Blogs Written by Dr. Richard Janis
When I went to dental school, there was very little information given to us about nutrition. Other than the relationship between sugar and dental decay, I only remember one day of lecture in 4 years that dealt with the subject. As a result, I have never considered myself an expert on nutrition, although I have attempted to learn more over the years.
A few years ago, I wrote a blog which I titled “The Cracked Tooth” The Cracked Tooth : Blogs Written by Dr. Richard Janis in which I discussed the increase in cracked teeth I had been noticing in recent years compared to earlier in my career. A check on dental forums confirmed what I had been noticing and some endodontists (root canal specialists) were even calling it an epidemic. No one seems to know the cause but an increase in teeth grinding (as a result of stress) is thought to be the biggest reason.
Whenever a patient of mine breaks a tooth, I ask what they were eating. Sometimes it is nothing hard at all and the tooth was just ready to break from a large filling or a crack, the food truly being a case of “the straw that broke the camel’s back”. But what I have come to notice is that often the cause of a tooth breaking is nuts, a healthy snack. The irony is not lost on me that the patient is doing something good for themselves, eating a healthy snack and as a result, their tooth breaks.
No question about, nuts are a healthy snack when it comes to your general health. They are a good source of fiber, protein, and unsaturated fat, in addition to containing many important vitamins and minerals. But look what they have done to some of my patients’ teeth! In one recent week, 3 patients broke their teeth eating almonds!
Studies show that people that eat nuts live longer than those who don’t. This is probably due to a their role in the prevention of certain chronic diseases, like diabetes and cardiovascular disease. I even found one study that showed nuts to be significantly associated with a reduced risk of cancer. Some of the nuts known to be good for your health are almonds, pistachios, walnuts, cashews, and pecans.
As far as your teeth, there are some benefits from nuts. Many are low in carbohydrates so they do not add to the risk of decay. Chewing nuts also reduces your risk for cavities by stimulating saliva production. So it is not exactly correct to say that nuts are “good for your health but bad for your teeth” because they can be good for your teeth but there can be some negative consequences as well.
Almonds seem to be the nut that I have seen break the most teeth. They are healthy but their texture is hard and can put stress on your teeth and cause cracks. I have one patient that broke two teeth eating almonds (one cracked down the whole root and required an extraction and an implant). She still eats almonds but tells me that she now eats them sliced.
What are some suggestions to continue eating this healthy snack but also to protect your teeth? One thing, with almonds at least, is to eat them sliced as my patient now does. Soaking them before eating can also make them softer and many believe this provides health benefits as well. If anyone has other ideas on how to make eating nuts safer for your teeth, please share them and I can put them in the comments section.
Pictures of the damage caused to some of my patients:
He was more than a friend. He was a member of our family. We got Rocky as a gift for my son twelve years ago. Last month we found out he had an aggressive cancer that could not be treated. The vet told us something I never knew: Dogs hide their pain for several reasons but one may be that they want to please you.Then sometimes you don't find out about things until it is too late.
I don’t think I have ever met a more gentle, kind being. He taught me that you can never have too many friends. He was always making friends. People of all ages, especially little kids, would always come up to him in the park, sensing his kind, gentle nature. People often would ask me how I relax, how I would de-stress. I would say that having a dog like Rocky was part of that. He gave unconditional love and loyalty, always had a sweet, sunny, disposition, always happy to see you, always wanting you to be happy. Nothing could bring him down. He could make the grumpiest person smile. It was just part of his nature.
Rocky hated conflict. He would get upset when he would see it. His nature was to fight against it. Are all golden retrievers like that? I don’t know but that was a very appealing part of Rocky’s personality. He had a calming influence on everyone. We had a lot of great times and great family trips. He loved to hike and we did so many over the years. He was very social and just loved being around people and other dogs as well. Parties made him happy. He would bark continuously if there was a party going on in the house and he was not allowed to be part of it.
The diagnosis was devastating for my family, especially since he only lasted for a few days afterwards. It was heartbreaking to see him go but he was suffering greatly. Having to put him down was honestly one of the hardest things I have ever had to do. I was there with him until the very end and it was very difficult for myself and my family.
