The Latest on TMJ

Temporomandibular Joint Disorder commonly known as TMD or TMJ is a very common issue in our population.  Most often it manifests itself as a “click” or a “pop” coming from the joint that is located in front of the ear.  It can also present as simply a pain from the joint, a locking of the mouth in the open or closed position or a “grinding” or “sandpaper” sound that comes from that region of your head.  Often times TMJ doesn’t really hurt, it is more annoying than anything else.  However, there are instances where the TMJ region can flare up and cause extreme discomfort.  Often these are in times of stress or fatigue in your life.  And interestingly we see it often in people who seem very happy, well adjusted and calm on the outside and internalize all their stress. Individuals such as these tend to clench and/or grind during their sleep which exacerbates their TMJ condition.  It can be very painful and even debilitating.

We strongly advise those whom are experiencing TMJ systems to not do anything invasive for treatment.  “Invasive” treatment would include any surgical options or any dental options that would include drilling, restoring or orthodontic options meant to permanently change your bite.  Treatments such as these can be incredibly expensive and are of limited to no value for permanent relief of the symptoms. Furthermore, we do not recommend any chiropractic “adjustments” of the TMJ area as this will cause internal damage to the joint area. In many of these “treatments”, the TMJ symptoms actually become worse leading to more pain and will limit how wide you can open your mouth (Range of Motion). 

Last year, the National Institute of Dental and Craniofacial Research, a department of NIH, released a comprehensive study and paper reviewing symptoms and current treatments for TMD.  Their conclusions?  Less is more. 

Their recommendations for treatment includes moist heat and cold packs, massage, trigger point therapy and TMJ mouth guards.  These recommendations are consistent with what we have been recommending to our patients for years and have found to be highly effective in eventually relieving the pain our patients experience.  In rare cases of severe TMJ damage, we will guide our patients to UCLA or USC’s pain management clinic both of who are well equipped to handle difficult cases armed with the latest research and equipment.

We encourage you to see a dental professional to assess which of these non-invasive treatments are appropriate for your specific situation.  And if you can not get to a professional immediately, constant rotation of moist heat and cold packs in combination with a pain reliever such as ibuprofen seems to help considerably. You can try over-the-counter mouth guards but if you notice an increase of pain, stop using it immediately and get a custom night guard from your dentist.

Remember, the rule with TMJ treatments is “Less is More.”

Posted by Go Dental, Your Valencia Dentist.

All You Need to Know About Teeth Whitening

The most requested procedure we see in our practice is tooth lightening/whitening.  It’s easy to understand  why - who doesn’t want a brighter smile?  It’s especially popular this time of year when people want to look best for their holiday party.  There are several different options how you can achieve a brighter smile and it doesn’t necessarily mean you have to go to the dentist to get one.

Most oral bleaching gels use a form of peroxide as the active ingredient to lighten the teeth.  Teeth whitening peroxides come in come in two forms - Hydrogen Peroxide and Carbamide Peroxide. These are the only two active ingredients which are approved by the FDA for teeth lightening so the consumer must be vigilant and make certain that the product they are considering  uses one of these options.  There have been instances of well marketed products essentially selling acid etch and white paint to lighten teeth (which is not approved in case you’re wondering).

Hydrogen Peroxide gels tend to work a little faster but tends have more side effects associated with it.  Carbamide Peroxide has an agent in the peroxide that controls the release of the peroxide so it works a little slower but has less side effects.  A solution strength 10% Carbamide Peroxide is equal to about 3.5% Hydrogen Peroxide.  In other words, you need less concentration of Hydrogen Peroxide to work have a similar results.

The most common side effect is extreme cold sensitivity and throbbing of the teeth.  Other than concentration levels, what differentiates brands of solutions from one another is how they address limiting these side effects.  Some don’t address it at all and will have a high likelihood of causing side effects.  Others add ingredients such as Potassium Nitrate or Fluoride to help reduce side effects.

The peroxides work through an oxidation process. They penetrate through the porosities in the enamel and react with compounds which cause teeth to stain and break them apart lifting the stain from the tooth.  Sensitivity occurs when the pores of the enamel are exposed allowing cold to penetrate through the enamel layer and irritate the nerve.  

