Gum disease only becomes painful when the teeth become loose and it hurts when biting hard foods, or the gum becomes swollen with a periodontal abscess. By this time, the bone loss around the teeth is often so severe that little can be done, and the tooth may have to be pulled. You may remember the story of the frog being placed in a kettle of boiling water. If the frog is thrown in when the water is boiling, he will jump right out. However, if the frog is placed in the water at room temperature, and the heat is slowly raised, he will become cooked without knowing it or protecting himself. Gum disease is very much the same; you could be on your way to losing your teeth and wearing dentures without even knowing it! How Will I Know if I Am at Risk? There are several factors that increase the risk and severity of gum disease. Some research has pointed to a genetic link in gum disease. If your parents, brothers or sisters have gum disease, you may be more likely to have it as well. You may not know if people in your family have or had gum disease, but if they have worn dentures for most of their lives, their tooth loss may have been caused by gum disease. People who have medical problems that affect the immune system are more at risk for developing gum disease. Diseases such as AIDS, leukemia and diabetes are a few that fall into that category. Medical conditions or treatments that reduce salivary flow can make a person more susceptible to gum disease. Diseases such as Sjogren’s Syndrome or dysfunction or removal of the salivary glands, and those who have undergone cancer chemotherapy or radiation, or who take any of the hundreds of prescription drugs that can cause dry mouth, may be more likely to develop gum disease. Saliva is important in protecting us from gum disease because it lubricates the mouth as a self-cleansing mechanism, and it contains other substances that protect the gums from disease. Teeth that are crooked or misshaped can contribute to gum disease. Likewise, poor dental treatment, such as fillings that don't fill in the gaps between the teeth completely, or crowns (caps) that are too big, bulky, or whose edge digs too far under the gum line can also irritate the gums, making them more susceptible to gum disease. Habits such as smoking, poor oral hygiene (sometimes due to a lack of manual dexterity), emotional stress, and poor nutrition can also significantly contribute to the severity of gum disease. In the past, and today in many developing countries, poor nutrition can also significantly contribute to the severity of gum disease. For example, a lack of vitamin C causes the disease called scurvy, and one of the first signs of scurvy is gum disease. Besides Losing My Teeth, What Other Health Problems Are Associated With Gum Disease? Over the last few years, a number of studies have shown a high correlation between gum disease and heart disease, heart attack, stroke, respiratory problems, and low birth-weight babies. Consider the following study: Dr. Walter Loesche, a professor of dentistry from the University of Michigan, and his colleagues studied a sample of 400 men at the Ann Arbor VA hospital in Michigan to determine if a relationship exists between gum disease and heart disease. Analysis of the plaque in men with gum disease found higher levels of gram-negative anaerobic bacteria in patients with heart disease than in patients without heart disease. This type of bacteria contains lipopolysaccharides (a fat and carbohydrate compound) that may be released into the bloodstream and cause obstructive clots in our arteries. A clogged coronary artery supplying the heart can cause a fatal heart attack. Dr. Loesche has established that men over 60 years of age whose gums bleed around almost every tooth (a main symptom of gum disease) were four and a half times more likely to have coronary heart disease. Dr. Loesche has also established a link between more advanced gum disease and cerebral vascular accident or stroke. People who had lost more than six millimeters of bone around the tooth roots and had gum disease involving many teeth (15-28) were highly associated with stroke risk. People who had had regular dental examinations at least once a year were four times less likely to have a history of stroke. This study deserves serious attention, especially due to the prevalence of both periodontal and heart disease in this country. How Is Gum Disease Treated, and Does It Hurt? Gum disease is treated a number of different ways, depending on how advanced it is. The main ways to treat gum disease is with deep cleaning under the gums, gum surgery, bone grafts, and antibiotics. Oral hygiene technique and instruction also plays a critical role in the treatment of gum disease. Gingivitis, the earliest stage of gum disease, is the only one that can be cured. Gingivitis can be cured with improved oral hygiene, which includes brushing properly at least three times a day for about three minutes each time, and flossing at least once a day. Antiseptic mouth rinses such as those containing dhlorhexidine gluconate (Peridex®) or those containing thymol such as Listerine® can also help eliminate gingivitis. Early periodontal disease is treated with a procedure known as scaling and root planing. The dentist or dental hygienist uses thin curettes and gently removes the plaque and tartar under the gum line. The tooth roots are also smoothed to make it more difficult for plaque to adhere to them in the future. This procedure is rarely painful, but some patients may prefer local anesthesia to numb the area prior to treatment. The gums will heal in a few weeks, and the previously red, puffy gums will usually appear healthy, tighter and more stippled -- like the surface of an orange. Moderate and advanced periodontal disease is usually first treated with scaling and root planing as mentioned above. After the gums heal, the surgical procedure is scheduled, partly because the dentist cannot effectively remove plaque that is more than five millimeters under the gum line. Treatment usually involves a quarter of the mouth at a time (from the last molar in the mouth to the front central incisor on the same side). The dentist numbs the mouth in the area that requires treatment. The gum is then gently separated from the bone, and the remaining plaque and tartar are removed, along with areas of diseased gum. In many cases, gum disease leaves the bone choppy and irregular, which requires it to be smoothed and shaped. If there are vertical areas of bone loss, the dentist may consider a bone graft. The material used for the graft may be either artificial, synthetic, or from other sources. The grafting material is placed into the area of bone loss, and a membrane, often Gortex, is used to cover the graft. The gum is then stitched up, and a bubble gum-like packing is placed over the area. Gum surgery is usually not painful. Believe it or not, I have had patients actually sleep through the procedure. There will be varying degrees of discomfort, however, after the anesthesia wears off. The dentist will usually prescribe narcotic pain medication as well as an antibiotic in some cases. Discomfort will generally persist for a few days. The patient returns in about one week to have the packing and stitches removed. If a graft was used, the patient may have to wait six weeks for removal of the graft membrane and specialized stitches. After the packing and stitches have been taken out, the antiseptic mouth rinse Peridex is often prescribed for several weeks after surgery to promote healing. The teeth in the area that have been treated may be sensitive to cold for weeks or months after treatment. This is because the tooth roots are now exposed to the rest of the mouth. The dentist can use in-office desensitizers; prescribe high concentration fluoride gels; and recommend desensitizing toothpastes such as Sensodyne® or Crest® for sensitive teeth to combat the sensitivity to cold. Antibiotics are sometimes used in conjunction with surgical treatment of the gums. The most common antibiotics used are tetracycline, amoxicillin, and metronidazole. These drugs are used to kill some of the bacteria associated with gum disease. The goal of surgical gum treatment is to bring the gums to a level where the patients can effectively remove most of the plaque by themselves when brushing and flossing. When a patient has four millimeter (or greater) periodontal pockets, they cannot remove most of the plaque. After any gum treatment, the patient should come to the dentist every three months for maintenance. The dentist can then remove any plaque or tartar missed by the patient. Recently, there have been several gels put on the dental market that are placed around the gums and provide a controlled release of antibiotics. While these treatments are interesting, very few long-term studies support their effectiveness. Even though there is no cure for gum disease, appropriate gum treatment by your dentist can greatly reduce the likelihood of losing your teeth at an early age. How much time can gum treatment buy? That is hard to say exactly because there are so many factors that influence the outcome. One common estimate is that gum treatments can double the life expectancy of a tooth. In other words, if a tooth was going to last 15 years without treatment, gum therapy can stretch it out to 30 years. Can Any Dentist Treat Gum Disease? Most general dentists treat early gum disease. Moderate and Advanced gum disease requiring surgery is usually treated by a dental specialist called a periodontist. Some general dentists who have had addition training are comfortable treating most if not all aspects of their patient's gum disease. How Can I Prevent Gum Disease? Gum disease can be greatly reduced by effective brushing at least three times a day, for about three minutes each time, and flossing at least once a day. Regardless of what you see on TV, no toothpastes or mouthwash can help cure any form of gum disease except gingivitis. See your dentist at least twice a year -- more if you are diagnosed with gum disease. Follow through with all of your dentist's recommendations. If you smoke or use smokeless tobacco, quit. Eat a well-balanced diet consisting of fruits and vegetables. By doing these simple things, you will greatly increase your chances of having teeth that last a lifetime!

