A couple of weeks ago I discussed the different types of materials that are being used today to “fix” teeth. I broke them down into two main categories – direct vs. indirect materials. Direct materials are things like silver amalgam and tooth-colored resin/composite that are placed directly into the tooth after the tooth is prepared. Indirect restorations are things like crowns, gold and ceramics in which the tooth is prepared and a manufactured restoration is cemented or bonded to the tooth.

Whatever your feelings are on amalgam, there is no disputing that it proved to be a very successful material over a long period of time. Despite this, it has not been used in most of Europe in decades and is used relatively infrequently in the United States. Its replacement, tooth-colored composite resin has made much progress in its ability to look good, allow more conservative treatment, and hold up well if used within the recommended parameters. However, it falls short when restorations get larger, cusps of teeth are involved, and/or when patients have bruxing/grinding issues.

In my experience, most patients don’t ask too many questions about the materials that will be used to “fix” their teeth. However, I think it is a conversation worth having. The expected lifespan of the materials being used in your mouth is good information to know to help you make a decision about your treatment. If you had a moderate to large silver filling to be replaced (that’s been there for 30 years) and the dentist told you that your new composite resin had an expected lifespan of 5-10 years, would you be okay with that?

I was recently at a training session for my CAD/CAM (computer-aided design/computer-aided manufacturing) machine which produces indirect restorations. The presenter discussed the fact that we live in a challenging time for our dental restorations. Teeth are under a lot of stress with the normal functions of eating. Throw in additional stress from grinding and an acidic environment from all the carbonated beverages we drink or gastric reflux issues people unknowingly have, and teeth are at a disadvantage.

This is why I think it is so important for patients to be more active participants in their treatment decisions. My first thought when I am determining what type of restoration to propose in any given situation is – What can I do that is the most conservative, yet adequately protective, keeping in mind that I want as much tooth around as possible for the next time this tooth needs to be fixed?

CAD/CAM technology allows the dentist to perform less invasive, longer-lasting dentistry. Tooth-colored direct composite resin is great for smaller to moderate sized fillings and should be used whenever cusps of teeth are not involved. The traditional crown (which covers the whole tooth) should be done less frequently with the use of CAD/CAM technology, which allows more conservative restorations to be done in one visit.

Ask your dentist about the materials being used to make your restorations and if you have any choices. If you have the time, google dental “onlays” to see what more conservative dentistry looks like.

One of the most important things you do when visiting a new physician or dentist is to fill out a medical history form. Many patients balk at filling out these forms, and in my experience, a high percentage of patients fill them out incompletely. There are many risks involved with not including all prescribed and self-prescribed medications.

The most frequently prescribed medications by therapeutic category are anti-hypertensives (blood pressure), cholesterol regulators, antiplatelet and anticoagulant agents (blood thinners), respiratory agents, antiulcer drugs, antidepressants, hypnotics, and anti-diabetic medications. In addition to including any of these medications on your history form, it is also very important to include any over-the-counter (OTC) drugs, as well as vitamins and supplements.

Many patients regard questions about current or previous medications as irrelevant to dental treatment and sometimes even obstacles to treatment. However, there are many drug-drug and drug-disease interactions that can occur with medications prescribed in the dental office. In addition, it is equally important to know everything that is being taken in the rare event of a medical emergency in the dental office.

Analgesics, such as acetaminophen, ibuprofen, and naproxen, are commonly prescribed or recommended in dental therapy. Acetaminophen, which is primarily metabolized in the liver, is dangerous for patients who take certain medications, such as anti-seizure and anti-depressants, as well as for those who consume moderate amounts of alcohol. Interactions with even small doses of acetaminophen can lead to liver toxicity. In addition, acetaminophen should not be used in patients on anti-coagulants as it may enhance the effects of the blood thinning agents.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can also react adversely with many of the same drugs. Prolonged use of NSAIDs can cause gastrointestinal ulceration or perforation and reduced kidney function. They should be avoided if you have pre-existing gastrointestinal or renal disease. NSAIDs have also been known to reduce the efficacy of certain blood pressure medications, interfere with the cardio-protective effects of daily low-dose aspirin, and should be avoided in the last trimester of pregnancy.

