Its Role in General & Oral Health

By Dr. Carole A. Palmer

Clarifying the Terms of Nutrition

Food is not only our primary source of nourishment — it’s also a profound part of our society, culture and community. What we eat critically impacts not only overall health, but also our risks for several of the leading causes of death like coronary artery disease, stroke, diabetes and some types of cancer.

First, a little clarification: even though the terms “nutrition” and “diet” are often used interchangeably, they aren’t synonymous. Nutrition is the end effect of food in the body; diet is an individual’s eating habits or food choices. Both play important roles in health. Foods are the substances we eat that provide the essential components of life — the nutrients.

Nutrients can be classified into six major categories:

• Carbohydrates (sugars, starches, and fibers)
• Proteins (from animal and vegetable sources)
• Fats (preferably from vegetable sources in liquid form)
• Vitamins
• Minerals
• Water

Together, all these types of nutrients perform three basic functions in the body: provide fuel (energy); regulate body processes; and contribute to building body structures. In fact, very few foods are composed of a single nutrient (refined table sugar, exclusively carbohydrate, is one of those rarities). Most contain a combination of nutrients plus other components. For example, milk contains carbohydrate, protein, fat, water and a variety of vitamins and minerals.

Calorie is another term that is often misunderstood. Calories and nutrients are not the same: calories are a measure of the energy available to the body from foods. Only carbohydrates, proteins, and fats provide calories. One gram of dietary protein provides four calories, one gram of carbohydrate provides four calories, and one gram of fat provides nine calories to the body. So, gram for gram, fats provide about twice the calories of proteins or carbohydrates. Alcohol has seven calories per gram, but is not considered a nutrient!

Nutrients also serve other important functions. For example, proteins provide the building blocks for tissues, while fats provide insulation and cushioning for the body. High fiber carbohydrates provide fiber for intestinal health. Calcium, vitamin D, folic acid and magnesium are needed for maintaining healthy bones.

Some foods are high in nutrients and low in calories, like salad greens. Other foods may be high in calories but low in nutritional value. For example, the only nutrient a soda contains is carbohydrate in the form of sugar. Vitamins and minerals do not provide any calories but they serve other essential functions in the body.

When foods are eaten, the nutrients are absorbed through the small intestine and go through the blood to the liver, and then to the body tissues and structures that need them. Depending upon the nutrient, excesses are either unabsorbed and pass out of the body, or stored in the body. Excess carbohydrates, proteins and fats are ultimately stored as body fats. Excess vitamins A and D are also stored and can be harmful if consumed in greater than recommended amounts. All nutrients are undergoing active metabolism — even “stored” nutrients are constantly being used up and replenished.

What is a Healthy Diet?

A healthy diet is one that includes all the essential nutrients in appropriate amounts to promote health and prevent disease. A healthy diet is based on the concepts of variety, balance, and moderation.

Variety: To gain variety in one’s diet, it’s important to choose a number of different foods — no single food can meet all of the daily nutrient requirements. Variety also makes meals more interesting while ensuring the diet contains sufficient nutrients.

Balance: We achieve a balanced diet by eating appropriate amounts of food from the recommended food categories on a daily basis. Using some form of guide (such as MyPyramid) can aid in balanced food selections.

Moderation: It’s important to choose foods and beverages in serving sizes that are appropriate to meet energy needs while controlling calories, total fat, cholesterol, sodium, sugars and, if consumed, alcoholic beverages. Moderation is vital to maintaining a healthy weight; it also may help protect against certain chronic diseases such as heart disease or cancer.

There are several tools available to help people achieve a healthy diet. These range from the detailed scientific information about human nutrition requirements found in the Dietary Reference Intakes (DRIs), to practical applications such as the Nutrition Facts label (required food labels on processed foods detailing their nutritional value) and the Dietary Guidelines for Americans. Another great tool is an online, user-friendly tool called MyPyramid.

MyPyramid is an online, user-friendly tool that helps consumers see how foods are grouped into categories based upon their nutrient composition (fruits, vegetables, grains, dairy, proteins, fats), and what foods are in each category. The guide also details the number of recommended daily servings of each food group based upon one’s own calorie requirements, so consumers can evaluate their own personal diets for nutrients and calories.

Consumers can type in their daily food intake and receive a summary of their nutrient and calorie intake in comparison to the recommendations of the DRIs and the MyPyramid guidelines through user-friendly charts and icons.

To get started with your personal plan, go to www.mypyramid.gov.

Oral Health & Nutrition Through the Life Cycle

Did you know that approximately 127 million adults in the U.S. are overweight, 60 million are obese and 9 million are extremely obese?

Pregnancy

Good maternal nutrition is essential for the development of a baby’s oral health during pregnancy. Children’s primary (baby) teeth begin forming at about the sixth week of pregnancy, and begin mineralizing at around the third to fourth month of pregnancy; the mother’s diet must be adequate in all nutrients, especially calcium, phosphorous, and protein to facilitate this process.

Other guidelines for a healthy pregnancy diet include:

• Liberal intake of all food groups: whole grains, fruits, vegetables, protein sources and dairy products;
• Possible iron supplement (upon doctor’s recommendation) to offset iron deficiency common in pregnancy;
• Sufficient folic acid (from fortified bread, green leafy vegetables and /or supplements) all during a woman’s childbearing years to help prevent birth defects.

Nutritional deficits can cause defects in tooth development, and salivary flow and composition. Deficiencies in protein and calories, Vitamins A, C, D, and iodine, and excesses in fluoride and Vitamin D, have all been shown to affect the development of human teeth.

Children and Teenagers

Children’s teeth continue to develop and mineralize from before birth (primary teeth) through the early teens (permanent third molars — wisdom teeth). In addition, the other tissues in the body are constantly recycling, and are in constant need of nutrients to support new growth and development.

A healthy diet will ensure proper mineralization and tissue growth of teeth and bones. In addition, the erupted teeth are susceptible to dental caries initiated by frequent consumption of simple sugars in the diet. Once teeth erupt into the mouth, surface mineralization will continue to be affected by saliva, food, fluids, dentifrices and fluoride rinses.

In childhood, major dietary risks tend to be the constant oral contact from natural or added-sugar-containing foods in bottles or “sippy” cups. In the teen years, major contributing factors are the constant availability and use of sweetened beverages such as sodas, flavored waters or sports drinks.

Did you know that approximately 62 percent of American females and 67 percent of males are considered overweight?

Adults

Adults still need an adequate diet for maintenance of body structure and tissue integrity, especially skin, connective tissues and bones. Adults are also at risk for developing dental decay and periodontal (gum) disease.

Nutritional deficiencies can reduce resistance to disease and the ability to fight infection. The signs of advanced nutrient deficiencies are usually first seen in the oral cavity. B-complex vitamin deficiency (thiamine, riboflavin, niacin) can cause cracks in the corners of the mouth and changes of the tongue. Iron deficiency can result in pale color of the tongue. Dry mouth from medications can also increase the decay-promoting risk of the diet.

Older Adults

Senior citizens face a variety of challenges that can affect their oral and nutritional health, and are at particular risk for nutritional deficiencies. Aging affects our ability to digest and absorb nutrients. As the mouth dries due to lack of salivary flow or medications, older individuals are more prone to decay. Appetite and the sense of taste and smell may decline as well. Dehydration is a common concern.

Common social issues such as lack of money, lack of ability to get and prepare foods and loneliness can undermine people’s ability and desire to obtain a healthy diet. Lack of teeth or dentures can make matters worse by making it difficult to chew foods that are part of a healthy diet. Older people should not overlook the importance of nutrition to health and well-being in the face of these other more pressing concerns.

Exercise: A Key Component to Good Health

A healthy diet contains the proper nutrients in the right amounts that your body needs. But that’s not the end of it — the next step involves balancing the distribution and use of those nutrients within the body. A good exercise plan is crucial to that balance.

First, the body needs calories for daily functions such as digestion, breathing and daily activities. You are constantly burning calories, even when sleeping. You have energy balance when the calories consumed are equal to the calories used by the body. Energy imbalance occurs when more (or fewer) calories are consumed than used up. The excess calories are then stored and weight gain occurs. Too few calories results in weight loss.

Millions of Americans suffer from illnesses that can be prevented or improved through regular physical activity.

Regular physical exercise plays an important role in offsetting energy imbalance by using up extra calories consumed. Exercise is important for cardiovascular (heart and blood vessel) health. It can also help reduce high blood pressure, regulate diabetes (adult onset type 2), contribute to weight loss in overweight individuals, reduce triglycerides, lower LDL (the “bad” cholesterol) and raise HDL (the “good” cholesterol).

Millions of Americans suffer from illnesses that can be prevented or improved through regular physical activity. They’re also missing out on other benefits: the development of healthy bones, muscles and joints; reduction in feelings of depression and anxiety; and improvement in mood and a sense of well-being. And, active people have a reduced risk for stroke and colon cancer.

Making the Right Nutritional Choices for Better Oral and General Health

When it comes to diet and nutrition, it’s all about the right choices. Remember these simple guidelines in your pursuit of good nutrition:

• Follow a guide, such as MyPyramid, for your age, gender, exercise, and calorie needs;
• Eat sufficient amounts of whole grains, fruits, vegetables, protein foods and calcium/phosphorous sources every day;
• Maintain variety, balance, and moderation in your food choices;
• Drink plenty of water;
• Restrict sweets to meals and dessert – avoid sugary snacks between meals;
• Limit your total sugar intake to no more than 10 teaspoon equivalents per day;
• Snack on fresh fruits and vegetables, low fat cheeses, whole wheat crackers or low-fat dairy products;
• Exercise regularly and moderately.

Good nutrition goes hand in hand with good general and oral health. In fact, taking care of your whole body through good diet and nutrition practices will help ensure a healthy, radiant smile. Bon Appetit!

Some Misconceptions about Nutrition

Here are a few popular “myths” about good nutrition and dietary practices, along with the facts:

Myth: Children have “baby fat” but they’ll lose the fat as they get older.
Fact: Currently, an estimated 65.2 percent of U.S. adults, age 20 years and older, and 15 percent of children and adolescents are overweight — and 30.5 percent are obese.

Myth: Genetics cause obesity.
Fact: Although 25-70 percent of the difference in weight between individuals may be related to genetics, genetic factors only predispose an individual to obesity — they do not cause obesity.

Myth: Americans don’t get enough protein.
Fact: Most people get more protein than they actually need. Too much protein can actually be harmful by putting stress on the kidneys.

Myth: Being fat won’t kill you.
Fact: Obesity is the second leading cause of preventable death in the U.S. As many as 47 million Americans may exhibit a cluster of medical conditions (a “metabolic syndrome” or “Syndrome X”) characterized by insulin resistance and obesity, excessive abdominal fat, high blood sugar and triglycerides, high blood pressure and high cholesterol.

Myth: Fat is bad and should be eliminated from the diet.
Fact: The body needs some fat. However, it’s the total amount of fat and the type of fat that’s important. There’s a strong relationship between dietary “saturated fats” (largely animal fats) and trans fats (found in many processed foods) in coronary heart disease. The most effective replacement for saturated fatty acids (and trans-fats) is with poly-unsaturated vegetable oils (like olive oil) and Omega 3 fats found in fatty fish like salmon and sardines. Omega 6 fats are also important and are found in nuts, naturally grown eggs and poultry. These lower coronary heart disease risk and increase high density lipoprotein (HDL), the good cholesterol.

Myth: Sweets can’t make you fat.
Fact: Any foods that provide calories can be stored as body fat and contribute to weight gain if consumed in quantities greater than the body can use up.

