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Τρίτη 30 Οκτωβρίου 2012

Clenching or grinding of teeth .Am I a bruxist?

   The theme of today's post is the habit that some people have and that is to clench or/and grind their teeth. And the proper medical terminology is "Bruxism"





                                             

  When we talk about bruxists,there are several categories.Some people only grind their teeth, others just clench them, and others clench and grind together. Bruxism is a para-functional habit.A para-functional habit is one  means that that we do and don't feel that we do it (unconsciously), which doesn't serve a particular cause.For instance when we bite and eat our food,it is a functional habit.Otan we bite our nails it is a para-functional or nonfunctional habit. Other parafunctional habits range from bitting the internal part of our cheeks, biting pen or pencil chewing ice (which we will deal in a separate post ) and of course clenching or gnashing of teeth.
  Especially as for the clenching or grinding of our teeth, it usually occurs during the night when we can't control it.It is possible to do it during the day (day clenchers), so it is easier to treat, since we realize that we are doing it. It is certainly a result of stress and becomes worse (more intense) in times of stress; a noise like a rubbing stone on another is heard, so our roommate / friend / parent / our brother tells us that he hears something like that during the night,coming from us so we then seek treatment for our condition. This sound can only be heard if you grind or clench and grind your teeth,because if you only clench your teeth there won't be a sound         

               "But how do para-functional habits cause problems in the mouth?"

                                                 

   Para-functional habits cause muscle and joint function when it is not necessary.


                                        

  So the muscles and the joints(TMJ TemporoMandibular Joints)are constant motion and contraction.That means that they get more burden when they don't have to,and less relaxation.Then fatigue kicks in.
Continuous muscle contraction can lead to headaches and migraines as well as problems in the joint (temporomandibular joint disorders or TMD) resulting in a clicking sound every time we open or close our mouth.Pain might co-exist when we open or close our mouth.Also as a result of the strain and the fatigue our jaws might feel a bit stiff when we wake up in the morning.     
                     
                       " But what happens to the teeth and what can we do? "

                                          
The prolonged clenching or teeth grinding teeth causes damages.Let us see examples of patients suffering from bruxism.
The first patient in the early stages of bruxism

                                                     



   


                                          



                                    
                              




 

The only thing is that we can notice are some cracks in the teeth and slight wear on the incisal edges of the teeth.
   If  treatment is not sought the problem will escalate and visible damage to the teeth will start to show.
 The teeth,due to the clenching and grinding begin to decline in height and appear slightly smaller,with a further wear of their incisal edges.

                         
If even the treatment is not sought,and we leave the condition untreated for a long period of time, then the teeth end up like this



 
See how worn and damaged the teeth are.And for a better understanding of the last picture let us process it a bit.
  Notice how much dental structure(tooth) has been lost length-wise. The patient has a fixed bridge in the upper teeth and this worsens the problem, because prosthetic restorations (crowns / bridges) are stronger than natural teeth, so the grinding and / or clenching of teeth cause damages to the natural teeth that oppose them.You can see the major aesthetic and functional problem createdfor this patient. And rehabilitation is much more difficult and much more invasive and more expensive of course for the patient.
  Besides the problems with the length of the teeth, clenching / grinding teeth creates non-carious lesions.

 

These are called "abfractions",and they are loss of tooth in the area over the gum line,that weaken the tooth even more.  Naturally,if left untreated ,problems only grow.
  
"What can I do now Doctor? I am more stressed than before"

 


  The treatment for bruxism is a splint or mouthguard which the patient during sleep.

                                              


It looks like a bleaching tray,for home bleaching of the teeth,but more tough. So when the patient grinds or clenches his teeth, he grnds the mouthguard leaving the teeth intact.Also the mouthguard relaxes the muscles, because they are not in continuous strain.And with the mouthguard out body(and mind) gradually learns not to clench or grind the teeth.Naturally the mouthguard need adjusting, especially in the early visits, in order to distibute the stresses evenly on all the teeth.Te adjustment is done by the dentist.
Let us see photos with the mouthguard worn

                                                       




























  The red and black dots are from the articulation paper used to check for even stress distribution on all the teeth. The mouthguard is not forever; it may need redoing, if damaged by the bruxist patient.
  It might seem a little strange at first to wear it during the night and sleep with it but this feeling is the beginning of the treatment.It will seem inconvenient at first and during the first few days you may not be able to fall asleep easily, because there is a  feeling of a full mouth or because of  the increased saliva secretion, but you will get used to it.If you can accept your problem and understand that this is the only treatent, then you will show discipline
   Exercises of the jaw,can also be started as treatment for bruxism , but it is dangerous t blog about them.N ot because I'm afraid to share my knowledge, but due to the fact that if the wrong exercises to address the problem are implemented , the problem may get worse..Also some cases can be treated with anti-stress medication.
Hope I've you informed even more.