Gum Disease: Do You Have It?

What Is Periodontal Disease? Periodontal disease is also known as gum disease or periodontitis. There are various stages of gum disease, and the two most common forms are gingivitis and adult periodontitis. Gingivitis is an inflammation or infection of the gums (gingiva) that is an early stage of periodontal disease. When left untreated, gingivitis may progress to periodontal disease, which can progress to the loss of teeth. Only a professional -- a dentist or periodontist -- can diagnose gum disease, which often is painless. Tobacco products contribute to poor periodontal health. Research shows that periodontal disease may also be linked to heart and respiratory disease, and to premature birth. How Does It Progress? A combination of bacteria and acids in the mouth form a sticky deposit called dental plaque that clings to the teeth. Plaque that is not removed from the teeth hardens into calculus and tartar, which aggravate the gums. Pockets (filled with plaque) form between the teeth and gums -- causing the irritated gums to detach or pull away from the teeth. At this point, the infection has advanced below the gum line and it can then destroy the soft tissue, bone and ligaments that support the teeth. The teeth may become abscessed and loose, and even fall out. Periodontal disease is the leading cause of tooth loss in adults. What Are the Symptoms? - Inflamed, swollen gums that bleed easily when they are brushed or flossed - Smokers may experience very little bleeding - Bad breath - Little or no pain in the early stages Late-Stage Symptoms of Periodontitis - Loose teeth - Spaces in between the teeth - Pain upon chewing - Pus around the teeth or gums, or abscessed teeth - Receding gums may be a symptom and the tooth may appear to look longer because the gums are withdrawing - The teeth may be sensitive to cold, hot and sugars Who Is at Risk for Gum Disease? Periodontal disease is not hereditary, but it may play a role in the progression of the disease. Individuals with diabetes and those on certain medications, such as immunosuppressants, may be at risk for periodontitis. Use of tobacco in any form can cause periodontal disease to advance more rapidly. How Do You Prevent It? Keeping the teeth clean by brushing and flossing on a regular basis will help prevent gum disease. How Is it Treated? Treatment is based upon the severity of the gum disease and how far it has progressed. Treatment may range from a thorough cleaning of the roots of the teeth to periodontal surgery for more advanced problems. When Do You Need to See a Dentist? The dentist is the individual who should monitor your overall oral health care and recommend that you see a specialist, if necessary. If you have any problems or suspect you may have gum disease, contact your dentist or a periodontist. Gum Disease: Frequently Asked Questions
What is gum disease? Gum disease describes inflammation or infection of the tissues supporting the teeth. There are two main forms of gum disease: gingivitis and periodontal disease. What is gingivitis? Gingivitis means inflammation of the gums. This is when the gums around the teeth become very red and swollen, showing that the area is inflamed. Often this swollen gum bleeds when it is brushed during cleaning. What is periodontal disease? Long-standing gingivitis can progress to periodontal disease. There are a number of forms of periodontal disease and they all affect the supporting structures of the teeth. As the disease progresses, the bone anchoring the teeth in the jaw is lost, making the teeth loose. If this is not treated, the teeth may eventually fall out. Am I likely to suffer from gum disease? Probably. Most of the population suffers from some form of gum disease, and it is the major cause of tooth loss in adults. However, the disease progresses very slowly in most people and can be slowed down to a rate that should allow you to keep most of your teeth for life. What is the cause of gum disease? Gum disease is caused by plaque. Plaque is a film of bacteria, which forms on the surface of the teeth and gums every day. Many of the bacteria in plaque are completely harmless, but there are some that have been identified as the main cause of gum disease. To prevent and treat gum disease, you need to make sure you remove all plaque from your teeth every day. This is done by brushing and flossing. What happens if gum disease is not treated? Unfortunately, gum disease progresses painlessly, on the whole. However, you may occasionally experience a burst of activity by the bacteria, which makes your gums sore. This can lead to gum abscesses and pus may ooze from around the teeth. Over a number of years, the bone supporting the teeth can be lost. If the disease is left untreated for a long period of time, treatment can become more difficult. How do I know if I have gum disease? The first sign is blood on the toothbrush or in the rinsing water when you clean your teeth. Gums may also bleed when eating, leaving a bad taste in the mouth. Your breath may also become unpleasant. What do I do if I think I have gum disease? The first thing to do is visit your dentist for a thorough checkup of your teeth and gums. The dentist can measure the 'cuff' of gum around each tooth to see if there is any evidence that periodontal disease has started. X-rays may also be needed to see the amount of bone that has been lost. This assessment is very important, so the correct treatment can be prescribed for you. What treatment may be needed? Your dentist will usually give your teeth a thorough cleaning. You'll also be shown how to remove plaque successfully yourself, cleaning all the surfaces of your teeth thoroughly and effectively. This may take a number of sessions with the dentist or hygienist. Once I have had periodontal disease, can I get it again? The periodontal diseases are never cured, but as long as you keep up the home care you have been taught, any further loss of bone will be very slow and it may stop altogether. However, you must make sure you remove plaque every day, and return for regular checkups by the dentist and hygienist.