Myth: Sugars are bad for your teeth, not your health.
Fact: Americans consumed more than 142 pounds of sugar per capita in 2003 (equivalent to 37 teaspoons a day). The maximum recommended a day is 10 teaspoons (one can of soda contain 6). Any excess sugar consumed is converted to fat.

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Is what you get what you want?

By Dr. Gerald Chiche

Perceptions and the Art of Dentistry

Does your dentist see what you see — and vice versa? Can you really communicate how you want to change your smile? These are important questions — so let’s start by examining what information is available to us from research on this important issue. Recent studies address this critical subject regarding communication between the public at large as a non-professional group and dental professionals, who may or may not “get” what you are trying to say about what you see and want to change in your smile.

One study set out to determine the differences in perceptions of lay persons and dental professionals. The study looked at variations in tooth size and alignment and their relation to surrounding gums and other facial features that make up a smile. The results are very enlightening because they show that there are varying levels of differences, which can actually aid the dentist artistically when making specific treatment recommendations.

There is no doubt that dentists look at smiles differently than non-professionals — which actually makes perfect sense. Dentists as a group are (and should be) more discerning of issues such as crown (tooth) length, midlines (how the teeth line up with other facial features) and gum-to-lip distance, to name a few.

According to the same study, lay persons place more importance on other features of facial aesthetics. For example, individuals rated mouth expression and lip shape as more noticeable than other “strictly dental” characteristics.

Vive La Difference

The art of “making smiles” lies in the dentist’s ability to integrate the individual’s personal perceptions of what is important and what he or she considers necessary to be aesthetically pleasing. It is the dentist as artist who must incorporate natural elements of dental anatomy and scientific knowledge into smile design. You must have confidence and trust that your dentist hears what you’re saying and that you are able to communicate what you want to look like. Indeed, trust is critical in this relationship with something as important as your smile, which is now in the hands of a dental professional.
Part of building the necessary trust is to accept that there will always be differing levels of perception between patient and dentist; minor variations in areas of smile analysis and design need not be an important concern to you. What is important, though, is for you and your dentist to understand what gets communicated in this encounter.

With a professionally trained and experienced eye, your dentist will actually see more dental possibilities than you do. It is therefore the responsibility of the dentist to inform and educate you so that you’re better able to make your own personal choices. On the other hand, the old axiom “If it ain’t broke don’t fix it” is also a good principle to follow, at least aesthetically speaking. In other words, if you’re happy with certain characteristics of your smile, leave well enough alone.

Blueprints for Success

It doesn’t matter if you’re having a total “smile-makeover” or just changing one tooth, the ability to preview the change to your appearance may be critical to your ultimate happiness. Computer imaging is a great tool to allow you to visualize a potential change before your dentist even touches a tooth.

A second way a dentist can help us see ourselves before work begins is to actually make a mock-up of the proposed dental work in white tooth-colored wax on models of your mouth. A third way is to build up your teeth with tooth-colored composite resin, which is yet another way of changing tooth shape, size and aesthetics.

Another great tool in dentistry is the “Provisional Restoration”. This has become a critical tool in testing the understanding between the dental professional and patient. A provisional restoration allows time for adaptation, to see if the proposed smile changes work for you and if they are compatible with gingival (gum) health, phonetics (speech) and biting function.
If the provisional restoration works, the final restoration is guaranteed to work. The essential difference between the provisional and the final restoration is the materials from which they are made. The final porcelains are more durable and longer lasting than the plastics generally used for the provisional restorations.

The dentist will take impressions of the provisional restoration and communicate all of the relevant information in that blueprint to a “dental technician.” Arguably, the most beautiful, lifelike tooth replicas are made of porcelains, in which case it is the ceramist — a dental technician skilled in the art and science of bringing these glass-like materials to life — who is entrusted with this responsibility.

Shades of Difference: Is What You See What You Get — Or Want?

The only way that you as a patient can ensure a positive answer to this question is to communicate fully with your dentist from the outset. By merging your own perceptions of what you want and need with your dentist’s keen eye for what works aesthetically, you’ll have a much better opportunity to achieve the smile you want and expect.

Questions to Ask Yourself

Dentists appreciate it when you can describe what changes, likes or dislikes you have regarding your smile. Can you describe the changes, whether subtle or large, that you would like? For example, it’s a good idea to take pictures and magazine images with you on your first appointment to better describe to your dentist how you think you’d like your smile changed. Please remember that these pictures should be used as general guidelines; you are not looking to have someone else’s smile. Images of how you’d like to look (or once looked, with the help of past photos) provide helpful information to your dentist. You should take time to ask yourself a few questions so you can more accurately communicate to your dentist what changes you would like to make:

• What do you like or dislike about your teeth regarding color, size, shape and spacing?

• Are you pleased with how much your teeth show when your lips are relaxed and when you smile?

• Do you want teeth that are perfectly aligned and are “Hollywood White” or more natural looking with slight color, shape and shade variations?

• Are you happy with the amount of gum tissue you show when smiling?

The answers to these and other questions will give your dentist an understanding of your perceptions and vision and help him/her create the smile you want and deserve.

When a person comes to consult for aesthetic treatment — smile change or enhancement — the consultation appointment is divided into a “conventional” evaluation (with charting, periodontal (gum), occlusal (bite) and radiographic (x-ray) surveys, as well as diagnostic study models) and an “aesthetic” evaluation involving an aesthetic analysis and a focus on the patient’s subjective aesthetic requests.

Two Types of Patients

The media image displayed in many advertisements has a very strong influence in contemporary dental treatment. In my opinion, today’s smile is becoming an increasing part of a youthful dynamic appearance. It is characterized by whiter teeth, which often fall beyond the range of traditional shade guides (“Hollywood White”).

From my standpoint as a clinician, it is possible to identify two types of people: “Perfect-Minded” (the Hollywood Smile) and “Natural-Minded.”

The “Perfect-Minded” Patient

Patients who fall into the category of the “perfect-minded” will typically expect maximum regularity and alignment along with maximum brightness. Part of the art of smile enhancement and imparting a natural appearance is to make certain features invisible and other features more visible. This is really where science and art meet in dentistry. Knowing what can and cannot change to create the perception of reality is a very important concept, not only for smile enhancement but for the human body generally. Nobody is completely the same on each side, but if there are significant differences between the right and left sides, they can become noticeable and distracting.

To ensure that a smile looks right it will be critical to provide patients with a smile that is symmetrical. In other words, if you were to draw a vertical line down the middle of the face, which we call the midline, that line would be directly between the front teeth, and around it the smile will look “balanced” from one side to the other. This is also true in a horizontal dimension, creating a regular smile line that matches the curvature of the lower lip. Now each tooth type is made to fit into this framework with symmetrical central incisors, lateral incisors and canines, along with gum lines that also match from one side to the other.

The “Natural-Minded” Patient

Adding artistic “natural” touches to teeth can make them look just different enough to create real character. Those individuals who want a more natural or subtle look, what I call the “Natural-Minded,” will typically expect a general sense of regularity and alignment along with definite “brightness,” but do not wish their teeth to be noticed at every turn. In any pleasing smile, tooth symmetry is found close to the midline; therefore the central incisors — the two upper front teeth — must be mostly symmetrical with only minor irregularities.

The main “asymmetry” (a-without, symmetry-matching), where individual characterizations can be added, can be provided between the lateral incisors, the teeth on either side of the two front teeth. The canines (“eye” teeth) will also provide minor asymmetry, as their gingival margins (gum lines) and their cusp tips (points of the teeth) do not need to be level horizontally. The depth of the incisal embrasures (the way the teeth line up and change shape going from the front to the back of the mouth) should be of a natural depth in addition to providing a natural progression.  

Communicating with the Dental Laboratory Technician

When planning a “shade prescription,” one must be aware that the most frequent shade variation of a front tooth is observed at the incisal third (biting edge). These are the technical details that need to be communicated in depth to the ceramist.
For the “Perfect-Minded” patient, the next most frequently observed category is when the shade distribution is nearly uniform, resulting in a monochromatic appearance (“mono” – one, “chroma” – color).

There are three typical scenarios that can be transmitted to the dental ceramist:

1. Lightly Monochromatic Shade Design
It is very common to find patients who are so displeased by the dark appearance of their teeth [Figure 5] that they end up requesting a very monochromatic (uniformly colored or all white) look with high brightness [Figure 6]. The shade prescription given to the dental ceramist is uncomplicated due to a lack of incisal (biting edge) color effects.

2. Lightly Monochromatic Shade Design with Color Effects
The typical natural incisal effects (biting edge) found on unworn incisors impart a very pleasing effect to the tooth shade overall. They include:

• Transparent incisal tip — an almost see-through effect of the tips of the teeth [Figures 7 and 8]
• Dentin streaks or mamelons (natural tooth characteristics especially on newly erupted or unworn teeth)
• Proximal translucency (an almost see through where adjacent teeth meet)

3. Lightly Polychromatic Shade Design
There are situations where several shades and various degrees of discolorations coexist in the same mouth; conversely, there are situations where different ceramic systems (types of porcelain) are present and do not perfectly match one another [Figure 9].
In such situations, the rule is to aim for maximum patient acceptance of the “restorations” [Figure 10]. This generally means that the central incisors are kept a slightly higher value than the other front teeth. If the value of the central incisors ends up a slightly lower value — due to some excessive translucency, for example — then it is very likely that the patient will reject the final result, even with the best designed proportions, display and length.

In Summary

Communication between you as the patient, your dentist and the laboratory technician are critical to the process of providing the best possible smile enhancements to meet your expectations. Research has shown that there are differences between individuals’ perceptions and those of dental professionals regarding not only teeth but other factors affecting smiles and facial appearance. The dentist’s role as health professional also includes educator and artist in this unique process, as the interpreter and creator of your vision of “beauty”.

The use of a special blueprint such as a “provisional restoration” is a useful tool to help envision potential changes before they are truly finalized. This can help ensure the most aesthetic and functional result for achieving your vision. Now the person in the mirror really can be the true you.

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How and why infected baby teeth are saved!  

By Dr. Joe Camp

Young children can lose primary (baby) teeth and even immature permanent teeth when the pulp, the living tissue inside a tooth, becomes infected. This is often the result of trauma or dental caries (tooth decay) and creates a special problem for the child. The primary teeth provide important guides for the newly developing permanent teeth that will replace them. And injury resulting in loss of young permanent teeth can be even more troublesome, because neither tooth development, nor jaw growth is complete. If teeth are lost prematurely, a malocclusion (“mal” – bad; “occlusion” – bite) can easily result. Tooth replacement techniques such as partial dentures, bridgework and dental implants cannot easily be used in children while everything is changing and growing so rapidly. “Space maintainers,” specially made appliances that can be attached to adjacent teeth or fabricated in a removable “retainer” style, are generally the best choice. Yet many do not restore function, and all require constant monitoring.
For both functional and cosmetic reasons, endodontic (“endo” – inside; “dont” – tooth) or root canal treatment is preferable to tooth loss. It can preserve tooth, jaw and tongue function. It can also prevent speech problems, and abnormal eruption of a permanent successor tooth, or even the loss of a tooth that has no successor.

What follows is a guide to understanding what to look for in your child and what can be done to save baby teeth until they are ready to be lost naturally

Different Strokes For Younger Folks

Many things are different when dealing with primary teeth versus permanent teeth. Their survival is shorter and more temporary, but while their shapes, structure and functioning are similar to permanent teeth, they too have differences. Treatment of root canal problems is affected by root resorption, the normal process by which the body absorbs the roots of the baby teeth to allow for eruption of the succeeding permanent teeth. This complicates the diagnosis and, therefore, appropriate treatment.