Sleep tight!



                                               

Τετάρτη 24 Οκτωβρίου 2012

Root Canal Treatment(RCT)

Today's post will be about  the endodontic or root canal treatment . 
 To be honest ,I can not really be sure what someone thinks when he hears the term root canal treatment. 
They might think something like that 

 
  or something or like that



  Certainly in both cases they are wrong!

 The endodontic or root canal treatment is the process in which the pulp of the tooth (or the nerve of the tooth), due to the fact that it has been contaminated by bacteria(microbes), is removed and replaced by a biocompatible material, so that the tooth can remain functional inside the mouth. 

  In the the past, and I mean up until 30 years ago,it wasn't a biologically accepted treatment option, but the dentist simply put a necrotic agent of the pulp (nerve), usually arsenic, and the tooth stopped hurting due to pupl necrosis.Naturally such teeth were doomed to be extracted, but we're talking about an era where knowledge of dentistry and dental education were very low.

Let us see the stages of root canal treatment together. 

We said that the nerve of the tooth (the pulp), has been exposed to bacteria(microbs).This can be happen due to damage of the tooth, ie from caries.Another possibility is a fracture of the tooth.

                                            

.As we see in the image below the decay has reached the nerve ( pulp) of the tooth.In this case we do the following:   

                           

 
  • Perform local anesthesia and then excavate the tooth,to remove dental caries and gain access to the root canals (canals where the nerve of the tooth is located). The whole procedure is done by isolating 
either with cotton swabs

   
 
 
or with a rubber dam
 
  
 
as the seen in the pictures.
Of course Greeks patients are not very familiar or happy with the use of the rubber dam, because they feel that it chokes them.
  •   We remove the nerve using endodontic files and at the same time we prepare the walls of the tooth to place the biocompatible nerve substitute.These endodontic files (some patinets refer to them as"hooks") are those depicted in the picture below.  
 
  • Between the different sizes of endodontic files we irrigate the inside of the tooth with an antimicrobial agent, which may be either sodium hypochlorite (or chlorine) or chlorhexidine or a combination of both under suction.This irrigation is done with a syringe and directly into the root canals,were the tooth nerve used to be.
  •  We then proceed in sealing the tooth with a biocompatible material.Usually guttapercha is used  in the form of cones. Guttapercha cones are these ones  

 
  • Finally, we restore the tooth.This depends on how much tooth structure is remaining.We can seal it with a filing or a crown. All these are described in the video below.
                                     

  Apart from the use of manual instruments,which I've shown above, now rotary instruments are used in the procedure of  root canal tretment therapy, doing the same job with the manual, faster.
  How many appointments does it take for the root canal treatment? Depending on the tooth and the philosophy of the dentist,it takes one up to four appointments, if ​​each stage is done separately. If the tooth is accompanied by a swelling,and during the tretment it there is a continuous flow of pus or a tooth abscess, appointments may increase. Between visits the tooth is covered with a temporary filling material,and if pus is present,we place a medicine (usually calcium hydroxide), to absorb the pus. You may be given antibiotics if the swelling is big.
  Who does the root canal treatment procedure? Both the general dentist and the specialist endodontist. There are some general dentists who do not perform root canal treatments, and there are some endodontists who believe that they and they alone can perform root canal treatment therapies.These two are the extremists of the dental profession.
  What is life expectancy of a root canal treatment? In this question I can not answer with precise.A root canal treatmant is a dental treatment. It can be for a long period of time,some times for a lifetime,but problems can also delelop.For this reason when recalling the patients for preventive treatment therapy an x-ray (radiographic) examination should be done.
 
      I hope I've helped a bit.Don't forget to smile!

                      

Τρίτη 23 Οκτωβρίου 2012

Doctor I think I need a filling

Today's post is the the procedure of dental fillings.We will about the how and the why and in one of our next posts we will analyze how and why teeth start to decay .
Suppose dear reader that your tooth occasionally hurts during cold stimuli , when consuming sweets or that you have an odd taste or smell in the mouth If you know what is good for you,you won't wait for it to pass,but instead you go to the dentist.And while sitting in dental chair and having the dentist looking at your teeth,the dentist sees this picture

 

This is a "hollow" tooth,and the black hole(or cavity) is dental decay!
  For the readers who do not like real pictures of the teeth, let's see it schematically

 

  The black lesion is caries or tooth decay and the red,illustrates the nerve of the tooth.And if left untreated, the damage will certainly grow,and infect the nerve and what will be the outcome?
Let me hear you say it

                         Endodontic treatment Doctor! 