How Periodontal Treatments Keep Disease in Control

Approximately 75 percent of all Americans have some form of periodontal disease, known by many as gum disease. These usually painless diseases often can go undetected until it is too late. If left untreated, gum disease can destroy the bone and tissue surrounding the teeth, causing them to become loose and, in some cases, painful. In addition, gum disease can cause bad breath and change the appearance of your smile. If the condition progresses far enough, you can lose your teeth. Common procedures include: gum surgery, bone grafts, gum grafts, crown lengthening, and guided tissue regeneration. Periodontal disease (pyorrhea) is an infection that begins in the gingival tissue (gums) and then spreads under the gums into the supporting jaw bone surrounding the tooth. In health, the gum is sealed to the tooth in a fashion similar to the seal between your skin and fingernail. This area is infected daily by plaque (a combination of bacteria and saliva that exists in everyone's mouth). If plaque is allowed to remain, then bacteria breaks down the seal. The infected pocket that results is impossible to keep healthy even with scrupulous care. When the germs remain under the gums, several significant problems occur. There is frequently swelling and bleeding. These bacteria invade the root itself, changing normally glass-like smooth root surfaces to a rough "barnacle-like" one. This infects the gums even further. The plaque itself hardens into a spike-like irritant called calculus or tartar. The most important consequence of this action is further deterioration of the jaw bone around the tooth. Once this bone is lost, it cannot be replaced. Other factors which have a significant effect on the severity of this infection are smoking, diet, stress, grinding and/or clenching of the teeth, general health and resistance, medical problems, and hereditary factors. The goal of periodontal treatment is to re-establish the seal of the gum to tooth, creation of a stable bite, and the establishment and maintenance of a healthy mouth. Treatment is usually in two stages. The objective of the first phase is to promote as much healing as possible by cleaning out the infection from under your gums. The rough root surface must be smoothed to produce a glass-like surface. This is called root planing. Removal of tartar or calculus is called scaling. The inner lining of the pocket is diseased and must be removed to allow the gums to heal properly. This is called curettage. These procedures do not involve surgery and are done in one-quarter to one-half of the mouth at a time. Novocaine® is used so that there is very little (if any) discomfort, usually no more than experienced with a routine filling. When these treatments are completed, the infection should be under control. After this, you can return to your normal activities, including work. We will then carefully re-examine your mouth to evaluate your healing response and determine if any damage to the bone support or gum seals exist. In areas where seals have been re-established, no further treatment is necessary. Where they have not, they cannot be kept clean and healthy; and we will have to consider the secondary phase of therapy. The objective of this second phase of treatment is to re-establish healthy seals by minor surgical procedures. The surgery is very delicate and done in small areas at a time, in the office, using Novocaine. You will not feel any discomfort during the procedure, but may be uncomfortable for a few days after. However, this is usually controlled by some mild pain medication that will be prescribed. The exact amount of discomfort you will experience cannot be predicted because everyone is, of course, different. However, we definitely expect that you should be able to carry out your normal activities the following day. If we jointly decide not to go ahead with pocket elimination, any seals which are still open will become re-infected, allowing the disease process and bone loss to continue. In these cases, we usually recommend that the patient return every three months, so a specially-trained hygienist can clean out these infected pockets. This is an attempt to maintain the highest level of health for what we call a "holding period" until the secondary treatment can be initiated. Since essentially we can only repair damage in your mouth and plaque returns daily, our long-term goal is prevention. Maintenance becomes primarily the patient's responsibility and is the key is to long-term dental health and prevention of disease. No treatment will be started until you understand the problems that exist, how they should be treated and the cost involved. The fee for the initial treatment can usually be accurately predicted at the first appointment. However, because it is impossible to predict one's healing response, it is impossible to predict exactly how much surgical treatment may be needed and the cost involved. This will be done before any additional treatment is initiated. Periodontal therapy can achieve a great deal in prolonging and maintaining the health of your teeth and their supporting tissues. Goals are to establish health and function and help you maintain it. When your treatment is completed, your mouth should be healthy with all damage repaired. We want you to be able to prevent this sort of problem from returning and retain as many teeth as possible for the rest of your life.