We gave him love and a good life but he gave us so much more. So many things were easier because of him, even dealing with the death of my parents. The way I feel about Rocky is that if everyone had a friend like him, the world would be a much better place. I saw a quote but don’t know who it is attributed to: “The cruelest trick on mankind is the lifespan of a dog.” I can definitely agree with that. I have had a lot of pets in my lifetime but don’t think I have ever missed one as much as I miss Rocky.
Dentistry is not often in the news but several months ago there were some stories about the lack of evidence for the benefits of flossing. It was reported that the recommendation to floss was dropped from the U.S. Dietary Guidelines this year, after having been recommended since 1979. An enterprising reporter wrote to the government and was told that there was just not much evidence for the benefits of flossing and that is why it was dropped.
Like everyone else, I was surprised at this as I had always accepted the benefits. The stories said there was no research showing the benefits of flossing. I don’t remember reading about any research when I was in dental school but it is just common sense that cleaning between the teeth would reduce the incidence of dental disease. My observations are just anecdotal, both with my personal experience and what I have seen in 25 years of dental practice. My personal experience is that I have a small cavity between two teeth in my mouth that has not progressed for over 25 years. I believe it is due to daily flossing. My personal observations are that my patients who floss regularly tend to have fewer cavities and less gum disease.
I have had a number of patients ask me about the stories they had seen and what I thought of this issue. Of course, I continue to recommend flossing. You would have a hard time finding any dental professional saying that flossing is not beneficial, regardless of a lack of research.
I looked a little deeper into this topic and it turns out that there really is not a lot of research out there. There are short term studies showing that flossing reduces mild gum disease but no long-term data. Most of the studies are funded by industry and so there is more chance of bias. The studies that are out there do show that flossing results in a lowering of plaque. But there is no hard evidence that flossing prevents periodontitis, the most severe form of gum disease.
So the consensus is that the scientific evidence is weak, meaning in this case that there is just no proof that flossing helps prevent dental disease. One of the problems with doing large scale research of health care issues of this kind is that they must rely on self reporting of behavior, which is not always accurate. Lack of research does not mean something does not work, however. I recently received a newsletter about this issue from the National Institutes of Health, which is a part of the U.S. Department of Health and Human Services. I am going to quote what one of the researchers said: “The fact that there hasn’t been a huge population-based study of flossing doesn’t mean that flossing is not effective. It simply suggests that large studies are difficult and expensive to conduct when you’re monitoring health behaviors of any kind.”
The newsletter goes on to say that even though scientific evidence is lacking, there isn’t any harm in flossing and it is low cost so why not do it daily? I agree completely. I also believe that everyone who works in a dental office, having seen the benefits of flossing, would agree with that as well and that is enough for me to continue recommending it.
I recently had the opportunity to complete a project that I started 7 years ago, when my mother passed away. My mother died in 2009 after a long battle with kidney cancer. She was treated for the last few years of her life at the City of Hope in Southern California, a wonderful center for cancer treatment.
Although my mother taught elementary school for over 30 years, her passion in life was art. She loved many forms of art including painting, drawing, sculpture, and ceramics and she studied all of them but was chiefly a painter of abstract art. Her art career spanned over 40 years, which included earning a master's degree and some time teaching art. She showed her work in galleries and art shows, mainly in Southern California, where she developed a good following of people who really admired her talent with colors and shapes. I have several of her paintings at my office and get many compliments on them. She was still doing art up until 6 months before she passed away.
Although my mother did sell her art, she was prolific and after she was gone we still had over 130 of her paintings, some sculptures, and hundreds of drawings and prints. My sisters and I had many pieces of her art so the question was: What should we do with the remaining art?
The City of Hope had been very wonderful to my mother and I decided to see if I could sell some of her art and donate all of the proceeds to them. The goal was to get her art out there for people to enjoy and at the same time raise some money for kidney cancer research. This was an ambitious project for me, a non-artist. I really did not know much about the art world, other than what I had learned from my mother. I had helped her at some art shows and got to learn a little about it that way.
