TMJ facts and fiction

The subject of "TMJ" can be very controversial among the dentists. There are several "camps" or schools of thought based on what theories dentists were taught about jaw joint problems.  I realized soon after graduating dental school that I needed a better understanding of how teeth bite together and function (known as occlusion) in order to become an effective dentist.  I wanted to learn how teeth work together in harmony to in order to prevent the dental work I did from causing discomfort or excess biting pressure.

Therefore, I took continuing education courses from Dr. Peter Dawson and faculty in St. Petersburg Florida.  Through these courses and Dr, Dawson's book, I got a better grasp of how occlusion works.  I found that Dr. Dawson's theories agreed with the basic anatomy I learned in dental school. His treatment recommendations seemed well though-out, and practical and I was able to adapt them into how I practice dentistry every day.

Over the years of speaking with patients and colleagues, I have noticed that there are a lot of differing opinions about the causes of TMJ problems and how they should be treated. Therefore, I wanted to address some of the basics about "TMJ", as I understand it here.

1. Everyone has "TMJ" - Technically everyone has 2 TMJs which refers to your jaw joints, the Temporomandibular Joints.  The correct term for speaking about problems with the jaw joints is TMD or Temporomandibular Joint Dysfunction.

The mandible

Glenoid Fossae found behind Zygomatic arch/cheekbone.

The Temporomandibular Joints consist of several components:The concave areas found on the right and left of the base of the skull are called the mandibular or glenoid fossae.

• Projections on the top of the lower jaw or mandible are called the condyles.  The right and left condyles fit into the glenoid fossae.  
• Each condyle and fossae have a disk made of cartilage between them. The disk acts like a shock absorber and because of its slippery surface, assists the condyle in moving back and forth in the joint.    
• There are ligaments that attach the back and sides of the disk to the top of the condyle and help it stay in position as the condyle moves in the joint.  There is also a ligament that attaches from behind the condyle (mandible) to the maxilla. This ligament limits the motion of the jaw. 
• Chewing muscles- These muscles attach the mandible (jawbone) to the maxilla (top of the skull).  They flex and relax which allows the jaw to open and close for chewing and talking etc.  Elevator muscles flex and cause the jaw to close.  Depressor muscles flex and cause the jaw to open. In proper function, these muscle groups work opposite of each other.  For example, when the elevators are active, the depressors relax and vice versa. When the TMJs are properly aligned, the muscles work together with coordinated movements.

Diagram of elevator muscles in action causing teeth to bite and jaw seated fully in the socket.

2. The Temporomandibular Joints work in a unique way.  -Even though the joints on the right and left side of the skull are separate, they work together because the condyles are connected by the body of the mandible/jawbone.  In addition, the TMJs work by rotating and gliding. Where as most other joints in the body work only one way. When both condyles are fully seated in their sockets (glenoid fossae), the jaw can rotate open about 20 mm.  If the jaw rotates open more than 20 mm, the ligament that attaches the condyles of the mandible to the maxilla stretch to their limit and force the condyles to glide forward down the glenoid fossae.  This allows the jaw to open fully while preventing the airway behind it from being compressed (a very useful adaptation).

TMJ closed, open, disk displaced.

3.What is TMD,Temporomandibular Joint Dysfunction?-TMD is defined as pain and dysfunction of the chewing muscles and Temporomandibular joints (the joints which connect the mandible to the skull). This may be accompanied by restricted jaw movement and noises (popping, clicking, grinding) from the Temporomandibular joints (TMJ) during jaw movement. Depending on the how advanced the problem is, patients may experience from mild to debilitating pain.

Common complaints I hear from patients experiencing TMD are:

• Tenderness in the jaw joints with chewing or talking.
• Sore chewing muscles, especially in the morning.
• Grinding or clenching of the teeth, sometimes during sleep.
• Jaw locking open or closed.
• Frequent headaches.
• Difficulty opening.
• Popping or clicking noises from the jaw joint(s).

Diagram of muscle hyperactivity due to a crown causing an interference.

4. What causes TMD, Temporomandibular Joint Dysfunction? -The most common causes of TMD are as follows:
Misaligned bite- Teeth are designed to fit and function together in a specific way.  Ideally when the teeth bite together, the jaw joints should be able to seat all the way in the sockets. This occurs when the elevator muscles flex and pull the mandible upwards, and the depressors relax.  If the teeth are not aligned properly, a tooth (or a few teeth) may be slightly higher than the others, which is known as an interference.