Information on Gingivitis

What is gingivitis? Gingivitis is an inflammation or infection of the gums (gingiva) that is an early stage of periodontal disease (gum disease). Healthy gums appear pink in color. Gingivitis causes the gums to become inflamed and swollen, and bleed easily when they are brushed or flossed. Gingivitis is reversible and there is no permanent damage to the gums or teeth when treated early. If allowed to progress, the infection can advance below the gum line and cause periodontal disease. Left untreated, gum disease can destroy the soft tissue, bone and ligaments that support the teeth. Teeth may become loose and then fall out. Periodontal disease is the leading cause of tooth loss in adults. Why does it occur? Gingivitis often results from poor oral health care. Individuals who do not brush or floss their teeth regularly or correctly, increase their chances of developing gingivitis. How does it happen? A combination of bacteria, saliva and acids in the mouth form a sticky deposit called dental plaque that clings to the teeth. Plaque that is not removed from the teeth hardens into hard calculus (tartar), which irritate the gums. What are the symptoms? Symptoms include gums that are tender, red and swollen. The gums may bleed when brushed or flossed, and it can also cause bad breath. In some cases, there may be no obvious symptoms. How do you treat gingivitis? If you have inflamed gums or your teeth bleed during brushing or flossing, you need to visit a dentist or periodontist. The first step is to have the teeth cleaned professionally to remove the soft plaque and tartar. Brushing and flossing at home cannot remove the hard deposits or calculus. There are several new antibacterial medications on the market to treat the early stages of periodontal disease. These oral medications -- available via prescription from a dentist -- appear to be a short-term promise. However, there is no long-term evidence or studies that show the medications are effective. How do you prevent gingivitis? The American Dental Association recommends: - Brushing your teeth twice a day to remove the bacteria from the teeth. - Cleaning between your teeth every day with floss to remove bacteria and food particles. - Eating a well-balanced diet and limiting between-meal snacks. - Visiting your dentist on a regular basis for an exam and cleaning.

Avoiding Periodontal Disease

What Is Periodontal Disease? Periodontal literally means "around the tooth." Periodontal or gum diseases are serious infections affecting the tissues surrounding the teeth. These tissues include the gums and bone supporting the teeth. Gone unchecked, periodontal disease can result in tooth loss (See Stages of the Disease). Periodontal disease is usually a slow, painless, progressive disease. Most adults with periodontal disease are unaware they have it. However, if diagnosed and treated early, the teeth can be saved. The Causes of Periodontal Disease The main cause of periodontal disease is the accumulation of plaque bacteria. Plaque is often a colorless mass of bacteria that sticks to teeth, crowns, bridges and other tissues in the oral cavity. Plaque is constantly forming on the teeth. Plaque irritates the gums, causing them to become red, tender and swollen. If not removed daily, plaque becomes the hard material known as tartar or calculus. Calculus cannot be removed by brushing and flossing alone. A dentist, periodontist or hygienist must remove it manually to stop the disease process. With time, the tissues that attach the gums to the teeth are destroyed by plaque and its by-products. The gums pull away from the teeth, and pockets begin to form between the teeth and gums. Plaque and calculus continue to fill these pockets until the jawbone supporting the teeth is eventually destroyed. Other factors can modify how your gums react to plaque or calculus, thereby altering your body's response to the disease and affecting your overall health: - Smoking/tobacco use - Diabetes - Stress - Medications - Clenching or grinding your teeth - Pregnancy and puberty - Diet and nutrition - Immunosuppression (e.g., leukemia, AIDS) Treatments for Periodontal Disease Chances are that if you have been diagnosed with periodontal disease, periodontal surgery may be recommended. Surgery is indicated when non-surgical methods are not enough to stop the disease process. Depending on how advanced your particular case is, treatment may involve any of the following: Scaling and root planing: Scaling involves the removal of the plaque and calculus deposits on the tooth surfaces, while root planing is the smoothing of the root surfaces in order to promote reattachment of the gum tissue to the tooth. Flap surgery: Allows the periodontist to gain access to the root of the tooth for removal of plaque, calculus, and diseased tissue. The gum is then carefully sutured back into place. Flap surgery may sometimes be accompanied by minor osseous (bone) shaping or removal in order to ease tissue positioning, facilitate home care and simplify your maintenance appointments. Guided tissue regeneration (GTR): Involves the use of a biocompatible membrane material, often in combination with a bone graft, that promotes the growth of lost tissue and bone around your tooth. Not every case is suitable for bone regeneration. Consult your dentist or periodontist. Periodontal Diseases in the U.S. Population The latest research shows that 92 percent of us have calculus in our mouths, and three out of every four has calculus beneath the gums, where it causes the most severe damage. Over half of the adults over the age of 35 are already in the early stages of periodontal disease. In fact, periodontal disease is the primary cause of tooth loss after the age of 35. Statistics taken from: -Oliver, Brown and Loe, Journal of Periodontology, 1998 -Albandar et al, 1999, Journal of Periodontology, 1999 What You Can Do Periodontal health begins at home. Together with the state-of-the-art treatment methods available today, you can be confident your teeth can be saved. But what can YOU do? Here are some tips for maintaining periodontal health at home: - Brush your teeth three times daily. - Floss your teeth at least once a day. - Eat good, well-balanced meals. - Avoid sticky, sugary snacks. - Examine you mouth for signs of periodontal disease regularly. - Visit your dentist for check-ups and cleanings at least twice a year. Your dentist is the first line of defense and in the best position to detect the early signs of periodontal disease.

