Articles Prepared by Dr. Hall and Published in the St. George Senior Sampler

When Is An Oral Sleep Appliance An Alternative Treatment To C-PAP? Loud Jaw Pop, Then Limited Opening? The Genetics of Sleep Apnea Could You Have Sleep Apnea And Not Even Know It? Seniors Susceptibility To Dental Disease Dr. Hall’s Dental Tips Guatemalan And Saint George Children With Toothaches Teeth Showing Their Colors? Mixed Signals: Muscles & Teeth Dental Tips From Dr. Hall Your Grand Children’s Mouths May Need Attention What Is A General Dentist? What Is Your Dental IQ? How Does A Dentist Help Doctors Treat Sleep Apnea? Arthritis And The TMJ An Alternative To CPAP Continued… An Alternative To C-PAP Therapy Silver vs. White Fillings… A Dentist’s Candid Opinion Breast Feeding Benefits Dental And Overall Health Snoring Is Not A Laughing Matter Snoring Grandkids? Accelerated Dental Care An Alternative Cosmetic Dental Treatment Option Blood Thinners And Dental Tooth Extraction Choosing Between Dental Implants, And Fixed Or Removable Crown And Bridge Work Dry Mouth… Improve Your Dental Hygiene To Touch Or Not To Touch… Jaw Pain Location, Location, Location, For Dentures Helping Your Grandchildren Develop Proper Oral Health Tooth Removal/Extractions Limited Jaw Opening… Disc Displacement Without Reduction Family Dental Tendencies… Jaw Size How Does A Denture Fit? …It’s All About Bone – Part 2 How Does a Denture Fit?… It’s All About Bone Snoring Consequences…A Sign Of Severe Medical Problems? Denture Stability And Retention… The Benefits Of Implants Improvements In Implant Dentistry… Hybrid Teeth/Dentures Denture Wearing… A Balancing Act Teeth And The Golden Years… Make A Lasting Choice How To Avoid The Dreaded “Denture Look”… It Isn’t As Easy As It Looks

Dental Sleep Medicine…. What?

Do you ever wonder why dentists have DDS or DMD behind their names? DDS stands for Doctor of Dental Surgery while DMD stands for Doctor of Medical Dentistry, both practice virtually the same. In France, I have a cousin that does dental procedures like wisdom tooth removal, but he is called a Stomatologist. He first received his physician’s degree and then specialized in the dental side of medicine.

Why in the US dentists and doctors are not all trained as physicians and then specialize in different areas of medicine including dentistry, I do not know. Different degrees can cause problems in the insurance billing world. Insurance will often pay for a certain procedure covered by an MD, but will not cover the same procedure performed by a dentist, or the other way around. The Temporomandibular Joint (TMJ) and its therapy needs are not covered by dental insurance and for the most part not covered by medical insurance either. People generally must pay cash for TMJ/TMD treatments. The jaw joint is a joint just as, if not more, important than say the knee, but receives no respect or reimbursement from medical insurance. Strange! You may have read my articles on Sleep Apnea and the use of an oral sleep appliance to treat it, instead of C-PAP (the mask that fits over your nose) machine helping you to breathe. Legally a dentist cannot diagnose and have a person tested for sleep apnea, only a Physician can do that. I refer people I suspect of having sleep apnea to sleep specialty doctors all the time for a diagnosis. The sleep doctors test and make the appropriate diagnosis of sleep apnea. The treatment MD’s most often prescribe a C-PAP machine, but if the patient refuses or cannot tolerate a C-PAP then an oral sleep appliance is most often the alternative. We are blessed in this area to have true experts in the field of sleep medicine. I love the change our combined efforts make in people’s lives. I believe I play an important role in patient care as a dental sleep medicine dentist.

Head and Neck Pain

Pain in the head and neck is often called craniofacial pain or a little more limited description might be orofacial pain. I am a general dentist so I deal with a lot of tooth or odontogenic pain. I also enjoy treating non-odontogenic pain of the head and neck. I enjoy the hunt for the cause of the pain and the relief I am able to give that no other health practitioner has been able to give or even diagnose. Pain, as we generally speak of it, is perceived in the cortex of the brain upon reception of neurochemicals transmitting a pain signal.
So, what is pain, really? Pain has been described medically as follows “an unpleasant sensory and emotional experience with actual potential tissue damage or described in terms of such damage.” In the region of the head and neck, the site and the source of the pain are often different. This is especially true with tempor-mandibular disorders including problems and pain associated with the TMJ (temporomandibular joint). The muscles of mastication and facial expression can refer pain to many different structures or areas like the ear, or the teeth, or the eyes. These muscles often impinge or put pressure on nerves leading to headaches.

My training is to sort out the source of the pain and then treat the source and not the area of the pain. Unfortunately, many dentists have resorted to root canal treatments of teeth and yet still have pain after their treatment. Worse yet, they resort to pulling the tooth, only to have the pain still remain. The pain was coming from an overused muscle which could have easily been treated without losing the tooth. Sometimes pain perceived by the brain can be maintained by the autonomic nervous system. The structure or area of damage is healed yet the pain persists. A knowledge of neuro anatomy as related to the head and neck is important. The knowledge of the way nerve signals can become mixed up to make the brain perceive the pain is coming from somewhere else than the actual pain source, is essential in sorting out the true source of pain. The right diagnosis is essential to success in treating pain disorders of the head and neck.

Sleep Apnea And The Palate

In my last article I touted the potential problems with the tongue and the aggravation it causes with Sleep Apnea.  Another oral structure that brings about complicating or aggravating factors to worsen one’s apnea is the palate.  I mean the hard bony palate or roof of our mouth and the soft or tissue palate extending behind the hard palate.  When I was young I thought a high palate meant you could be a good singer.  Now when I do an oral exam on a patient and find a high vaulted palate, it’s a red flag to look further for other anatomical variations that increase a person’s likelihood of having Sleep Apnea.  With this type of patient, often both dental arches are too narrow and teeth are crowded and crooked. The uvula that hangs down from the soft palate will often be red and inflamed.  Some people have very long soft palates that go back into their throat a long way.  In these people, the uvula is often long and thick.  If they never had their tonsils removed, I wonder how they can breathe even when conscious, let alone when they lay down to sleep.  If they have a deep over-bite and a scalloped tongue, you can bet they have Sleep Apnea.

You don’t have to be a dentist to observe some of these things.

If you have some of the other symptoms for Sleep Apnea like daytime sleepiness, difficult breathing events at night, snoring, and obesity, then you need help.  Breathing normally, providing adequate oxygenation, is essential for life.  Remember, apnea means the absence of breath.  If you or your spouse have the physical characteristics or symptoms I’ve described, I urge you to come to my office for a free consultation and referral if appropriate to a Board Certified sleep specialist.  We will also explain how, in many cases, the oral appliance works well instead of using a CPAP machine.  Medical insurance covers you and my staff will pre-approve your treatment.  I have a great working relationship with all the MD sleep specialists in Saint George.

Check Their Tongue! Maybe Yours Too!

And you thought we dentists just looked at teeth.  Tongues can push teeth crooked. They can beat up the dentist trying to do a filling on a lower tooth.  Tongues seem to have eyes of their own and go right to where the dentist is drilling or filling a tooth.  Both the dentist and the dental assistant come away exhausted after wrestling a tongue to get it out of their way. Tongues can look weird too.  They can be all gross with thick yellow and black gunk all over them when the person is a smoker.  They collect sulphur smelling debris on the back base of them giving people bad breath. They choke people when unconscious.  They can have marks all over them that look like craters on the moon that move from day to day. Their sides can look perfectly scalloped.  They can have a fissure down the middle of them looking like a miniature Grand Canyon. They taste everything. They are our first connection with the outer world feeling everything that touches them from a mother’s breast to a toy, fingers, and yes dirt.  And now for the rest of the story………

Tongues are the main culprit in obstructive sleep apnea.  When we are asleep lying down they slump back and close off our airway. Not only but especially in a REM stage of sleep, there is no muscle tension or motor activity stimulation to keep them out of your airway.  They can vibrate causing snoring sounds. They grow larger as we gain weight. Large tongue equals getting up going to the bathroom more often in the night. Why? Because your brain try’s to arouse you by sending signals to the tongue to come to attention and quite blocking your airway.  You don’t wake up all the way but just enough to think you have to go to the bathroom.

Big weird tongue equals probable sleep apnea and shorter life span.

TMD or TMJ What’s The Difference?

TMJ stands for temporomandibular joint.

TMD stands for temporomandibular dysfunction.  When someone has pain in their “jaw joint” they say they have “TMJ”.  That’s like saying I have knee when you have pain in your knee joint.  The more meaningful description is to say I have TMD or I have pain in my jaw joint or pain in my facial muscles.  Anyone will know what you mean when you say I have TMJ, but to a dentist trying to figure out exactly where your pain is coming from, he will ask you to point to that area of you face where you feel pain.  Then he will ask you, “When does it hurt?  How long have you been hurting this way?  Is there anything that makes this pain go away or that makes the pain worse. Have you EVER been in an automobile accident?  Were you ever struck in the jaw?  Do you have arthritis or other inflammatory diseases?  Do you have popping or clicking when you chew or open your mouth? Is the popping or clicking painful?”