Excess biting force on an interference (high tooth) can cause pain. So just as when you have a rock in your shoe,you adjust your steps to avoid stepping on the rock, your chewing muscles adjust your jaw position to prevent you from pounding on the high tooth.  This adjusted jaw position prevents the jaw from seating fully in the sockets when the teeth bite together.  Due to reflexes, chewing muscles may sense a high tooth and try to "grind it down". Unfortunately the single high tooth cannot be ground down alone so usually all teeth wear. This habit of teeth grinding or clenching in response to a misaligned bite is called bruxing. It also can make the jaw muscles feel overworked, tired, and painful.  Prolonged contraction of specific depressor muscles also causes the disk to be pulled out of position and deformed overtime.  The patient may then experience popping, clicking, or grating noises in the jaw joint as a result of the disk displacement.

Sometimes dental work can unintentionally introduce an interference by making a tooth or teeth higher than the others.  Problems can also arise with the bite when supporting teeth are extracted and not replaced. This is why it is important that the dentist have a good understanding of a patient's occlusion prior to doing dental work.

Trauma- a blow to the jaw can cause changes in the patient's bite.  Damage can occur to the disk, ligaments, mandible, and other structures and cause TMD.  The details of what actually can occur in the jaw joint as a result of trauma are too extensive to be covered adequately here.  For those who wish to learn more about this subject, I recommend reading Dr. Dawson's textbook, Functional Occlusion from TMJ to Smile Design .  I used this textbook and Dr. Dawson's training manual The Concept of Complete Dentistry (Seminar I) as a reference for this post.

*Stress- Stress is a factor and can cause symptoms to worsen especially if stress causes the patient to grind or clench their teeth more than usual.  However stress is not the original cause of TMD.  Patients who grind or clench their teeth only do so if they have interferences in their bite. A patient who's bite is free of interferences does not normally brux whether they have stress, or not.  A lot of people are taught that stress causes bruxing and are advised to "try to relax".  Unfortunately their TMD may go un-diagnosed and untreated for years due to this kind of advice.

5. How is TMD treated?- I was trained to take a verbal history of TMD patients' jaw joint problems.  I also learned how to listen to jaw joints using special equipment called a TMJ Doppler.  Based on the sounds, I can estimate where damage has occurred in the joint depending on when the joint makes noise with movement.  Images such as MRIs-magnetic resonance images and Cone Beam Computerized Tomography images are also helpful to see the extent and location of damage to the TMJs.  I use palpation to check for sore chewing muscles and ligaments.  In addition, I look for interfering teeth and am able to analyze the patient's bite.  I use all this information to customize treatment recommendations based on the level or severity of damage to the jaw joints.  People are often unaware that TMD can worsen in some patients if left untreated.  Therefore early diagnosis and intervention are important.

Occlusal Splint

An occlusal splint is often the first line of treatment for patients with mild to moderate TMD.  A splint is a clear, plastic, removable appliance that fits over the biting surfaces of the teeth.
The dentist adjusts the splint so that the bite is balanced (all teeth touch evenly).  The splint prevents interferences from keeping the teeth from sliding around freely.  The balanced bite on the splint also helps shut off the chewing muscle reflex that causes most patients to brux.  If a patient does continue bruxing (there is a small percentage who will brux regardless), they will only damage the acrylic and the teeth or supporting bone.  Therefore an occlusal splint is a good, non-permanent option to treat patients with TMD.  However it is not indicated in some patients with acute, severe disease.

For patients with minor interferences in their bite, an occlusal equilibration, may help to alleviate problems with TMD.  First a study is performed to see how severe the bite is misaligned.  Once it is determined that only minimal adjustments to tooth structure or restorations are needed to eliminate interferences, a occlusal equilibration is done.  This consists of selective grinding of teeth and restorations to eliminate high spots.  Sometimes restorations or missing teeth need to be replaced to accomplish this.  Many patients report feeling their jaw muscles relax and soreness in teeth subside after having their teeth properly equilibrated.

Teeth marked with occlusion paper to see interferences.

Occlusal equilibration.

Some patients with severely misaligned teeth may need orthodontics, also known as braces, to move the teeth so that their bite is even.  It is important to work with an orthodontist that plans cases with the goal of ensuring that the jaw joints can seat fully in the socket when the teeth bite together.  Unfortunately, some patients begin to have issues with TMD because their teeth were moved orthodontically to positions that do not allow this to occur.  They often report having headaches, sore teeth, and bruxing after their braces were removed.

In the most extreme cases, some TMD patients may have to have surgical intervention to repair damage to their jaw joint.  These patients are often in acute, debilitating pain and have very limited mobility of the jaw.  In my opinion, these cases should only handled by surgeons who specialize in TMJ surgery.

Hopefully this post has given some clarity on the causes of Temporomandibular Joint Dysfunction and the treatment options available.  Patients experiencing these problems should not hesitate to alert their dentist and seek help so that their problem does not get worse.  A solution can often be found to help stabilize the patient's TMD if it is caught soon enough.  If you have any further questions regarding this subject, feel free to contact Dr. Lisa Curry via email at info@currydentalcenter.com

Happy Smiling!