The first thing I did was to get all of her art into storage in Southern California. I rented a U-Haul and my nephew helped me move all of the art. My mother had a website for her art but it didn’t have many of her paintings on it so I hired an art student to help me photograph the remaining art and I uploaded the photos of the remaining paintings. I contacted the City of Hope and they took some pieces for a fund-raising auction and I gave a painting to my mother’s oncologist and one to the nurse who cared for her. I wrote to auction houses, galleries and art dealers throughout Southern California. Some of the art dealers and gallery owners did like her work but they could not commit to anything. They explained to me that the art world was getting increasingly competitive and that they were constantly being inundated with requests from artists trying to sell and market their work. I realized this was going to be difficult. I constantly asked for advice and what I was told was that the best avenue for selling my mother’s art was to contact the people who had previously bought from her.My mother had a mailing list of over 200 people who had bought her work or talked with her at one of her shows. I composed a letter to all of them, telling them of my mother’s death and explaining the project I was working on. I provided the link to her website and offered to deliver the paintings personally to anywhere in Southern California. I received many very nice letters and e-mails back. People told me stories about meeting my mother at art shows and it was very heartwarming. A number of people wanted to buy her work and I initially sold about 30 paintings this way, delivering them to the Los Angeles and San Diego areas. It was a fun experience for me to walk into people’s homes and see my mother’s art on their walls. I got to see how much people admired her and her art.I continued this project for some years, always working on it when I made trips to Southern California. I continued to contact people from her mailing list who asked me to stay in touch and I was able to sell some more paintings this way. I wrote to hospitals, banks, cafes, hotels (anywhere I would see art) and asked them if they would display my mother’s art. Some expressed interest but told me that they were inundated with requests and had a waiting list of artist’s work to display.
A few years ago I decided to donate her remaining art. I had exhausted my best avenues for selling it and I had raised thousands of dollars for research at the City of Hope. I wrote to art departments at colleges and universities and asked for advice. Most had no ideas but one suggested I try health care facilities and senior centers so I wrote to some in the Pasadena area, where the art was being stored. I was able to donate some paintings that way. I would sometimes list the paintings for sale on craigslist before one of my trips and I sold a few that way.
Recently I realized that I still had around 60 paintings left as well as many drawings and prints. I wanted to complete this project. Listing the paintings for sale on craigslist had never brought about a big response. This time I decided to do something different. I posted an ad on the "free" section of craigslist. I was a little wary of doing this as I wanted my mother's art to go to people that would appreciate it. The "free" section is filled with things like old couches and computer monitors that people want to get rid of. Would I find people there that would appreciate original abstract art of the type my mother did?
I placed the ad, showing just one painting and saying that I had some beautiful, original art to donate to those who would appreciate it. The response to just this one painting stunned me. Within just 2 days, over 50 people responded to my ad, many asking if they could come right away to see the art. I wrote back to everyone and sent them a link to the website, where they could see everything. This generated even more interest and I received many more e-mails about how much people admired my mother's art. I had a trip planned to Southern California where I could only be at the storage unit for one day and I set up some time for people to look at my mother's paintings.
When I arrived in Pasadena, I first set aside time for a few people that had previously purchased my mother’s art. One woman came all the way from Phoenix and another from San Diego to choose some of my mother’s art. I also gave some pieces to the director of a health care facility near Pasadena. After that, I met with people who had contacted me regarding the ad I placed. There were 15-20 people that came. One was a woman who wanted some paintings for a fundraiser for her father, who had just been diagnosed with cancer. Others came who had just moved into new homes and were looking for some original art. One man was an art instructor who wanted to use some of my mother’s art for his classes. What they all had in common was that they loved and appreciated my mother’s work. The people who came were of all ages and what I learned is that there is a real hunger for original art, even though many people cannot afford it. By the end of the day, all of the art was gone and some were disappointed that there was not more. I had found a place for all of my mother’s art and my project was completed.
I asked people to send me photos of my mother’s art when they had it up and many have done so. Everyone who came on that day was very grateful for this donation of art. What they didn’t understand was that I was very grateful as well. Before my mother passed away, not wanting to burden me, she had told me to toss out her art after she was gone. I told her that I would not do that. Over 7 years I was able to sell and donate her remaining work to people who really appreciate it and I am very happy that I was able to end the project this way.
The same can now be said with regard to implants. I learned about implants in school but almost no one, including the instructors, was doing them. In my first years of practice, I only restored a handful of implants but in the last 10 years, I have restored hundreds, including both large and small cases. Years ago most of my patients had heard little about dental implants and most did not know anyone that had one. Now it is rare that I find a patient who doesn’t know someone who has had a dental implant. In my own family, my father had dental implants even after the age of 80 and my younger sister had an implant in her 20s due to a childhood accident which caused her to lose a front tooth at a young age.