When should you seek treatment for a TMD condition?  There are three things to remember to answer this question:  One, is their pain?  Two, is there dysfunction (popping, clicking, grinding on opening, are your jaw muscle painful when you open close or chew something)?  Three, is your quality of life affected by this jaw pain (can you chew or open your mouth wide without pain?).  If you have two out of the three things listed above, then you need to see a dentist that is knowledgeable at treating jaw joint or facial pain conditions.  Not all general dentists know how to treat TMD.  There is no dental specialty recognized by the ADA (although there should be) that treat TMD or head and neck related pains.  There are academies or groups of dentists that pursue advanced learning in these areas.  I have made the effort to learn these skills and love helping people with “TMJ” TMD problems.

When Is An Oral Sleep Appliance An Alternative Treatment To C-PAP?

C-PAP stands for constant positive air pressure. C-PAP devices deliver room air not oxygen to the patient at varying pressures. The maximum pressure level is set depending on the apnea of the patient Positive air pressure of a sufficient amount can keep a person’s airways open so that there is no obstruction to breathing.  This pressure is delivered to a person usually through a mask over the nose or sometime a mask that covers the entire face or a tube under the nose.  People fail or are intolerant of this type of treatment all the time and are classified as C-PAP intolerant or C-PAP failures.

Some of the common reasons people give for being C-PAP intolerant are the following:

  1. Mask leaks air all the time
  2. Just can’t get the mask to fit properly
  3. Too much discomfort caused by straps and headgear
  4. Disturbed or interrupted sleep caused by the presence of the device
  5. Noise from the device disturbs them and their bed partner
  6. C-PAP restricts movements during sleep
  7. Pressure on upper lip hurts or chin strap pressure hurts TMJ
  8. Claustrophobic feeling
  9. Unconscious removal of mask every night
  10. Patients don’t like the lines made on their face every day
  11. Leaking air around mask hurts eyes or dries eyes
  12. Stomach fills with air
  13. Air leaking around and out of mouth gives a terrible dry mouth
These are just a few of the reasons patients have given for not wearing their C-PAP device. Fortunately more and more the sleep physician, when they know there is a problem, will send them to me to make an oral appliance.  Oral appliances have some draw backs as well, but are generally more universally accepted by patients.  After one year, patients who have been prescribed the oral appliance are more compliant vs. patients who have been prescribed the C-PAP.  Oral appliances can be recommended initially over C-PAP in cases where the patients’ Sleep Apnea is mild to moderate in severity.

Loud Jaw Pop, Then Limited Opening?

I often have many TMJ patients come to me with a history of hearing a loud pop followed by pain in their jaw joint and an inability to open very wide.  Usually they have a lot of pain when they try to open very wide for the first few days or weeks.  The clinical description for the diagnosis for such a problem is, “Disc displacement without reduction.”  This means that you “can’t get the door stop out and so can’t open the door all the way.”  The door in this case is your jaw that can’t open very wide.  Perhaps 25 to 35 millimeters (two fingers wide) is as wide as you can open.  A normal opening measurement for a person is 48 o 52 millimeters (three fingers wide).  The ability to open your mouth normally allows you to eat a Big Mac sandwich.  The door stop is your TMJ disc that has become stuck in front of the ball (condyle) of your jaw joint.  It usually lies between your skull and your condyle traveling forward as you open your mouth.  With compression of you TMJ you can push the disc forward, in from of the condyle, which inhibits your ability to open wide.

Chronic clenching for many years is a common cause of this condition.  If you try to force your mouth open when the disc is locked forward, the disc becomes pinched and inflamed, making it even harder to resume its normal position.  Once this disc remains in the wrong place for very long it becomes possible permanently stuck there and it take a person some five years to gradually be able to open wide again.  If you hear the loud pop and your joint becomes locked like this try opening by moving your jaw from side to side from one extreme to the other as you gently try to open wide again.  If you cannot achieve wide opening again come and see me quickly.  If you come soon enough I can usually get you unlocked and through treatment, keep you there and out of pain.

The Genetics of Sleep Apnea

What does genetics have to do with Sleep Apnea?  Obstructive Sleep Apnea is a condition in both male and female populations.  It is a medical condition experienced while sleeping where a person’s airway becomes blocked or obstructed by the tissues in their throat and they cannot breathe for periods of time lasting for at least 10 seconds.  Note that the usual time of no breathing is often for 30, 40, or more seconds; often longer than a person can hold their breath. Just as people have obvious outward physical characteristic differences, their internal physical  characteristics are also different.  Examples of this are, the size of a person’s airway, mouth, tongue, tonsils, palate, uvula, nasal passages, throat, etc.  These are a result of the gene pool you inherited.  So if your parents or other close relatives in your family have been diagnosed with Sleep Apnea, chances are great that you have it or will have it.  

Ignoring the symptoms of Seep Apnea can bring on other complicating health conditions called co-morbidities of Sleep Apnea much earlier.  They include high blood pressure, diabetes, stroke, heart attack, atrial defibrillation, and other suspected conditions indicative of poor health.  Tissue and nerve damage occur throughout the body the longer a person is not treated for their apnea.

Some signs of Sleep Apnea are the following:  morning headaches, snoring, dry mouth in the morning, gasping for breath in the night, stopping breathing as witnessed by your bed partner, frequently waking and having to go to the bathroom in the night.  Treatment is not always the dreaded C-PAP machine.  It can often be the use of an oral appliance fitted by an experienced dentist in the treatment of Sleep Apnea.  Non-treatment is deadly in the end.   “He just died in his sleep!”

Could You Have Sleep Apnea And Not Even Know It?

Sleep Apnea is a sleep disorder occurring at night when a person does not breath for a minimum of 10 seconds or longer. The time can often be for periods of 30 to 60 seconds.  Sometimes a person will be obstructed and their body will try so hard to breath that they gasp for air. You ask the average person if they think they do this, and most will say no.  The spouse or bed partner will often tell a different story, saying that the person snores and gasps for air. The next morning the person with the problem can’t remember having any difficulty breathing.  Men are worse than women when it comes to being in denial.

The National Sleep Foundation surveys show that 75% of Americans report at least one sleep symptom and approximately 60% of adults drive while drossy.  Between the ages of 30 and 60, 24% of men and 9% of women have Obstructive Sleep Apnea.  Within the obese population 50% of men and 60% of women have Obstructive Sleep Apnea.  The national epidemic of obesity is why there are so many people from youth to the aged that have sleep apnea.  Left untreated, people complain of excessive daytime sleepiness, memory problems, and other health issues.  Sleep Apnea tends to bring on problems with high blood pressure, heart attack, stroke, weight gain, diabetes, atrial fibrillation, to name a few.  You see the odds are high that you may nave sleep apnea.  Come to my office to for a free consultation.  I will make a referral to a sleep physician specialist to diagnose your condition.  I will let you know if you are a possible candidate for an oral sleep appliance that can treat your Obstructive Sleep Apnea.  It is covered by medical insurance.

Seniors Susceptibility To Dental Disease

It’s often said that in people’s latter years, they become more like children in many ways.  Forgetfulness often affects personal hygiene habits.  Loss of physical dexterity can also effect oral hygiene.  Just as a child doesn’t brush their teeth very well, or forgets to brush their teeth before going to bed, so it seems that many Seniors begin to follow the same pattern,  even in their sixties.  I see this sad scenario repeat itself nearly every day as I examine my dental patients.

As oral hygiene declines, dental plaque increases.  Gum tissues that were healthy and firmly attached around the teeth and bones now become horribly inflamed, causing deep periodontal pockets to form around the necks of the teeth.  Soon thereafter, people who haven’t had a cavity in years, now have multiple sites of decay deep around the roots of their teeth or around the margins of their crowns.  These seniors, coping financially with retirement, cannot afford to restore their teeth and have no help from dental insurance that they lost upon retiring.

Here are a few of my suggestions on how to cope with dental disease in your latter years:

  1. See your dentist’s hygienist more often, maybe 3-4 times per year.
  2. Purchase an electric toothbrush if your dexterity is lagging or if arthritis is affecting your hands.
  3. Use a fluoride mouth rinse every night before bedtime.
  4. Control the amount of sugar in your diet.
  5. Use dental hygiene products that help with dry mouth syndrome.
  6. Anticipate and plan for dental care in your budget.
  7. In cases of Dementia or Alzheimer’s, include in the instructions to your family, that they take you to a dentist for cleaning every 2-3 months, and also see to it that someone brushes your teeth daily.
  8. Last of all, but very important, if your teeth are in very poor condition, and you have lost many of them already, a possible, practical solution is to have all of your remaining teeth removed and be fitted for dentures that are held in place by implants.
  9. Being in your latter years and having an abscessed tooth removed when you have many serious medical conditions can actually be life-threatening.

With resolve and good planning, you should be able to avoid the heartache of pain and suffering from your teeth in your latter years.