Figuring Out What’s Wrong

Examination begins with a thorough medical history; a child with systemic (general) disease may need different treatment than a healthy one, and the dentist must consider any implications of the child’s condition related to root canal treatment. The characteristics of pain in a primary tooth are particularly relevant in helping to determine the status of the pulp. In the absence of trauma, pain is most often due to tooth decay reaching the pulp, which contains the nerves within the teeth.

 
Symptoms of pain usually accompany pulpal inflammation. However, extensive problems may arise without any history of pain. If possible, a distinction should be determined regarding whether the pain is spontaneous or only occurs when provoked; pain that ceases after removal of the cause is usually reversible and indicative of minor inflammatory change. Pain-provoking stimuli include: thermal, hot and cold; chemical, caused by sweet or acidic foods or beverages; and mechanical irritation, biting, or wobbling a loose tooth. Other common causes include deep tooth decay, faulty restorations (fillings), soreness around a primary tooth that is loose and ready to fall out, or an erupting permanent tooth.
Spontaneous (unprovoked) pain is characterized by constant or throbbing pain that occurs without stimulation and continues long after any causative factor has been removed. Spontaneous toothache is usually associated with extensive degeneration of the pulpal tissues extending into the root canals; this may be followed by swelling of the gum tissues and abscess formation as infection spreads beyond the roots of the teeth and into the surrounding bone.

Radiographs (x-rays) of good quality are essential after the clinical examination. Like permanent teeth, areas of infection appear at the root ends of primary front teeth. In primary molars (back teeth), changes are also most often apparent in the furcations, the areas where roots join each other in multi-rooted teeth. In advanced cases of infection, and where the permanent tooth bud may be in jeopardy, removal of the primary tooth may be necessary.

Mild but chronic pulpal irritation as seen in tooth decay might stimulate the pulp to deposit more dentin (the living tissue of which the body of the tooth is made). This “reactionary” dentin is nature’s way of healing the tooth. When looking at radiographs of a child’s primary tooth where tooth decay has reached the pulp, advanced pulpal degeneration occurs and extends into the root canals. Interpretation of radiographs of primary teeth is always complicated by the presence of new permanent teeth. Although all decay that penetrates into the pulp causes inflammation, the larger the penetration, the more likely it is to cause death of the pulp tissues.

We’ll Get By With A Little Help From Our Friends

Pediatric dentists specialize in the treatment and management of children and adolescents, in growth and development of the teeth and oral structures, and they routinely treat root canal problems affecting primary (baby) teeth. They are particularly adept at figuring out what’s wrong with primary teeth. Additionally, endodontists, who have had two to three years of additional training following dental school, specialize in the diagnosis and treatment of pulpal problems. General dentists who have taken additional training may also treat root canal problems of primary teeth. This additional training is important because there is not always a definitive correlation between symptoms and the state of the tissues of the tooth when dealing with primary teeth. Also, younger patients are often not the best historians and accurate reporters of problems. All of this complicates the diagnosis of pulp health and disease in primary teeth and in immature permanent teeth.

Primary teeth with a history of spontaneous pain are generally candidates for more traditional root canal treatment or extraction. But outside of this situation, there are alternative pulp treatments to prolong the life of primary teeth so that they can perform their necessary functions until they are lost naturally. Another important factor to consider is the proximity of infected baby teeth to their permanent tooth successors. The treatment least likely to damage the permanent tooth should always be chosen. Infected permanent teeth in children may require special management due to problems associated with incomplete root development. Endodontists routinely treat these cases in children and should be included as part of the dental treatment team.

Roughly half of traumatized primary teeth develop transient or permanent discoloration. These colors vary from yellow to dark grey and usually become evident one to three weeks after trauma. Primary teeth with yellow discoloration frequently have radiographic signs of root canal calcification, bone-like deposits that can completely obscure the pulp. Injured primary teeth with dark gray discoloration are reported to have necrotic (dead) tissue in their pulps in 50-80% of cases. Almost all pediatric dentists and endodontists agree that completely knocked out (avulsed) primary front (incisor) teeth should not be replanted because of the possibility of danger to the underlying permanent tooth buds.

Root Canal Treatment Options For Primary Teeth

The treatment of primary and young permanent teeth is quite safe and predictable, backed by a large body of research detailing the best clinical techniques and practices. With sound clinical techniques and some rather extraordinary compounds, a lot can be done to save baby teeth. As always, treatment is based on assessment and diagnosis, and, especially in the case of primary teeth, may be decided by the state of the tooth at the time of examination.

The treatment of primary and young permanent teeth is quite safe and predictable. What follows is a summary of the state-of-the art treatment techniques for the various stages of pulpal involvement for baby teeth with trauma and decay:
Indirect pulp treatment works best for teeth with deep decay approaching and/or barely exposing the pulp, where removing all the decayed parts of the tooth would expose it. Instead, as much soft decay is removed as possible, leaving only harder remnants without penetrating into the pulp. Then applying an antibacterial agent and restoring the tooth to seal it prevents further infection. In this procedure, outer layers of infected dentin are removed and a layer of lining cements are placed over the exposed dentin. These materials reduce the acidity caused by decay and sterilize the surrounding infected dentin. By allowing inflammation to subside, reactionary/reparative dentin is deposited by the pulp to further protect itself. A temporary filling is then placed in the tooth to ensure comfort and healing. A more permanent filling is placed after 10-12 weeks. When properly applied, this procedure has proven 90% successful over three-year periods.
Direct Pulp Capping is recommended for “small incidental exposures of the pulp when there is no decay.” Here, the dentist will essentially “cap” the exposure directly using similar materials as mentioned above, to create a dentin “bridge” to seal the exposure.

Pulpotomy is literally a “partial pulp removal,” a tried and tested technique, and is successful in 90% of cases. It is used to treat pulp exposures, a result of decay in primary teeth, when the inflammation/infection is confined to the coronal (inside the crown) area of the pulp. The procedure includes removal of the coronal portion of the pulp, preserving the vitality of the remaining root areas of the pulp. Success is based on the dentist’s determination of whether the remaining pulp is healthy or reversibly inflamed. Effective control of infection is also crucial; it includes complete removal of inflamed pulp tissue, appropriate wound dressing, and effective sealing of the tooth during and after treatment.
Dentists use medicines and preparations to stabilize vital tissue and prevent it from becoming infected. This allows the remaining vital or living tissues of the pulp to survive so that the tooth can function normally until lost naturally. One of the newer compounds developed in the mid-nineties, MTA (Mineral Trioxide Aggregate), has remarkable properties. It is biocompatible with living tissues, and promotes healing; it has cement-like properties and therefore seals the root canals, preventing leakage and the spread of infection. Most importantly, it can encourage dentin formation so that the tooth can heal itself.

Pulpectomy involves complete removal of all the pulp tissue because it is infected. If a child has tooth pain, particularly if there has been accompanying swelling of the gum tissues or cheek, this will need to be managed first. A small opening is drilled in the biting surface of the tooth to drain infection and/or a course of antibiotics is given. This will set the stage for the removal of infected tissue from the root canal/s completely. This procedure resembles traditional root canal treatment, with removal of all the infected tissue from the root canals; disinfecting, cleaning, shaping and filling the canals to seal them. The sealant material must be absorbable so that the body can absorb the roots normally, allowing the primary tooth to be lost and replaced by its permanent successor. The materials most commonly used are zinc oxide/eugenol paste, or iodoform paste and calcium hydroxide. Some researchers have reported a mixture of calcium hydroxide and iodoform as nearly perfect — it is easy to apply, absorbs at a slightly faster rate than the roots, is non-toxic to successor teeth and is radio-opaque, which means it is visible on radiographs (x-rays).

Upon completion of root canal treatment for primary teeth, the restoration of choice for a back tooth is a stainless steel crown and, for a front tooth, a composite tooth-colored resin.

This has been a guide to understanding what to look for in your child and what can be done to save baby teeth until they are ready to be lost naturally. Pediatric dentists, along with endodontists and general dentists are an exceptional resource for any additional questions you may have.

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September 21, 2011 – Can a medicinal root that tastes like candy be used to prevent caries and treat drug-resistant thrush? What about helping to treat alveolar bone loss in periodontal disease?

Maybe if it’s licorice root. Recent research suggests that licorice extracts and licorice bioactive ingredients such as glycyrrhizin, glabridin, licoricidin, licochalcone A, and licorisoflavan A have potential beneficial effects on common oral diseases, according to a literature review in Oral Diseases (August 18, 2011).

Although many people associate licorice with a flavor, many licorice-flavored foods are actually flavored with extracts of anise seed or fennel seed. Licorice root itself is a sweet, woody root with a yellow pulp, harvested from a couple of species from the Glycyrrhizagenus: G. glabra and G. uralensis.

In recent years, licorice compounds have been studied for their potentially beneficial effects in the treatment of cancer, atherosclerosis, gastric ulcers, hepatitis, bacterial infections, immunodeficiency, and oral disease, according to the Oral Diseases review authors.

“Hundreds of studies have brought evidence that licorice and purified molecules from licorice may have beneficial effects for various aspects of human health,” study co-author Daniel Grenier, PhD, the director of the Research Group in Oral Ecology at Laval University, told DrBicuspid.com. “However, as for other natural compounds, it is not a miracle material and taking it in excess cannot solve all problems.”

While the anticariogenic properties of licorice have been suggested for more than 30 years, few studies on this aspect have been published, according to Grenier and his colleagues. Some pilot clinical studies have been performed on glycyrrhizin — the sweet component of licorice root — with limited results. For example, a 1989 spit-mouth study on 21 subjects found that glycyrrhizin had a tendency toward a statistically significant effect for controlling dental plaque formation after just a few days (Israel Journal of Dental Sciences, November 1989, Vol. 2:3, pp. 153-157). However, another pilot study involving 40 subjects showed that toothbrushing for up to 42 days with a toothpaste containing glycyrrhizin had no effect on the plaque index compared with using a control toothpaste (Journal of Clinical Periodontology, March 1991, Vol. 18:3, pp. 210-212).

“Based on the above studies, it appears that glycyrrhizin, at concentrations and exposure times tested, offers few [sic] potential for caries control,” Grenier and his co-authors wrote. “Further randomized, controlled trials are required prior to recommending for or against the use of glycyrrhizin in oral hygiene products.”

Other compounds fare better

Other studies have found that some compounds in G. uralensis inhibit the growth of the cariogenic bacterium Staphylococcus mutans (Journal of Natural Products, January 2006, Vol. 69:1, pp. 121-124). Based on these findings, the research team from the University of California, Los Angeles (UCLA) prepared a licorice extract enriched with glycyrrhizol A and developed a sugar-free, licorice-containing lollipop as a potential anticaries product.

Researchers from the University of California, Los Angeles (UCLA) developed sugar-free, licorice-containing lollipops as a potential anticaries product. The lollipops are commercially available through Dr. John’s Candy. Image courtesy of Wenyuan Shi, UCLA.

Subsequent pilot studies indicated that a 10-day use (twice daily) of the lollipops led to “a marked reduction” of salivary S. mutans (European Archives of Paediatric Dentistry, December 2010, Vol. 11:6, pp. 274-278;International Journal of Oral Science, January 2011, Vol. 3:1, pp. 13-20).

The lollipops are now commercially available through Dr. John’s Candy. Each lollipop has 20 mg of licorice extract that includes the glycyrrhizol A compound developed at UCLA, according to Wenyuan Shi, PhD, the chairman of oral biology at the UCLA School of Dentistry and one of the researchers involved in developing the compound.

The lollipops are “a new way to combat tooth decay, especially for the ones who cannot correct their sugar-eating behaviors,” Shi told DrBicuspid.com. “The killing kinetics is about five minutes, and it takes five to 10 minutes to melt a lollipop.”