Antibiotics, such as penicillin or amoxicillin, can also interact with frequently prescribed medications. For example, these antibiotics may inhibit vitamin K formation and potentiate the effects of anticoagulant medications. They are also thought to decrease the efficacy of oral contraceptive agents.

Although you should be questioned at each visit to determine if your health status or medication list has changed, always let your dental hygienist or dentist know if there have been any changes. Review the list of medications, and anything else you take, even if you don’t consider it important, to make sure it is accurate.

Research shows that babies are born without any harmful bacteria in their mouths. However, once bacteria colonize in the mouth, children are more prone to cavities in their baby teeth and permanent teeth. How do they get the bacteria? Caregivers.
Most parents don’t know that they can pass harmful bacteria from their mouth to their baby’s mouth. The most critical time is during the child’s first 2 and one-half years of life. Most children are born without a single tooth. Can bacteria passed to children without teeth affect their decay potential for their whole life? According to research, the answer is yes.
If you have a history of poor oral health, including many fillings in your mouth or gum problems, you are much more likely to transfer these harmful bacteria to children. How? Typically, this takes place through common parental or caregiver behaviors such as sharing utensils or cleaning a baby’s pacifier with your own saliva.
Prevention starts as early as 6 months into a pregnancy. Research shows that expectant mothers who chewed gum containing the sweetener xylitol are much less likely to have decay-causing bacteria in their saliva. So, take-home point number one is; it is essential for expectant parents and caregivers to keep their own mouths healthy. If you reduce the bacterial levels in your own mouth you are not only benefiting yourself but also that of your unborn child. Visiting a dentist regularly, even more often when you are pregnant, improving your homecare, and using products that specifically reduce bacteria, are all essential.
Here are some things to consider after your child is born. First, eliminate as many potential ways of transferring saliva to your baby. Do not share utensils or let grandma or grandpa lick a cloth to clean around a baby’s mouth. Wiping your baby’s gums with a clean cloth after meals is also good practice to help reduce bacterial levels.
Once a child starts getting teeth, diet plays a significantly greater role. Minimizing snacks and drinks with fermentable sugars is key. This starts with the bottle. Bottle syndrome, also known as baby bottle tooth decay, occurs when teeth become exposed, at length and frequently, to liquids containing a form of sugar. All liquids that contain sugar can cause bottle syndrome, including breast and cow’s milk (which contain the sugar lactose), formula, fruit juice (which contains the sugar fructose), soda and other sweetened drinks.
Decay is caused by the constant presence of milk, formula, or fruit juice in a child’s mouth during the night, during breastfeeding, during naps, or for extended periods during the day. The liquid pools around the teeth and gums, providing food for the bacteria in plaque. The bacteria produce acid as a byproduct when they consume the sugar. This acid attacks your child’s teeth and causes decay.
When your child feels comfortable with a toothbrush, brush their teeth and gums twice a day with an extra-soft toothbrush. Use a pea-sized amount of toothpaste without fluoride until your child is old enough to spit. If your child doesn’t like toothpaste, it’s fine to brush without it.

Prevention starts before babies are born. It starts with taking care of your own mouth. Visit your dentist regularly and strive for optimal health.

Many patients and dentists face a decision-making process when it comes to keeping a natural tooth with root canal therapy vs. removal of a tooth and replacing it with a dental implant. The introduction of dental implants has proved to be a pivotal technology in dentistry. In a profession that strives to help patients keep their dentition, the point when it becomes necessary to opt for dental implants is a judgment call.

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Dentists are taught the skills in dental school and beyond to diagnose and treat dental decay, gum disease, tooth loss, and other things to help preserve teeth for a lifetime. A more mystical area of dentistry for many dentists is the ability to identify, communicate and treat bite-related problems that occur over long periods of time.

The term in dentistry for how the teeth come together is called occlusion. The masticatory system is composed of the teeth, the joints (TMJs), and muscles. How the teeth occlude and what a person does with their teeth, determines what happens to the teeth, muscles and joints over time. If these three things are not working together in harmony, something has to give; teeth wear down, joints and muscles can become sore, etc.