Dr. Hall’s Dental Tips

Weekly, on various radio stations, I have given out short informative bites of information I call my “Tip of the Week.”  Those who have missed hearing them might like to read them:

  1. Most people I see have a hard time brushing on those back teeth, especially on the cheek side. If you’ll just close your mouth around that tooth brush handle, it will reach back there easier and keep those teeth cleaned.
  2. So you’ve been told you have bad breath and yet you brush your teeth. Well, it may be coming from the back of your tongue.  Brush your teeth, but don’t forget to reach way back there and brush your tongue.  You’ll be amazed how much it helps.
  3. The types of candy that produce the most decay stay in your mouth for long time. You know, the hard tack candies you suck on. A little bit of chocolate rinsed down with a drink is not as bad.  Avoid the sticky candies that stay in your mouth a long time.  Choose wisely.
  4. Are you a fanatic when it comes to brushing your teeth? Like five times a day or after every meal and snack?  Technically correct and thorough brushing and flossing of your teeth once a day beats haphazard in and out brushing.  It’s not how often you brush but how well you brush.
  5. How long have you been using the same toothbrush? Has it been through your latest cold or flu?  Are the bristles having a bad hair day?  Toss it! The few dollars you spend on a new toothbrush will cost a lot less than repairing a tooth that you couldn’t brush correctly.
  6. Tell your husband he can’t kiss you until he gets his cavities taken care of! It’s been scientifically proven that cavity causing bacteria can be transmitted through saliva.  A clean plaque-free mouth promotes fresh breath.  Fuzzy teeth aren’t sexy!
  7. If your spouse’s health is failing and they’re not feeling well, good oral hygiene is usually the first thing to go. It’s time for you to step in with a clean new toothbrush and come to the rescue of your loved one.  Your spouse will feel better and will be less susceptible to disease.
  8. Stressed? You probably clench your teeth a lot.  Except for when you swallow, or chew, your teeth should be a thick eighth of an inch apart.  Clenching and grinding are habits that lead to muscle soreness, headaches and TMJ problems.  Just relax and blow a little air between your cheeks and teeth.  Keep those teeth apart.
  9. Did you know that for approximately one half hour after drinking something containing sugar, dental plaque continues to ferment the sugars and continues to produce acid. So if you sip on a big drink for hours, you are really promoting dental decay.  You’re enamel will dissolve away.
  10. It’s the weekend or it’s after 5 at night and all of a sudden you have a toothache! No dental office is open!  Use some oil of clove from the pharmacy.  Dip a little cotton ball in the oil and place it into the cavity or missing filling in your tooth.  You’ll feel better and survive the night just fine.
  11. A fluoridated toothpaste helps your tooth enamel to be more resistant to the acids made by dental plaque and the acidic foods you eat including soda pop. Sugar in any form, plus dental plaque equals acid.  It dissolves your enamel.  So, make sure your toothpaste has fluoride in it.
  12. Why do you have receding gums? It may be because you use a stiff bristle tooth brush.  Or you might brush with big back and forth strokes.  Use shorter strokes with varied motions and a soft bristle toothbrush.  Your gums will be less likely to recede and your teeth will be cleaner and less sensitive.
I hope you have found a tip or two that will help you with your oral health!

Guatemalan And Saint George Children With Toothaches

Before the advent of antibiotics and modern dentistry the toothache with its unrelenting pain was one of the most feared agonies know to man.  Next to the common cold, it is still the second most common disease known to man.  The access to dental care for the suffering is good here in St George.  However, there are still many who can’t afford treatment.  We have social programs such as state administered Medicaid and the Chips program for children. An adult with a “blue” Medicaid card is eligible for one X-ray and can have teeth pulled but not repaired.  Although these programs pay the dentist very poorly I participate as a dentist provider from a humanitarian position.  So I see pain and suffering every day in my office.  Believe me, untreated dental pain still exists on a fairly large scale right here in St. George.

Now let me take you to the land of Guatemala which is south of Mexico.  The majority of the indigenous Myan people live in high mountain villages on collective farms. They live in small huts with walls of sticks and mud. They usually have tin roofs and dirt floors. The more fortunate ones have cinderblock walls.  They make their little fires for cooking on the floor, breathing in the smoke and sometimes having their babies fall into the fires receiving horrible burns. They make corn tortillas and eat a lot of beans and rice.  Due to lack of nutrition, the children are underdeveloped mentally and physically.  Yet I find these people amazingly happy and full of faith in Jesus Christ. Somehow sugar has found them; but not dental hygiene.

The Saint George Rotary Club helps in our community but we also have a humanitarian focus in Guatemala.  After a good water source is secured and a school for children built and waste sanitation obtained, our Club goes in to villages and makes or has made, efficient wood burning stoves with cook tops and venting through the roof.  We oversee somewhere around three hundred stoves being place each year through our fundraising efforts.  While my colleagues are doing stoves, I bring my little head light, anesthetic, gauze, and surgical tools, and remove abscessed teeth all day as fast as I am able.  No drill, no x-ray, no suction or dental chair.   Just children and adults laid out on a table top in the school.  These poor people have been suffering for months with toothache pain.  Mothers bring me their children with multiple abscesses.  Think of it, a mother unable to stop her crying child’s pain from a toothache.  My Rotary Club is going again at the end of this May.  If you want to help in any way Google St. George Rotary Club and through our 501C3 charitable trust, you can donate to this effort.  Human suffering is everywhere.  Doing a little to help feels good.  Try it and you’ll see.

Teeth Showing Their Colors?

Teeth wear down over time due to various reasons.  Sometimes a very high fiber diet over a lifetime can cause more wear.  People with GURD (acid reflux) lose a lot of enamel as it simply dissolves away.  Big time bruxers (tooth grinders) wear down their teeth at an alarming rate.  Chemical/drug abusers with what we dentists call “meth mouth” totally destroy their teeth.  The outer enamel is white but the inner dentin that starts showing with excessive tooth wear, is a darker yellow.  Dentin has nerve endings running through it, enamel does not.  People can become very sensitive to temperature changes or even chewing normal food can produce pain.  Some people don’t have any pain because the process has occurred slowly over time.  The inner part of the tooth (dentin) is porous and bacteria can traverse it making nerve damage possible.  The take home message is this; if your teeth look like they are full of pot holes, very wore down, sensitive, yellow looking, etc. you need dental work.   Sometimes crowns are needed because the wear is so excessive.  For those lower front teeth that are all chipped and worn down looking and very yellow on top, the process to shore them up and make them look better may not be too complicated.  In my office I will bond tooth colored material to the tooth after minor preparation.  The patient doesn’t usually require anesthetic.  When I’m done my patients are amazed and happy with how their teeth look and with how little drilling it took.  The teeth are stronger and less likely to continue to chip.  Dental insurance covers the procedure as a filling.  And now your grand kids won’t look at your teeth when you hold them close and ask “what happened to your teeth grandma”?

Mixed Signals: Muscles & Teeth

Dentists are in the business of diagnosing dental disease, namely tooth decay, gum disease, and Oral Pathology.  Often people come into my office thinking they have dental decay because they have something that feels to them like a toothache.  When I tell them their tooth is just fine but their problem is really facial muscle problems they are perplexed as to how this can be.  Sometimes the dentist is fooled and so fillings or root canals are performed only to have the problem area still hurt. This is really not good when a good tooth is taken out needlessly.

Here is the answer:  Yes, the problem is all in their head.  Joking aside, this phenomenon comes about because of anatomy and neurological factors.  The 5th cranial nerve innervates the muscles of mastication as well as the teeth. For the most part it has a sensory function, but there are also motor or movement-signaling components to certain branches of this nerve.  The sensations of cold or hot on your teeth, along with decay irritation signals, go back to the brain stem before being forwarded to the cerebral cortex of your brain.(your conscious and awareness center).  Muscle pain signals from muscles being over worked or injured also go back to the same general area of your brain stem.  There they sometime “jump track” and get mixed up because of very little insulating coverage of these pain nerve fibers. The brain then interprets them as coming from a tooth when indeed the problem is really in one of the muscles of mastication. Medically, the process is called “ephapsis”, producing REFERRED pain. So the site and source of the pain are two different places. The toothache feels like it is coming from you lower first molar when it is really coming from the masseter or check muscle.  In these circumstances I can often push on the muscle and the tooth will ache. Sometimes the muscle in the temple area of your head, called the temporalis muscle, will make top teeth ache from the back to the front teeth depending on the circumstances.  TMJ pain can make your ear ache or feel full.  This earache can also come from the deep portion of the chewing or masseter muscle.  There are many variations of this anomaly.  So if your dentist is puzzled and says lets just watch it, or take two aspirin and I’ll see you in a week , or worse,  “lets take out that tooth”, its time to get another opinion.  Preferably, a second opinion should come from a dentist who is verse in the many variations of craniofacial pain.  Dull, aching pain is usually of muscle origin. Sharp, electric or severe pain is usually from your teeth.