What are implants? Dental implants are metal rods or posts made of titanium that are surgically placed in the bone. Over a period of months they integrate into the jawbone and then they can be used to support a crown, bridge, or a denture. The ability to integrate into bone is the development that makes them a game changer because now when a tooth is lost, there is a replacement that feels and functions like a natural tooth. When I ask one of my patients with an implant how their implant is doing, the response I usually get is, “I no longer even know it is there.”
Why are implants better than other alternatives for missing teeth? If a single tooth is lost, an implant can be used and when it becomes fused to the bone, a crown can be placed over it. The adjacent teeth will not be touched. A fixed bridge is also a way to replace a missing tooth but it involves grinding down adjacent teeth to support a missing tooth. Those teeth used to support a bridge are now more susceptible to needing other treatment, including root canals. Before implants were common, I was doing many bridges every year. Now I only do them on rare occasions because an implant is usually better treatment. In replacing a single missing tooth, an implant is taking a one tooth problem and leaving it as a one tooth problem. A bridge is solving a one tooth problem but potentially creating a three teeth problem. Since implants are made of titanium, they can never decay. However, they are susceptible to periodontal disease just as natural teeth are.
Implants can also be used to support a denture or partial denture, providing much greater stability and retention. This procedure has, in my opinion, provided greater satisfaction for my patients than any other treatment I have done.
What about costs? Implant are not inexpensive and certainly cost more than other procedures. If an implant is done to replace a single tooth, the cost will generally be about 25-30% higher than the cost of a bridge. However, even with the greater expense, I have yet to have a patient that regretted having a dental implant done. It is the best procedure dentistry has for replacing a missing tooth and it is almost always the treatment that I recommend.
I had a gum tissue graft surgery done on me last fall. It was the first dental treatment I had needed for a while. It was done by a colleague of mine, Dr. Stephen Reid, an excellent periodontist that I have known for a long time. The need for the treatment was that I have a lot of recession and the strong tissue needed to prevent further recession was missing on some teeth. The procedure involved removing some tissue from the palate and placing it next to those teeth that have recession. Dr. Reid did a couple of grafts on me more than 10 years ago and those have been very successful in preventing further recession and bone loss.
Not many people enjoy going to the dentist and I can't say that I am any different, especially if it involves palatal injections and palatal surgery. But the procedure went very well and I had minimal pain. My treatment caused me to reflect on how we are influenced by our experiences and how my experiences have affected my philosophy of practice as a dentist.
Growing up, I had no bad dental experiences (if I had, I am sure I would not have become a dentist). My oral hygiene as a kid wasn't too great and I ate a lot of sweets. I had a few cavities but for the most part I was lucky and had little decay. I went to the dentist regularly and had fluoride treatments. How do I think luck played a role? Well, my teeth were straight and didn't have a lot of grooves in them, making them easier to clean and less prone to decay. When I got to dental school, we did tests for bacteria in our saliva and I was found to have little of the main bacteria known to cause decay. To me, that was another explanation for my lack of decay.
As an adult, my oral hygiene has been very good, at least since entering dental school. Just before entering dental school, I went to a dentist, who found a cavity between my teeth. He said it was small and was only in the enamel (the outer layer of the tooth). He advised me to floss daily and said that if it progressed, the cavity would need to be filled. Well, since that time, I have flossed nearly every day. That tooth has been x-rayed many times and the cavity has not gotten larger, even though it has been over 25 years! Small cavities between the teeth can become arrested and remineralize, if there is good oral hygiene. I knew this and learned it in dental school but nothing is more powerful than your own experience, which has influenced me in the way I practice dentistry, causing me to be very conservative in my approach.
What about the recession and bone loss I have experienced? Why didn't good oral hygiene prevent them? Dr. Reid believes that I am one of the people susceptible to the bacteria that can cause bone loss. The treatment recommendation has been regular cleanings, good oral hygiene, antimicrobial rinses, and gum graft surgeries to prevent further recession. This has worked for me over the last 13+ years that I have seen Dr. Reid. My first grafts are over 12 years old and have prevented further recession.