Would you want to know that there is a potential problem or prefer to have it ignored and deal with the consequences when and if they should arise?

The fact of the matter is – every person is different and does different things with their teeth. How do you compare a 90 year-old with all of their teeth with minimal wear to a 30 year-old with 25% of their tooth structure missing (unknowingly in many cases)? Both individuals eat, sleep and breathe but present very differently. Theories abound; there is no question that some people put greater forces on their teeth when they sneeze, swallow, chew and sleep than others.

Greatly underdiagnosed, these forces help cause things like teeth wearing, teeth breaking, TMJ/muscle soreness, tooth loss, tooth sensitivity, gum recession, and poor sleep patterns. Many dentists (including myself) see the signs but often choose to avoid a challenging conversation with a patient about a disease process that is not fully understood. Unfortunately, ignoring these signs is not in the best interest of the patient. It is the obligation of the dentist to raise the patient’s awareness of these forces and to discuss strategies to combat them. It is only through this awareness that patients will be able to decide if they want to do anything about it or not.

Keep in mind that many of the bodies functions, including the forces put on teeth, occur without any cognitive thought. Patients will often say, “I know I grind my teeth in my sleep when I’m stressed”. Things like stress may have some effect on this, but is it important to look beyond specific instances and evaluate the bigger picture of what is really going on.

For example, breathing is perhaps the most essential of all life functions. If you are not getting the proper oxygenation when you sleep, there are some crazy things your body does as a defense mechanism to get air. Sleep-related breathing disorders are underdiagnosed and undertreated and may just be one of the leading causes of tooth wear and TMJ problems.

I am finishing my “mini-residency” at Tufts this week in dental sleep medicine so I will be bringing this topic up again in future columns with updated information. If you have any questions about this topic, or any other, please send me an email.

This is the final column of this series. If you missed any of the past segments, you can find them at www.thetowncommon.com.

I’ve heard of some new cosmetic techniques that can improve smiles. Are they appropriate for older adults?

Older adults can benefit from many of the options available today for improving the look of a smile. Your dentist can describe and discuss with you the range of treatments that would be right for you. Part of older adulthood is the acceptance of aging and the development of realistic expectations for appearance. In that context, dental treatment for older adults can be a healthy and adaptive way of maintaining dental health and emotional well-being.

Our teeth and mouth play a critical role in psychological development and well-being throughout our lives. Modern dentistry has expanded esthetic options for people of all ages. Coupled with good oral hygiene and regular dental visits, cosmetic techniques can help improve the appearance of your smile.

I’m on a limited, fixed income and can’t really afford regular dental treatment. Are there any resources available to help me?

Even if you cannot pay for dental care, you don’t need to live without it. Thousands of dentists across the country assist the elderly on fixed incomes by offering their services at reduced fees through dental society-sponsored assistance programs. The availability of such aid varies from one community to another, so call your local dental society for information about where you can find the nearest assistance programs and low-cost dental care locations, such as public health and dental school clinics. Other sources of such information are local social service organizations.

What is dentistry doing to better serve older adults?

Dentists are experiencing a quiet revolution in their offices as the number of older patients increases steadily. The profession knows that this burgeoning population group is wearing fewer dentures and is keeping natural teeth longer. Also, we know that some patients in this group require special consideration because reduced mobility and dexterity may make daily oral hygiene difficult. In addition, medical conditions and impairment are factors that dentists take into account for certain patients.

Sometimes, lack of awareness about available treatments and techniques leads older patients to make false assumptions about their dental health and tolerate conditions such as toothaches, bleeding gums and clicking dentures. Dentists are gaining practical information on how to effectively manage the treatment needs of older patients. Many dental societies have set up access programs to assist older adults, individuals with physical or mental disabilities or indigent persons to receive care.

The dental profession is increasingly sensitive to the special needs of and the importance of dental health in the older patient. Older adults are more health conscious as a group than ever before. Their oral health is an important part of their overall health and the dental profession is committed to providing the treatment and guidance older adults need to maintain it.