Dental Tips From Dr. Hall

Here are a few common sense tips or responses to frequently asked questions on common dental problems that I use on the radio on my tip of the week series.  Hope you find them useful:

  1. White teeth are “in” and there are lots of whitening toothpastes from which to choose. Frequently, however, people’s teeth become sensitive while using these toothpastes.  So if your teeth are already sensitive, stay away from whitening toothpastes.
  2. Dental insurance policies provide benefits only usable in the current calendar year. Dental benefits don’t roll over to the next year.  If you don’t use them, you lose them!  So schedule now to get your dental work done before the end of the year while appointments are still available.
  3. A fluoridated toothpaste helps your tooth enamel to be more resistant to the acids made by dental plaque and the acidic foods you eat, including soda pop. Sugar in any form plus dental plaque equals acid that dissolves your enamel.  So make sure your toothpaste has fluoride in it.
  4. Why do you have receding gums? It may be because you use a stiff bristle toothbrush with big bath and forth strokes.  Use shorter strokes with varied motions and a soft bristle toothbrush.  Your gum tissue will be less likely to recede and your teeth will be clean and less sensitive.
  5. So you like the 44 oz soda drinks? Did you know that for approximately 1/2 hour after drinking something containing sugar, dental plaque continues to ferment the sugars and produce acid.  So if you sip on a big drink for hours, you are really asking for a lot of dental decay.  Your dental enamel will be dissolved away and so will the money in your wallet!
  6. It’s the weekend or it’s after 5 at night and all of a sudden you have a toothache and no dental office is open? Use a crushed cooking clove or the oil of clove from a pharmacy.  Dip it in a little cotton ball and place it into the cavity or missing filling in your tooth.  Within minutes you will feel better and survive the night just fine.

Your Grand Children’s Mouths May Need Attention

Ask your grandkids about their teeth.  Encourage good dental health with the normal questions about brushing, etc.  Take it one step further by being observant of their smile and how their teeth meet. One more important thing to figure out is whether they are predominantly mouth breathers or nose breathers.  Ask their parents if they snore or grind their teeth at night. 

Oral health starts in the womb and right after birth as a person acquires proper swallowing habits.  Nursing develops proper swallowing and nose breathing.  In turn this leads to proper balance between the pressures of the tongue exerted in the right way to shape the dental arch and balance pressure from the lips and cheeks that draw the teeth inward.  If your grandchildren’s teeth don’t meet in front and look crowded or are widely spaced and if they are in a cross bite relationship either in front or back, they most likely aren’t swallowing properly.  A proper swallow is accomplished when the tongue goes to the roof of the mouth behind the front teeth and the teeth come together as the person swallows.  If the tongue juts forward or out of the mouth as one swallows and does not go to the roof of the mouth, malocclusions develop.  Also mouth breathing instead of nose breathing occurs more often and the child starts to tip their head forward with their chin up. You can take this much further than you might imagine when the swallow habit isn’t correct with things like obsessive-compulsive disorders or body-focused repetitive behaviors among things like nail biting, skin picking, Trihotillomania (hair pulling), etc.  These things may not seem to be connected but an understanding or all that a correct swallowing habit does to stimulate the nervous system holds the answers.  I use my training in orofacial myofunctional therapy to address these and other habits of the tongue, lips, and jaw.  

What Is A General Dentist?

A simple answer to this question is the obvious a general dentist is a dentist that does what most dentists generally do.  Do general dentists do what dental specialists do?

The answer is sometimes yes. 

There are five areas of dentistry recognized by the ADA .  They are oral surgery, periodontics, pedodontics, prostodontists, orthodontics, dental radiologist, & endodontists.

General dentists cannot, without approved graduate school training and testing, say they are a specialist in any of these areas. Some general dentists will limit their practice to a particular area of expertise like wisdom teeth removal, or root canals etc. There are some areas of expertise that have been proposed to the ADA for specialty status like implantology, crainiofacial pain, and dental sleep apnea.  There are a lot of politics involved within the ADA and established dental specialties that, to this point, have not been resolved for granting specialty status to these and other areas. Short of a general dentist selling or closing his practice and going back to school for two to three years to become a traditional specialist in some area, the dentist may attend postgraduate training courses to expand his knowledge in certain areas. There are also academies of special interest areas of dentistry that a dentist can join and associate with to excel in certain areas.

I will use myself for an example of what I have been talking about.  I am a general dentist that sees patients and I provide all the services that are routine for a dental office like exams, x-rays, cleanings, fillings, crowns, root canals, extractions, dentures, implants, etc.  I also have taken nearly 1000 hours of postgraduate training in TMJ, head and neck pain, trigger point release techniques, physical therapy remedies and dental sleep apnea treatments.  I have earned fellowship status with the American Academy of Craniofacial Pain and diplomat status with the American Academy of Dental Sleep Medicine, & and board certification with the American Board of Dental Sleep Medicine. I am a general dentist.

What Is Your Dental IQ?

As a grandparent, I have often stood in the bathroom with my grandchildren as they brushed their teeth before bed.  I can see they have been taught well by their parents the importance of good oral hygiene.  Their mother and I taught some of those parents when they were children. Good dental hygiene is a concept and a tradition or way of life for many modern families. The sad contrast of neglect of training or effort is what I often see in my dental practice. In most of these cases, I believe it is a form of child neglect. Another way to say dental IQ might be dental awareness, dental priority, dental dedication, and dental health standard. By the time you read this I will have just come back from my annual trip with the Saint George Rotary club to the highlands of Guatemala.  There my Rotary club installs efficient wood burning cook top stoves in the Mayan’s little shakes.  I spend my time alleviating the dreaded tooth ache by removing irreparable abscessed teeth. There for reason that are mostly economic, or access and yes a plain lack of personal dental care (low dental IQ) the ravages of tooth decay has taken a dreadful toll.  The people there are humble and great full for the help.  I know I have helped the needy and the mothers who had no way to console her child with a tooth ache that has been going on for months. I come home with a keener sense of the many blessings of life here in Saint George.   Then I return to my office to see in similar ways cases of children ravaged by decay and my heart aches.  Whatever your stage in life, grand parent or parent we need to all help to raise the dental IQ of our homes and community.  Ask your children or grandchildren if they brush.  Get them into a dental office & help out if economic problems exist. I and many of my fellow dentists help out as much as we can. A part of self esteem is good oral health.

How Does A Dentist Help Doctors Treat Sleep Apnea?

Sleep apnea is a medical condition.  It is the absence of breathing (usually by obstruction) for ten seconds or longer at least 5 times (often 30 to 60 times) per hour. This condition helps hasten severe heart problems, diabetes, weight gain, daytime sleepiness etc.  Many people stop breathing fifty or more times an hour for much longer than 10 seconds.  Physicians diagnose and treat this condition by prescribing for the patient a CPAP machine. This machine pumps room air that is pressurized and is given through some sort of mask. This pressurized air helps by not letting the patient’s airway close or obstruct.  Patients, however, often have a very hard time using CPAP machines.  They don’t like the mask on their face or they can’t stand the air blowing in their face and eyes.   They hate carrying around their machine when they travel or they are just out of luck if the power is out or they have no way to plug their machine in. These types of problems are common. 

Since 2006 sleep physicians have recognized the value in treating their C-PAP failure patients with oral orthotic devices made by specially trained dentists who have an understanding about sleep apnea and the associated medical complications.  These dentists also refer patients to sleep physicians for proper diagnosis.  With a request from the physician, the dentist makes an oral sleep device for the patient.   The patient is then returned to the physician for testing that confirms their sleep apnea is well treated with the oral device.  Sleep dentists need to be skilled in the conditions and workings of the TMJ joints. They must also know how to work with medical insurance including Medicare, to get payment for the patient’s treatment.

I am the only Board Certified Dentist in dental sleep medicine in Washington County.  Call 435-656-1111 today for your free consultation appointment.

Arthritis And The TMJ

As we age, and even for some young people, arthritic conditions take their toll on freedom of jaw movement producing pain and stiffness. Luckily the temporal mandibular joints or TMJ’s are made to last and function well, long after many parts of the body give out. These important joints make possible or aid with speaking, chewing, swallowing, and breathing which are functions of primary importance to our quality of life. Instead of bony parts mingled with hyaline cartilage that does not heal, the jaw joints are intertwined with a type of cartilage made from fibro-connective tissue that can heal and adapt with injury or disease. Even with their great adaptable qualities, however, the TM Joints are susceptible to arthritic bony changes also bone spurs, cancers, and anatomic changes. Should you be experiencing significant chronic daily pain you should be professional examined by a dentist trained in the diagnosis and treatment of TMJ disorders. Some doctors and people are afraid or have heard that if they have any TMJ issues they wouldn’t be able to wear an oral sleep appliance. This is generally not true. By moving the mandible (jaw) slightly down and forward as does a sleep appliance, the TMJ joint space is decompressed reducing nerve impingement often bringing pain relief to the area of the TMJ, facial muscles, and the ear. So a sleep appliance can serve two purposes to treat obstructive sleep apnea and TMJ pain. What are the treatments for arthritic type problems associated with the temperomandibular joint? Unless a tumor or sever disc displacement is involved, surgery is rarely performed. Other treatments include various oral orthotics, anti inflammatories, including steroid injections and prolo therapy; also arthrocentesis (joint lavage), various exercise programs to keep the jaw joints as mobile as possible and maintain vertical range of motion, and other physical therapy modalities. Most seniors deal with mild arthritis of their TM Joints to some degree without much, if any, form of treatment. 