Stages of Gum Disease

This table summarizes the stages of periodontal disease progression and their associated signs and symptoms. Healthy Gums - Coral pink color - Gums hug teeth tightly - No bleeding Gingivitis - Bleeding while brushing or during probing - Inflamed, sensitive gums - Possible bad breath or taste in mouth Mild Periodontitis - More pronounced gingival bleeding or swelling - Gums may begin to pull away from teeth - Bad breath or taste - Pockets 3 to 4 mm deep Moderate Periodontitis - Teeth may look longer due to gum recession - Gum boils or abscesses may develop - Bad breath or bad taste - Teeth may begin to drift and show spaces - Pockets 4-6 mm deep Advanced Periodontitis - Teeth may become mobile or loose - Constant bad breath and taste - Teeth sensitive due to exposed roots - Pockets greater than 6mm deep - Some teeth may be extracted

Stages of Gum DiseaseHealthy GumsGingivitisMild PeriodontitisModerate Periodontitis

Preventing Tooth Decay Before It Happens

Tooth decay, also known as dental caries, is a disease of the teeth that affects individuals of all ages, although is it more common in children and young adults. Dental caries occurs when the tooth enamel is destroyed. Decay begins at the tooth's hard external surface, and may advance to internal structures of the tooth including the dentin and pulp. The earlier decay is treated, the better chance of saving the tooth. How Tooth Decay Develops The bacteria inside of the mouth change the food (primarily sugars and starches) we eat into acids. Over a period of time, the bacteria and acids form a sticky deposit called dental plaque that clings to the teeth. If the plaque is not removed, the acids will destroy the tooth's enamel surface -- resulting in holes or cavities. Sugar and starches (such as candy, cakes, cookies, milk and soda) are responsible for much of tooth decay, but sour or acidic foods (such as lemons and fruit juices), also contribute to decay because they change the pH (acidity level) in the mouth. If left untreated, the decay will progress and can lead to tooth infection. Children's teeth primarily decay in the grooves. In addition to the grooves, older adults decay in other areas, including the roots of the teeth, which may be exposed as a result of receding gums. How to Prevent Tooth Decay Taking good care of your teeth, eating nutritious foods and visiting the dentist on a regular basis will help prevent cavities. The American Dental Association provides these guidelines for preventing tooth decay: - Brushing twice a day with a fluoride toothpaste - Cleaning between the teeth daily with floss - Eating well-balanced meals and limiting snacking - Visiting the dentist on a regular basis for check-ups and cleanings - Talking with your dentist about the use of fluoride to strengthen the teeth and dental sealants (a plastic protective coating put on the surface of the back teeth) to protect from decay - If brushing is not possible, the next best thing is to rinse the mouth with water to neutralize the acids and change the pH level in the mouth, which may curb tooth decay. When to Contact a Dentist The Chicago Dental Society recommends visiting a dentist at least every six months for a cleaning and a thorough examination. You should consult a dentist if you experience any problems or need emergency care.