Dr. John’s claims that a 10-day regimen of the lollipops, used as directed, will significantly reduce S. mutans in the mouth for three to six months. However, Grenier and his co-authors caution that there can be adverse side effects if the product is overused.

“Further studies on licorice-containing lollipops need to demonstrate an anticavity effect clinically rather than just a modification of the oral microflora,” they wrote. “While the above licorice lollipops may represent attractive anticaries products for high-risk children and the elderly, users should be well-informed about the potential adverse effects, such as hypertension associated with excessive or prolonged use of such lollipops.”

Periodontal disease, candidiasis, ulcers

Additional studies have indicated that licorice compounds may be effective in treating periodontal disease and other soft-tissue conditions, according to Grenier and his colleagues.

For example, “although no human clinical trials have been carried out, in vitro studies have brought evidence that licorice and its bioactive ingredients may represent potential phytochemicals for the development of a new natural therapy to treat or prevent periodontitis,” they wrote.

A crude extract from G. uralensis was found to suppress both the growth and formation of biofilm formation by Porphyromonas gingivalis (Journal of Dental Research, 2008, Vol. 87:special issue B), while licoricidin and licorisoflavan A have been shown to have anti-inflammatory effects (Journal of Periodontology, January 2011, Vol. 82:1, pp. 122-128).

Other research has shown glabridin to stimulate osteoblasts, possibly indicating a promising treatment for the alveolar bone loss found in severe periodontal disease, the researchers added (Biochemical Pharmacology, August 1, 2005, Vol. 70:3, pp. 363-368).

“It suggests that if this molecule could be incorporated into a gel or fiber installed in the diseased periodontal pocket allowing a constant slow release, it could have a positive impact on alveolar bone,” Grenier said.

Meanwhile, although few studies have investigated the effect of licorice on Candida albicans — the most common form of candida — “findings suggest that licochalcone A and glabridin show promise as therapeutic agents for treating oral C. albicans infections,” Grenier and his colleagues wrote.

For example, there have been reports of G. glabra having an antifungal effect on C. albicans (Journal of Ethnopharmacology, June 2003, Vol. 86:2-3, pp. 235-241), and an in vitro study showed that glabridin has potent activity against amphotericin B-resistant strains of C. albicans (Phytotherapy Research, August 2009, Vol. 23:8, pp. 1190-1193).

More recently, Grenier and Céline Messier, one of his co-authors on the Oral Diseases paper, investigated the effects of two licorice extracts (licochalcone A and glabridin) on C. albicans and found that both acted in synergy with nystatin to inhibit the growth of C. albicans (Mycoses, May 25, 2011).

“Phytochemicals are structurally different from classic microbially derived antibiotics; therefore, there are few chances that pathogens demonstrate resistance,” Grenier said.

Finally, the research surrounding the effectiveness of licorice in treating recurrent aphthous ulcers has been so far been mixed. A randomized, double-blind clinical trial observed a dissolving oral patch containing a licorice extract (glycyrrhiza) for up to eight days to improve ulcer size and pain compared with a placebo patch (General Dentistry, March-April 2008, Vol. 56:2, pp. 206-210).

However, a 2009 study that investigated the efficacy of licorice bioadhesive hydrogel patches to promote healing and pain relief found that the control patches — which did not contain licorice — were equally effective in reducing pain and promoting healing (Phytotherapy Research, February 2009, Vol. 23:2, pp. 246-250).

Additional research is needed in this area before any conclusions can be made about the benefits of licorice in treating recurrent aphthous ulcers, Grenier and his co-authors noted.

“Licorice extracts and licorice constituents incorporated into oral hygiene products such as mouthwash, toothpaste, gel, and chewing gum need to be further

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By Dr. Carl Misch

The goal of modern dentistry is to restore normal function, comfort, aesthetics, speech, and health to individuals who are missing teeth. Given that our population is both aging and growing, an increasing number of people are being affected by the loss of teeth. However, the more teeth a person is missing, the more challenging this task can become. As a result of continued research in the development of diagnostic tools and innovative treatment, predictable success is now a reality in many challenging dental situations. This is a blessing, because tooth loss has some serious consequences — particularly for older people, who are more likely to be missing teeth.

The Unseen Effects of Tooth Loss

The most obvious effect of missing teeth is aesthetic. The way you look affects the way you feel, and the psychological and social consequences of tooth loss can also be profound, as we shall see. But it’s not just about unsightly gaps; there’s something less apparent going on in the area of a lost tooth that can affect function, health, facial aesthetics — just about everything.

Believe it or not, in the beginning and at the end — it’s not so much about teeth as it is about bone, which needs stimulation to maintain its form and density. In the case of alveolar (sac-like) bone which surrounds and supports teeth, the necessary stimulation comes from the teeth themselves. Teeth make hundreds of fleeting contacts with each other throughout the day. These small stresses are transmitted through the periodontal ligament (“peri” – around; “odont” – tooth) that suspends each tooth in its socket, prompting the bone to remodel and rebuild continually.

When a tooth is lost, the lack of stimulation causes loss of alveolar bone — its external width, then height, and ultimately bone volume. There is a 25% decrease in width of bone during the first year after tooth loss and an overall 4 millimeters decrease in height over the next few years. As bone loses width, it loses height, then width and height again, and gum tissue also gradually decreases. Ability to chew and to speak can be impaired. The more teeth lost, the more function is lost. This leads to some particularly serious aesthetic and functional problems, particularly in completely edentulous (toothless) people.

And it doesn’t stop there. After alveolar bone is lost, the bone beneath it, basal bone — the jawbone proper — also begins to resorb (melt away). The distance from nose to chin decreases and with it, the lower third of the face partially collapses. The chin rotates forward and upward, and the cheeks, having lost tooth support, become hollow. Extreme loss of bone can also make an individual more prone to jaw fractures as its volume depletes more and more.

So-called bite collapse can occur when only some of the back teeth, which support the height (vertical dimension) of the face, are missing. This can cause the front teeth to be squashed or pushed forward. They were not designed to support facial height or to chew food — only to hold and incise or tear it. Toothless people appear unhappy when their mouths are at rest because their lips, too, have sagged; unsupported by teeth and gum tissues they just cave in. Without teeth present, the tongue spreads into the space and the face collapses. The same is true of self-confidence.

The First Teeth To Go

In the United States, 70% of the population is missing at least one tooth, usually a back tooth. The first, or “6-year molars” are the first permanent (adult) teeth to erupt into the mouth and, unfortunately, are often the first teeth to be lost — as a result of decay, failed endodontic (root canal) therapy or fracture. In addition, they often have one or more crowns, which are still susceptible to recurrent decay. Longevity reports for crowns vary widely. The mean life span at failure of a crown has been reported as 10.3 years. Other reports range from a 3% failure rate at 23 years to a 20% failure rate at 30 years. Ultimately heavily restored and root canal treated teeth fail to recurrent decay, infection, structural failure or fracture. These teeth are at risk for extraction as a result of these complications, which are the leading causes of single posterior (back) tooth loss in adults.

Up until now, the most common — but not necessarily the best — option for replacing a single back tooth has been a three-unit fixed partial denture (FPD), also called a fixed bridge. In this case, the two teeth on either side of the gap, known as abutment teeth, are crowned and the two crowns together support a “pontic” — a false tooth in the middle (from the French word for bridge). This type of prosthesis (false replacement) can be fabricated within one to two weeks and provides normal shape, function (eating, talking and smiling), comfort, aesthetics and health. Because of these benefits, FPDs have been the treatment of choice for the last six decades. Every dentist is familiar with how and when to use them; they are widely accepted by the profession, the public, and dental insurance companies. FPDs are not invariably successful over time. If not well maintained, the pontics can act as reservoirs for bacterial biofilm and the abutment teeth can decay. As a result, the supporting abutment teeth are susceptible to structural failure from decay, failed endodontic therapy and/or fracture, increasing their risk of loss.

The abutment teeth of FPDs may be lost at rates as high as 30% within 14 years. Such unfavorable outcomes of FPD failure include the need to replace them and the loss of an abutment tooth or teeth.

Ingenuity At Its Best

What can be done to replace missing teeth and avoid debilitating bone loss? That depends on how many teeth have been lost. A better treatment option to replace a single missing back tooth is a single-tooth implant. A dental implant is actually a tooth root replacement, to which a crown is attached. The implant, made of commercially pure titanium, has a uniquely biocompatible property, which allows it to “osseointegrate” with the jawbone (“osseo” – bone; “integration” – fuse with). A crown, the portion of a tooth seen in the mouth, attaches to the implant, which looks, feels and functions like a natural tooth. And better yet, if for any reason the crown needs to be removed or replaced, it is removable, so that the implant is not compromised or damaged. Now that’s ingenious.

For years, patients were advised to accept the limitations of a FPD as it was the best treatment for tooth replacement. The primary reasons for suggesting a fixed bridge were its clinical ease, reduced cost and treatment time. However, if this concept were expanded, extractions would replace root canals and removable partial dentures would be used instead of fixed bridgework. But the primary reason to suggest a particular treatment should not be related to time, costs or difficulty of the procedure; it should be the best possible long-term solution for each individual.

In 2008, my research colleagues and I surveyed more than 1,200 implants placed over a 10-year period. We found that over 99% of the implants were successful and functional. As important, survival of the adjacent teeth was not compromised. In comparison, FPD failure rates were as high as 20% within 3 years, and 50% rates at 10 years. The single-tooth implant represents the treatment of choice from both a health and value standpoint.

Health-related advantages of a dental implant tooth replacement include no risk of decay and decreased risk of periodontal (gum) disease. There is also a decreased risk of abutment tooth decay, endodontic (root canal) failure, and improved aesthetics since the adjacent teeth remain un-capped. Psychological advantages are significant as well, especially with congenitally missing teeth (“con” – without or missing, “genital” – birth).

Moreover, a single-tooth implant compared to a bridge becomes more advantageous financially over time. Although a single-tooth implant may be a little more expensive initially, survival time is greater making the implant option more cost-effective.

Replacing Multiple Teeth

Implants can also benefit those missing some or all of their teeth — and the number of these individuals is growing. A 1999-2002 survey found that Americans older than age 60 have lost an average of 9 teeth. Incredibly, approximately 30 million Americans or about 17% of the entire United States adult population had at least one full arch of teeth missing. Although the rate is decreasing every decade, the elderly population is rising so rapidly that the number of adults in need of one or two complete dentures is actually predicted to increase from 33.6 million adults in 1991 to 37.9 million adults in 2020.

For these individuals, implants offer many advantages. They can be used to support bridges without the need for abutment teeth, or even a full arch of false teeth that would otherwise rely on support from pressure on the gums and underlying bone, which continues to resorb and melt away. A removable denture (complete or partial) pressing on the gum and oral membranes accelerates bone loss. Biting force is transferred to the bone surface only, not the bone structure. As a result, blood supply is reduced and total bone-volume loss occurs. This issue, which is of utmost importance, has been observed but not addressed in the past by traditional dentistry. In fact, denture-wearers are not always made aware that bone loss will cause their dentures to slip, and bone loss accelerates when dentures fit poorly. Implants prevent more than a twentyfold decrease in alveolar and jaw-bone loss, compared with removable dentures. Furthermore dentures may reduce function to one-sixth of the level formerly experienced with natural teeth, whereas implants may return function to near normal limits.