An Alternative To CPAP Continued…

Since my last column, I have been flooded with inquires about the process involved to obtain an Oral Sleep Appliance.  Sleep Apnea is a medical diagnosis.  When a patient cannot tolerate or will not wear their CPAP machine and requests that I fit them for an Oral Sleep Appliance, the following is the sequence of events that transpire:

  1. Preliminary consultation and screening in my dental office wherein I confirm that the patient is a candidate for an Oral Sleep Appliance.
  2. Insurance and other pertinent health information is gathered.
  3. Contact is made with the sleep physician’s office informing them of the CPAP failure condition of the patient, requesting an order to fabricate an Oral Sleep Appliance.
  4. Patient reports to my office for impressions and a bite registration for the proper positioning for the fabrication of the Oral Sleep Appliance.
  5. 2-3 weeks after impressions, the patient returns to my office for fitting of the Oral Sleep Appliance and instructions on its use and care.
  6. The patient is given 2-3 weeks for a trial use period during which any alterations, adjustments, etc. are made if needed. (seldom needed)
  7. Patient returns to my office with report of wear compliance, general sleep experience including bed partner report.  Also report of the patient’s general well-being and diminished daytime sleepiness, if this was a problem in the past.
  8. Based on symptomatic findings to this point in time, a referral is then made returning the patient to the Sleep Physician’s office.
  9. The Physician obtains objective information through a follow-up sleep study confirming the effectiveness of the Oral Sleep Appliance.

CPAP users who want a back-up for power outages or travel, camping, etc. follow the same scenario.  Medical insurance and Medicare cover most, if not all, costs for the above treatment.

An Alternative To C-PAP Therapy

C-PAP therapy is the treatment for sleep apnea that is most often prescribed by physicians. C-PAP stands for “continuous positive air pressure.”  Think of a vacuum running in reverse attached to your nose or whole face.  This air pumped from the C-PAP machine, going to your lungs with pressure, keeps your airway from closing off or obstructing while you sleep. Does this sound fun?  Not hardly!   Although many advances in the size and efficiency of C-PAP devices have been made, it’s still a pain to drag around and use.  Sleep apnea is deadly so if you have it you’d better accept the treatment. Dentists have known how to stop snoring for decades.  A simple orthotic keeps your lower jaw slightly forward and stops snoring.  It also keeps the airway open, thus treating people with sleep apnea very well.  Medicare recognizes the effectiveness of these orthotics and pays 100% of the cost.  Other advantages of a dental sleep orthotic are:

  1. More convenient for travel because of its small size.
  2. No electricity needed.
  3. No hassle in airports and can be used to sleep on an airplane
  4. Stops irritating bed snoring
  5. No motor noises or rushing air noises.
  6. More romantic bedroom environment than C-PAP masks and hoses.
Dentists who are qualified to treat patients in this manner need to have extensive training in dental sleep medicine and a thorough knowledge of the temporomandibular joint.  Board certification by the American Board of Dental Sleep Medicine tests the knowledge and clinical treatment by dentists of patients for Sleep Apnea.  There are fewer than 200 Board Certified dentists in the world.  For over 15 years, I have taken a special interest in this field and am one of the above mentioned Board Certified dentists and have the expertise and knowledge to treat patients with both TMJ and Sleep Apnea Problems.

Silver vs. White Fillings… A Dentist’s Candid Opinion

Many people think that modern dentistry only dictates using white fillings.  I feel there is a place in good patient care for both a traditional amalgam (silver) filling and the composite (white/plastic) filling.  For me, it’s all about the size and location of where the filling is to be placed. Having observed the longevity of both types of fillings in back molar teeth for over 20 years, I believe the larger than average molar silver fillings last longer than white ones.  This observation comes from seeing more than 8,000 patients in this community who have come to me with fillings from other dentist in their back teeth that have needed replacement.

Dental benefits for Medicaid recipients only pay for silver fillings.  This is because fees for white fillings are much more than for silver fillings.  Both the American Medical Association and the American Dental Association have currently and for many decades published sound scientifically-based studies showing that amalgam (silver) fillings are very acceptable and poses no health risks to the public.

I like white fillings because they are cosmetically superior to silver fillings.  If a patients requests that I replace all of their silver fillings with white ones for cosmetic reasons I understand.  Remember though that ever time you drill on a tooth you run the risk of nerve damage. I advise patients to replace the silver filling with whites ones as either they have more decay in that tooth or if the filling or tooth breaks.

A dentist must be able to totally control moisture to place a white filling.  If the location is well below the gum like under the edge of a failing crown, or a large area in a back molar than a silver filling is better. Talk over the options with your dentist the next time you need a filling.

Breast Feeding Benefits Dental And Overall Health

The February edition of the American Dental Association has as it cover story “Oral and General Health Benefits of Breastfeeding”. It quotes many studies that state that some of the following benefits for babies from breast feeding; 1- less acute otitis media, 2- protection against diarrhea, 3- more antibodies and bactericidal properties in breast milk that combat severe lower reparatory tract infections, 4- less necrotizing enterocolitis, 5-less incidence of infant Leukemia, 6- fewer cases of SIDS, 7-protection from developing asthma, and 8-less likelihood of developing obesity.  

The rest of the story is the dental benefits for the developing child.  Proper breastfeeding develops a flatter and broadened palate.  This makes a child less likely to develop sleep apnea and also a significant reduction in malocclusion of the teeth, namely posterior cross bites. Proper positioning while nursing can have a positive effect for nasal development and nasal versus mouth breathing.  If care is not taken while nursing in the cradling position or lying in bed, the baby’s nose can become covered or blocked.  This develops the habit of mouth breathing.  A baby can drink mother’s milk and breathe at the same time for the first 4 months or so of their life. This ability goes away as the throat lengthens and the larynx descends making speech more possible. Because of these early habits, mouth-breathing or chronic congestion, which is more prevalent in non breast feed babies, leads to a foreword head posture, poor dental occlusion, developing TMJ and craniofacial anomalies, headaches etc. as a child develops into an adult. Chronic low oxygen due to a poorly developed airway or out-right pediatric sleep apnea can lead to or exacerbate attention deficit syndrome and other personality deficits.

Breast feeding as the sole source of intake for a baby is encouraged for 6 months with ongoing nursing for at least a year.

Snoring Is Not A Laughing Matter

Did you know that the life expectancy of someone who snores can be significantly less than for someone who does not snore? The short answer of why is sleep apnea.  Sleep apnea is not just associated with the old and over weight but all ages.  It’s the condition where a person stops breathing many times during the night for 10 seconds or longer.  It helps to worsen or bring on things like weight gain, diabetes, high blood pressure, heart attack, stroke, congestive heart disease and other conditions along with daytime sleepiness, mental confusion, lack of energy and lessened libido. There is at least a 70 % immediate association with snoring and sleep apnea. All the rattling and vibrations associated with snoring effect the nearby carotid arteries.  The lining of these arteries change and cholesterol plaque adheres more easily to them.  When these plaques break loose, stroke is often the result. The snoring sounds are caused by the vibrations of various tissues in the back of the mouth and throat.  

Is there such a thing as simple snoring? Researchers are now saying no.  If a person snores there is an anatomy problem in the airway which will eventually lead to full blown, killing, sleep apnea. Well meaning dentists make anti-snoring devices, but if not trained in the medical model for diagnosis of sleep apnea, make what are called silent apnics. These people are at great risk of death due to the undiagnosed condition of sleep apnea. I urge all of my patients who snore to undergo a sleep study for a proper diagnosis and treatment plan.  The result may be an oral appliance properly fitted and tested or a C-Pap machine.  The alternative is Russian roulette with death. We used to say “he just died in his sleep.”   Now we know it was probably snoring, sleep apnea, and its co-morbid partners.

Snoring Grandkids?

When the kids or grandkids come for a visit do you hear them snore?  Maybe you hear little ones grind their teeth or make unusual sounds when they sleep.  Do your kids tell you of your grandkids having emotional problems, attention deficit problems or bed wetting? How about sleep walking or night terrors? Do your grandkids wake up screaming and yet they are not awake and you can’t get them to wake up?  Ever wonder how early or at what age a deviated nasal septum starts to develop? (very important)  What about severely worn down baby teeth (real short or flat)? Are your teeth really crooked and worn down? Do you have acid reflux problems and your teeth just seem to be melting away with pot holes all over them and a lot of sensitivity to cold?  Do you or your kids or grandkids have frequent headaches in the night or in the morning?  Does the back of your head ache besides being tender?  Do you ache around your jaw joint?  Are you waking up unable to open your mouth wide because your jaw seems stuck?

Ok, enough questions.  Answers to almost all of these questions revolve around our airway, both oral and nasal.  In short, a dentist trained in Craniofacial growth and development, pathology, and dental sleep medicine, can give you answers and solutions to all of the symptoms listed above.  TMJ and sleep problems are intertwined to a high degree.  Pediatric sleep apnea is often a result of overly enlarged tonsils or too narrow a palate and nasal structures.  Tonsillectomy and rapid palatal expansion will cure 95% of you grandkids night time and daytime problems.  The AAOP (American Academy of Oral facial Pain), or the AACP (American Academy of Crainio facial Pain), or the AADSM (American Academy of Dental Sleep Medicine) are a few organizations of dentists who take great interest in these kinds of problems. They list members by State and City.