                           
 That is correct.,because the caries haw reached and infected the nerve of the tooth.

                                        

  And what do we do when we have active caries? The treatment of choise is a dental filling and the process is as follows:
First we numb the area and thoroughly clean the tissue is infected.That means to clean the tooth from the decay with dental handpiece.
Then, in cooperation with the patient, we choose the material that is to be used for the filling. Today  nine out of ten times,in Greece, we use white fillings or dental resins,which are higlhy aesthetic, because they mimic the color of the tooth.In the video below we can see the whole procedure for resin dental fillings 
 
 

We isolated the area to control the moisture of the mouth, because white fillings are sensitive to moisture.We put a metal ring,so we can control the ouline of the dental filling and prevent excess material from going into places that we do not want it to go.We prepare the tooth for the white filling. For the material to harden
(because when it comes out of the tube it is a bit viscous),we use a dental curing unit that emitts blue light. In the end we polish the filling and check for any problems such as excess material or that the patient has something that stops him from chewing properly.
  An equally good video for white fillings are the following






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For black fillings procedure is about the same..













Again anesthesia, isolation, caries removal and tooth fillings.  

I hope I've informed you.Don't forget to smile

Guidelines after tooth extractions

Today's post is about the instructions to be followed after tooth extractions.
  
So, dear and faithful readers of the blog,you had a tooth extraction.This might be due to many reasons,that have been covered in the posts about extractions and surgical extractions.The tooth of the photograph below had to be extracted, due to mobility as a result of periodontal disease(periodontitis). 
                                
The post today is not why the tooth had to be extracted.It simply had do.It happened. The question is what are the guidelines after the tooth extraction.
After tooth extractions we do the following                                                  


  • First of all ,and that goes to all of the smokers out there, do not smoke;especially for 5-12 hours after the extraction.And the less you smoke during the healing process,the better it will be.Now,I know in advance that the smokers would look at me as if I were an alien! But there is a very good reason for my advice!
                                 
  Cigarette smoking causes a disfuction in the healing process  and lengthens the time it takes for the gums to heal. Also the puffing action of the smoiking itself and the increase of the temperature in the mouth doesn't help at all.There have been reported cases where the gums do not heal at all after a few days, as it should happen  under normal cisrumstance, and there is a continuous ache in the part of the mouth that the extract was done.This phenomenon is called "dry socket" and it is one of the situations that can happen after a tooth extraction. Under normal circumstances eg patient middle aged non smoker gums heal in 10-20 days.If sutures are done,they are usually removed in 10 days.
  •  Avoid spitting blood. The increase in pressure prevents clot formation and subsequent healing of the wound tooth extraction site.
  • Eat semi-liquid or liquid food.Avoid hard foods.
  • Eat cold or semi-warm food.Avoid hot foods ie soups.
  • If pain starts to kick in,take  some pain-killers(analgesic) or anti-inflammatory drugs, always in consultation with our dentist. Do not take aspirin, because it causes a problem in the healing of the trauma(prevents clot formation) at the extraction site.Take paracetamol or an anti-inflammatory drug
  • If the tooth extraction was difficult we can put a cold patch at the external part of the mouth to the afflicted region ie ice to prevent the swelling.Under normal circumstances swelling of the region after extraction, might happen but is very small. If you have had a surgical extraction, which ment that a little bit of bone had to be removed,then the swelling is more likely to occur.
  • Many patients ask about the use of antibiotics after tooth extractions. If the patient is a high risk one,medically speaking ie certain heart conditions or diabetes or other diseases, there is no need for antibiotics before the extraction. If there is a health problem, the dentist always prescribes antibiotics in consultation with the patient's attending physician(medical doctor) .
  •  Is it possible to extract the tooth and then when the numbness starts to wear off,the patient might have a bit of a fever.This could be due to the fact that the extract was a little more difficult than anticipated or there was an inflammation, so the body raizes its' temerature in order to eliminate remaining microbial population.There is no need to start on antibiotics quite yet.We can take a simple anti-inflammatory drug, but definitely consult with the doctor first.The fever usually passes the next day.
  • Finally, many people ask me about the pain during or after detal extraction. I tell my patients that the anticipation of pain is worse than the pain itself. If you have it in your mind that the procedure will hurt, then it will. I'm not asking you to be relaxed and smile,because afeter all,your tooth is about to be extracted.But the extraction itself will not hurt almost at all, because you will be under local anesthesia.After the numbness goes away it might or might not hurt.Everyone has a different threshold of pain ;so something that I find painful, might be aknowledged as simply annoying by you,the fans and fearless readers of the blog!
I hope I've helped.Good healing and remember; you're never old enough to stop believing in the tooth fairy!