A fixed bridge or even a removable partial denture secured in place by implants is much more stable than a denture that relies only on the soft tissues of the mouth for support. Removable dentures (unsupported by implants) affect a person’s ability to chew. Studies show that 29% of denture wearers are able to eat only soft or mashed foods, 50% avoid many foods and 17% claim they eat more efficiently without their dentures. Those who wear removable dentures tend to avoid fruits and vegetables. This can lead to poor nutrition, digestive tract problems, illness and even shortened life expectancy.

How Implants Stop Bone Loss

Dental implants fused and integrated into the jaw-bone serve both as anchors to support teeth and as one of the better preventive maintenance procedures in dentistry. A primary reason to consider dental implants to replace missing teeth is the maintenance of jaw bone. As you may recall, bone needs stimulation to stay healthy. An implant-supported tooth, or teeth, allow for normal function of the whole stomato-gnathic system (“stomato” – mouth; “gnathic” – jaws) including the nerves, muscles and jaw joints. Moreover dental implants fuse to the bone, stabilizing and stimulating it to maintain its dimension and density.

In addition implant-supported fixed bridges function the same as natural teeth. Beneficial effects of improved diet have been reported, as well as significant improvement in eating enjoyment and social life. And those with dental implant tooth replacements judge their overall psychological health improved by 80% compared with their previous state while wearing traditional, removable dentures. In fact, they reported feeling that their implants were an integral part of their body.

The success rate of dental implant prostheses (tooth replacements) varies, depending on a host of factors that change for each individual. However, compared with traditional methods, they offer increased longevity, improved function, bone preservation, and better psychological well-being. Dental implants regularly attain a 10-year survival of more than 90% and most can last the life of the person.

I believe the current trend of expanding the use of implant dentistry will continue until every dental practice uses them on a regular basis, as the primary option for all tooth replacement. At the very least, all people should ask about the option of dental implants to replace missing teeth so that they can make intelligent, well-informed decisions regarding their healthcare.

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By Victoria Ho

Do artificial sweeteners have a role in health and diet? They certainly seem to be everywhere today, from chewing gum to the ubiquitous packets of yellow, blue, and pink found in coffee shops nationwide. With popular media continually portraying sugar as the villain in a national battle against obesity, terms like “added sugar” and “high fructose corn syrup” are increasingly viewed by consumers with skepticism and even aversion. Add the fact that diets high in refined carbohydrates can predispose individuals to a myriad of health issues — dental caries (tooth decay), high triglycerides (cholesterol and other fats), and rapid swings in blood sugar being only a few — and it’s understandable why sugar seems to be the current Nutrition Enemy Number One.

Today’s selection of artificial sweeteners helps satisfy a desire for a sweet taste without any potential negative consequences. A preference for sweet tastes is inherent in humans, with sweet foods triggering the brain to feel satisfied and happy. Given that a “sweet tooth” is at least in part biological, it’s no wonder that American consumers are continually seeking ways to get their sugar fix while avoiding overconsumption.

Ironically, the first sugar substitute, saccharin, was discovered completely by accident in 1878. These days, artificial sweeteners are a lucrative area of research and development in the food industry. The Calorie Control Council, a not-for-profit association representing low-calorie foods and beverages, estimates that roughly 85% of the US population uses artificial sweeteners in some form. A wide range of foods is formulated with various artificial sweeteners, and therefore consumers may not even be aware of the total number of foods with artificial sweeteners they are eating.

What’s Out There: An Overview Of Sweeteners

Currently, the Food and Drug Administration (FDA) has approved six artificial sweeteners: acesulfame K, saccharin, aspartame, neotame, sucralose, and rebaudioside A. All of these products are intensely sweet chemicals, which range from hundreds to thousands of times sweeter than table sugar. With the exception of rebaudioside A, they are all man-made compounds. Calories from any of these sweeteners are near negligible because only very small amounts are needed and the body excretes most of what is consumed.

Acesulfame K, marketed under trade names Sunett and Sweet One, is most commonly used in combination with other artificial sweeteners due to a bitter aftertaste.

Saccharin, one of the most well-recognized and widely used artificial sweeteners, is available under a variety of trade names, with Sweet’N Low and Sugar Twin being the most common. Saccharin is used in sugar-free and low-calorie foods ranging from beverages and cookies to dairy products.

Aspartame is also well recognized, being the “blue packet” counterpart to saccharin’s “pink packet.” It is commercially available as Equal or NutraSweet. Aspartame is unsuitable for cooking or baked goods because its structure degrades at high temperatures. Although aspartame is safe for the general population, in people with a rare genetic condition called phenylketonuria, aspartame cannot be properly processed by the body. Products containing aspartame must carry an FDA warning label by law stating, “Phenylketonurics: Contains Phenylalanine.”

Neotame is a relative newcomer to the artificial sweetener market. Produced by the makers of NutraSweet, neotame is derived from aspartame and has a similar taste but is metabolized slightly differently in the body. As a result, neotame-containing products do not need to carry the same FDA warning as those with aspartame.

Sucralose, widely marketed under the name Splenda, has been touted as having the most natural flavor profile of any artificial sweetener and is currently the most popular option. Early marketing campaigns utilized the slogan “Made from sugar so it tastes like sugar”; sucralose is made by chemically altering table sugar so that the body can’t process it. Lawsuits eventually forced the company to repeal the message, though. Sucralose is broadly used in sugar-free products, including the well-known beverage Diet Coke. It is also stable at high temperatures and varying pH levels (of acidity and alkalinity), making it well suited for cooking and baking.

Rebaudioside A is the most recently FDA approved artificial sweetener, and is a highly purified compound originally found in Stevia plants and now produced synthetically. Stevia, previously available as a dietary supplement, is an intensely sweet tropical plant and has often been marketed as a natural alternative to artificial sweeteners. Besides being sold as dried or pure Stevia plant, Stevia-derived sweetener is sold under the names PureVia, Truvia, Sun Crystals, and Stevia in the Raw.

In addition to true artificial sweeteners which have zero calories, low-calorie sweeteners also exist that provide sweetness with fewer calories than sugar. Also called sugar alcohols or polyols, these are naturally occurring substances often used in place of sugar or in combination with an artificial sweetener. Truvia, for instance, is a combination of Stevia extract and a sugar alcohol called erythritol. Sugar alcohols are absorbed slowly by the body and incompletely digested, so the body receives less calories compared to sugar. Examples of sugar alcohols commonly found in the US food supply are sorbitol, mannitol, xylitol, erythritol, and d-tagatose. Recently, extra attention has been paid to the sugar alcohol xylitol because it can be used to prevent tooth decay.

The Sweet Side: Health Benefits of Sweeteners

The FDA has determined that there is significant scientific agreement regarding safety of the six artificial sweeteners listed above and has therefore granted its approval for their use. Additionally, the American Dietetic Association has stated that “It is [our] position that consumers can safely enjoy a range of nutritive and non-nutritive sweeteners” and has approved the use of artificial sweeteners in the general public, including people with diabetes, pregnant women, and children.

Among the major benefits of artificial sweeteners is their impact on dental health. Artificial sweeteners can help reduce intake of sugar, and unlike regular sugar, sucrose, they do not promote growth of the bacteria that cause cavities. Rather than eliminating sweet items entirely from the diet — which may be unrealistic and unsustainable for a variety of reasons — individuals can substitute sugar-free versions of desired foods. Both sugar alcohols and artificial sweeteners have been used to sweeten chewing gums, hard candies and beverages. Currently, the American Dental Association awards the ADA Seal to a variety of chewing gums containing artificial sweeteners and/or sugar alcohols. Gums sweetened with artificial sweeteners or sugar alcohols benefit oral health by stimulating the flow of saliva, which has many beneficial properties. Saliva buffers acidity in the mouth and in bacterial plaque. Saliva also returns necessary minerals (such as calcium and phosphate) to the tooth surface, which acid dissolves out.

As mentioned before, current research suggests that sugar alcohols may play a greater role in prevention of dental caries than previously thought. Xylitol use in the form of chewing gum has been shown to significantly reduce levels of Streptococcus mutans bacteria, the major decay-causing bacteria within the mouth. These bacteria are unable to ferment the sugar alcohol, resulting in bacterial starvation.

Artificial sweeteners and low-calorie sugar alcohols can also play an important role in overall health promotion. Although often thought of as a tool for dieters to use in their quest to reduce caloric intake, or a way for people with diabetes to avoid spikes in blood glucose, these products can be used not just as a temporary substitution for high-calorie sweeteners, but also as a way to promote more lasting lifestyle changes. Artificial sweeteners can be an option for gradually reducing intake of added sugars. For instance, a consumer may not be willing to give up a three-soda daily habit, but might be open to the idea of switching to diet versions. By satisfying a desire for sweet taste, individuals feel less restricted and deprived, which can be a starting point for building long-term healthy habits.

The Controversy: Are Sweeteners As Safe As They Seem?

On the other side of the argument, however, are those who claim that low-calorie and artificial sweeteners do more harm than good and should be viewed with greater scrutiny. The FDA has established acceptable daily intake levels for artificial sweeteners, which average consumption levels likely fall well below (for instance, reaching the level set for aspartame would be equivalent to drinking twenty regular-size cans of diet soft drinks daily). For low-calorie sweeteners, excessive consumption (in the range of 20-50 grams per day) can cause upset stomach and diarrhea. In the 1970s, saccharin in particular fell out of favor and was nearly banned following reports linking its consumption to bladder cancer in rats. It has since been established that there is no elevated bladder cancer risk in humans, and the FDA, US Environmental Protection Agency, and National Cancer Institute have removed it from lists of potentially harmful agents. Consumer advocates continue to call for more safety data on regular consumption of artificial sweeteners, particularly newer entries to the market such as neotame, sucralose, and rebaudioside A/stevia.

Current controversy centers largely on how artificial sweeteners affect taste perception, metabolism, and overeating. While widely touted as a potential factor in combating the United States’ obesity epidemic, artificial sweeteners have also become a target. A 2008 study showed that rats fed saccharin ate a greater quantity and gained more weight than those who didn’t receive artificial sweetener. Although the study was small and conducted in animals, it raised several questions about how artificial sweeteners drive eating behavior. Researchers speculated that sweeteners may actually increase hunger by stimulating responses to sweet tastes without providing nutrition. High-intensity sweetness may also decrease sensitivity to sweet flavors, driving eaters to seek more and more.

A study comparing brain activity of women who consumed sucralose to that of women who consumed sugar, showed that both substances activated regions of the brain associated with taste, but sugar activated brain regions related to satisfaction more strongly. Potentially, the body can recognize a difference between sugar and artificial sweeteners, so that simply providing a sweet taste may not fulfill the brain’s expectations and reward pathways.

Critics of artificial sweeteners also point to a 2008 epidemiological study in Circulation that associated drinking one can of diet soda daily with a 34% increased occurrence of metabolic syndrome — a combination of medical disorders that significantly increases risk of cardiovascular disease and diabetes — compared to those who did not drink any soda products. Regular soda drinkers had an associated risk only 10% higher than non-soda drinkers.

What To Put In Your Shopping Cart — And Your Mouth

So in light of all this information, what should the average consumer do? It’s clear that artificial sweeteners are here to stay and will continue to be found in products ranging from the medicine cabinet to the kitchen pantry. It’s also true that questions surrounding sweeteners, and answers both factual and fictitious, will continue to circulate.

Currently, there are no FDA or government guidelines against the use of artificial sweeteners and strong evidence for their use in preventing tooth decay. They can be an important tool in helping to combat overeating, which in turn promotes improved health through maintaining a healthy weight and lowering risk of diet-related diseases like heart disease and diabetes. Looking for artificially sweetened versions of products like chewing gums, flavored beverages, candies, or yogurts can help cut down calories without feelings of deprivation. In moderation, artificial sweeteners can satisfy the taste buds without compromising dental health or adding too many calories, and can be part of an overall healthy lifestyle.