Dentistry, like medicine, is not an exact science. Sometimes one treatment that works on one person will not work well for another. I have seen a lot of things that have surprised me. I have seen people move here from other countries as adults that have never seen a dentist in their life and they have not had a single cavity. This is likely due to the lack of sugar in their diet when growing up. I have also seen patients come every 3 months to the dentist only to continue to have decay, even when controlling their diet. There are often multiple factors involved in causing dental problems, like teeth grinding or dry mouth caused by medications. For the most part, however, we know how to control dental disease. I wrote about some of this a few years ago in a blog I called “How to keep your dental bills low”. The last advice on the blog, visit your dentist and hygienist regularly, does sound self-serving but it is one thing guaranteed to lower your dental costs and dental problems over time.
I am writing this blog because I have noticed an increase in the number of fractured and cracked teeth in my practice over the last 6-7 years as compared to the previous 15 or so years. Why is this? I don’t know for sure but there are likely multiple reasons for this, including old fillings, the type of restoration in the tooth, and teeth grinding- which I believe is the major cause of the increase.
I have researched this, even talking to a colleague of mine who is a root canal specialist. Root canal specialists diagnose more fractures than other dentists as they utilize a microscope and have more advanced training. He says that everyone is seeing more fractures but the reasons for them are not documented in the research yet. It is becoming so prevalent that there is even a lecture at one of the dental meetings entitled, “Cracked Teeth. A Modern Epidemic?”
When teeth break, like in the below on the left, it is easy for us to see and make a diagnosis. However, cracked teeth without obvious signs are hard for even
experienced dentists to diagnose and it is a perplexing issue for many. I am talking about situations like the one in the photo on the right, where the patient has a shallow filling and no evidence of decay or fracture on the x-ray.
When I removed this filling due to pain, a fracture was seen and a root canal was needed because the pain did not go away, indicating a communication with the nerve of the tooth. I suspected this beforehand because there was a small filling only and no decay. What else could be causing the pain? The diagnosis is often made by a process of elimination. X-rays rarely show a fracture.
Actually, there are some other factors that could be causing the pain, including headaches, joint problems, and sinus issues. This is what makes the diagnosis difficult. Early diagnosis will often result in a better prognosis for the tooth. Many fractured teeth end up needing root canals or extraction. Sometimes doing a crown will prevent this but it is hard to know when to do one. We want to be sure that the pain is not arising from another source, such as mentioned above. Craze lines on the chewing surfaces of teeth can often be mistaken for other, more serious types of cracks and it would be a mistake to initiate treatment on all teeth with these as it would result in unnecessary treatment much of the time. I would want more evidence of a problem before beginning treatment.
What do I look for? Well, most commonly a patient will report pain upon chewing, especially with tough, grainy foods and sharp pain when something cold touches the tooth. Cracked teeth may have symptoms that range from slight to severe pain. Some people point the finger at old silver fillings, which corrode and are often thought to cause teeth to break but that is controversial because I have seen fillings last for more than 30 years without causing teeth to crack. On the other hand, most of the broken teeth that I see have an old silver filling in them. Removing an existing filling always results in the loss of additional tooth structure so you want to have a good reason for doing it.
These are some things that I can conclude about cracked teeth, along with preventive measures:
1) If a tooth has a filling (especially an old one) and there is pain that is persistent, it is best to remove the filling and evaluate even if the filling looks fine in the clinical exam and on the x-ray. Sometimes we will find just a little decay and we can replace the filling and that is all that is needed. Sometimes I will see a crack that goes deep into the tooth, indicating the need for a root canal and crown. In the worst case scenario, the fracture extends down the root and the tooth will need to be removed.
2) Early treatment leads to the best prognosis for the tooth. If a tooth breaks, it should be evaluated fairly soon. Decay will not happen rapidly but if there is a crack in the tooth, it would be best to protect the tooth with a new restoration, possibly a crown.
3) If there is persistent pain on a tooth, particularly upon biting, it should be looked at. It may be something else, like a sinus infection, (especially if the patient recently had a cold) or a jaw joint problem. If the pain is mild, sometimes we can monitor the tooth. The nerve may become inflamed, but that inflammation may be reversible and the pain may go away. A fracture into the nerve will result in pain that will not subside, however, and treatment will be necessary.