                                

What is a surgical tooth extraction?

 Today's post  (and a previous promise of mine) is the analysis of the secrets of surgical tooth extractions.We will see what that intails, which teeth are most likely to be surgically extracted and overall to  extract the mystery surrounding this dental treatment.
  Surgical extraction is the treatment of teeth or tooth roots that are so damaged  they can not be removed in the usual way from the mouth.So in this case we are forced to cut open the gum a little and remove some bone.
  
"Whoa,Whoa Doctor. You mentioned too many new words and ugly pictures,and we  we did not understand one bit of it!

 Ok.Lets take it from the top,shall we?See the image below ?It is a mouth.

 

  Sorry, wrong picture.I ment to put a human mouth.
Here we are then

 

Now then,if any of these teeth need to be extracted,it is fairly simple to do so,because we have easy access to the teeth with our dental tools .

The sketch below depicts a wisdom tooth (third molar) which is impacted(meaning that the tooth is in the gums and not in the mouth).
 \
 

     Panoramic Dental x-ray

 
(Fig. 1)


 How it looks in the mouth of a patient

 

  (Fig. 2)

In order to extract this tooth,we have to cut open a part of the gum (or to put it medically "to perform an incision") and remove a small part of the surrounding bone,so that we can free the tooth,and then execute the well known extraction procedures we are well aware of from the previous post.

 Below is a video very helpful for the understanding of my words.We begin the video having on our minds the situation of the patient that is shown in Fig.2.








You see that we made an insision,we retracted the gum,we released the tooth,and we sutured the gums to help with the healing process.

If the tooth was further impacted we would have to remove the bone sourrounding the tooth a bit,but the process would be about the same.And to convince you,here is another animation about the extraction of a tooth further impacted in the mouth.


In this video the tooth was cut in half (bisected) to makethe extraction easier.

The same procedure is followed in all cases where a tooth is not easily accessible due to severe damage from dental decay or there is very little of the crown of the tooth left  or because the tooth is still impacted in the gums.



  A necessary procedure for tooth extractions,and of paramount interest in surgical extraction is the radiographic imaging of the region, ie the dental x-ray.  I believe that  a panoramic x-ray as the one shown in  Fig.1 is needed or an even more detailed radioografic test , to show us the direct connection of sensitive anatomical parts of the area in relation to the soon-to-be-extracted-tooth. The decision on the type of radiography is being made by the dentist who will perform the extraction.
  Who does surgical extractions?Surgical extraction can be performed by the general dentist, if he is familiar with the technique or by a specialized dentist ie an oral surgeon or maxillofacial surgeon or even a periodontist.
After the extraction,toy should be very careful about a few thing.We will list them in a following post

  I hope I've helped a bit in solving the mystery surrounding the surgical extraction of teeth.
Don't forget to smile!

Δευτέρα 22 Οκτωβρίου 2012

Problem with the tooth;Extraction needed!

  Today's post is about the tooth extractions.Good old simple tooth extractions.
But are they really that simple?
   Let get one thing clear. There is no such thing as a simple extract.It might seem simple for the patient and many people thing that is the easiest thing for the dentist to extract teeth etc etc, but this is not exactly the case. Every extract has its' difficulties and may not forgive the dentist,should he chooses to take the procedure lightly!There are those teeth that will come out easy, others that seem to come easily but that was not the case, other teeth come out the hard way and others seem hard at first glance but in the end come out very easy.As for the patient,the key thing is to be relaxed.
 Because if the patient is relaxed, then the dentist is more relaxed. If the patient is on the dental chair and he is feeling like he /she is sitting on a bed of nails,then the dentist must first use his magic to try to calm the patient and then another some of that magic to extract  the tooth.
 
      
 
And sometimes there simply is not enough magic to go around! 
 
Now a key question is this
 
"Why does my tooth needs to be extracted Doctor?"
 