Dealing With Toothaches After Dental Treatment

One fascinating thing about the Internet is that once you publish an article, it is available to anyone with a computer and access to the World Wide Web. Articles that I have published for the Bucks County Courier Times as well as prominent Internet websites often appear on dozens of other sites, including Howstuffworks.com, Dentistry.com and the Encyclopedia Britannica web site. Every day, I receive emails from just about everywhere asking me questions about different dental problems. No matter where the question comes from, it’s amazing how similar most of the problems are. This column will answer a very common question I recently received online. Q: I recently had two fillings in my front two top teeth at the same exact time. After I got home and the Novocain® wore off, I noticed my left tooth is extremely sensitive to the touch. When I touch it with my finger, tongue or bite into any food it hurts extremely badly, but when I’m just sitting around doing nothing, it doesn’t hurt. I went to my dentist and he said that it’s just sensitive because of the filling and that if it doesn’t go away in a week then I will have to get a root canal. Do you think this is normal? I don’t think it’s normal because the tooth had no pain at all before I went in there and now it’s extremely sensitive and seems like it’s getting no better. I had the fillings on Tuesday and now it’s Friday night. What do you think I should do? Please offer your opinion. A: There are several reasons that a tooth can become sensitive after it has been treated. The most common is that part of the tooth and all of the decay must be removed for a filling to be placed. In some cases, this procedure can cause sensitivity. As a general rule, the deeper the cavity (closer to the nerve), the more likely there will be discomfort after the procedure. Some people may also be sensitive to the materials used to fill the tooth. I often tell my patients that some discomfort is possible for up to two weeks after a tooth has been filled. A frequent problem that occurs is when there is too much filling material in the tooth. This can cause a disproportionate amount of pain, but can be easily remedied with a simple adjustment of the tooth. If pain increases over time, or lasts longer than two weeks, I recommend that the patient come back to my office to have the tooth re-evaluated. A tooth that becomes increasingly sensitive to cold or hot foods or beverages, or hurts when biting down (when the bite is normal or has been corrected) can indicate an infected tooth that would require either root canal or extraction. Mistaking Neuralgia for a Toothache
A patient felt a sharp pain in her upper right jaw and went to a dentist who carefully examined her but could not find anything wrong. After the pain continued for 10 weeks, the dentist diagnosed the problem as an infection laden soft tissue at an upper molar and persuaded her to undergo root canal surgery. But the pain did not go away, and they went to a specialist -- an endodontist -- who performed a second root canal. Again the problem persisted, and the patient developed an excruciating pain in her cheek and upper lip. When Nothing Helps Novocaine did not help. Nor did the removal of the tooth and massive amounts of codeine, to which the patient became addicted. “I went to 11 dentists and doctors before getting the proper treatment,” said the patient. “The pain lasted three years.” The proper treatment, it turned out, was surgery to relieve pressure on an irritated trigeminal nerve, the major pathway between the face and brain, said Dr. Steven Graff-Radford, associate director of the Pain Management Center at the University of California at Los Angeles, who made the correct diagnosis. Like a small, but significant number of toothache sufferers, he said, the patient had absolutely nothing wrong with her teeth. An endodontist, a dentist who specializes in root canals, probably sees one to 10 such patients each year. But endodontists are not trained to diagnose pain unrelated to the teeth and gums. Because the pain can look like a regular toothache, dentists do what they are trained to do: operate. Again and again. “We call this domino dentistry,” said Dr. William Solberg, a dentist who directs the U.C.L.A. Pain Management Center. “They do root canal after root canal.” They might extract a tooth and when the problem doesn’t improve, he said, they move on to the next tooth.” “It’s not that dentists are stupid,” Dr. Solberg said. “Chronic facial pain is a perplexing problem that we are becoming more aware of. We are still learning that not all toothaches are caused by the teeth.” In a study published earlier in The Journal of the American Dental Association, Dr. Steven Graff-Radford and Dr. Robert Merrill, a U.C.L.A. lecturer on orofacial pain and occlusion, studied 61 patients who complained of shooting or dull pains in their teeth and lower face. Faulty Diagnosis Two-thirds of the patients had received incorrect diagnoses of dental problems, Dr. Graff-Radford said. The group had undergone 101 unnecessary dental procedures, he said, including root canals, extractions, and splints applied to the jaw. Only one person had had a dental problem -- a cracked tooth. All had experienced pain for six or seven years. The real problem lay in the trigeminal nerve, which arises in the brain stem, enters the face and divides into three major branches, Dr. Graff-Radford said. When the trigeminal nerve becomes irritated or is squeezed by a blood vessel, pain is felt in the distant nerve endings -- a condition called neuralgia, he said. In classical trigeminal neuralgia, the pain strikes like lightning, lasting for a few seconds or minutes. Victims describe an electric shock sensation that is triggered by simple acts like washing, shaving, talking or brushing teeth, and say the pain comes and goes without warning. The pain is so intense that patients wince, giving it the name “tic douloureux,” meaning painful twitch in French. “Every dentist who graduates from school learns there is a disease called trigeminal neuralgia,” Dr. Solberg said. “But the problem doesn’t always present itself in the classic fashion.” “Pretrigeminal neuralgia, an early stage of trigeminal neuralgia, is characterized by intermittent, aching pains that last minutes to hours and perfectly mimic toothache or temporomandibular joint disorder,” Graff-Radford said. This pain confuses patients and dentists alike. “The patient comes in complaining of a toothache,” Dr. Solberg said, “He does not wince or blink. The teeth look normal. Results of the neurological examination are normal. The dentist is perplexed.” At this point, Dr. Solberg said, patients may beg the dentist to try something, anything to kill the pain. “They complain that you missed something, that you don’t know what you’re doing,” he said. “A damaged tooth would show signs of inflammation,” Dr. Solberg said. It would change over days and weeks, getting better or worse. Healthy teeth would look normal. But the dentist, prodded by the patient, thinks, “Gee, maybe I missed something,” Dr. Solberg said. “He loses confidence and operates.” Sometimes the patient gets worse pain, Dr. Solberg said. Other patients seem to get better for a while, but then the pain comes back with a new trigger point. Patients and dentists need to take more time to evaluate facial pain before doing invasive procedures, Dr. Graff-Radford said. The source of the problem can often be traced by injecting anesthetics into various parts of the nerve, he said, and can be treated with anticonvulsant drugs or surgery on the nerve.