How to care for Baby Teeth

I have noticed a lot of friends on Facebook who have recently had babies.  It is fun to look at the pictures of those sweet little faces.  It reminds me of when my children were that small.  It also occurred to me that new parents may have questions on how to care for their infant's teeth.  I will post the most frequently asked questions about caring for baby teeth (and answers) here.

 
When should I start brushing baby's teeth?
Start at 4 months which is before most babies have teeth.  I recommend using an extra soft tooth brush for babies (Oral B has good ones). Gently brush the gums, massaging the gum tissue which feels good!  If baby chews on the brush a little, its okay.  That's also why I don't recommend the finger tooth brush because baby may chomp on your finger and those little gums hurt! 

Incorporate brushing into the daily bath time/ face washing routine.  Then, when baby's teeth come in they won't object to brushing because it will already be part of their day.  Babies will tend to fuss less  if they are used to daily brushing.  Even if they do cry, it's okay because then you can really see in their mouth to brush!  It is better for baby to cry a little with daily brushing then cry a lot having cavities filled!  I find that parents who don't brush because their baby or toddler cries usually will have a child who has several cavities.

Toothpaste: Yes or No?
I personally recommend using the tiniest amount of children's toothpaste possible once baby has a tooth or teeth.  Swipe a hint of toothpaste on the brush and then gently brush all surfaces of the tooth/teeth.  This amount is so small that it won't be harmful even if it is swallowed.  Then baby will be used to the flavor of toothpaste and won't object to it later.  I have seen kids fight and refuse tooth brushing when toothpaste is introduced.  I used a miniscule amount fluoridated toothpaste on my kids everyday, and they are cavity free.  Although fluoride use is considered safe at appropriate doses, it can be very controversial to some.  Therefore, use your own discretion about choosing toothpaste. 

image of dental fluorosis
There are a lot of anecdotal reports about fluoride being harmful.  However, the only real documented problem with excess fluoride is dental fluorosis.  This is when excess fluoride is taken up into the structure of permanent teeth and causes white or brown spots.  Although it may be unsightly, dental fluorosis is not harmful.  It can also be treated cosmetically with micro-abrasion, up to having the teeth crowned or capped as an adult.

While it is true that fluoride can be poisonous if an overdose is taken, it is extremely difficult to do.
 A fluoride overdose is equal to 5mg/kg or 340 mg for a 150 lb adult.  According to the American Dental Association or ADA, there is 192 to 211 mg fluoride in a large (6.4 oz.) tube of toothpaste and 138 to 152 mg fluoride in a small (4.6 oz.) tube of toothpaste.  Therefore, one would have to consume at least 2- 3 tubes of toothpaste to overdose.  Fortunately we have natural protection against this because excess fluoride combines with stomach acid to make Hydrofluoric acid, which automatically induces vomiting.  Thus, there are no known or reported deaths/ overdoses from ingesting too much fluoride.

Yes, baby teeth can get cavities!
Cavities form when the germs that cause cavities take the sugar from the foods you eat or drink, make acid, which then erodes the teeth.  Even milk or formula can cause cavities because there is sugar in milk/formula called lactose. Sugar bugs (cavity causing bacteria) can use that sugar to cause cavities. 

That is why dentists and pediatricians do NOT recommend putting baby to sleep with a bottle of milk or juice.  This can result in severe tooth decay, especially in the front teeth also known as "baby bottle rot".  It is best to only give water in bottles at bed time.  Also, be sure to brush baby's teeth before putting them down at night.  What about night time feeding?  Most babies are able to sleep through the night by the time they have several anterior baby teeth.

I used to give my children a bedtime snack once they started on solid food.  After snack, I made sure to brush their teeth. This little meal would often hold them until morning without the need to wake up for a bottle.  However, if an older baby knows he/she will get a bottle when they cry in the middle of the night, they won't grow out of it.  I've seen babies 18 months who still wake up at night for a bottle! 

 
Baby teeth are important!  As you may know, baby teeth are instrumental for chewing and talking.  They also are involved in the proper growth and development of the jaws.  Baby teeth are necessary to save space for un-erupted permanent teeth. A baby tooth usually remains in the child's mouth until a permanent tooth underneath it is ready to erupt through the gums. The roots of the baby tooth dissolve and the tooth becomes loose and falls out. Then the permanent tooth "comes up" a few weeks later. If a child loses a tooth too early--before the permanent tooth is ready to erupt--or if it is accidentally knocked out, or is removed by the dentist because of disease, the space must be saved. A space maintainer can be inserted to hold the place of the "baby tooth" until the permanent tooth is ready to emerge.  If not, the permanent tooth could be trapped below the gum and bone and may need surgical and orthodontic intervention to come into proper position.