 There are many reasons. Maybe the tooth has been severy damaged due to tooth decay, maybe it starts to have great mobility due to periodontal disease (periodontitis),maybe it got fractured,maybe it is a wisdom tooth that needs extraction or extraction may be necessary due to orthodontic treatment maybe .. maybe .. maybe!
 In the picture below you can see a tooth that is fractured, but it can be simple extraction, and the dentist, with the proper tools,can easily access the tooth.There is no need of a surgical extraction(something that we will discuss in one of the next posts)
                                        


  How is an extraction done?
 First we would first do an x-ray, in order to obtain  information about what is happening in the area, what is the morphology of the tooth roots and what anatomic parts are near the tooth.Then we perform local anesthesia,to numb the area.
 I usually use a periotome,which is a tool to release the tooth from the periodontal fibers and the periodontic ligament that hold the tooth connected to the bone and the jaw.When we release the tooth from its' shackles, it starts to have a mobility.At this point I use a lever to further increase the mobility of the tooth.
 
                                   
 
   Eventually the tooth can be extracted with the lever or with the use of  dental forceps, to grasp the tooth and extract it.
 
 
 
 
 
 
 Under normal circumstances eg patient middle aged non smoker the gums heal in 10-20 days.If sutures are required,they are being done and are usually removed in 10 days.  
It is not uncommon for the patient to have a bit of a fever after the extraction and after the anesthesia has ceased.This is hardy a reason to alarm the patient;it might be due to that the tooth was a bit difficult to extract or that the area of the extraction had inflammation, whereby the body acts so as to eliminate the remaining microbial population.There is no need for antibiotics.If we want we can have an  antiinflammatory drug,but definitely consult with the doctor first.The fever usually passes the next day.

 All of the above are described in the following video.
                        





                          And this concludes today's post.Don't forget to smile!!
                                   


                                       

Local Dental Anaesthesia


 Today's post is about one of the most important weapons of the dentist in order to perform dental procedures. And of course I am referring to dental anaesthesia.
 In the past, any and every  dental procedure-mainly tooth extractions-were done without anaesthesia. This resulted in something like the following picture where the tooth- drawer (not dentist), using all his talents, especially his physical strength was able to get the job done!  
                       
Things fortunately have changed since then! Nowadays most dental procedures eg fillings, periodontal treatment , endodontic treatment, extractions, etc. are done ​​under local anaesthesia. Even a dental cleaning of the teeth, for patients who are sensitive and anxious, can be done under local anaesthesia.
 Local anaesthesia is(..wait for it!) the bait for patients to come to the dentist. What do I mean? Visiting the dentist is not the most favorite thing for many people due to the fear of pain. But if the patient knows that it will not hurt or that they will not feel it as much, they are more likely to come. Anaesthesia not done with this  

                                      
nor that 

                            
Anaesthesia is performed with special anaesthetic solutions, which are in a glass container/tube like the following. 

 
This glass tube goes into a dental syringe.

 
 And in order for the anaesthetic to be administered locally to  the tissues, a dental needle must be used. Of course these materials are used for anaesthesia in dental surgeries . 

 

There is also the local anaesthetic, which is used to avoid the patient feel the pinch of the dental needle, which is either in a spray form or in the form of gel (with different flavors) ,as shown in the next pictures
 
   I know in advance that many will have goose bumps, by simply looking at the previous pictures, but I believe that words that are more intimidating than the pictures, so I have pictures to accompany all of the steps of dental anaesthesia. Because at the mere sound of the words “Dental/local anaesthesia” we  all have a tendency to fear, because we think it will hurt. Many times words hurt more than the process itself.

  Now let us see together the procedure of dental anaesthesia.

There are two types of dental anaesthesia: The supraperiostal anaesthesia, which is the light anesthesia, usually in the upper jaw, because the bone is more porous,so the local anaesthetic can infiltrate the nerve more easy. The  technique presented in the following video:





 The branch bloch anaesthesia(inferior alveolar nerve) is usually in the lower jaw, where the bone is more compact ,in order to numb a  smaller branch of the trigeminal nerve.It numbs the whole quadrant of the area administered.





The branch block anaesthesia takes longer to regain consciousness than the supraperiostal one. Meaning that the numb feeling of the quadrant of the mouth(or the half of the jaw),that affects the inferior alveolar nerve, takes about 4 hours to go away; whereas  for a subperiostal anaesthesia it takes about half an hour up to one hour. In that case the patient must be careful not to bite the inside of his/her cheek.Due to the fact that he/she can not feel the bite,there is the risk of constantly chewing it  like a bubble gum,thus resulting in an injury. 

One last thing to remember.There is also a procedure for local anaesthesia called sedation.During a sedation a mixture of  nitrous oxide is used,in order to make the patient feel a bit dizzy.The procedure is explained in the following video

This kind of dental anaesthesia is not used in Greece,but it is an option on other countries.


I hope I have  informed you about dental anaesthesia and  demystified the process a bit . Do not forget to smile!