4) The most likely cause of an increase in tooth fractures is grinding of the teeth, thought to be caused by stress. People predominantly grind their teeth at night and I have witnessed how hard people can be on their teeth. A nightguard is recommended in those cases. Those who grind their teeth are more likely to create cracks in them but a nightguard can prevent the need for more extensive and expensive treatment, such as a root canal and crown, or even an extraction and implant.
5) Evaluating a possible cracked tooth can be a challenge for any dentist. Other conditions can mimic tooth pain and it is important to be aware of that. This is an area in which there is an ovelap of medicine and dentistry. Many patients end up seeing both their physician and their dentist in order to find the source of their pain.
This tooth below had no decay or filling but ended up with a fracture that extended down the root and needed to be extracted.
Dentistry in the last 15 years has experienced nothing short of a revolution in terms of technology, materials, and restorative options. Some of it is not apparent to the patient, such as technologies used in the dental lab and bonding agents and materials that are much stronger. What this has allowed, however, is for us to be able to be much more conservative in many situations.
One thing I noticed when I first got to dental school (and probably every other dental student did as well) was how much tooth structure needed to be removed in order to restore teeth. You can see this in the first photo on the top right. It truly amazed me that for even a small cavity, a large amount of tooth structure would often need to be removed. This is because most of the fillings we were using didn’t bond to the tooth and so mechanical retention was needed. That is something that has changed. (See the photos below of the tooth colored filling with only minimal tooth structure removed.)
Even more surprising to me was when a crown was needed. Posterior teeth have multiple cusps (peaks on the teeth that are used for chewing). When one breaks, a filling is no longer a good option as it will not be strong enough to support the tooth. So even when only one cusp would break on a molar tooth (which generally has four cusps), the whole tooth would need to be trimmed down for a crown, if an esthetic option was desired. Of course, a conservative gold option has always been available but most people want something more cosmetic.
A full crown often would seem to me to be too aggressive, especially when only a small part of the tooth would be broken. More tooth removal leads to greater risk of root canals or other dental problems. But until fairly recently, we had no other good esthetic options. Now we do, with partial crowns, porcelain onlays, and veneers. These rely a lot more on bonding than mechanical retention. But with newer, stronger materials and better bonding systems we can preserve a lot more of the tooth than we could before. The photos above and below compare a full crown with a porcelain onlay (which only replaces the missing, broken or decayed portion of the tooth).
Another area that allows us to be more conservative is the use of dental implants when a tooth is lost. I wrote a blog about this a while back (Implants: The Game Changer In Dentistry). If a tooth is lost, an implant can be used to replace it and this remains a one tooth problem. A bridge is also an option but it involves grinding down adjacent teeth and takes a one tooth problem and makes it a three tooth problem. When adjacent teeth are involved and are trimmed down, they now become more at risk for other dental problems. A bridge is definitely not a conservative option and I rarely recommend it over an implant.
Sometimes being aggressive with a treatment is needed, such as when more tooth structure needs to be removed for esthetic reasons or bonding is not possible in an area of the mouth. But in most cases, it is best for the patient when we try to be conservative. Thanks to the advances in dentistry, this is now something we can achieve.
A common occurrence in my office is for someone to show up with a broken tooth. A question that I get asked a lot when a tooth breaks badly is, “Can this tooth be saved”? The answer is not always so simple. I have been doing this for over 20 years and my views have changed with the advent of predictable implant treatment. A better question is, “Is this tooth worth saving”? The answer is, “It depends”. Often, a tooth that is badly broken down can be saved with a root canal, crown build-up, and a crown. If the tooth has broken far below the gumline, then crown lengthening by a periodontist may also be needed to expose more tooth structure to support the crown.
However, another and often better option exists, and that is removal of the tooth and placement of an implant and crown. Of course, extraction and a bridge is also an option but for the purposes of this blog, I will discuss the best option, an implant and crown. A dental implant is a device made of titanium that is placed in the bone to replace the missing root. A crown is then placed on top of it. In the case where a tooth is badly broken down, this option will have a better prognosis. A root canal, build-up, and crown can be a good option and I have done many of them but I have also seen failures. Sometimes all of that is done and a few years down the road the patient comes in with a crown and tooth broken and not restorable. An extraction now has to be done and that, of course, is very frustrating and it has caused me to think long and hard about what is the best investment for my patient. So when is a tooth that is broken down worth saving? I believe if there is a good implant option, then a tooth is only worth saving if it has a better than fair prognosis. In other words, a good prognosis or better. How do I decide on the prognosis? Well, of course only time will tell if the decision was a good one but it is experience that allows me to decide.