Referred Pain: A Toothache on the Move

"Hello doctor, my tooth has really been hurting me, and I know which one it is,” says the patient. “How long has the tooth been hurting, and what makes the pain worse?” the dentist asks. “The tooth has been sore for about a week, especially when I eat hot and cold food. Sometimes it feels like every tooth on my right side of my mouth hurts, but this is the tooth that has the problem,” states the patient, pointing to an upper molar on the right side of her mouth. The dentist has his assistant take an X-ray, carefully examines the tooth, uses hot and cold stimulus to test the area, and then lightly taps on the tooth. The patient has no abnormal reaction. “I’m sorry Mrs. Jones, but the tooth you are pointing to is just fine. I’ll need to examine the rest of the mouth to find out which tooth is infected.” The dentist examines the rest of the teeth and soon finds out that a different tooth, a premolar, is where the pain was coming from. The premolar is two teeth in front of the tooth that the patient pointed to. The patient looks at the dentist with surprise. She was sure it was the molar. It had a big black filling and seemed to be in the exact location of the pain. The dentist explains to her that she will require a root canal on the premolar, and that will take care of her problem. It may surprise you to know that the above scenario is very common. The reason for the patient’s confusion is a phenomenon called referred pain. Pain from an infected tooth can travel from tooth to tooth on the same side of the jaw, and sometimes to the ear. In fact, pain from an infected tooth on the upper jaw can even travel to the lower jaw on the same side of the mouth, and vise-versa. Referred pain does not, however, cross the middle of the mouth (midline); for example, pain will not travel from the right side to the left side of the mouth. It is important to note that it is only the sensation of pain that travels, not the infection itself. Treatment of the infected tooth is the only way to stop the pattern of referred pain. One surprising pattern of referred pain has nothing to do with an infection of the teeth. It occurs when a person is having a heart attack, and pain is referred to the jaw and teeth. Usually the pain is referred to teeth on the left side of the mouth. People with a history of heart disease and angina need to be aware of this possible referral pattern, especially if they are in good dental health. Trigeminal Neuralgia and Dental Work

Four professors from the Parker E. Mahan Facial Pain Center and the University of Florida College of Dentistry in Gainesville discussed the link between dental problems and Trigeminal Neuralgia. Some TN patients are initially misdiagnosed by a dentist and have unnecessary root canals or extractions. According to clinical assistant professor Brian D. Fuselier, D.D.S., dentists assume that if tapping a tooth produces severe pain, the tooth generally has pulpitis (inflammation of the pulp or nerve); the appropriate treatment is root canal. However, in rare cases the problem is not dental. A dentist should take an extensive medical history, do a thorough examination, and ask detailed questions about the pain, said Dr. Parker E. Mahan, D.D.S., Ph.D., a distinguished Service Professor Emeritus at the pain center that bears his name. To help in the diagnosis, Dr. Fuselier added, the dentist can test the health of the tooth with hot or cold; if that hurts, pulpitis is likely. A dentist uncertain about whether the pain truly is a dental problem can refer the patient to a pain-management specialist, such as a neurologist, who can prescribe Tegretol®. Dr. Henry A. Gremillion, D.D.S., of the Mahan pain center, described a condition that appears to be a precursor to trigeminal neuralgia. The patient may report sporadic, stabbing pain like that of classic TN or, more typically, a dull ache that comes and goes or is constant. There is no specific trigger zone on the face, he said, but chewing, drinking hot or cold liquids, yawning, talking, or brushing teeth can bring on an attack. To make a diagnosis, the dentist numbs the area with a long-acting local anesthetic. If the problem is dental, relief is short lived. If it’s a precursor to TN, the patient may remain pain-free after the anesthetic wears off. In some cases, a series of injections of local anesthetic can give relief lasting for months or even years. Major dental work can increase the pain of TN or end a remission. Dr. Mahan noted that the surgical procedures used to treat TN often fail to produce permanent relief, and it probably doesn’t take much stimulation to trigger a breakthrough of pain. TN presents a paradox, he said. On one hand, it’s of the utmost importance to maintain good dental health in order to avoid dental problems that worsen TN symptoms. On the other hand, because having major dental work can aggravate the tngeminal nerve, you should have only procedures that are truly necessary -- for instance, don’t agree to let your dentist replace a very large filling with a crown if the filling is still serviceable. For someone who must have major work done, Dr. Mahan recommends preemptive anesthesia to prevent the pain of the dental procedure from “jazzing up” the transmission of pain signals from the trigeminal nerve to the brain. He suggested these steps: - For a day or so before and after the procedure, increase the dose of any TN medications you’re taking. - Ask your dentist to use Marcaine® without epinephrine for the local anesthetic. Marcaine is long-acting, so you’re less likely to need multiple injections -- each one producing pain signals. Epinephrine is a vasoconstrictor; it’s sometimes added to local anesthetics to prolong their numbing effect. However, epinephrine can trigger nerve pain, so you’re better off without it. - Ask the dentist to inject the local anesthetic at a site as far as possible from the trigger point for the TN pain. - Several hours before the procedure, take a pain-killing medication such as codeine. After the procedure, take it again. The goal is to have at least five hours afterwards during which you’re free of pain. - If dental procedures make you very nervous, you might ask for laughing gas or IV anesthesia to reduce emotional trauma. If tooth brushing is intolerably painful, Dr. Mahan said, ask your dentist to prescribe a topical anesthetic called viscous lidocaine to numb your mouth. If that fails, try a prescription mouth rinse called Peridex®. An oral antibiotic, it can leave a stain, so wipe off your teeth as best you can. Drink only lukewarm fluids to avoid stimulating the nerves in your mouth. When the pain flare-up is over; remember that you should have your teeth cleaned by your dentist at least twice a year if you have TN, to forestall dental problems.