Accelerated Dental Care

In my office, for those who need it, we promote dental cleanings more often than every 6 months.  Having a regular dental visit every 6 months is considered by many “regular dental care.”  The fact of the matter is that I have some patients I don’t schedule for re-care visits but once a year.  For them, this is adequate.  Others are at such high risk for decay or progressing gum disease that every three months is just barely enough.  Does dental insurance pay for these more frequent dental cleanings?  No, they would rather pay for more fillings, etc.  There are two times when people are most at risk for dental disease:  When they are children and when they are seniors. These two groups either forget to brush or sometimes can’t brush.  Children seem to get their hands on carbohydrates (sugars) more often and seniors suffer from the consequences of dryer mouths which make them highly susceptible to tooth decay. Seniors also lose the ability to brush due to physical ailments or they simply don’t remember anything including dental hygiene.  One of the hardest things for a senior to hear in my office is that all of their crowns have decay around them and they need to be replaced or they need dentures.  A retired senior usually has no dental insurance and a fixed budget based on Medicare, or the lucky ones have a retirement plan.  I’ve written before about the accelerated activity of dental plaque in a dry mouth.  The cause for less saliva is due to disease or the common side effects of blood pressure, diabetes, or most other medications that seniors take. That is why I have, for some time, been motivating my senior dental patients to come in more frequently and see my wonderful hygienist, Joni, for a good cleaning. “Accelerated dental care” is worth it.

An Alternative Cosmetic Dental Treatment Option

An often asked question from my dental patients is, “How can I make my smile look better without crowning or veneering all my front teeth?”  The answer depends on the condition of their front teeth of course.  If they are riddled with fillings on every surface, then crowning is the only option.  If their teeth are extremely crooked, then orthodontics is the reasonable approach.  If, on the other hand, they have a few fillings here or there and they are discolored, stained or mildly crooked, then a reasonable alternative is what I call a chair-side veneer.  White filling material (composite) is bonded (adhered) to the front side of the tooth. I then sculpt the material with my hand piece to the desired shape.  Generally no anesthetic is needed because I am not drilling into the tooth, but sculpting the surface of the adhered material just like a manicurist does when doing fingernails.  The resulting new look can be dramatic.  Crooked and discolored teeth can look perfect.  The cost is about one third the cost of a porcelain crown or veneer.  So what are the drawbacks?  Longevity, strength, and opacity are definite drawbacks to name a few.   Although a chair-side veneer, as I have described it, looks quite good, it is not as stunning as finely fired porcelain with the laboratory craftsman’s touch of color and translucency that copies nature.  If you are looking for a cosmetic change that might last five to ten years and costs a lot less than crowning, direct bonding (chair side-veneer) is the way to go.  Make sure your dentist does this procedure.  Not all dentists are comfortable in doing multiple teeth.  Some offices are willing to give a complimentary char side consultation and estimate as I do to help you make your decision.

Blood Thinners And Dental Tooth Extraction

What consequences are there, when extensive dental work is needed, in light of the often compromised health of aging seniors?  Of course, the answer depends on the health problem facing the senior.  It can be diabetes, high blood pressure, heart conditions including prior by-pass surgery or stint placement, joint replacement or bone density treatments with bisphosphinates.  Seniors worry most about the effect that blood thinners will have if they need dental extractions.  It used to be that, faced with a single or multiple extractions, a person on blood thinners would be taken off the blood thinning medication for at least 5 days before the surgery and 2 to 3 days following the surgery. Medical studies showed that there were more complications for people being off their medication for the approximate week than complications from bleeding following surgery, while still taking their blood thinning medication. So the standard protocol now followed is for the patient to go ahead with the tooth extraction and keep taking their medications.  Now with anything there are no 100% rules to follow for all circumstances.  If a person is not having his clotting time check periodically by his physician and or has been warned that he or she is at greater risk than normal for being on blood thinning medication when faced with surgery and should check with his physician before any scheduled surgery, than this situation might be different.  Dosages of medication can be changed etc. 

What I have observed is this:  even when I have to remove multiple teeth as for an immediate denture, the wound sites may be a little more oozy for a few more days but I have not had to send anyone back to their physician for clotting factor therapy. Single or multiple tooth extractions are generally tolerated without complication by people on blood thinners.

Choosing Between Dental Implants, And Fixed Or Removable Crown And Bridge Work

If you’ve lost teeth to the point that it is either cosmetically a problem or you can’t eat very well, dentistry does have answers. Just watch the TV and you’ll hear testimonials of how wonderful it is to smile and chew again. Which treatment option may be right for you? It may be time for a reality check when cost is a consideration.  The total replacement of all teeth with the popular “all on four” (meaning four specialized implants and a special kind of hybrid bridge/denture) can be between $20,000 to $30,000 per dental arch or in other words $50,000 to $60,000 dollars for the entire mouth. A complete set of dentures runs on average $2,200.00 in Saint George besides the cost of tooth extractions. A partial denture can be around $1,100. A single crown can be $900.  There are the cut-rate, down-graded outfits that may charge less or half (of what?) but that’s a whole other ball game.  One way or another, the old adage that you get what you pay for generally applies. There are a number of considerations the dentist must choose from when offering you a choice.  He bases his proposal on experience and training with different materials and devices.  He must choose materials that work best in his hands, for his patients.  The best advice I can give you when it comes to complicated major dental treatment plans is to get more than one opinion or estimate. Become educated the best you can on your overall options and then go with your intuition and feelings about what has been proposed to you.  Ask around; reputation and experience count for a lot. If your family and relatives have the experience of having been well treated for years by the same dentist, then that counts for a lot, versus the new in town highly discounted, slick add, discount, dental office. Buyer beware!


Dry Mouth… Improve Your Dental Hygiene

With advancing years, health concerns seem to creep up on most people.  Most medications including those for things like high blood pressure, diabetes, depression, etc. often cause a reduction in saliva production. Chemotherapy treatment for cancer also can reduce saliva. The result is that the mouth becomes very dry.  Saliva (spit) is very important for a number of reasons; from swallowing and digestion, to immune system interaction.  A critical roll saliva plays is the neutralizing of the acids produced by bacterial plaque on our teeth.  With lessened saliva, a person can become highly susceptible to dental decay. You mix things like loss of dexterity to brush teeth well, poor diet, medications producing dry mouth and possibly dementia and you have a wild fire of decay.  Even worse, people will often resort to a constant diet of mouth lozenges containing sugar to help stimulate saliva formation and that’s like throwing gas on a fire when it comes to dental decay.  A sad social comment is that our seniors in rest homes and care facilities, who can’t take care of themselves for their personal hygiene needs, suffer terribly from rampant decay around all their teeth, crowns, and fillings.  People who have had wonderful dental care all their lives suddenly can be faced with decay around all their crowns and fillings and are the least prepared to financially repair the damage now that they are retired and perhaps no longer have dental insurance. You can’t stop taking your medications or stop having another birthday, so what should you do? Here are a few suggestions:  Improve your dental hygiene efforts to the maximum.  Use fluoridated toothpastes and mouth washes.  Instead of waiting six months or a year for a dental check up and cleaning, schedule a cleaning every three months. Avoid a lot of sugars in your diet. Brush immediately after eating and don’t wait to do it just before bed. If you have a relative in a care facility, visits them and brush their teeth for them.

To Touch Or Not To Touch… Jaw Pain

Whenever my patients complain of pain in their jaw, I ask them to point to where it hurts. More often than not, they point to one of their chewing muscles.  Other patients complain of dull, aching toothache pain, but can’t tell me which tooth is hurting them, or if the pain is coming from the upper or lower jaw.  With these patients, I usually find the source of the pain is coming from their jaw closing muscles, and not in their teeth.  The pain from their muscles is being referred by their nervous system to make the patient believe it is coming from their teeth.  What brings about this type of masticatory muscle pain?  The answer is:  clenching.

A person clenches their teeth by forcefully holding their teeth together for a prolonged period of time.  There are only three times when teeth should touch.  They touch very lightly when pronouncing certain words or sounds.  They touch momentarily every time we swallow.  They touch periodically as we chew our food.  Humans do not grind their food like horses or cows.  Apart from these three types of tooth contact, a person’s teeth should be separated by a skinny eighth of an inch.  In other words, when the jaw is at rest the teeth should not be touching.  Dentists call this space between the teeth, the “freeway” space.  When my patients are having head and neck pains and associated tension headaches I invariably find clenching to be the root of the problem. 

What causes people to clench?  Apart from momentary physical exertion, the most frequent cause is stress.  Most people don’t realize that the way they are subconsciously dealing with the stress in their lives is to clench or grind their teeth together.  The repetitive contraction of muscles without proper resting periods damages muscle fibers and stimulates pain receptors that effect your nervous system, thereby telling your brain you have pain.  Referred pain and/or stimulation of headache is the result.  My treatment options for patients with muscle associated head and neck pain are as follows:
  1. I teach them self-awareness and self-observation in hope of consciously breaking the habit of clenching and stopping themselves from doing it.
  2. I make a dental splint or orthotic that when worn does not allow the patient to clench as forcefully and is a physical reminder that draws attention to the fact they are clenching.
  3. In certain circumstances I inject muscles with Botox, paralyzingly to some degree, the muscle and lessening its ability to contract. 
  4. I release taut muscle bands of overworked muscles, referred to by most people as knots, or technically called myofascial trigger points.  This is done by numerous techniques.  Some of the techniques I utilize are, pressure and massage, electrical stimulation, anesthetic injections, dry needling with acupuncture needles, and cold laser.
Over many years, clenching habits cause damage to the hard and soft tissues of the temporomandibular joint besides head and neck muscles.  But that is another topic.