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“We have lots of data showing a direct correlation between inflammation in the mouth and inflammation in the body,” says Anthony Iacopino, director of the International Centre for Oral-Systemic Health, which opened at the University of Manitoba Faculty of Dentistry in Canada in 2008. Recent studies also show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes.

Such findings are fueling a push for dentists to play a greater role in patients’ overall health. Some 20 million Americans—including 6% of children and 9% of adults—saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month.

“It’s an opportunity to tell a patient, ‘You know, I’m concerned. I think you really need to see a primary care provider,’ so you are moving in the direction of better health,” says the study’s lead researcher Shiela Strauss, co-director of statistics and data management for New York University’s Colleges of Nursing and Dentistry.http://online.wsj.com/article/health_journal.html

George Kivowitz, a restorative dentist with offices in Manhattan and Newtown, Pa., says he has spotted seven cases of cancer in 32 years of practice, as well as cases of bulimia, due to the telltale erosion of enamel on the back of the upper front teeth, and methamphetamine addiction. “We call it ‘meth mouth,’ ” he says. “The outer surface of teeth just rot in a way that’s like nothing else.”

Some of the most distinctive problems come from uncontrolled diabetes, Dr. Kivowitz adds. “The gum tissue has a glistening, shiny look where it meets the teeth. It bleeds easily and pulls away from the bone—and it’s all throughout the mouth.”

An estimated six million Americans have diabetes but don’t know it—and several studies suggest that dentists could help alert them. A 2009 study from New York University found that 93% of people who have periodontal disease are at risk for diabetes, according to the criteria established by American Diabetes Association.

It’s not just that the same lifestyle habits contribute to both gum disease and high blood sugar; the two conditions exacerbate each other, experts say. Inflammation from infected gums makes it more difficult for people with diabetes to control their blood-sugar level, and high blood sugar accelerates tooth decay and gum disease, creating more inflammation.

Diabetes also complicates dental-implant surgery, because it interferes with blood vessel formation and bone growth. “When you put a dental implant in, you rely on the healing process to cement it to the jaw, so you get a higher failure rate with diabetes,” says Ed Marcus, a periodontist in Yardley, Pa., who teaches at the University of Pennsylvania and Temple University dental schools.

Dr. Marcus notes that about 50% of periodontal disease is genetic—and even young patients can have significant bone loss if they have an unusually high immune response to a small number of bacteria. Giving such patients a low dose of doxycycline daily can help modify the immune response. “It doesn’t really control the bacteria, but it helps reduce the body’s reaction,” he says.

There’s also growing evidence that the link between periodontal disease and cardiovascular problems isn’t a coincidence either. Inflammation in the gums raises C-reactive protein, thought to be a culprit in heart disease.

“They’ve found oral bacteria in the plaques that block arteries. It’s moved from a casual relationship to a risk factor,” says Mark Wolff, chairman of the Department of Cariology and Comprehensive Care at NYU College of Dentistry.

Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere, which is why people contemplating elective surgery are advised to have any needed dental work performed first.

The American Heart Association no longer recommends that people with mitral valve prolapse (in which heart values close abnormally between beats) routinely take antibiotics before dental procedures, since it’s now believed that oral bacteria enter the bloodstream all the time, from routine washing, brushing and chewing food.

But the American Heart Association, the American Medical Association and the American Orthopedic Association all urge people who have had a full joint replacement to take an antibiotic one hour before any dental visit for the rest of their lives to reduce the risk of post-surgical infections. “I have my guidelines taped to the door in my hygienists’ room,” Dr. Kivowitz says.

Dentists say they also need to stay up to date with all medications, supplements and over-the-counter drugs their patients are taking. Blood thinners can create excess bleeding in the mouth. Bisphosphonates, often prescribed for osteoporosis, can severely weaken jaw bones. Both should be stopped temporarily before oral surgery.

Antihypertensive drugs, calcium-channel blockers and some anti-inflammatory drugs can cause painful ulcerations of the gums. Many medications, from antidepressants to chemotherapy drugs, cause dry mouth, which can cause cavities to skyrocket, since saliva typically acts as a protective coating for teeth. Additional fluoride treatments can help.

Some proactive dentists have glucose monitors for another check on blood-sugar levels if they suspect diabetes. Some also take patients’ blood pressure and hold off on invasive procedures if it’s extremely high.

The Centers for Disease Control and Prevention recommends that dentists offer HIV testing, because some of the first symptoms appear in the mouth, including fungal infections and lesions. Dentists can do the HIV test with a simple mouth swab and get results in 20 minutes.

Breaking the bad news is often more difficult. “I went into oral surgery because I didn’t think I would have to deliver that kind of news to patients,” says Clifford Salm, an oral and maxillofacial surgeon in Manhattan who has found leukemia, lymphoma, AIDS and metastatic breast cancer after performing biopsies on suspicious spots. “It can be a difficult conversation,” he says, “but most patients are very grateful.”

Don’t Be Fooled by White, Shiny Teeth

A gleaming, white smile is a sign of a healthy mouth, right? Not necessarily.

“Whiteness and the health of your teeth are totally unrelated,” says Mark Wolff, an associate dean at New York University College of Dentistry.

In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease.

Even people who have no cavities can still have inflamed and infected gums. It could be that their saliva is particularly protective of their tooth enamel, while their brushing and flossing habits, needed to keep gum tissues healthy, could be lax.

“I get these patients in their mid-30s who don’t have cavities, so they haven’t been to a dentist in 10 years. But they have full-blown periodontal disease,” says George Kivowitz, a restorative dentist in Manhattan. “They are losing all the supporting structure, and I have to tell them that these gorgeous teeth will fall out of your head if we don’t turn this around.”

Using whitening products more often than recommended can erode some of the enamel and cause teeth to appear translucent. But whether that actually harms teeth is controversial. “No one has really shown that it’s damaging, but no one knows the long-term results,” says Dr. Marcus, the periodontist in Yardley, Pa.

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Tooth decay — or dental caries — is an infectious disease process that causes damage to the structure of teeth. Cavities (hollowed out spaces or holes) are the most notable consequences of dental caries. Left untreated, caries leads to pain, tooth loss — or, in rare cases, death. In this most extreme case, infection can advance to the “cavernous sinus,” an air cell behind the eye, from which it can then enter the brain. Tooth decay amounts to more than just the inconvenience of “drilling and filling”: it has the power to change a person’s diet, speech, quality of life and overall well-being. Did you know that tooth decay is one of the most common of all diseases, second only to the common cold?

Decay — A World Wide Epidemic; Painful, Costly and Preventable

Oral diseases range from cavities to cancer; they cause pain and disability for millions of Americans each year. Even more disturbing — almost all are preventable. Dental decay is a worldwide epidemic, especially among young children. The disease begins early — tooth decay affects more than one-fourth of U.S. children ages 2 to 5 and half of those ages 12 to 15. Low-income children are hardest hit: about half of those ages 6 to 19 have had decay. In addition to pain and other dysfunction, untreated cavities can cause absence from school and other social interactions, low weight and poor appearance — problems that may greatly reduce a child’s capacity to succeed in life.

Tooth decay is also a problem for U.S. adults, affecting more than ninety percent over age forty. A quarter of adults over age sixty have lost all of their teeth primarily because of decay affecting self-esteem and contributing to nutrition problems by limiting the types of foods that can be eaten.

A New Way of Looking At Dental Decay — A Dynamic Process

The mouth is an ecosystem where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of non-living enamel (the hardest substance in the human body) and an inner core of living dentin, with a consistency and composition similar to bone. Enamel is highly mineralized and crystalline in structure, composed mainly of calcium and phosphate. The teeth are bathed in saliva, a most remarkable and seldom discussed fluid. It has many important functions in keeping mouths healthy; one of the most important is its role in maintaining a “neutral” environment — a balance between acids and bases.

(Acidity is measured scientifically by the “pH” scale that runs from 1 – 14. pH 1 is extremely acidic, pH 14 extremely basic. The pH of the mouth is generally 7 – neutral.)

The oral environment is also loaded with bacteria. There are more bacteria in a single mouth than there are people who have ever lived on the earth. Certain of these bacteria have the potential to cause decay.

Here’s how it works — specific bacteria (mutans streptococci and lactobacilli) attach themselves to dental plaque, the whitish sticky film that collects on teeth in the absence of effective oral hygiene. When sugars or carbohydrates are eaten, these particular bacteria have the ability to break down the sugars to use for their own metabolism. In the process, though, they produce acid as a by-product which in turn drops the saliva pH. At about pH 5.5 the minerals in the enamel just below the surface begin to dissolve in a process known as “de-mineralization,” in which more calcium and phosphate leave the tooth surface than enter it. The effects of early de-mineralization in enamel can be seen as a white spot on the tooth.

Dentin and root surfaces have much less mineral than enamel and are much more vulnerable to acid dissolution de-mineralizing at a much higher pH (about 6.0 to 6.5).

Bacterial acid attacks of short duration can be “buffered” (neutralized) in about thirty minutes by adequate amounts of healthy saliva, thereby returning calcium and phosphate into the tooth sub-surface. Saliva contains a lot of calcium and phosphate “ions” (charged moving particles) that continually leave the surface enamel and are replaced from the saliva, and vice versa. This process is chemically the reverse of de-mineralization and is known as “re-mineralization.” Although the white spot may not disappear, re-mineralization is nature’s way of repairing early damage and returning the tooth surface back to status quo.

Nothing in nature is static, but instead it is dynamic and therefore changing constantly to maintain a status quo. Primarily composed of mineral, teeth continually swing between “DE-mineralization” from the bacteria on the tooth surface, and “RE-mineralization” from the effects of saliva. This interchange occurs on the microscopic level, but still very important in maintaining the normal balance.

The Caries Balance

Given similar habits, you might wonder why some people get cavities and others don’t. This dilemma can be better understood by picturing a balance between pathogenic (disease-causing) and protective (health promoting) factors. Each individual has his/her own unique balance that dynamically changes as time goes on. The trick is to identify what is out of balance and how to tip it towards health and protection.

Pathogenic factors include the large amounts of specific acid-producing Bad bacteria, the Absence of healthy salivary function, and poor Dietary habits. By contrast, protective factors include healthy Salivary function and Sealants (to seal the areas most likely to decay), the use of Antibacterial agents, topical Fluoride, and a healthy and Effective diet.

How to Assess Your Risk

Not everybody has the same level of risk for developing dental caries; this is further complicated by the fact that the risk is dynamic and changes daily, as well as over time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Modern dentistry is moving toward an approach to tooth decay management that is “evidence-based” from years of systematic, accumulated and valid scientific research. In other words, it allows individualized treatment based on current science that is customized to the patient’s actual risk that he/she presents with, rather than a “one size fits all approach.”

Risk assessment allows preventive and treatment decisions to manage those in greatest jeopardy. This approach allows for “targeted” management appropriate for individuals whether in low, medium, high or extreme risk groups. Protocols have been recently established based on the Age One Visit (for infants and toddlers) as well as for children age 6 through adulthood.

Strategies for Prevention

You can see now that prevention doesn’t simply mean brush and floss and don’t eat sugar. It is a complicated topic with many implications. In fact, your dental office may offer some additional steps to measure your caries risk (salivary and bacterial analysis) and then recommend some products that specifically manage your risk level (sealants, antibacterial agents, topical fluoride, calcium and phosphate supplements, pH neutralizers, special toothpaste and rinses, and xylitol gum). These strategies are based on tipping the balance toward health by maximizing the protective side and minimizing or eliminating the pathogenic side. Prevention must be strategic, since it affects planning on an individual and community level.