Trigeminal Neuralgia: What Your Dentist Can’t See

Q: I have been experiencing shooting pain on the right side of my mouth for several months. My dentist has examined the area and taken X-rays, but can’t find any problems. I got a second opinion, with the same results. Do you have any suggestions? A: In most cases, pain in the oral cavity (mouth) is related to disease of the teeth or gums -- namely cavities or gum (periodontal) disease. Less frequently, strain of the TMJ (jawjoint), and infection of the maxillary sinus can cause pain that radiates to the teeth or ear. If two dentists have ruled out these possibilities, we must look at some of the more rare disorders that can cause your symptoms. Your symptoms lead me to suspect a relatively uncommon disorder known as Trigeminal Neuralgia or Tic Doloureux. The trigeminal nerve supplies both sensory (feeling) to the forehead, eye, cheek and jaws, as well as motor (movement) to the mouth. Trigeminal Neuralgia is usually a benign but debilitating disorder where electric shock-like pain is triggered by laughing, chewing, brushing your teeth or even touching the face. Rarely, multiple sclerosis or certain brain tumors may cause it. A MRI can help rule out these more serious disorders. The diagnosis can be elusive to dentists or physicians unfamiliar with this disorder. I consulted with a patient during my hospital residency with trigeminal neuralgia that had had every tooth on the right side of her mouth extracted due to numerous doctors’ unfamiliarity with trigeminal neuralgia. I recommend you see a specialist in facial pain (preferably with a background in oral surgery) or a neurologist. Treatment usually involves taking anti-convulsant drugs such as Tegretol®, or in some cases surgery-involving decompression of the nerve may be required. What Causes a Toothache?
Dentists recognize that an aching tooth can be an intimidating and frightening experience. I assure you that the dental profession takes a very gentle approach to make you comfortable once again. For most of our patients, the greatest amount of fear stems from a fear of the unknown. I hope that the information on this page helps reduce some anxiety, should you have any. Most of us have experienced some type of toothache over the course of our lifetime, and the number of reasons for this discomfort are so great that I cannot expound on all of them here. Often, the first idea that comes to mind is, "Uh oh, I have a cavity." I can assure you that a great number of our patients have happily learned that this was not the case. To understand the source of a toothache, it is first important to understand the anatomy of a tooth. Our teeth are living entities, complete with nerves and a blood supply to keep them healthy. Underneath the enamel of the crowns that we brush is another hard (but more yellow) mineral substance called dentin. Dentin is composed of thousands of microscopic pores which communicate with the nerves inside our teeth. When these “windows” are exposed, they produce sensitivity to heat, cold, sweets or other stimuli. Such pores are also prominent in the roots of our teeth since our roots do not have an outer enamel coating. Cavities are certainly one way to expose the dentin of our teeth, essentially when bacteria tunnel holes through the enamel of our teeth. Fracturing enamel or losing an old filling may also expose the tubules which can cause discomfort. If you have gum recession, which exposes more of the roots of your teeth, there may be exposure for this reason and often painting a sealant on such teeth is all that is needed. Our teeth may hurt for other reasons as well and include more extensive etiologies such as infection, trauma or mobility. We have all heard of dental abscesses and these occur when a tooth gets infected and builds up pressure around the root of a tooth. As with any infection in our body, it is very important to have this treated by a medical professional. Trauma comes in many sorts, including long term self-induced trauma such as bruxism, or grinding of your teeth. When we grind our teeth, we create forces which not only wear away the enamel on our teeth, but also can cause gum recession and irritate the tissues and ligaments around our teeth. There are several devices and treatments available which can alleviate these symptoms as well. Sometimes, mobile teeth can also cause irritation. Stabilizing these teeth (e.g., splinting to adjacent teeth) may be a treatment option. If you have impacted wisdom teeth, their “movement,” or eruption, may also be a cause. Teeth are not the only sources of toothaches. If the ligaments or gums around your teeth are irritated, you may be interpreting this as a toothache as well. Such inflammation may be reduced by a dental cleaning and improved home oral hygiene. Even less obvious reasons for toothaches include causes of referred pain. This occurs when nerves in other parts of our body are irritated and our nervous system interprets this as a toothache. Rarely, heart disease or myocardial infraction can create a toothache in lower molars and must certainly be considered by the dentist if no other reasons for a toothache are apparent. Another example of referred pain is when a patient has an earache due to a cavity in a lower molar. I hope that this information alleviates some anxiety you might be having about dental treatment. It is impossible to know the definitive causes of a toothache without a complete dental exam.

When is a Toothache Really a Toothache?
It might hurt a lot, but the pain that seems like a toothache could actually come from another part of the mouth or body, say dentists. "Sometimes a tooth may ache from non-dental sources, such as other sites in your head, your neck, or even your heart," explains Keith Suchy, D.D.S., a general dentist. Toothache pain, he says, can be referred from one part of your body to another. "The site of the pain isn't necessarily where the pain will be felt," says Dr. Suchy. Pain can be projected or distributed along a nerve that is the source of pain. For example, pain in the head, jaw or heart could be projected through a nerve that will translate as pain in a particular tooth. Virtually every category of headache and facial pain can cause toothaches, including sinus infections and colds. Other non-dental sources of toothaches include tumors in the head, hiatal hernia, osteoarthritis or rheumatoid arthritis, diabetes, osteomyelitis (inflammation of the bone) and depression. Angina pectoris, or heart spasm, may be one of the more serious types of referred pain to a tooth, says Dr. Suchy. As the coronary arteries narrow with angina pectoris, the blood supply diminishes to the heart, creating pain that can be felt in a tooth. Angina pectoris has been known to radiate to the neck, jaws, throat, brows, cheek and ears. One study showed that angina pectoris radiates to the jaw about 12 percent of the time. "Dentists recognize that pain in a tooth can actually come from another part of the body," says Dr. Suchy. "That is why patients are asked all those questions on the medical history form. Many people seem confused that we ask about health problems that do not seem to related to the oral cavity, but remember, many symptoms appear first in the oral cavity and dentists are the first to detect them. They can then refer to the appropriate source for treatment. Dentists truly are on the frontlines of diagnosis."

Above matter is copy right from Futuredontics.Inc.