Location, Location, Location, For Dentures

It’s true in business and it’s true in denture retention. Implants locate dentures in the proper location over the ridges of bone left after tooth removal.  They also keep the denture in place for efficient chewing of food and proper speech. Implants for dentures keep the denture from slipping or falling out of position or even the mouth.  I could tell you many stories of people who were ill and then vomiting flushed their dentures down the toilette.  Others yelling out a window or off a building have lost their dentures.  When we chew, the forces of mastication can pinch the underlying tissues if the denture is out of place even a very small amount.  This causes chronic irritation to the tissues of the mouth.  The old equation for cancer in the mouth is: repeated irritation plus the unknown equals cancer.  I’ve seen it.   

The common reasons people give for not getting implants to retain their dentures are, they heard they fail, cost, pain, don’t know what kind they need, their dentist doesn’t do them. Dental implants are over 95% successful.  Four Mini implants in my office, using Care Credit, can be around $200 dollars a month for a year with no interest.  In many cases old dentures can be retrofitted for the implants.  Medication is prescribed for the modest pain that is sometimes felt following implant placement. Four Mini implants per dental arch are the minimum number that should be used and are far superior in stability than the older way of just placing two large implants in the canine area.  The old two implant method still allows for rocking like a teeter totter.  Your dentist can refer you to my office if he doesn’t do implants.  My patients tell me “I wish I had gotten these Mini implants years ago”.

Helping Your Grandchildren Develop Proper Oral Health

People always want to know when their children should first see a dentist.  The answer is at about 1 year of age.  However before the child is born the fetus is developing an oral cavity that can be influenced for good through the nutritional health of the mother.  The next thing is the proper nursing of the baby.  A baby should be nursed in an upright position. A baby can breathe and swallow mother’s milk simultaneously for the early months of its life. This cannot take place if the baby is lying down and with its nose blocked from breathing. On my recent humanitarian visit to Guatemala I observed that the mothers there did this correctly.  The Mayan babies were held in a wrap that went over their mother’s shoulders and held them upright as they nursed. The proper position and correct breathing through the nose develops the baby’s airway and lengthens and forms the mandible (lower jaw).  The width of the palate and the whole position of the front of the face are affected in their growth when the child is held upright to nurse. Nitric oxide is formed in the nose and thus breathed in as it should be for the overall health of the baby.  When a child starts out as a mouth breather, they often stay that way.  They have problems later on with an underdeveloped face, leading to a shorter mandible and thus crowded teeth and tongue space.  This all leads to pediatric sleep apnea and a much greater potential for full blown sleep apnea as an adult. As the child develops through its first year the ability to swallow and breathe at the same time is done away with as the throat lengthens. Observe and educate your daughters and granddaughters how to nurse correctly.

Tooth Removal/Extractions

Teeth are removed by dentists for various reasons.  Depending on the condition and circumstances, not all teeth can or should be saved.  

I just returned from Guatemala with my Saint George Rotary Club.  The club members were installing vented stoves to help prevent respiratory disease among women and children in the high mountain villages.  I brought along my dental head light, extraction forceps and anesthetic.  While my club built stoves I announced that I could remove infected or abscessed teeth.  Most of the children had never seen a dentist.  Within minutes a table was draped and it became my operating table.  I saw both young and old for hours, having to leave with still many people hoping for care.  It was rewarding to be able to help, but an eye-opening experience that made me think about the dental pain and suffering many people live with on a daily basis.  

In our community dental services are readily available.  However, right here in Saint George, many people, especially children, still fall through the social safety nets and live with dental pain.  I’ve advocated in other articles the need to be a little nosy with those around you, especially family members, good friends or your grandchildren, as to their dental needs.  Many times a permanent tooth has not come up directly under the baby tooth.  When this happens the baby tooth’s root does not absorb and so the tooth does not become loose.  This can lead to crooked teeth, or a toothache.

Find out if there is a need that has been missed for perhaps financial reasons.  Be the Good Samaritan if you can, and help your grandchildren or your friends, or those around you if you are in a care facility to get relief from that toothache.

Limited Jaw Opening… Disc Displacement Without Reduction

Does the following story sound familiar? “My jaw joint used to pop or click all the time.  Then I heard a loud pop and from that day until now my jaw joint doesn’t make any sound, but I can’t open my mouth as wide.  It’s been gradually improving but it’s been three years, and I still can’t stick more than two fingers width between my teeth.”

If this has happened to you, your TMJ joint is in a partially locked condition. The correct diagnosis is “Disc Displacement Without Reduction”. This is as if your jaw joint were like a door that was stopped partially open.  Your TMJ joint is like a ball and socket with a disk that fits between the ball and the socket.  If the TMJ disk slips on and off the ball of your joint you hear a click or pop as you open and close.  When the disk gets stuck in front of the ball (like a door stop) then you can’t open all the way and it doesn’t make any sound because its movement is limited.

Should all people who hear a pop or click when they open and close their mouth seek treatment for their TMJ joint?  The answer is generally no unless you are having frequent locking and pain in your joint. Specialized splints (dental orthotics) can be made to stabilize your jaw joint before it locks up permanently.  After initial treatment this splint may need to be worn only at night.  Once the joint locks it can be very difficult and sometimes impossible to unlock.

Accommodation or a return to normal range of motion is possible to some extent with proper exercises and time.  In rare circumstances surgery can rectify the problem.  If you are symptomatic, early treatment is important to have a successful outcome.

Family Dental Tendencies… Jaw Size

Have you ever heard someone say, “I’ve got teeth like my dad’s or mom’s side of the family?” Genetics play a big role in the size and shape of not only the teeth, but the upper and lower jaw. I would like to focus your attention on your family tendencies of jaw size.  Seniors know the generation that has past on and see their own children and their grandchildren’s facial appearances. You may see when looking at all the people in your family, a square jaw, a protruding lower jaw, a retruded upper jaw, a wide smile, a little bird-like mouth, or big teeth in a little mouth.  Did you know that by the time a child is around seven years old the basic pattern for their dental arches and their relationship is established. There are studies that document that a properly proportioned size of both the upper and lower jaws, and their correct relationship, and “straight” teeth, are great predictors of success in life? I’m talking about good health, good self esteem, scholastic success, being socially adjusted, and often being financial successful.  As I have studied the development of the airway and sleep apnea in both adults and children I have gained an even greater appreciation for the development of the dental arches. The message I want you to take home is this; you don’t have to go to a foreign country to do humanitarian service.  The opportunity is all around you to better the lives of those you love.  Teach, stress, or pay for, if needed, the professionally guided facial growth and development of your grandchildren, or your neighbor’s children.  Take them to the dentist or orthodontist before the age of 7 and change a life. Adult orthodontic treatment or jaw surgery is an option at any age.

How Does A Denture Fit? …It’s All About Bone – Part 2

Part 2
In my last article the importance of bone, suction and seal with regards to denture retention/fit were discussed. This time I promised to help you with the decision of when (if needed), to remove your compromised teeth and replace them with implants and dentures. When teeth are removed the bone around the necks of those removed teeth shrinks with healing.  This process occurs over four to six months.  Almost always a denture is placed immediately after the teeth are removed.  Then in 4-6 months the denture is relined to fit the then healed ridge.  If a person has periodontal (gum) disease throughout their mouth, tooth loss is inevitable.  Generalized severe periodontal disease is if you have many 7milimeter or greater pocket depths, (the depth a small probe can be place along side a tooth and down beneath the gum line until the attachment of the gums to the tooth root occurs), with greater than 50% bone loss.  If tooth removal is postponed, the bone loss continues due to inflammation. Usually your dentist will tell you if this is your situation.  For various reasons which can be financial, psychological, time, fear, etc. patients put off the removal of the diseased teeth then more bone loss occurs. When the inevitable occurs and teeth are replaced with dentures there is very little bone left and even less after healing to hold a denture in place.  There may not be enough bone to hold implants in to retain the denture if the bone loss is great enough. The bottom line is to keep your teeth and gums healthy. If things are bad, do something now and don’t procrastinate or you can wind up in a terribly difficult situation.  Grafting is done if you want to use a rib or the crest of your pelvis or cadaver bone.  It’s expensive and painful.

How Does a Denture Fit?… It’s All About Bone

Part 1
Dentures (false teeth) strattle the ridge of the jaw bone.  A person’s upper denture also rests on the palate.

Think of a saddle on the back of a horse.  If you don’t cinch up the saddle with straps that go around the horse then the saddle won’t stay put as the horse moves and especially if someone is sitting on it.  You can’t strap a denture in place so how is it supposed to stay put?

The answer is suction and seal. Remember holding a glass upside down on a dish with some water in it?  If conditions were right you could lift the glass and plate together without them coming apart.  If you have a good fit of the denture base to the bony ridges of the mouth, with saliva and in some cases denture adhesive, you get a seal and suction of the denture.