There are over the counter solutions that can work pretty well for many people.  Most of the major brands of toothpaste manufacturers have some sort of lightening system.  They are usually of lower concentrations to prevent major side effects from occurring.  I would advise you against buying lightening solutions off the internet or from radio commercials only because there is very little accountability with companies like these.

If these over the counter systems prove not to work effectively enough, you should probably pursue the professional lightening systems.  These are not the systems you see at the mall, but rather systems that your dentist can distribute and closely monitor for you.  Your dentist can also prescribe treatments to help completely eliminate any side effects that you may encounter.

One other quick note - systems with light activated solutions have been not been proven to work better or faster than traditional lightening treatments.

Additional Sources:

http://www.ada.org/1902.aspx

http://science.howstuffworks.com/innovation/everyday-innovations/tooth-whitening.htm

Posted by Go Dental, Your Valencia Dentist

Abused Dental Procedures Part 2: Crowns, Fillings & Root Canals

This is the second of two articles discussing common ways less than honest dentists can take advantage of patients. In the prior post, we discussed in some detail periodontal scalings which is commonly over prescribed by dental practitioners. We have also discussed the importance of your right as a patient to get a second opinion or even a third opinion.  While there is much in dentistry that is subjective, the reason for treatment must make sense to you as a patient and should be backed with objective research.  I will follow up today with the remaining procedures that we see diagnosed by others but in truth, do not really need to get done.

Crowns:

Crowns (aka caps) are done very often in dentistry and for good reason.  When older white or silver fillings begin to show signs of leakage, often times, the next progression for restoration of the tooth is to do a crown.  But not every restoration replacement requires a crown. Criteria for a crown include:

1. The existing restoration shows signs of breakdown, leakage and recurrent decay under the filling.  If your dentist has an intra-oral camera, have them take a photo so that you can see the breakdown of the restoration. You will see cracks, brown and black outlines around the tooth and sometimes a dark “halo” around the restoration.  These are the signs of recurrent decay.  If your dentist doesn't have an intra-oral camera, it’s time to change dentists.  
2. On the x-ray, the existing restoration should be large taking up over 60% of the tooth above the gum line.  If it’s not a large restoration, chances are you don’t need a crown.
3. A crown may be necessary if there is pain when you bite into certain foods.  This is a sign that your tooth may be cracking and propagating down to the nerve of the tooth.  Placing a crown acts to keep the parts of the tooth together and evenly distributes the load forces associated with chewing preventing the tooth from splitting further.

Be wary about doing a crown if the existing filling is small or if you simply see cracks in a tooth without pain or existing restorations.  Sensitivity to sweets can be a symptom to leaking restorations and/or decay but just because you don’t have sweet sensitivity, doesn’t mean you don’t have leaking fillings.

Fillings:

Fillings are done when there are areas of decay in the tooth.  Basically, decay is a bacterial invasion of the tooth which continues to get larger unless the affected tooth structure is completely removed then sealed with a dental restorative material.
  

1. Fillings usually need to be done if you feel sensitivity to sweets.
2. They are done when there is less than 60% of the tooth surface is affected.
3. On dental x-rays, you can see a triangular dark area in between the teeth which is not viewable during your clinical exam.
4. If on the top of the tooth, a dental explorer may “stick” into the tooth, indicating a soft spot that decay has penetrated through.

The biggest misconception is that if the groves on the top of the teeth are brown or stained, that this a cavity which needs to be filled.  The tops of teeth are naturally stained and this usually does not mean that they have cavities.  If there is a “stick” with the explorer or radiographic evidence of decay, then these stains are probably decay which need to get treated and restored.

Root Canals

Intentional misdiagnosis of root canals is not nearly as common as the aforementioned diagnosis, but we see this from time to time so I thought I would quickly mention it here.  Usually a root canal needs to be done if you are in dental pain which can be attributed to a specific tooth.  However, that is not always the case.  There are times when a root canal needs to be done because there simply is not enough tooth structure above the gumline.  You may have had pain on a tooth and suddenly it doesn't bother you anymore.  This is often a sign of necrosis.  The tooth can be saved, but a root canal must be done to remove the dead material inside the tooth.  If you have doubts if your tooth needs a root canal, you should seek an opinion from a root canal specialist or endodontist.

