San Francisco Surgical Arts

Malocclusion means the teeth are not aligned properly.

http://www.umm.edu/ency/article/001058.htm

A dental restoration or dental filling is a  used to restore the function, integrity and morphology of missing tooth structure. The structural loss typically results from caries or external trauma. It is also lost intentionally during tooth preparation to improve the aesthetics or the physical integrity of the intended restorative material. Dental restoration also refers to the replacement of missing tooth structure that is supported by dental implants.

“Apnea” translated from Greek means “without breath”.

People who suffer from sleep apnea may not know it, because the disturbance in breathing may not fully awaken them.  All they know is that they are regularly tired to the point of exhaustion and so is the person they are sharing their living space with.  This is because of the loud snoring sounds and restlessness at night associated with sleep apnea.

A person who has sleep apnea might have hundreds of episodes a night, each lasting from a few seconds to a minute or so.  Try holding your breath for 60 seconds, and imagine doing this throughout the night.

Furthermore a person who does not receive the proper treatment for sleep apnea can shorten their lifespan, with increased risks of heart attack, high blood pressure, heart disease, stroke, diabetes, depression and many more.

In the past sleep apnea has been seen most frequently in men, but recent studies show a comparable amount in women and even children.

Your primary care physician or general dentist can do the initial screening for sleep apnea, but in order to be properly diagnosed one must do a “sleep study”.    “A sleep study examines one’s sleep and generates several records of activity during several hours of sleep, usually about six. Generally, these records include an electroencephalogram, or EEG, measuring brain waves; an electroculogram, or EOG, measuring eye and chin movements that signal the different stages of sleep; an electrocardiogram, EKG, measuring heart rate and rhythm; chest bands that measure respiration; and additional monitors that sense oxygen and carbon dioxide levels in the blood and record leg movement. None of the devices is painful and there are no needles involved. …Usually the bedroom where the test is conducted is more like a comfortable hotel room than a hospital room.”  http://www.sleepapnea.org/diagnosis-and-treatment/diagnosis.html

Calculus (noun): A hard deposit found on the teeth, that forms when plaque is not removed

What happens if I do not take care of cavities?

Your general dentist can detect cavities, a.k.a “caries”, with a combination of an oral exam and x-rays.  Once a cavity is detected it must be cleaned and filled properly, it will not just go away spontaneously.

The process of cleaning a cavity begins with removing the infected and decayed enamel and dentin.   The remaining defect in the tooth is then sterilized and filled with a material that is bonded to the tooth.  The filling material is designed to imitate the natural anatomy of the tooth, so that it can withstand the forces of chewing and occludes properly.  But no matter how good the technology,  and the latest advances in nano-technology (white resin fillings) we can never 100% mimic the natural tooth.  That’s why its so important to prevent cavities from occurring in the first place.

Some people chose to not to follow the recommendation of their general dentist, and hope that the cavity will spontaneously get better.  On the contrary, if the cavity is not removed, it will worsen and go deeper into the pulp chamber of a tooth, leading to further need for a root canal.  The more delay, the more the discomfort and financial burden.

A tooth typically have 5 surfaces: occlusal (chewing), lingual (tongue), buccal (cheek), mesial (front) and distal (back).  If too many surfaces of the tooth are affected, the strength of the tooth can be compromised making it unethical to fill the cavity.  At this point the tooth might crack or even break.  In this case, we need to place a crown (cap) on the tooth.  Depending on the number of surfaces involved, there are different codes signifying the amount of work that needs to be done.  In general the more surfaces, the more complicated the filling procedure and the more expensive the treatment.

A crown is typically placed with there is little tooth structure left to just fill it.  The crown is designed to hug the tooth like a winter hat, basically a molded replica of the tooth.  Crowns are fabricated in a lab from a mold (an impression) of the original tooth.  The natural tooth first is prepped (cleaned of decay) and then the crown is securely glued to the prepped tooth.

Sometimes the tooth has been so severely decayed that it has infection has spread to the pulp chamber or the root.  This is when the pain and facial swelling can become unbearable and dangerous.  At this point the material inside the pulp chamber must be removed via a “root canal” procedure.  This is most commonly done by an “Endodontist”(a dentist who specialises in root canal therapy).  Most commonly your general dentist will refer you out for this procedure. The endodontist will first empty the pulp chamber of the infected material, sterilize it, and fill it with a special inert material that prevents future infections.  In the majority of the cases where a tooth has been root-canaled, a crown is need on the tooth to protect the tooth and its new root canal.  On occasion, some patients forgo the crown placement after a root canal, in order to save money.  Unfortunately this habit will only lead to further problems in the future, such as a fracture of the tooth and/or the eventual loss of the tooth.

In some instances, if the tooth is severely compromised, or is cracked below the gum-line (sub-gingival), the tooth must be extracted to prevent further spread of the infection into the head & neck area.  This can sometimes be life-threatening, as a result of difficulty in breathing.  There have been several documented cases of people dying from non-treated infected teeth.  People of all ages, races and ranges of health and fitness have been affected, so it is not safe for anyone to ignore the hazards caused by tooth decay.  Make sure to schedule your bi-annual evaluations in order to get screened for potential oral health issues.

Most well-trained general dentist can pull a simple tooth.  However with more complicated procedures and teeth with multiple roots, it is more common for the dentist to refer you to a specialist, or an Oral Surgeon.  An Oral Surgeon has special equipment and training to make extraction more safe and comfortable, in a lot less time.  An oral surgeon at a minimum has 4 extra years of training in just the extraction teeth, see our previous post “What Is Oral Surgery” for more information on the education and training of an Oral Surgeon.

