From The Doctor's Desk

It seems like just yesterday I posted our picture from last year's marathon, but here we are again! Last weekend, Tina, Max, and I ran the 27th California International Marathon in Sacramento. It's the same race as last year, but we had a much better showing this time around. I broke my PR by 17 minutes, and Mom and Dad both ran qualifying times for the Boston Marathon! It's amazing how quickly you forget what it felt like to run 26.2 miles - we're already picking the next race, and can't wait to cheer on Tina & Max at the 2011 Boston Marathon. See you on the road!

It's holiday season again. Silver and gold decorations abound on lamp posts, storefronts, and front doors. Some of you may have teeth to match - silver and gold fillings that most likely have been there longer than the old fruitcake in the back of the cupboard. Metal dental materials have gotten a bad rap over the last decade, especially as some of the more esthetic materials like porcelain and composite have improved. I have quite a few requests for completely metal-free dentistry. Some of that reputation is rightly deserved, but certain metals can actually be a good choice in specific situations. Let me explain why, in our office, we have chosen to use some metals, and avoid others, and when they are best suited for your mouth.

If you're over the age of 20 and you have a history of dental work, there's a good chance one or more of your fillings is silver amalgam. First introduced in the 1800's, silver amalgam is still used today as a low-cost alternative to the more aesthetic, tooth-colored composite resin. Amalgam is an alloy of mercury (~50%), silver (~30%), tin, copper, and zinc. There has been a lot of media attention on the presence of mercury in silver fillings. Some countries have outlawed them for use in pregnant women or small children. The American Dental Association has long supported their use and the FDA has continued to agree. Regardless of the controversy, silver amalgam has one very significant drawback that has prevented us from using it in our office for over 10 years: it breaks teeth. Witness exhibit A:

This upper molar seemingly had nothing wrong with it. That silver filling had been in the patient's mouth for 20+ years and never gave the patient any problems. Then one day, while eating something innocuous, a huge piece of the tooth fractured right off. Notice the filling is still in place, but the tooth around it is gone. This is very typical of what happens to teeth with silver amalgam fillings. Why? Silver amalgam is not bonded to the tooth, like composite resin. It is simply wedged into place. After placement, the metal expands and puts undue forces on the enamel. Microfractures start to form around the filling that continue to grow, much like a star in your car windshield, and can eventually split the tooth. If you're lucky, the fracture will just occur through the dentin, as it did here. Sometimes it can fracture into the nerve of the tooth, necessitating a root canal. And in really unfortunate cases it can actually split the tooth right in half, down the root, and require extraction. Major bummer from something as small as a silver filling. For this reason, we encourage our patients to consider removing the silver BEFORE the tooth breaks and placing a bonded filling that will hold the tooth together, preserve more of the natural tooth structure, and look a whole lot better. Witness exhibit B:


Now, what about gold? Gold is a different story. Gold does not wedge teeth apart - to get a bit scientific, it has a very similar coefficient of expansion as natural tooth structure. Gold also wears at a very similar rate as enamel, which means it is soft on the opposing teeth. For this reason, gold is a fantastic option for people who grind or clench their teeth. You can't break it, it won't break your other teeth, and, barring recurrent decay, it will probably last for well over 10 years. True, it is not the most aesthetic option, but when it comes to function and longevity it really is the gold standard, no pun intended.

So this holiday season, when it comes to your mouth, think about ditching the silver and keeping the gold.

If you suffer from chronic headaches or migraines, you know what a toll it takes on your daily life. Hours of headsplitting pain, sometimes accompanied by nausea, sensitivity to light, and an overall bad mood. Some people are literally holed up for days in a dark room trying to mitigate the pain. If you are one of these headache sufferers, you have also probably tried everything under the sun for relief. Advil barely touches these headahces. Chiropractic adjustments may work for a few days, but it rarely holds. Then there is the list of prescription drugs for both prevention and treatment. They treat the symptoms, but they don't always address the cause. So what is the cause, anyway? And why is a dentist talking about it?

Chronic headaches and/or migraines can be caused by several things. If you wake up in the morning with a headache, there's a good chance your headache is related to sleep breathing disorder like Obstructive Sleep Apnea (OSA). A lack of oxygen coupled with the grinding that occurs with OSA can easily translate to a severe headache. Patients who treat the OSA will frequently see the morning headaches subside completely. Headaches that occur later in the day can actually be due to a problem bite. Unbalanced or unstable bites create a lot of muscle fatigue, including fatigue in the anterior temporalis which is the huge fan shaped muscle over the temples responsible for jaw movement. The fatigue or spasm of this muscle, or any of the other muscles responsible for jaw movement, can cause significant headaches or even migraines. As neuromuscular dentists, we are uniquely qualified to address these problem bites and relieve the associated headaches and facial pain. Click here for more information on how we do this, or come in for a consult so we can answer your questions in person!

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Most people, when asked, will tell you they don't grind their teeth. Maybe they were told at some point by a dentist that they brux (the dental term for grind), but they don't believe it because they never catch themselves doing it throughout the day. I'm here to tell you that most people, unfortunately, are mistaken. The image you see here is NOT toothbrush abrasion - how many people have told me this situation happened because they brush too hard! Those notches in the teeth by the gumline are called "abfractions," and they are caused by grinding and clenching. The enamel is thinnest at the neck of the tooth. When grinding occurs it flexes the tooth and the enamel starts to chip off at the neck. Over time it forms a wedge shape into the tooth - much the same way an ax cuts into a tree trunk. These abfractions can be a major source of sensitivity and are prone to decay. So if most people don't even know they're grinding, how do these abfractions occur? The answer lies in what happens at night.

Sleep bruxism is a very common problem in the general population. In fact, according to a 2001 study published in CHEST, it is the third most frequent parasomnia. (A parasomnia is anything that causes a partial arousal during sleep. Sleep walking, night terrors, and bed wetting are all examples of parasomnias). Parasomnias can be responsible for excessive daytime sleepiness because they interrupt deep restorative sleep. So if you're grinding your teeth at night you may be more likely to feel tired when you get up in the morning. Interestingly enough, there is also a high correlation between sleep bruxism and obstructive sleep apnea. Nobody knows the exact reason, but apneics are SIX TIMES more likely to grind their teeth than a normal population. Therefore, if I see front teeth that are worn down and abfractions everywhere I always ask about snoring. It's yet another reason your dentist is in a special position to screen for sleep apnea - the signs show up all over the mouth.

The National Transportation Safety Board has recommended that the FAA request information related to sleep apnea on their application for an airman medical certificate. In reference to their concern for pilot fatigue, the August 7 letter recommends that the application "elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder." Several of our patients who fly have commented on how taxing commercial pilot schedules are. Their propensity for daytime sleepiness due to this schedule, coupled with undiagnosed and untreated OSA, could be a potentially life-threatening situation for everyone on board. Not only is there a risk of falling asleep while piloting an aircraft, but there is a risk of suffering a stroke or heart attack during the flight. Especially in the early morning hours of those red-eye flights, when most apnea-related cardiac events occur. This recommendation is another important step towards recognizing sleep apnea as the wide-spread, life-threatening condition that it is.