I have been in my present office for almost 8 years and worked at the same place previously for over 15 years so that has given me the advantage of following-up and seeing what works and what doesn’t. A root canal, build-up and crown with periodontal surgery are sometimes what we might call “heroic measures” to save a tooth. Historically, that is what was done routinely, even if the prognosis was fair, because that was all we had other than extraction. Implants have brought a paradigm shift in dentistry and I rarely recommend heroic measures anymore. Dental implants are predictable and have a very good prognosis and that is why they are often the better option. Of course, there are exceptions, such as when the patient is unable to have an implant for medical reasons or if the tooth that breaks already has a root canal and the patient would be better served by just putting a crown on rather than having an extraction and an implant.
And what about the cost? A root canal, build-up of the tooth, and a crown can cost about 30% less than an extraction and an implant but if periodontal surgery is involved, the cost would be only 10-15% less. So cost is a consideration but I believe that the long-term prognosis should be the bigger consideration. An implant has a very good long-term prognosis. I am fond of saying that I have never had a patient regret the investment of having an implant done. I know that my patients are thinking of their improved quality of life and the long-term prognosis when they tell me that.
My dad passed
away peacefully in his sleep last month at the age of 87. He had a great influence on my life and I
miss him very much. He was a veteran of
World War II, fought in the Battle of Okinawa, and was training to be involved
in the invasion of
When I was growing up, we did a lot of great things together, one of which was to go to a lot of baseball games as we shared a passion for the game. My dad just missed seeing Babe Ruth but he saw all of the other great players of his era. We attended hundreds of games together and it was always fun and interesting to talk with him about different aspects of the game.
We also went to a lot of great museums. My dad would take me to museums of natural history, history, and science and it sparked my interest in those subjects.
My dad liked to take me to see movies and we saw some great ones, some that had a big impact on me. One that I will never forget is a movie that he took me to when I was a teenager, “The Man Who Would Be King”, which is still my favorite. He knew that it was a movie that would inspire me due to the great story of adventure. For many years we would reminisce about that film and how much we enjoyed it.
My dad read to me when I was very young and reading is something I still love to do. He got me interested in writers like Jack London and Mark Twain (still two of my favorites) and great adventure stories like “Mutiny on the Bounty.” History, especially American history, was a passion that we both shared. He was always giving me articles or books to read about the Civil War, World War II, or other interesting events in American history that we could talk about.
My dad was a man of deep faith and became very spiritually oriented later in life. Judaism became very important to him and gave him great comfort, direction, and a sense of peace.
Some years ago, my dad gave me a birthday card. It was very simple and just said, “To the best of sons.” I was lucky to have him as a dad. I was inspired by his desire to be a perpetual student and always keep learning. In the last year of his life, he read several books on history, which he recommended to me. I plan on reading them and in my mind I’ll imagine talking to him and sharing ideas with him as we would always do. I’ll imagine talking to him about baseball when I watch a game. I miss him and there is an emptiness that is difficult to describe. I know my dad would want me to keep learning new things and grow as a person. This is what I intend to do.
Sleep disordered breathing (which includes snoring and obstructive sleep apnea among other more complex conditions) is very common and is estimated to affect more than 25 million Americans. Obstructive sleep apnea is a debilitating condition that is defined by episodes of stoppage of breathing or shallow breathing throughout the night. It is a situation in which air flow stops because the entire upper airway is blocked. Snoring is a condition that develops when air passes through an airway that is too small to allow unobstructed flow and it is often accompanied by shallow breathing that is tied to obstructive sleep apnea as well. In some cases, snoring presents without sleep apnea.
