How Have You Been Sleeping?

I specialize in and around the oral cavity, and honestly, if you asked me about your herniated disk or weird rash on your foot, my guess would be as good as yours. But sometimes systemic disorders appear in the mouth and that's when I come in handy.

Case in point: A long time patient who has not been in for about a year comes in for a cleaning and check up. He is a middle aged male with a non-contributory medical history and good oral hygiene. His dental history is only front veneers placed many years ago and still in good shape. The patient apologizes for "not coming in for so long because work has been crazy over the last year." His stress levels have risen dramatically. On exam, everything is within normal limits except for the inside part of his 3 front upper teeth. A close up picture is posted above. There is dramatic wear on the lingual aspect of 3 of his 4 incisors (1 tooth is crowns and thus covered in porcelain). None of his other teeth show this kind of wear.

So what's going on? I asked the patient how has he been sleeping the past few months? "Well, I probably get about 6 hours of sleep a night, but I don't think I've been sleeping all that well to be honest." Can you count the red flags so far?

1.Higher levels of stress
2.Not sleeping very well
3.New wear facets on upper teeth

I asked and the patient said he has not noticed any heart burn of late. I asked him if he has heard of Gastroesophageal reflux disease (GERD), condition in which the acidic stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). Due to positioning of the body while sleeping, the acid tends to sit and wash at the backs of the front teeth. The patient said he's heard of it but he didn't think he had it. I recommended the patient see his physician regarding these new symptoms, but the patient said he was far too busy to do that. So I recommended him take an over the counter antacid before sleeping, and if he had a restful sleep than that might persuade him to see his physician for further testing.

Let's fast forward 6 months. The patient comes back for a cleaning and on asking him how things have been, he replies "really great. A few months ago, I took your advice because I was still sleeping poorly and felt pretty fatigued through the day. So I tried an antacid before sleep and I had my first good night sleep in months. The next week I saw my doctor and after some tests he diagnosed me with GERD. Working on my diet, my stress levels and taking medication, I've been doing really great and sleeping like a baby."

In the end, a little tooth wear was the beginning signs of a larger, more systemic medical disorder.

Implants And Bridges, Oh my!

When a patient is looking to replace a missing tooth, the most common question is always "What are my options?" The following question asked is "What do you think?"

Let's first discuss all the options available to replacing missing teeth. I'm going to keep this entry specific to replacing a single tooth, which in most cases eliminates partial dentures as an option. With that said, the 2 best options are bridges and implants.

A bridge is a restoration that is made of 2 crowns on either side with a fake tooth in the middle. These 3 components are permanently fixed together and cemented to the teeth. Depending on the type of bridge (inlay vs conventional), some tooth structure needs to be removed in order for the bridge to sit on the adjacent teeth. The appointment is typically 1 hour to prep the teeth, take an impression and make a temporary. 2 weeks later, the final bridge is cemented in a 30 minute appointment.

An Implant is a titanium screw surgically placed into the bone. About 3-6 months later, an abutment is fit into the implant and a final crown is placed over the abutment. The adjacent teeth do not need to be touched. Depending on the bone level and gum level, a bone or tissue graft might be necessary before placing the implant.

So when it comes down to replacing that missing tooth, which should you choose? Well...it depends. Let's take the case where the bone and gum levels are ideal. For me, the biggest indicator is what restorations are on the adjacent teeth. If there are crowns and big fillings in the adjacent teeth, then I'm more inclined to use those for the bridge. By removing those restorations, you make space for the bridge without having to touch too much tooth. On the other hand, if the adjacent teeth have no restorations, an implant would be advised because otherwise perfectly good teeth would need to be prepped.

A second consideration that the patient tends to use as the final factor is time. For a bridge, from start to finish the tooth can be replaced in 2 weeks. For an implant, the time of treatment is extended to 3-6 months, and that is if it is a straight forwards case.

So if it was your mouth, what would you go with?

The New World: 1 visit Crowns

Everyone remembers the good old days when you went to the Dentist for an Onlay or Crown. An hour in the chair got you half way to the intended goal. A smelly compound was forced into your mouth to take an impression, and then a temporary was placed with a "We'll see you back in 2 weeks to cement the final Crown!" In those next few weeks, favored the other side of your mouth. You worried about being out with friends for dinner and Crack!, the temporary broke or came out, only to have to wait until the next morning to reach the Dentist and explain what happened. And hopefully it was not a Friday night dinner, because then you were out of luck until the following Monday. If all of the above didn't happen, your tooth was probably sensitive for days and had a funky smell coming from under the crown.

Cad Cam dentistry has changed all of that. With the Sirona Cerec machine, we are able to take digital impressions, make a computer generated onlay or crown, and mill and cement that final restoration all in 1 visit. There is no waiting for the lab to make the crown. No worrying about temporaries falling out. And best of all, sensitivity is reduced due to the fact that the bacteria in your mouth have much less time to contaminate the tooth. 1 hour versus 2 weeks makes a big difference with regards to your time and sensitivity.

Also, the best part of using the Cerec machine is adhering to the philosophy of Minimally Invasive Dentistry. When a tooth breaks or is in need of a restoration stronger than a filling, many Dentists will just do a full crown because it's less technique sensitive and temporaries are much easier to make. Since we don't need to make temporaries and can bond the restoration to the tooth, we can save healthy tooth structure with an Inlay or Onlay. These all porcelain restorations are extremely strong and durable, and at the same time we do not need to cut as much tooth structure with these restorations compared to a crown.