In other articles I have extolled the virtue of implants as a huge boost to denture stability. Even implants need enough bone to hold them in place. For denture retention one way or another it’s all about bone. Natural teeth become loose if a person has periodontal disease.  The inflammation from the infection of the gum tissue destroys bone.  Add smoking to your lifestyle and its like throwing gasoline on the fire.  The quality of a person’s life has a lot to do with their mouth and what shape it’s in.  If your mouth is sore all the time it affects your mood, your speech and your ability to nourish yourself.  Chronic pain causes depression and personality changes.  In my next article I will tell you when it’s the right time to cash in your pearly whites.  Of course prevention is the key to good oral health. But split milk is spilt.

Snoring Consequences…A Sign Of Severe Medical Problems?

Emotionally, a lot of heartache is caused by snoring. Married couples sleep in different rooms or even get divorced over the problem.  Besides the unpleasant noise that keeps those in near proximity from sleeping, it can be a sign of severe medical problems. Young, or old, thin, or overweight, if you snore you have a good chance of having obstructive sleep apnea (OSA).

Think of snoring as the tip of the ice berg. If you snore you may have destructive medical issues, undiagnosed, that you are not aware of YET. OSA can be a direct contributor to acquiring hypertension, cardiovascular disease, headaches, respiratory conditions (especially asthma), diabetes, gastroesophageal acid reflux disease (GERD) and all with weight gain.  It also places you at high risk of stroke, and congestive heart failure.

With children, snoring at night often is resolved by the removal of oversized tonsils and expanding the dental arch to allow of more nasal breathing instead of mouth breathing. Exclusive mouth breathing can lead to improper facial growth, shiners with long faces and retruded lower jaws. Think of snoring like a jack hammer on the other side of a wall.  Before long everything vibrates off the wall and then the wall crumbles.  Our carotid arteries are on right next to our airways.  Snoring vibrates your whole airway and your carotid arteries to excess and inflammation sets in.  Then a cascade of events leads to artery disease and the high risk of stroke.  

As a dentist that is trained in the recognition of the signs and symptoms of sleep apnea, I make it a part of my oral examinations to look not only at the teeth but at the area of the back of the mouth (uvula, tonsilar area, upper pharynx) for sign of inflammation.  Then with a few key questions I can determine if it is prudent to refer to an M.D. sleep specialist who may refer the patient back to me to make a sleep orthotic instead of wearing a C-PAP machine.   Snoring is not just annoying it can kill you.

Denture Stability And Retention… The Benefits Of Implants

A lower full denture is usually not stable and chewing with it can be quite a difficult and an embarrassing balancing act. What’s the solution?  Implants.  There is a great variety of implants and ways to attach them to people’s dentures to hold them in place. I have chosen to use a system that you might compare to a trailer hitch.  On the end of the implant is a round ball that fits into the bottom of the denture which has a housing (keeper cap) that fits over and holds onto that ball. This keeper cap has a little rubber O-ring to snug down onto the ball for retention. The “snap on” types of attachments are, in my opinion, like riding in car with no shock absorbers.  The ride is jarring and rough.  With a rubber O-ring the ride is cushioned and resembles the small give of tissue and so the bite feels more natural while still being retentive.  For stability and balance the use of four or more implants is best.  A teeter-totter is comparable to a denture with only two implants for retention. It rocks from the front to the back of the mouth on the implants. The types of titanium implants I use are called mini implants. I can use four and get the greater stability for less money than the two wide body implants with the “snap on” feature (the rough ride type).  The “Snap on” type engage with plastics clips that lose there retentiveness within months. I have over 1,000 of these types of implants placed and in service. I have patients that have had mini implants with the rubber O-ring type retention devices in place for as long as 8 years before needing replacement.  The average replacement time is two to three years.

Improvements In Implant Dentistry… Hybrid Teeth/Dentures

Have you ever heard a denture wearer complain about their false teeth? Sometimes besides the superlatives they will exclaim “I wish the dentist could just glue these darn things in permanently so they would stay put”.  Well that day has arrived. As the art of implant dentistry has improved along with most dental materials the ability to replace teeth has become more technically possible.  Working as a team dentists and laboratory technicians can replace teeth that have been lost, with dentures that are secured semi-permanently (at least they aren’t taken in and out by the patient). These dentures are called hybrid dentures.  Four to six implants are strategically place around the dental arch of missing teeth.  A denture is made that has specialized attachments to connect to the implants.  After the denture is fitted and adjusted it is then screwed or attached on to the implants.  The holes through the denture are then filled in with acrylic and polished.  The advantages are as follows.  Instead of ten to fourteen individual implants with crowns and bridges attached, only four to six implants are required. This is less expensive and more possible when the patient doesn’t have enough bone or sinuses to dodge.  The shape of the dentures can be made to be much smaller than a regular denture not covering the persons pallet or go around the sides of the dental arch.  They are cleanable and maintainable. You do not have to take them in our out to clean and of course they stay absolutely in place. Should there be a problem they can be removed serviced cleaned and replaced. This is a more complex procedure then a denture held in with mini implants. I team up with by dental technician and an oral surgeon to assure the finest of results for the patient.  

Denture Wearing… A Balancing Act

The lower denture is like a little horseshoe floating on a sea of saliva with the big tongue pushing it all around.  It’s not stable and chewing with it can be quite a difficult and an embarrassing balancing act.  Thank goodness for titanium posts (implants), that dentures can be attached to, to hold them in place.  There is a great variety of implants and ways to attach them to people’s dentures.  I have chosen to use a system that you might compare to a trailer hitch.  On the end of the implant is a round ball that fits into the bottom of the denture which has a housing (keeper cap) that fits over and holds onto that ball.  This keeper cap has a little rubber O ring that snugs down onto the ball for retention.  Snapping on is not a good description of this type of retention.  The “snap on” types of attachments are, in my opinion, like riding in a car with no shock absorbers.  The ride is jarring and rough.  With a rubber O ring the ride is cushioned and resembles the small give of tissue and so the bite feels more natural while still being retentive, and less stressful on the implant.  

For stability and balance the use of four or more implants is better.  A teeter-totter is comparable to a denture with only two implants for retention.  It rocks from the front to the back of the mouth on the implants.  My preference is to place four implants as far apart as possible avoiding the nerves in the jaw bone.  This distributes the pressures of chewing.  The types of titanium implants I use are called mini implants.  I can use four and get the greater stability for less money than the two wide body implants with the “snap on” feature (the rough ride type) 

Teeth And The Golden Years… Make A Lasting Choice

In past articles I have extolled the many advantages for seniors and their overall physical health to be able to eat properly when they are battling the aging process.  There is enjoyment and satisfaction being able to enjoy a meal alone or with friends and family without pain or embarrassment.  My hat is off to the many that have made good decisions about dental care along the way.  Seniors need to place value and priority on getting and maintaining the best dental health they you can.  What is it worth?  Is it too much to spend one thousand, ten thousand, and twenty thousand dollars?  How much do people spend on cars, vacations, animals, four wheelers and other recreational desires?  Is dental health a budgeted, planned expense?  Or do you spend money on dentistry only if it’s an emergency when a tooth hurts or is broken? 

I frequently hear “I’m on a fixed budget…I have no dental insurance…I’m not going to live that long…I don’t care about how my teeth look, etc.”  I’m a realist and know there are limits that vary with personal budgets.  I’m not saying that every last tooth should be saved at all costs.  Sometimes the best solution has to be tooth extraction or dentures.  My plea is do something about your dental condition that will sustain or improve it while you have choices.  I see difficult and physically dangerous situations that I have to take care of due to prior procrastination, non-treatment, or having chosen in the past the cheapest and quickest fix.  Misery and suffering from dental neglect is costly both financially and emotionally.  Dentists are caring individuals who are concerned about their patient’s well-being.  I feel great satisfaction when I am successful at motivating people to make lasting choices for their dental health. 

How To Avoid The Dreaded “Denture Look”… It Isn’t As Easy As It Looks

Have you ever looked at someone and said “That sure looks like a denture smile?”  When people lose teeth and get them replaced with false teeth it happens in stages.  The back teeth are lost first.  Partial dentures are made to fit the opposing teeth.  With time, other teeth are lost and so the partial denture is added to, or an upper denture is placed and the natural teeth are removed.  In the process of all these changes the proper relationship of the top teeth to the bottom teeth is lost and this is when the “denture look” creeps in.  There are certain harmonious relationships and curves to the dental arch that need to be considered. 

Patients often say their upper denture fits well and want me to make a lower denture and place the mini implants I’m known for, to hold it in better.  Sometimes I can, but often I need to tell them no.  In order for their dentures to work well I need to correct their bite and have it balanced carefully to accommodate implants.  The smile line, length, and color of teeth are important.  The fullness of the lip, the midline of the smile, and many more things all contribute to either a natural looking smile or the “denture look.”  To make only one denture to relate to a poorly constructed old opposing denture just insures that the old mistakes will be passed on to the new denture.  As ridges resorbe the vertical dimension (the distance between the dental arches) collapses and the denture wearer over closes and again, the dreaded “denture look” appears.  

In my office, I take great care to insure that a natural and balanced set of dentures is the final result.  See my ad for an example of a natural look vs. the “denture look.”

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