Tipping the Balance — the Right Recipe

Simply put, for dental caries (tooth decay) to occur you need the right (or rather wrong) recipe:

• Susceptible teeth (not all teeth get caries),
• Acid producing bacteria,
• Sugars or carbohydrates — the “perfect” food for the acid producing bacteria
• Prevention aims to shift the balance in favor of promoting health in three main areas:

Protecting the teeth from caries — this is best accomplished by applying fluoride topically to the crystalline structure just after the teeth erupt into the mouth. The tooth surfaces are dynamic and will allow incorporation of fluoride ions into the surface structure. Many studies show that low doses of fluoride are safe and effective against decay. Sealants are very successful and are a companion treatment to fluoride because they seal the places where decay occurs in the tiny hidden pits and fissures [Figure 1]. Clinical studies using sealants show 99% cavity-free results during six years of clinical testing on more than 1,100 teeth studied.

Identifying and reducing acid-producing bacteria — these bacteria can be identified by a simple test administered by your dentist. If these bacteria are identified, they can be modified to reduce tooth decay by the use of tooth protective products. We can further modify these harmful bacterial concentrations with the use of antibacterial mouthrinses (such as chlorhexidine) and pH neutralizing agents. It is important to note, infants are not born with the specific decay-causing bacteria but that these bacteria are actually transmitted through saliva from mothers, caregivers, or family members to young children — another reason to practice prevention.

Controlling diet — sugars and other carbohydrates can be fermented by bacteria to produce acids. It’s important to reduce refined sugars from the diet or restrict intake to mealtimes. Natural sugars (in raw fruits and vegetables) are better than the free (added) sugars found in juices, sodas, candy and the like. Total sugar intake should be less than fifty grams, about ten teaspoons, per day. Snacking between meals is dangerous because it promotes an acid environment that would take up to thirty minutes for healthy saliva to neutralize. Healthy non-sugary or non-carbohydrate snacks are therefore better, like carrots, vegetables and fresh fruits. Xylitol is an example of an “alcohol sugar” used in some chewing gums and dental products that actually reduces decay-producing bacteria, and is proving useful in decay preventing strategies. One study showed that pregnant mothers who chewed xylitol gum before giving birth reduced the transmission of these strains of bacteria to the child, thus reducing the likelihood of decay.

Today’s Treatments Can Reduce and Eliminate Tooth Decay

We understand that tooth decay, or dental caries as it is known, is a disease process, and we know the causes. As we’ll see in future articles, methods of prevention, early detection, protection and treatment have continued to improve. Dentists are using a more preventive strategy — profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life.

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Pick up most magazines or newspapers these days and you’re likely to see an ad about dental implants. And with the advent of “implant centers” in major metropolitan areas, television ads are now delivering the message that an implant center, with everything conveniently offered under one roof, is the state-of-the-art choice for dental implant treatment. Some even extol the virtues of getting your new “Teeth In A Day!” Bombarded with so many different messages about dental implants, how does the consumer make the right decisions?

While this kind of marketing distorts the limits of our current research and knowledge, this new end of the spectrum may not necessarily end in a rainbow. This important and controversial topic will be covered in two parts. A clear understanding of the increasing options available for implant treatment is a good place to start together with alternative replacements for missing teeth and their economic impact. This first part will also educate you about the problems associated with tooth loss and why implants are considered the state-of-the-art tooth replacement system.

In part two, we’ll discuss who are the most suitable and experienced dental professionals to place implants. We will discuss the why, when and where to make your implant choices including how to navigate through the implant marketing hype.

Dental Implants: The Optimal Tooth Replacement

Let’s begin by taking a look at what makes implants the most optimal tooth replacement system today. An implant connection to the bone is different than how a tooth connects to the bone but it performs the same function. Dental implants act as substitute tooth roots in a unique way.

Implants actually stabilize bone and prevent the inevitable bone loss that occurs when teeth are lost. Commercially pure titanium, of which almost all current implant surfaces are made, has the unique property of being “osteophilic” (osseo-bone, philic – loving), thus joining biochemically to bone. Osseo-integration (osseo – bone, integrate – to join or fuse with) was discovered quite by chance and has revolutionized dentistry. The fusion is almost like a pillar in concrete, allowing no movement at all. Stresses of biting forces are transmitted directly through implants to the bone — which they allow for very well. They provide virtually the same function as natural teeth roots, including stimulating the bone, thereby stabilizing it and preventing its loss.

Consequences of Tooth Loss — Believe It or Not, It’s All About Bone

The bone that encases the teeth known as “alveolar” bone, (from alveolus – sac, an extension of the jaw bone), is the special bone that surrounds and supports the teeth. It develops with the teeth as they erupt into the mouth, accompanies the teeth in life and is lost when the teeth are removed. As one famous scientist put it, “Alveolar bone is like any other bone in the body, it just lives more dangerously,” said Dr. Harry Sicher.

When teeth are lost or removed the alveolar bone, which is fragile in structure like an ice cream cone, “resorbs” or melts away. What complicates matters is the “pattern” of resorption or the melting away process. Where the bone is thinnest, it resorbs more quickly. This is particularly true for the upper front teeth where bone, gum and even the lips can appear to cave in or collapse. The dental literature indicates that 79% of the population has a smile line that will not cover these types of “defects.” This is very noticeable when smiling and many people become quite self-conscious about their appearance as a result.

It Ain’t Necessarily So!

Bone resorption always occurs naturally when teeth are lost, unless measures are taken to prevent it. We are fortunate to live in an era when this melting away process can be compensated for by grafting techniques — which can work well in experienced hands. Although bone can now be restored by grafting techniques, it’s preferable and easier to prevent its loss from occurring. Bone maintained in both sufficient volume and position will allow for proper implant positioning, which in turn will stabilize the bone and prevent further resorption. The desired end result — completely natural looking teeth.

Keys to Implant Success

In the hands of an experienced “team,” implants placed surgically in the right position not only allow for the fabrication of implant-crowns that look natural, but also function properly and are maintainable — indistinguishable from real teeth. In the wrong position or without proper forethought implants can create a nightmare for the restorative dentist and dental technician who make the crowns.

The key to implant success — can be summarized by answering two questions:

• Can an implant be placed in correct position to allow for natural aesthetics and proper tooth function?
• Is there enough bone and is it in the right place to allow tooth replacement with an implant?

Implant placement and positioning is dependant upon adequate bone volume and density, which are therefore critical to success. In experienced hands, implants are extremely successful. Documented research and clinical studies indicate success rates of over 95% — which is higher than any other tooth replacement option. Even in areas of low bone density success is quite common. Once integrated and functional, implant restorations can last a lifetime.

Success from Concept to Design

The concept and design of implants has been very well researched and tested. Implant tooth replacement systems often comprise separate and interconnecting units, which can allow the crown components to be removed and replaced if the need arises. Once an implant is placed in the bone time must be allowed for the osseo-integration (bone fusion) process to take place, usually between two to four months. One of the primary reasons for early implant failure is “loading” them with biting forces too early. Only in carefully controlled circumstances where stability of the implant(s) can be assured, is it possible to place implant crowns early, with any degree of predictable success.

The “Teeth In A Day” concept is somewhat misleading, because the crowns placed on the implants are functional, but most often temporary in nature. This is more commonly effective in the lower front jaw where the bone is denser and implants can be splinted (joined) to crowns atop the implants assuring their initial stability. It is a little less predictable in the upper jaw and for single tooth replacement, but still possible in the right hands and circumstances.

Form and Function — Consequences of Tooth Loss

We tend to think about teeth as individual units, your dentist even gives each tooth a name and number, but in fact they make up a complete system, each one adding to its neighbor to function as one. Think about how the keystone in an arch holds all the other stones or bricks in place. For purposes of description we can think about the human dentition (full complement of teeth) as being composed of the anterior (front teeth) and posterior (back) teeth. The anterior teeth (the canines and incisors) are used for cutting and tearing food, and the posterior teeth (the premolars and molars) are used for grinding and chewing.

Importantly, the posterior teeth also support the vertical height of the face. If they are lost, the face tends to lose height and close down; this is called “posterior bite collapse”. Unlike implants, teeth move; not only do changes occur to the remaining back teeth affecting their spacing and biting function, these changes also put pressure on the front teeth which tend to move or splay forward.

All of these changes have implications for normal form (aesthetics) and function (bite). They also have ramifications for other facial and jaw structures which can affect anything from the skin to muscles and jaw joints. Appearance begins to change as the height of the jaw decreases, wrinkles increase and the corners of the mouth droop. Additionally, it can become difficult to eat food because the front teeth were not designed for chewing. This is to say nothing of the social consequences of tooth loss; smiling, talking, singing, laughing and enjoying a nutritionally sound diet — all leading to both poor general and mental health.

Traditional Tooth Replacement — Not So Traditional Any More

Dental implants are a relative “new kid on the block” for replacing missing teeth, but how do they really compare to other more traditional systems?

Removable options — Past methods of removable tooth replacement have included plastic “flippers” (non-precision, simple, temporary in nature and relatively inexpensive) and precision made metal based partial dentures, which are more expensive. Both can replace individual or groups of teeth. A fundamental problem with removable prostheses (replacements) is that for stability they rest on the teeth and gums tending to cause further problems all related inevitably to their design. These include tooth decay and periodontal (gum) disease and hastening the loss of bone and teeth through pressure transmitted through the gums upon which they rest. They constitute short term options with documented studies indicating that removable partial dentures are replaced about every 5 years.

For total tooth replacement whether in the upper or lower jaw full dentures (plates) have been the only option. Since they are kept in only by pressing on the gum tissues they transmit force to the underlying bone which accelerates its loss even more quickly. They also compromise the facial structures. As they continue to collapse, full dentures must be relined (made thicker) to compensate for additional bone loss and facial sagging. They also become particularly problematic in the lower jaw where there is no palate for suction and in addition tongue forces tend to destabilize them.

Non-removable options — Fixed bridges are non-removable prostheses (tooth replacements) which are attached to the natural teeth. They act by joining other teeth together with a false tooth or teeth between them “bridging” the gap. But the biggest disadvantage; these “abutment” or adjoining teeth are cut down into small peg shapes which compromises their long term health. As well as carrying the additional load of the missing teeth they replace, they become more prone to bacterial plaque accumulation, decay, root canal problems and periodontal (gum) disease. Bridges do not have a long life span therefore they will eventually need to be replaced. Studies indicate that bridges are only 67% successful at 15 years.

Economic aspects: Comparing the Cost of Implants to Fixed Bridgework

Consider this scenario: if you lose a single tooth, the two most common methods of tooth replacement are a tooth supported bridge or an implant supported crown. The American Dental Association (ADA) reports that bridges last an average of 10 years. Clinical studies indicate that implants are over 95% successful for 20+ years.

Even with partial insurance reimbursement, the cost of a tooth supported bridge is more expensive long term. The total cost over 20-25 years or more could be significantly higher than shown above. And with an implant supported crown, the adjacent teeth are not compromised so that additional treatment is not necessary. Consider too, the concept of amortization — the process of decreasing or accounting for the cost over the period of time they are likely to last.

Implants may seem more expensive initially. But for patients who are candidates, not only are they a better treatment choice, they will last longer, possibly a lifetime, thereby making them the ideal choice and most cost effective option long term. As we shall see in part two when we guide you through the marketing hype, well planned implants most often require a team approach in assessing whether they’re right for you. Placing implants and attaching crowns to them require precision procedures and techniques.