Once a tooth is extracted, it should be replaced in order to recreate the harmony that typically exists in out dentition.  In addition to being unsightly, the missing tooth will cause the other teeth to shift and cause misalignment (malocclusion) of the teeth.  Teeth can be replaced with either a bridge or an implant.  Please refer to our previous article “What Is A Dental Implant” for more detailed information about bridges and implants.

Extraction (noun):  the removal of one or more teeth from the supportive bone and tissue.

Occlude (verb): To bring together (the upper and lower teeth) in proper alignment for chewing.

In the Ancient Egyptian Culture dental infections often lead to death.  It was very rare for a dentist to pull an infected tooth, in fact, instead a doctor would drill a whole in a person’s skull in order to drain the infection.  Opium was commonly used to alleviate the pain of this procedure.

Although there are some signs of dental restorations found in excavated mummies, they are believed to be preformed postmortem.  One mummy was discovered with thin gold wires holding the teeth together, replicating a bridge.

Many mummies are discovered with their teeth still in place, this might be because of the surplus of calculus surrounding the remaining teeth.

Strangely enough, cavities were not a common ailment in Egyptian culture.  A popular food of the time was corn flour, processed by adding sand.  It is thought that the sand wore the teeth down so rapidly that cavities were simply ground away.

In 400 BC there is a noticeable improvement in the wear of teeth, possibly because of improvements in the methods of creating flour.

Fun Fact:  Nefertiti had lost all of her teeth by the time she died in her 40s.

Today in the news and television commercials we often hear the term “gum disease”, but what exactly is gum disease is?

Gum disease is an infection in the tissues that surround and support your teeth.  Your mouth has a “V” shaped sulcus in between every tooth.  A healthy gingival sulcus hugs the tooth like a turtleneck, protecting it from the onslaught of food particles as we chew.  As gum disease develops bacteria grows in between the gum tissues and the tooth, causing a deeper pocket in the sulcus, which leads to bone loss.  Its this loss of bone, that leads to a weakening of the foundation for teeth.  Eventually when there is adequate loss of bone surrounding a tooth, it will begin to get loose.  We measure the severity of gum disease by the depth of the sulcus pocket.  The deeper the pocket the more severe the infection.

Gum disease comes in two stages:

Stage I: Gingivitis. 

Gingivitis is mild and reversible, affecting only the gums.  Gingivitis can be treated by your General Dentist, usually with a deep cleaning or root planning.  Also it is recommended to follow a strict oral hygiene regimen at home.

Stage II: Periodontal Disease.

Periodontal disease is a more severe case of Gingivitis.   If left untreated the bacteria and plaque that cause gingivitis becomes a mineral referred to as calculus.  Calculus causes damage to the tissues surrounding the teeth and results in the gum recession, away from the teeth and its supporting bone structure.  If Periodontal disease is left untreated it may result in the teeth becoming loose and falling out.  Although you do not have to have loose teeth in order to have gum disease.  It is possible to have gum disease and not notice any symptoms.

Warning signs of gum disease may include:

• The gum tissue bleeds easily

• The gums that are receding away from the teeth

• Persistent bad breathe

• Permanent teeth may be loose or separating.

Some factors that may increase your risk of gum disease:

• Chewing and/or smoking tobacco

• Bridges or other restorations that do not fit properly

• Crowded teeth

• Pregnancy

Smoking has many negative affects on one’s health, but did you know that it also increases your risk of periodontal disease.

“Recent studies have shown that tobacco use may be one of the most significant risk factors in the development and progression of periodontal disease. In addition, following periodontal treatment or any type of oral surgery, the chemicals in tobacco can slow down the healing process and make the treatment results less predictable.” http://www.perio.org/consumer/smoking.htm

Smokers may have an increases development of calculus, causing deeper pockets and more severe bone loss.

Did you all know that some people even have more than their 3rd molar.  Although uncommon, we do come across these types of cases where patients have extra teeth, a.k.a. “supernumerary”.  In a recent study in the Journal of Oral & Maxillofacial Surgery, Dr. Shahzad and his team studied the prevalence of forth molars and found it to be 2%.  More common in black patients and typically in the upper jaw and only on one side.   The decision to whether to remove them is based on the same risks/benefits ratio as the removal of their molars.

So why are third molars such an issue?  There was a literature review done in 2007 looking at all the date on Ovid Medline, PubMed, Google Scholar, and the Cochrane.  This was later published as the “white paper”.

The following is a brief summary of some of the findings related to third molars:

•  The presence of visible third molars is associated with overall elevated levels of periodontitis (gum disease) and that of immediately adjacent teeth (second molars). 
•  In the presence of visible third molars, periodontitis involving adjacent teeth is progressive and only partially responsive to therapy (typically deep cleanings and antibiotics). 
• The presence of pocket depths of ≥4-5 mm and/or bleeding on probing should be recognized as possible predictors of future progression of periodontitis (gum disease). 
• Periodontal disease as indicated by probing depths > 4 mm exists in and around asymptomatic third molars
• GTR and/or DBP (bone grafting after extraction) may be beneficial in instances where there is evidence of significant pre-existing attachment loss (bone loss on the back side of the second molar). 
• Absence of symptoms does not indicate absence of disease or pathology.
• Periodontal disease progresses even in the absence of symptoms. 
• Periodontal defects, as assessed by pocket depths, deteriorate with increasing age in the presence of retained third molars. 
• Caries (cavities) in erupted third molars increases in prevalence with increasing age. 
• The incidence of postoperative morbidity following third molar removal is higher in patients > 25 years. 
• Germectomy (removal of the third molar that is premature and has one third or less of root formation) may be associated with a lower incidence of postoperative morbidity.