When should you stop letting baby use a pacifier or suck their fingers/thumb?
 This is a touchy subject!  I had one child who used a pacifier and one who sucked her fingers.  I will say, I preferred the pacifier because they could be disinfected and eventually thrown away!  Finger sucking habits can last a LONG time, or indefinitely without intervention.  That being said, babies soothe themselves by sucking pacifiers or fingers when they are small and that is a good thing. 

I encourage parents to start talking to their toddlers about stopping the pacifier habit at 2.5 years.  They may not stop then, but they do understand and often you can reason with them or bribe them to stop.  My daughter gave up her pacifier in exchange for a new toy.  Mercifully she chose Candy Land!  I would definitely try to have them stop using pacifiers/ sucking fingers by 3 years old at the latest.  Prolonged use of pacifiers or finger sucking can cause the bones in the upper jaw to malform and anterior teeth to flare.  This may require orthodontics or surgery to correct their bite in the future. 

I also recommend parents talk to children about finger sucking habits at 2.5-3 years of age.  It may require intervention though because as stated earlier, you can't throw fingers away.  I recommend using a product called the T-guard. You can view and purchase it online with the link to the left. Here is the description of how it works from the website, "Rather than trying to prevent thumb sucking, its patented technology allows it: but without the suction that creates the pleasure. If you break the suction, you break the habit! With a success rate greater than 95% " 
I have parent testimonials who bought this product and found it very effective in stopping a finger sucking habit in their children.  I did not have to resort to using a T-guard with my youngest because she started telling us she didn't suck her fingers anymore. When we caught her and pointed it out, she'd get upset so eventually she stopped on her own!  As she used to say, "I'm not a baby!"

 
When should I schedule baby's first visit to the dentist?
According to the  American Academy of Pediatric Dentistry, " It is recommended that the child be seen by a pediatric or general dentist at the time the first tooth comes into the mouth, and no later than the child’s first birthday."

This may be ideal, however the reality can be altogether different.  I do not discourage parents who want baby to be seen that young.  However, parents may be disappointed that their child may not fully cooperate for a dental exam and cleaning at one years old.  We try to inspect the teeth as best we can and brush using a soft toothbrush instead of the polisher we usually use.  We find that some babies will accept the toothbrush better because it doesn't make noise.  Also, hopefully the parents have been brushing at home so it is a not totally new experience for the child. Baby may feel more comfortable sitting in a parent's lap in the dental chair or being examined laying on a parent's knees, laying back toward the dentist as above.

At baby's first dental visit, we also reinforce home care habits such as brushing morning and night.  We recommend parents avoid giving babies cavity-causing foods like candy, fruit snacks, sugary drinks (sweet tea, kool aid, sports drinks), and acidic fruit juices such as orange, grapefruit.  That often also means having a serious talk about diet with well-meaning, but over-indulgent grandparents. 

We strongly advise parents to prepare baby prior their first visit to the dentist by reading books or watching children's movies about going to the dentist.  There are many titles starring the latest cartoon characters available at the local library.  Also we recommend letting your child watch an older sibling or cousin at a dental visit IF that child is well behaved and calm during their cleaning visit.  Watching family members or friends in the dental chair demystifies the visit and young children are often look forward to having "their turn" to get their teeth cleaned.

Hopefully I have touched on most of the major questions parents have about caring for baby teeth.  If not, please feel free to contact me with any concerns.  I may be reached via email:  info@currydentalcenter.com.

Happy Smiling!

Rumors about Root Canals

I recently attended a women's conference at a friend's church and was surprised to find that the speaker talked about root canals.  She stated that she was having a lot of problems with her hip joints and was considering hip replacement surgery.  The speaker was referred to a company that treated her with some kind of electronic therapy that reduced her hip pain significantly.  Oddly enough, the people at that company told her that root canals were the source of the her arthritis because they believed infection remained in the treated teeth.  As a result, the speaker was advised to have several root canaled teeth extracted as soon as possible.

Of course the statement about root canals and advice to extract her teeth really captured my attention.  I made a note to research this subject when I got home.  I logged on to www.snopes.com, a fact checking website, and searched "root canals and arthritis".  I found a post that addressed whether root canaled teeth cause arthritis (and even cancer).  I have attached the link for the post here medical toxins and root canal.

First let's briefly discuss what root canal therapy entails.  Once a tooth develops a cavity that gets large enough to reach the nerve, the bacteria which caused the decay infect the nerve.  This infection causes a response from the body which sends white blood cells to try and fight the infection.  In the early stages of infection, patients may notice tooth pain and sensitivity to cold and hot foods.  They may also experience pain with biting or develop swelling around the tooth.  The swelling is called an abscess which is a build up of white blood cells that are trying to clear the infection.  An abscess is also an indication that the nerve of the tooth is dead or dying.  Once the nerve of a tooth is infected, the dead or dying nerve must be removed either by root canal therapy or by extracting the tooth altogether.

During root canal therapy, the tooth is usually numbed using a local anesthetic. A hole is made in the tooth that allows access to the dead or dying nerve.  The space inside the tooth that contains the nerve is called the canal, hence the name "root canal treatment or therapy". The dentist uses small instruments and antibacterial rinses to remove the infected nerve tissue from inside the tooth.  The cleaned canal is then sealed with a rubbery like substance to prevent infection from getting back into the tooth.  The root canaled tooth is then restored with a filling or a crown (cap).  Modern dentists use great care to ensure that root canal therapy removes infection from treated teeth.   

Now back to the rumor floating around questioning the safety of root canals: What I found on snopes is that there was dentist named Weston Price back in the early 1900's who believed that root canaled teeth remained infected after therapy and were believed to cause degenerative diseases in the heart and circulatory system.  This is known as the focal infection theory.  The American Dental Association reviewed Dr. Price's research from the 1920s and discovered that it does not follow modern scientific practices. Therefore, due to lack of credible evidence, Dr. Price's theory has been widely rejected.  However, in spite of this, there are some who feel that the medical establishment has merely suppressed his work.

Personally, for me to adopt a theory as fact, I want to see that the hypothesis is proven by sound scientific methods.  I want to see that results from testing are repeatable by different research teams.  Unfortunately this is not the case with the focal infection theory proposed by Dr. Price.  It has been repeatedly tested and disproved by several credible research organizations including the American Association of Endodontists, AAE (root canal specialists).  You can view the link from the AAE on root canal safety here.  However, the focal infection theory has enough "sciencey" sounding terms to make it seem plausible to some.  Those who are not used to reading science journals regularly and determining if research stands up under scrutiny might miss the signs that this theory is not valid.

Not withstanding, the practice of root canals has vastly changed and improved since the early 1900s.  Dentists do not use the same materials or methods commonly used by dentists back then.  Therefore, comparing a root canal performed in 1900s to one in present day is hardly comparing apples to apples.  There have been great improvements made in root canal therapy to prevent leaving infection in root canal treated teeth.  The success rate for root canals is reported to be over 95% according to a study by Torabinejad et. al in the Journal of Prosthetic Dentistry, 2007 Volume 98, Issue 4, Pages 285–311.

So even though it may be meddling, I sent a message to the speaker from the women's conference. I recommended she do more research about root canals and at a minimum, read the post on snopes.com about root canals and their safety.  I think it is best  for anyone to have the most accurate and up to date information possible before scheduling the extraction of multiple teeth.  Hopefully she will find the information helpful in planing her future health decisions.  I also hope that those reading this post will gain some useful information and peace of mind concerning root canal therapy as well.

Happy Smiling!

Surprising Sources of Bad Breath

Many of my patients tell me they are worried about having bad breath or halitosis and ask what they can do to prevent it.  According to Dictionary.com, halitosis is defined as the condition of having offensive smelling breath.  There are several sources of bad breath, but thankfully most are preventable.  The most common sources of bad breath are as follows:

dental plaque- the sticky white film that develops on teeth surfaces consisting of bacteria, mucus, and food.
Impacted food- Often food can get stuck between the teeth if not brushed and flossed out.  Over several days, this food begins to break down and give off foul odors.
Tonsiliths- These are small round white globs that form in the tonsils and occasionally get coughed up from the back of the throat.  Tonsiliths are an accumulation of mucus and volatile sulfur compounds (VSCs) which come from bacteria in the mouth.  The VCSs give off a smell like rotten eggs.

Now that we have addressed the most common sources of bad breath, let's talk about some sources of bad breath you may not know:

Tooth decay- Did you know that severely rotting teeth give off a distinctive odor?  Tooth decay is caused by bacteria that produce acid which erodes the teeth.  Once cavities become big enough, they can be quite smelly and this can affect the breath.  Patients also may have decay beneath old fillings or crowns as well.  Regular dental visits and routine x-rays can help alert you if you have cavities. Of course getting cavities fixed, and defective fillings and crowns replaced will help keep your breath smelling fresh.

Periodontal "gum" disease- Gum disease is also caused by certain types of bacteria.  These bacteria give off chemicals that cause gums to weaken, bleed, swell, and recede.  These chemicals also cause bone destruction which can eventually lead to tooth loss.  Gum disease usually progresses due to poor oral care habits (not brushing and flossing regularly) and infrequent dental hygiene visits.  Patients with moderate to severe gum disease tend to have halitosis associated with their disease due to the bacterial infection and tissue destruction.  There are estimates that 85% of adults have some form of active gum disease.  Early diagnosis and treatment of gum disease is recommended.

Sinus infections- Patients with seasonal allergies or who have recently had a cold may experience inflammation and swelling of the tissues inside their sinuses.  This swelling may prevent sinuses from draining properly, allowing bacteria to multiply and sinuses to become infected.  Signs and symptoms of a sinus infection may be as follows: Dull throbbing facial pain, post nasal drip, headache, toothache, colored nasal discharge, cough, congestion, fatigue, facial swelling, and fever.  Since the maxillary sinuses drain through the nose and mouth, the infection may also cause the breath to smell bad.  Patients who suspect they have a sinus infection should see their physician for evaluation and treatment.

Dentures/false teeth: Dentures are removable, custom-made appliances worn in the mouth to replace missing teeth.  Dentures are made of acrylic which, overtime can pick up stains and odors if not properly cleaned.  Food, plaque, and tartar (a hard build up consisting of bacterial plaque and minerals found in saliva) can build up on dentures, just like on natural teeth.  It is recommended that patients clean their dentures every day.  Also patients with dentures should have them professionally cleaned regularly to reduce the build up of bacteria.  This cleaning can be combined with a regular oral examination to screen for oral cancer or infection and is recommended at least once a year.

Dental Abscess- An abscess is a localized collection of pus in the tissues of the body, often accompanied by swelling and inflammation and is frequently caused by bacteria.  They form after the nerve of a tooth dies.  The nerve may die due to a deep cavity, caused by bacteria. These bacteria can infect the nerve, cause inflammation, and if untreated, cause the nerve to die.  In addition, teeth that are subjected to trauma may get disrupted from their blood supply and die.  The body recognizes the dead nerve tissue in a tooth as foreign matter and sends white blood cells to try to clear it away.  The resulting swelling and inflammation is what is known as an abscess.  The bacteria from the abscess and the dying tissue give off a characteristic smell, causing halitosis.

Acid reflux/GERD, and ulcers- Patients with acid reflux, also known as Gastroesophageal reflux disease and ulcers may have associated halitosis.  Both GERD and ulcers are serious medical conditions which need to be diagnosed and managed by a physician.

So, the question is, how do you prevent bad breath? Many of the above mentioned sources of bad breath can be prevented by having good oral hygiene.  Brushing twice a day, and flossing once a day go a long way to prevent halitosis.  Don't forget to brush or scrape your tongue to remove the odor-causing bacteria that live there.

 Avoiding sugary drinks, and sweets also helps keep bacterial plaque levels down. Be sure that the gum and mints you choose are sugar free to prevent tooth decay.   Drinking water also helps prevent dry mouth as well. Ironically mouthwashes with a high alcohol content can be drying to mouth tissues.  This dryness creates a welcoming environment for the bacteria that give off bad-smelling VSCs. Try to choose a mouthwash that is alcohol free for fresher breath.

Lastly, regular preventive dental visits and medical visits can help patients avoid conditions that contribute to bad breath.  Staying cavity free, gum disease free, and healthy are key to having fresh breath!

Happy Smiling!

Questions? Email Dr. Lisa Curry at info@currydentalcenter.com 

Sour on Social media

Imagine my dismay this morning when I received an email from Yelp! informing me I had a new review on their site.  I logged in to my Yelp! for business page and discovered that a patient whose insurance paid less than expected and was billed for $7.00 (yes, seven dollars), was flaming my practice on the internet.  I am officially over Social media for my practice.  *Sigh*

Like most dentists, I listened attentively as advertising gurus spouted the importance of having a great online presence and reputation for your dental practice.  I read several articles on the web with titles like "7 Pearls to Reach Patients through Facebook and Twitter".   There are also multiple references on how to get patients to post positive online reviews about you and your office.  However, I have discovered a few realizations about the much touted Social media wave which I will now share.

1. Maintaining an ACTIVE online presence is a full-time job.  I found that trying to keep my dental Facebook page updated hourly, daily, weekly with pictures, posts, jokes etc. takes up a lot of time.  I already have a job and am not interested in another one, thanks.  Does having a fresh Twitter feed say anything about my skills as a dentist, really?  I have found that I would rather catch up on conversations with my patients.
2. Most REAL people who review dental offices have an axe to grind.  There are very few unsolicited reviews of dental offices that are positive, at least in my experience.  I think I may have one or two genuine positive reviews out there somewhere.  Unfortunately, the majority of people who take the time to write a review feel like they had a negative experience at an office and it is usually due to financial reasons.  Just like in restaurants, sadly, few people take the time to tell management when they felt their experience was great.  Most only speak up when things fell short of expectations.  Similarly, offices that have a bunch of glowing reviews online either write them themselves, incent patients to write them, or get their staff members and their family members to write reviews.  Why?  The more mentions of the practice and doctor's name on the internet, the more the office comes up in internet searches.  This means patients searching for dentists on the web will be more likely to see their name.  However, again this is not a real indicator of the doctor's skill in dentistry, but rather of their skill as a marketer.
3. Word of Mouth is still the best referral source for dentists.  I have been in solo practice since 2003.  I have tried advertising in several types of media.  Yes, I do agree that it is important for patients to see your name and face, and know that you exist.  The more you get your name out there, the better result you will have.  However, patients still want to know a few things about a dentist that an ad cannot convey.  That is why a word of mouth referral from and actual patient is more valuable and effective than any other type of advertising.  An online or print ad can tell you that I do a good job giving injections, but a testimonial from a friend in your bowling club holds more weight.
4. A slick, fancy, web page does not equate to an increase in patients calling your phone. One day I will have to do a study to confirm this theory.  However, I don't believe that there is a direct relationship between the amount of money spent on a practice website and the number of patients who schedule appointments.  What I have found is that most patients who find me on the web USUALLY already have my name from another source.  They use my site to get contact information, directions, confirm that I take their insurance, or third party payment plan.  They may look at my photo to make sure I don't look crazy.  Some may even read my bio if they are especially bored or nervous about their visit.
5. People don't care about friending, following, or linking to their dentist.  I personally use social media on my down time.  I find ads (and invitations to play games, hint) on these sites annoying.  I am usually logging in to connect with friends and family, have a laugh or some fun.  Believe it or not, I am not there to talk dentistry.  I am also okay and comfortable with the fact that most people do not equate going to the dentist with fun.  Even though a lot of my patients will say that they do laugh a lot at my office because we like to joke around during the day.  Side note: I also do not care if I see people drinking soda or eating candy when I am in social settings.  Those are your teeth!
6. Internet contests.  Yawn...  People may be attracted to a dental site or page if they are giving out free goods or services.  However, this does not necessarily mean that these people will become part of their patient family.  I would rather people seek me out as a dentist because I do a good job, not because I give out swag.
7. A lot of the "free" review sites are not free.  There are sites that claim they do not charge businesses to have a profile which is partly true.  Just like the old phone book may have a free listing of basic information, these sites may have a simple listing of a practice name and phone number.  However, if business owners want to edit their listing, have access to/ or dispute reviews, there is often an advertising fee to do so.  I prefer not to advertise on these sites because I do not find I receive sufficient referrals to justify the expense.   I also do not like the deceptive advertising that says patients can trust these sites because businesses do not have to pay to appear on them.

So, given what I have shared above, I have decided not to spend a lot of time actively cultivating my online reputation.  Social media for dentistry, in my experience, has not been the boost it was said it could be.  I am sure if I invested more time, money, and energy in it, I could see a better result.  However, given my disappointing experience thus far, I plan to focus on practicing the best dentistry I can for the patients in my community.  This is not to say that I will not participate online in the future.  I will just be more realistic in my expectations of Social media's impact on my dental practice.

Common Causes of Discolored Teeth

One of the most common complaints people have about their smile is that their teeth are too dark.  There are several factors that can contribute to discolored teeth and we will discuss several of these causes below:

What determines the color of teeth?
Teeth are made up of layers of mineralized material.  The outer layer is called enamel and is usually translucent.  This means that the enamel itself does not really affect the color of the teeth because it is see through.  The inner layer of the tooth (just outside of the nerve or pulp) is made of dentin.  The dentin makes up the bulk of the tooth and it is colored.  The color of the dentin shows through the enamel layer which gives the teeth their color.  The more darkly pigmented the dentin is, the darker the teeth appear.
Factors that can affect the color of the dentin:

• Age- As we get older, the nerve tissue or pulp of the teeth continues to make more dentin on the inside of the tooth.  As the dentin thickens, the color of the tooth intensifies.  This helps explain why teeth appear to darken with age.
• Medications- There are certain medications that expectant mothers can take that may affect the color of their unborn infant's teeth.  Tetracycline is an example of a medication that is known to cause such discoloration.





tetracycline staining

• Genetics- There are certain specific genetic disorders that may cause individuals to have darkly colored enamel.  These disorders may also have symptoms in other organ systems in the body and are somewhat rare and usually diagnosed in infancy.  An example of such a disorder is Dentinogenesis Imperfecta.
• Necrosis- Sometimes when a tooth sustains trauma, the blood supply to the tooth is cut off and the nerve of the tooth dies.  When this occurs the tooth may darken in color.  A tooth with a dead nerve is diagnosed as being necrotic.  Necrotic teeth are treated either with a root canal (endodontic procedure) or extraction to clear away the dead, infected nerve tissue.




Necrotic upper left central incisor



Factors that affect the color of the enamel:

• High fever in infancy- Some patients who had a high fever as an infant may have bands of discolored or and even malformed enamel on their teeth.  This is because the fever disrupts the normal function of the enamel producing cells as the teeth are being formed.  The location of the defects depends on how old the patient was when the fever occured.
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  Fluorosis-  Patients who are exposed to high levels of fluoride in their drinking water and other beverages while teeth are being formed may develop white and brown spots on the enamel of their teeth.  This is because the fluoride is taken up into the structure of the teeth in place of calcium and therefore alters the structure and appearance of the tooth.  Although it looks unsightly, it is not harmful to the tooth.  Patients with fluorosis may opt to have cosmetic dental procedures to improve their smile as adults.



fluorosis

• Cavities-  It may seem obvious, but cavities also cause teeth to be discolored.  Bacteria in the mouth metabolize sugar from foods and drinks and produce acid as a by product.  The acid produced causes tooth enamel and dentin to erode which results in white spots, as well as brown, and black areas on the teeth. 
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• External Stains:
• Tobacco Stains- smoking and using smokeless tobacco products can leave stains on the enamel of the teeth.
• Beverages- Coffee, tea, dark colored sodas also can leave stains on the surface of the teeth.

tobacco stained teeth

Fortunately, most external stains can be removed with a professional dental cleaning.  However, repeated use of staining materials may leave behind a fine residue in the texture of the enamel that can only be removed by dental tooth whitening or other cosmetic procedures.

As you can see, there are several factors that can cause discoloration of the teeth.  If you are displeased with the color of your teeth.  Talk with your dentist to see what options are available to you to improve the appearance of your smile.

Happy Smiling!



Harmful Habits

Over the years I have gotten emergency calls from patients who have accidentally damaged their teeth or mouths.  Unfortunately these patients were often unaware that certain practices can be harmful.  Thus to raise awareness about some of these potentially problematic habits, I decided to describe them below:

• Chewing ice- Some patients have a habit of chewing on ice or ice cubes.  The problem with this is that it can weaken the teeth and cause them to crack or fracture.  Often times a patient will only partially crack their tooth while biting ice.   Later when they eat something soft like a sandwich or chewy like a bagel or bacon, a piece of their tooth will break off.  If the patient is lucky, the tooth can be repaired with a restoration like a filling or a crown.  However in some cases the tooth is not salvagable and may have to be extracted.  People who feel compelled to regularly chew ice may be suffering from Pica which is a form of iron deficiency.  I advise my patients who compulsively chew ice to have their iron levels checked and fight that craving unless they want to have a dental emergency.

• Using teeth as tools- Sometimes patients who call to report they "chipped a tooth" will remorsefully admit that they had been using their teeth as a tool when it broke.  I have heard of patients who open bottles, crack crab legs or nuts, pull tags off clothes and perform various other tasks with their teeth.  These habits may not cause problems initally, but one day a weakened tooth may receive too much pressure and crumble.  My advice is, don't be lazy.  Go and get the appropriate tool for the job because it is cheaper and less painful to replace the tool than it is your teeth!
• Tongue rings-Some years ago, tongue piercing became popular among women and men.  For the sake of brevity, I will not go over the background and history of this practice.  However, the only reason I mention it is because I have observed that many of my patients who had a tongue ring eventually managed to chip or crack their teeth with it.  Most where not aware that this was a potential hazard of having this type of piercing.  Fortunately there are other options available such as soft plastic attachments that can help avoid tooth fracture.  However, the best way to avoid such problems is to remove the tongue ring altogether.
 

• Eating lemons (acidic foods)- There are people who actually enjoy eating lemons (go figure!).  The only problem with this is the prolonged exposure of the teeth to acid.  This can cause erosion of the tooth structure /wear away the enamel.  Teeth can then become sensitive and more susceptible to decay.  Also once the damage has been done, patients are often displeased with the appearance of their teeth and may require veneers or crowns to restore them.  Erosion can also occur with consuming oranges, grapefruits, their fruit juices as well as other acidic foods.  Therefore try to limit eating highly acidic foods and drinks to prevent damage.

• Aspirin burns- Since we are talking about acid in the mouth I thought I should also cover aspirin burns.  Occasionally patients with a severe toothache will decide to place a tablet of aspiring on the gum near the aching tooth to try and numb the pain.  Unfortunately,this often results in an extremely painful ulcer as the acidic aspirin burns a hole in their cheek or gum, worsening their pain.  I always ask these patients if they rub aspirin on their forehead when they get a headache.  They get the picture and hopefully you will too.  Never place any medication designed to be swallowed directly on the delicate cheek or gum tissue!  Take all medicine as directed on the packaging or as prescribed by your doctor.
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  Note the whitish appearance of the aspirin burned cheek

  

The habits listed above are the things I've most commonly observed to cause dental emergencies.  My advice to stay healthy and problem free? Break these habits or avoid them! Happy smiling!