Benefits of Dental Implant Treatment

• Enhanced quality of life
• Integrity of the facial structures is preserved
• The smile is restored as close as possible to its natural state
• Long term health of adjacent teeth is not compromised
• Replacement teeth that look, feel and function like natural teeth
• Increased stability
• Improved health due to improved nutrition and proper digestion
• Renewed self-confidence
• Improved appearance
• Improved ability to taste foods
• Increased convenience of hygiene and maintenance

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The Art of Periodontal Surgery

Periodontal surgery is a plastic (reshaping) surgical procedure designed to restore and regenerate normal form and function to lost and damaged periodontal structures which support the teeth (the gum tissue, periodontal ligament and bone). This article is an overview of what a candidate for periodontal surgery can expect and a primer for further information and discussion.

Periodontal Surgery in Perspective — What makes it work

An understanding of what periodontal surgery is designed to do, what makes it successful and what sustains the results over time is critical to successful treatment of periodontal disease. Periodontal surgery is not a cure, but rather an adjunct to making long-term treatment outcomes more favorable. Unlike surgery to take out an inflamed appendix, which removes the disease with it, the potential for the recurrence of periodontal disease still remains in susceptible individuals. The long-term goal of periodontal surgery is to increase the life expectancy of the teeth.

Over a lifetime, the treatment for periodontal disease is primarily aimed at controlling its cause, microbial dental plaque. The purpose of periodontal surgery therefore is to treat deformities and tissue loss created by the disease process. This is accomplished by eliminating “pockets” of diseased tissue; regenerating and reconstructing gum and periodontal tissue attachment to the teeth and generally to provide an environment more conducive to daily oral hygiene and professional maintenance care.

The Consequence of Periodontal Infection

The end results of periodontal disease include loss of the tight attachment of the gum and periodontal tissues to the teeth. Just as one can put a hand in a pocket, a space by the side of clothing, pockets can also form around the teeth, into which fine probing instruments can be inserted to measure the degree of vertical tissue detachment [see illustration above]. This detachment, results from chronic inflammation as described above. Breakdown ultimately causes bone and periodontal tissue destruction giving rise to different patterns and shapes of bony defects which surgical treatment aims to regenerate and repair. For the most part the detached gum tissues either recede or remain as a detached curtain around the teeth.

Diagnosis

“There may be many ways to treat a case, but there is only one correct diagnosis”

Morton Amsterdam, DDS

Periodontal disease is detected when your dentist physically and visually evaluates the gingival (gum) tissues, probes to determine whether the attachment levels to the teeth are normal or abnormal, and evaluates bone changes through dental radiographs (x-rays). Depending on these findings, along with your general health status and health history, your dentist may also refer you to a periodontist, a dentist specializing in the diagnosis and treatment of periodontal diseases.

The diagnosis of the specific type of periodontal disease that may require surgical treatment is important, because it will have a direct bearing on the techniques used and long-term outcome of treatment.

Diagnosis may also include risk assessment, to aid in determining long term outcomes, known as prognosis. Both personal and professional assessments of individual risk are available (American Academy of Periodontology www.perio.org).

Initial Preparation Sets the Stage for Surgery

Behavior Change: Consistent behavior change is the most important element in maintaining long-term periodontal health, since daily plaque removal in large part will set the stage for sustained, successful surgical treatment. For many people this involves forming new oral hygiene habits, along with cessation of smoking and other lifestyle changes.

Calculus (Tartar) Removal: Your dentist will also see that your teeth receive a thorough cleaning to remove the deposits of calcified plaque called calculus or tartar and other bacterial toxins which become ingrained into the root surfaces. This process of mechanical cleaning is generally known as scaling and root planing, using hand scaling, ultrasonic or laser instruments and will sometimes require local anesthesia.

Occlusal Bite Therapy: Generally, attention to the bite or bite disorders are treated during or after initial therapy once an inflammation free environment has been established. It is important to stabilize loose teeth prior to surgery, because this in itself encourages healing of the periodontal structures and bone.

Re-evaluation Following Initial Therapy

After three or four weeks your dentist/periodontist will evaluate the response of your periodontal tissues to the initial therapy which is being used to control the inflammation and infection induced by dental plaque. This includes oral hygiene instruction, scaling and root planing (deep cleaning) among other possible treatments. In cases where pockets are deep, 5 mm and above, the chances of successfully removing all the bacterial deposits from the root surfaces diminish, which means that they may only be removed at surgery when they can be visualized. This also applies to areas that are impossible to clean adequately because of their shapes, like “furcations,” the areas of bone loss between roots of “multi-rooted” teeth, which may only be accessed surgically.

Superficial gum tissue health in response to plaque control is critical to surgical success. If the gum tissues have not responded adequately then bacteriological testing may be indicated to ensure removal of pathogenic (disease causing) strains of bacteria by either local (applied at the site) or systemic (bodily) antibiotic treatment, or review of the diagnosis for medical conditions that may be limiting the response to initial treatment.

Surgical Therapy

Periodontal surgical treatment today encompasses a variety of sophisticated plastic surgical procedures. These include techniques to repair and regenerate soft (gingival) [Figure 1 and 2] and hard (bony) tissues and replacement of missing teeth with dental implants. Procedures are usually performed by a periodontal specialist trained in these techniques and in some cases general dentists who have taken advanced training in periodontal surgery. Most procedures are performed with local anesthesia (numbing of the gum/periodontal tissues and teeth), sometimes with the additional use of oral anti-anxiety/sedation medication or intravenous conscious sedation (twilight sleep).

The objective of surgery is generally to eliminate pockets, regenerate attachment and to create more normal periodontal form, function and esthetics. The goal is to provide an environment more conducive to oral hygiene and maintenance care so that teeth can be kept for a longer period.

Risks, Benefits and Alternatives

It is important to have a discussion with your periodontist or general dentist to educate yourself regarding the risks, benefits and alternatives before undergoing treatment:

• The specific procedure you need should be discussed so you can understand what is involved. It should include what to expect after the surgery; generally mild to moderate discomfort for a day or two, usually managed by non-steroidal anti-inflammatory and analgesic medication of the Ibuprofen or Celebrex family, antibiotics and antibacterial rinses. No vigorous activity should be undertaken for the first few days to ensure that bleeding does not occur. It is also likely that the teeth will be somewhat more sensitive to cold which will disappear over time, particularly with the application of fluoride varnishes.
• What are the benefits and likely outcomes of treatment including a determination of prognosis — what results to expect and how long they will last;
• What are the alternatives to surgical treatment; this will depend upon the type and the extent of periodontal disease you have and the procedure that is recommended.
• These issues will differ somewhat depending upon the type of periodontal surgical procedures. This process is called an informed consent, and you will probably be asked to acknowledge this process in writing.

Contra-indications

It is important for people undergoing surgery to be in general good health and not overly stressed. It is also important to give your dentist/periodontist a full medical history with all current conditions and medications you are taking, including those to which you are allergic. Situations exist medically where it is not advisable for individuals to undergo surgical treatment. These mainly fall into the following categories:

• Uncontrolled periodontal disease
• Smoking and alcohol — can not only make periodontal disease worse, but will delay healing following surgery
• Systemic (bodily) or medical conditions which are uncontrolled, e.g. diabetes, HIV (AIDS), immuno-compromised patients (in whom resistance to disease is diminished), cardiovascular (heart and blood vessel) disease, to name a few
• Medications that can affect periodontal disease or surgery, e.g. aspirin, coumadin which may cause bleeding that is difficult to stop; medications that cause gum overgrowth, e.g. calcium channel blocking drugs used to control cardiovascular disease, other medications used to control transplant rejection, and more

Current Techniques

Current techniques are based on a sound understanding of wound healing and therefore enhance and maximize the body’s healing potential. For descriptive purposes, a rather broad distinction can be drawn between periodontal surgical techniques used to treat:

• Periodontal disease that has resulted in loss of periodontal attachment with pocket formation
• Aesthetic techniques to re-contour or graft new tissue in cosmetic areas (like the upper front teeth) where there is excessive tissue, or to cover exposed roots where gum tissue has been lost
• Bone and gum tissue regeneration to develop sites for future implant placement following tooth loss or other prosthetic (false) teeth replacement
• Implant placement to replace missing teeth

Surgical techniques to treat periodontal disease have been documented as far back as 1862 when Robicsek in Hungary developed the “gingivectomy” (gingiva-gum, ectomy-removal) to treat gum overgrowth, a technique still in limited use today, in a modified form. He is also credited with early “flap procedures,” which are still the “work horse” basis of many periodontal surgical procedures today.

Flap surgery is the most conservative and versatile of procedures and consists of making an internal opening allowing a “flap” to be raised, much like opening the flap of an envelope. This allows the surgeon to work within the periodontal tissues to:

• Remove inner diseased and detached tissue lining of pockets
• Gain access to further clean and treat root surfaces
• Repair and regenerate bone, periodontal ligament tissue complex
• Close the tissues completely leaving no open wounds for rapid and comfortable healing
• Tiny suture placement to retain the gum tissues in place. Sutures either self-dissolve or are removed after a week or so. In some cases an unobtrusive dressing is applied to protect tissues while healing ensues.

Innovations in regeneration

The last two decades have seen an explosion of knowledge and new techniques to regenerate periodontal tissues. Up until the 1980’s most surgery was “resective” in nature — removing diseased tissue. From the 1960s to the 1980s soft tissue gingival (gum) grafting techniques to increase gum tissue were predictably successful. Regeneration techniques were already understood from wound healing studies and knowledge of the cell types that “coded” for new gingival, gum tissue. However techniques were less predictable when attempting to regenerate lost alveolar (tooth supporting bone) and the adjacent periodontal ligament.

Regenerating Periodontal Tissues

• • The periodontal ligament is a thin, fibrous ligament that connects the tooth root to the bony socket. Normally, teeth do not contact the bone directly; a tooth is suspended in its bony socket by the periodontal ligament which is attached to the tooth root via cementum.
  • Without new periodontal ligament formation, new attachment and bone regeneration is impossible. In the past, the difficulty had been stopping gum tissue cells growing down the freshly cleaned roots before the new periodontal ligament cells had a chance to grow and reattach to the root surface cementum. Stopping the gum tissue cells from advancing was the race that science needed to win in order to regenerate new periodontal attachment.

Guided Tissue Regeneration

• • Periodontal tissue regeneration was ingeniously solved with the advent of sub-gingival (sub-under, gingival-gum) “barrier membranes,” sort of minute subterranean band-aids. These barriers stop the growth of gum tissue cells and allows regeneration of new periodontal ligament by guiding cell growth. This technique is known as “Guided Tissue Regeneration.” Membrane technology has now advanced to the point where membranes will last exactly the appropriate amount of time needed for healing and then dissolve so that they don’t have to be removed.

Growth Factors — Magic Molecules

• • Most recently, basic science has further demystified wound healing with an understanding of growth factors. The process of inflammation, the body’s response to injury and infection causes the attraction of particular cells and liberation of their components, so-called growth factors — “magic molecules” which initiate and promote wound healing. The ability to isolate these substances, determine their roles and then to be able to manufacture them has allowed periodontal and other surgical specialists to use growth factors to regenerate tissues, making results more predictable and healing uneventful.

Summary

Today’s highly sophisticated and meticulous surgical techniques allow the periodontal surgeon to regenerate and reconstruct lost and missing tissues. Modern procedures are kinder to the patients; are carried out with local anesthesia (numbing the area/s) in combination with either oral (anti-anxiety) sedation or intravenous conscious sedation (twilight sleep). There are minimal post surgical issues, minimal discomfort and little bleeding, either during or after surgery. Periodontal surgery includes elements of art, experience and a great deal of scientific knowledge of techniques and wound healing to prolong the life of your teeth with greater predictability than ever before.

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