Most dentists are honest professionals who really have the best interest of their patients at heart. However, it is always ok to get a second opinion and most dentists who are trustworthy welcome second opinions.  Always follow your intuition and if something doesn't make sense to you, don’t move forward with the procedure.  Getting dental work done is time consuming and expensive.  Make certain that it is something you need done before moving ahead with treatment.

Go Dental, Your Valencia Dentist

Abused Dental Procedures Part 1: Deep Cleanings

In my last post, I discussed seeking a second opinion if you have doubts about your dental treatment plan.  I also explained the way HMO and PPO practices work and why they may not represent the most cost effective way to get your treatment done.  I would like to add that just because a dentist is fee-for-service, doesn’t mean they are a “better” dentist so please do not ever hesitate to go with your instincts and ask for a second opinion if things just don’t add up in your mind.  That’s not being disrespectful, that’s being a smart consumer.

In my next few posts, I would like to discuss some of the most abused “procedures” in the dental world.  Typically, these are procedures that dental offices know they can get away with billing to insurance and getting the patient to buy into treatment acceptance.  Keep in mind that if you should receive a treatment plan that has these procedures doesn’t mean your dentist is being dishonest, but rather you should be able to ask the right questions to justify in your mind that these procedures really need to get done.  Again, if in doubt, get a second opinion.  And if still in doubt, get a third opinion.  It’s worth your time to give yourself peace of mind that you are doing the right thing for your body.

“Deep Scalings” aka “Periodontal Scalings” or “Deep Cleanings”

By far, the most commonly abused procedure in dental offices today.  It is very common amongst dental practice consultants to recommend that dental practices become more aggressive in treating their patients for periodontal disease.  There is very good evidence that completely supports that periodontal disease has a significant effect on a patient’s general health.  So there is definitely science backed studies that show that as a profession, we must be diligent about identifying and treating periodontal disease.  However, some offices will use this as a scare tactic and convince patients that they need this treatment when in fact, the diagnosis is completely incorrect.  

The criteria for diagnosing periodontal disease (early-moderate-advanced) are:

1.     Generalized Pocket depths over 4 mm: Pocket depths are determined by using an instrument called a periodontal probe which is gently slipped between the tooth and gums.  It should not hurt to do periodontal probings although with some patients, it does feel a little uncomfortable. I had a patient come into our Valencia dental practice the other day whose previous dentist recommended deep scalings without ever doing probings.  That is like a physician diagnosing heart disease without ever listening to your heart.  You cannot diagnose periodontal disease without getting probing depths – impossible.

2.     Bleeding pockets: Your gums bleed on probing.  On healthy gums, gums do not bleed when they are gently probed. With periodontal disease, they bleed when probed.  If the dentist or hygienist is probing your gums and it hurts like heck and bleeds, then they are probing you too hard and getting false reading and causing you unnecessary pain.

3.     Generalized bone loss: You need a full mouth series of x-rays to diagnose periodontal disease.  You will see the bone level lower on all the teeth indicating that there is some process that is causing the bone to recess.

4.     Subgingival Calculus: Also known as “Tartar” in the mainstream media.  These are deposits of calcifications which harbor colonies of bacteria.  When they are trapped below the gumline, they cause inflammation of the gum tissue, bone loss and gum recession. On x-rays, they look like spikes stuck on the tooth below the gum tissue.

When three or all four of these criteria are met, then periodontal scalings are needed.  This procedure should involve using local anesthetic to numb a quadrant and always using hand scalers (and sometimes water scalers but never just water scalers) to clean out the affected areas.  If your dental office is completing a periodontal scaling of four quadrants in just one hour without any anesthetic, you are not receiving periodontal quadrant scaling.

Why do practices like to do periodontal scalings?  Because they can bill you and your insurance company much more than they can get for just a regular cleaning.  If a typical dental cleaning costs $100, a periodontal scaling costs over $1000 dollars.  The money is much better for the practice but in so many cases it’s a procedure that is completely unnecessary for the patient.

Don’t be scared to ask questions of your dentist and make sure the explanation makes sense to you.  And again, if in doubt, ask for a second opinion.

Go Dental, Your Valencia Dentist