Snoring and sleep apnea are caused by the same thing: a narrow airway that collapses. Snoring may often lead to sleep apnea and can be a symptom. In fact, it is the most common symptom, followed by excessive daytime sleepiness and high blood pressure. Someone who snores should be evaluated for sleep apnea. What is the big deal about sleep apnea? Sleep apnea results in many episodes of breathing cessation at night. This greatly increases the risk of development of high blood pressure , heart attack and stroke and increases the risk of death if left untreated. The good news is that with treatment these risks decrease. When someone dies, sleep apnea is almost never listed as the cause of death, although it can be the underlying reason as severe derangements in our nervous system controls due to sleep apnea and lack of oxygen can cause an unstable heart rhythm and/or stoppage of the heart rhythm that can be lethal . It increases the risk of heart attack and stroke, more than any other factor, including smoking. It leads to daytime tiredness, which results in more accidents and reduced work production.
In short, it is a very serious problem.
What causes sleep apnea? Weight gain is one factor. Your genetics play a role and anatomy of the face and oral cavity are other factors that can contribute to the development of sleep apnea. Childhood obesity and nasal allergies can cause anatomical changes in a school age child or teenager that result in sleep apnea as an adult and need to be addressed. There are also many other factors that can cause an obstructed upper airway, both medically and dentally related. These are best discussed with a physician and dentist who work in the area of sleep disordered breathing. What are treatments for sleep apnea and snoring? For mild and sometimes moderate cases, a dental appliance can be a very good option. It opens the bite and moves the jaw forward, resulting in a more open airway. Palatal expansion, particularly in teenagers, can result in benefits beyond orthodontic issues. It can greatly reduce the risk of developing sleep apnea. For severe cases, the gold standard is a C-PAP (Continuous Positive Airway Pressure) machine. This works by pushing continuous air pressure through the nose and into the throat. This pushes back the tongue and other tissues and opens the airway. The C-PAP machine works wells but some patients find it difficult to use. In those cases, a dental appliance that opens the airway is a good alternative. Surgical options also can be used in rare circumstances, mainly in people with certain facial abnormalities.
Anyone suffering from sleep disordered breathing should be evaluated by a sleep specialist. Getting treatment for sleep apnea will improve your health, life expectancy, relationships, and work productivity.
“A game changer.” “One of the best things to ever happen in dentistry.” I have been to many dental courses about implants and these are some of the things I have heard from leaders in the field about dental implants. I tend to agree. I have been practicing for over 20 years and implants more than anything else have allowed us to improve the quality of our patients’ lives.
What are implants? Simply put, they are a titanium rod or post that is surgically placed in the bone. Over a period of months, the implant integrates into the bone, a truly revolutionary development. After the integration, an abutment or post and then a crown are placed on the implant and this is stable. The crown will look just like any other crown and most patients say that they function so normally that they lose awareness that they even have an implant.
Implants are the best way to replace a missing tooth and their advantages are numerous. They can never decay as they are made of titanium. They can restore chewing function without damaging the teeth next to them. A bridge is also a way to replace a missing tooth by grinding down the adjacent teeth and creating a framework that will include a replacement for the missing tooth. However, this is in most cases not desirable as the adjacent teeth become more susceptible to decay, the potential need for a root canal, and periodontal disease. The beauty of an implant is that the adjacent teeth are not touched at all. Although implants cannot decay, they can develop periodontal disease and patients are cautioned to maintain their normal oral hygiene with them.
To replace a missing tooth, an implant costs about 25-30% more than a 3 unit bridge. Insurance will sometimes pay for part of the implant. Insurance companies are starting to see that it is cost effective to pay for an implant because there is no risk of harming the adjacent teeth, unlike a bridge, which may lead to more costly treatment later. Of course, if more implants are needed, the cost differential between them and a bridge goes up but I would still recommend implants. I have yet to have a patient regret doing implants.
Another use for implants is to stabilize a loose denture. In most cases, a full lower denture lacks retention, due to the bone resorption of the lower jaw. Very few people are satisfied with their lower denture but that has changed with implants. The placement of two implants in the lower jaw can dramatically increase retention in a lower denture. In fact, I don’t think there is another procedure in all of dentistry that can give a greater increase in quality of life because it allows a patient to chew and function in a way that they could not before.
Age is rarely a factor in doing implants. I have had young patients who never developed certain permanent teeth get implants in their 20s and I have had patients in their 80s get them and be very satisfied. I urge anyone who is thinking of replacing any missing teeth to consider dental implants.
Please note the before onlay and after onlay pictures below: