The Dental Corner
- Why do I have a toothache?
Most of us know untreated cavities will grow into the nerve and cause pain. However, the question of why do we have nerves in our teeth in the first place still arises. The nerves in and surrounding our teeth serve as sensors that feed back information to the brain. They help us know how hard and crunchy the foods are.
The nerve in the tooth also serves as the first line of defense to an infection. Cavities are caused by bacteria invading the tooth structure. When the cavity grows deeper, the nerve in the tooth will be irritated and send the pain signal to the brain. These signals tell the body that there is something wrong with the tooth. A toothache can range from mild sensitivity to constant pounding pain that can wake you up at night. This is when we start thinking about calling our dentists. (see image below)
- What purpose does a toothache serve in my overall health?
The toothache is the first sign of the body defending itself from a possible infection. We need to take care of the pain because pain is usually caused by a tooth with a cavity and possible infection. The teeth are connected to the body’s jaw bone and blood vessels. The pulsating pressure of the artery next to the infected nerve causes the pulsing and pounding pain.
Infection from the gum and teeth are leading the bacteria into the blood, this has been proven many times in research and real life fatality cases. Most recent documented case was report by USA Today News on Feb 1, 2017: “What began as toothache ends with young dad’s death.” These risks of systemic health affected by infection from the mouth are very real and deadly.
- Consequences of Prolonged toothaches…
Toothache progression from a cavity or infect tooth:
Symptoms start with mild sensitivity to cold, lasts for short period of time, then progresses to sensitivity to hot and cold with a prolonged period of time. Then the toothache may stop for a while and this is the most confusing part of the toothache.
- Did the toothache get better by itself?
- Is the infection gone?
- Do I still need to do what the dentist recommended?
The reason the tooth stopped hurting is because the nerve is dead. You will not feel anything because the infection has killed the nerve. The infection will continue work its way down the nerve canal and the next time you feel the pain is when the infection is exiting the nerve canal and spreading to the bone. Abscess and swelling of the face are the next stage of the infection. The consequence of ignoring the toothache could be seriously painful and fatal.
To sum it up, ignoring a toothache isn’t always the best option. Please listen to your tooth when it talks to you. All toothaches should be investigated and addressed accordingly.
– Dr. Vinh Le
In our previous newsletter, we cited many scientific studies to show the link between gum infection and systemic diseases. In this newsletter we will be discussing the Treatment of Gum Infection, Perio Maintenance, and Prevention of Gum Infection.
Treatment of Gum Infection
The primary goal of periodontal treatment is to clear infection from the gums and teeth. Periodontal infection is a chronic and non-curable bacterial infection. The traditional deep cleaning technique tries to clean the pockets forming between the gums and teeth due to infection. This method had been working very well but also had its limitation.
One thing one must understand is that infected periodontal pockets have two walls: tooth side and bone-gum side (Figure 1)The deep cleaning treatment utilizes scalers to physically scale and clean the teeth side of the infected pocket. However, bacteria has also penetrated and destroyed the gum and bone surrounding the infected teeth. Adjunct treatments such as medication and laser help to reduce and remove infection in the gum and bone side. The idea here is to create two clean sides (tooth side and bone-gum side) which ensure that no bacteria are trapped during the healing phase.
What is the difference between perio maintenance and a regular cleaning? Why do I need to have cleanings more often (every 3-4 months)? These are questions that are routinely asked by our patients. The perio maintenance program is designed to help patients with history of gum infection. The general rule is, if you already have a history of gum infection, which causes the change of the bone level supporting your teeth, then you need to get cleanings more often.
During routine home care with the proper cleaning technique, patients can clean up to 3 mm below the gum line. If you had gum infection in the past, most likely you would have some areas of the gum that are deeper than 3 mm due to the history of bone loss. These areas need to be cleaned out by the hygienist with special tools. Cleanings every 3-4 months are required in these cases to prevent infection from starting again. Just imagine you have some areas in your mouth with food stuck in there and rotting out for 3 months. Since you cannot clean past 3mm depth of gum, the hygienist has to do that for you every 3-4 months.
For a regular cleaning, a patients gum depth is less than 3mm, there’s no bleeding, and can maintain an excellent hygiene routine at home. Cleanings every 6 months are recommended at this stage of oral health.
Prevention of Gum Infection
Promptly removing foods in between your teeth is the goal of brushing and flossing to help in preventing gum infection. How often one should brush and floss really depends on how often one eats in a day. Routine dental care with your dentist and hygienist is a must. Our body is a very sophisticate machine; however, just like our car, we need tune-ups regularly to keep our body functioning properly for many years to come.
– Vinh Le, D.D.S
A recent literature review article has showed the strong connection between gum infection (periodontal disease) to other systemic diseases. In this newsletter, I will help to explain some common links between patients’ bleeding gums to their overall health.
Periodontal disease is the infection of the gum, teeth, and bone that surround teeth. Current estimates show that 75% of North American population has some form of gum infection. Normally these are a low-grade chronic infection, which does not show any signs and symptoms besides occasionally bleeding of the gums and teeth while brushing and flossing. Due to the lack of symptoms, gum infection is usually undiagnosed or untreated.
Chronic inflammation response of the gum and bone surrounding the teeth cause the total body inflammation response to increase overall. This heighten inflammatory response contributes directly to worsening of systemic diseases which are caused by inflammation such as rheumatoid arthritis, osteoporosis, and pneumonia.
Inflammation factors from the gum also causes dislodging of fatty deposits in the blood vessel. These dislodged fatty deposits will travel through the blood system, which could block a blood vessel at the heart causing a heart attack or block a blood vessel in the brain causing a stroke.
Periodontal Disease and Alzheimer’s Disease
There is evidence that periodontal disease may be a risk factor for dementia through the bacterial and viral infections commonly found in periodontal disease. Oral infection can either directly or through systemic signals to the brain contribute to the development of Alzheimer’s disease.
Periodontal Disease and Cancer
Periodontal disease also have strong link to several type of cancer such as oral cancer, upper GI and gastric cancers, pancreatic cancer, lung cancer, and esophageal cancer.
Periodontal Disease and Diabetes
The association between diabetes and inflammatory periodontal diseases has been studied extensively for more than 50 years. Large evidence research shows that diabetes is associated with the increase in gum infection. Also periodontal disease can also adversely affect the metabolic control of diabetes. Patients with diabetes who have periodontal disease have two chronic conditions, each of which may affect the other, and both of which require frequent professional evaluations by health care providers.
Periodontal Disease and Premature Birth
The oral cavity works as a continuous source of infectious agents, and its condition often reflects progression of systemic pathologies. Periodontal infection happens to serve as a bacterial reservoir that may exacerbate systemic diseases. Research suggests that the bacteria that cause inflammation in the gums can actually get into the bloodstream and target the fetus, potentially leading to premature labor and low-birth-weight babies.
The common links of these systemic diseases to gum infection are bacteria in the blood and inflammation factors that produce by-chronic infection on the gum and teeth. The consequences of untreated gum infection often time would lead to serious health implications and the loss of multiple teeth. Scheduling a periodontal evaluation with your dentist is the first step to fight this silent deadly disease.
To Be Continued In Next Newsletter…
 Friedewald et al. Editors Consensus: Periodontitis and atherosclerotic cardiovascular disease. Am J Cardiol? 104:59-68, 2009. Published simultaneously in the Journal of Periodontology. July, 2009.
 Watts, A.; Crimmin, E.M.; Gatz.M.: Inflammation as a potential mediator for the association between periodontal disease and Alzheimer’s disease. Neuropsychiatric Disease and Treatment. 4(5):
 Comlan Missih, DDS, MPH: The link between periodontal disease and cancer: A review. Perio- Implant Advisory website.
 Mealey BL. J Am Dent Assoc. 2006 Oct;137 Suppl:26S-31S. Review. Erratum in: J Am Dent Assoc. 2008 Mar;139(3):252.
 Saini R, Saini S, Saini SR. Periodontitis: A risk for delivery of premature labor and low-birth-weight infants. J Nat Sci Biol Med. 2010 Jul;1(1):40-2.865-876, 2008
These are the common questions patients usually ask when their dentist recommends a crown for their tooth:
- Why do I need a crown on my tooth?
Crowns or “Caps” are the most common recommended treatment in the dental office. The tooth needs a crown when its tooth structure is unable to withstand the normal chewing force. The general rule of thumb “if the tooth structure has been damaged due to a cavity or a fracture more than half the width of the tooth, we need to restore it with a crown.”
Tooth structure is compromised when it has had a large filling, a broken tooth structure, a crack or when a root canal has been done. When a tooth has a visible crack, the potential of a fracture and broken tooth increases. A root canal is usually needed when the cavity has already hit the nerve. During a root canal, the entire cavity and some tooth structures are removed in order to access the nerve. After a root canal treatment, the tooth is hallowed on the inside. A tooth with a root canal is like a dead tree which has high probability for a fracture. A crown provides the strength for the tooth and protects the tooth from fracturing.
- When should I get my crown done?
The best time to do the crown is before the tooth breaks. Unfortunately, we just don’t know when the fracture will occur. Due to the nature of a crack and fracture we cannot predict how the cracks will travel and how big the fracture will occur. If the fracture is past the bone level, you will loose the tooth. The consequence of tooth loss is already discussed in our previous newsletter. When your dentist recommends a crown, you should get it done as soon as possible.
- What types of crowns are available to pick from?
Crowns can be made of gold, porcelain fused to metal (PFM), or all porcelain. The best material for a crown is 14K gold. Due to property of gold metal, it provides the best fit for crown treatment; but gold creates a cosmetic problem for the cosmetic zone. All porcelain crowns are ranked close to second compared to gold due to the newly discovery of zirconia (a type of porcelain). Pearly white as teeth with the compression strength as steel, zirconia crown is the perfect solution for the crown treatment. PFM crown is no longer a good choice for single crown treatment due to its limitation on fit and cosmetic appearance.
- What should I expect from a crown treatment after it’s completed?
Crown treatment helps restore the tooth to its original strength and function. a crown will also provide the cosmetic restoration of damaged front teeth. Crowns should feel as comfortable and normal as real teeth. A good crown would last up to 20-30 years. With the proper routine dental care crowns will last for many years to come.
-Vinh Le, DDS
The Fight Against Cavities…
Why do I get cavities on my teeth?
Over the last 10 years while practicing dentistry, I realized that a lot of confusion comes from our patients when it comes to the question “Why do I get cavities on my teeth?”
“Is it from too much candy, soda, soft teeth, or a combination of all these reasons?”
The science on how we get cavities has been well studied and documented. Cavities or decay on our teeth cause by bacteria byproducts. In a more simplified concept:
- Sugar from our food = Bacteria food.
- Bacteria eats sugar and produces a byproduct = Acid content.
- Acid produced by bacteria destroy our teeth and create a hole on our teeth = Cavity.
When do I need to fix my cavities?
Let’s review the anatomy of the tooth before I answer the above question.
The tooth has 3 parts: Enamel, Dentin, and Nerve.
Enamel is the hardest part of the tooth and also there are no pain receptors in the enamel. Dentin is the soft part of the tooth and is also the alive part of the tooth. The nerve chamber is where the nerve and blood vessels bring in nutrients to keep the tooth alive.
When a cavity starts, it has to break through the enamel part. Since this is the hard part of the tooth, it may take many years for the cavity to break through. Usually at this state, the patient won’t feel anything due to lack of pain receptors in the enamel layer.
Eventually the cavity will get to dentin layer. At this state, the cavity starts to change its color to brown or black due to the natural yellow color of the dentin layer. Since dentin is the alive part of the tooth, the patient starts feeling sensitivity on the tooth with the cavity especially to sweet, sour, or cold food and drinks.
If the cavity is left untreated, it will end up reaching the nerve. Once the cavity reaches the dentin it begins to grow very fast. Since the dentin is the soft part of the tooth, the cavity can grown and hit the nerve in only a few short months. Patients will experience extreme pain when the cavity hits the nerve. Symptoms range from sensitivity to hot and cold drinks, sharp spontaneous pain, constant dull aching pain, to extreme pain, which gets worse when lying down. Once this happens it is already too late to do a filling.
The best time to fix your cavity is when it is still in the enamel layer. However, most patients only visit the dentist when they start feeling something hurt. By the time cavity starts cause some discomfort, it is already in the soft part to the tooth. At this point, we only have a few months to fix the cavity before a full blown toothache arrives.
So the best answer is to keep up with your 6-month appointment so the doctor can catch the cavities early; when a cavity is diagnosed, we need to fix it ASAP.
– Dr. Vinh Le
January 2016 Newsletter
3 Common Oral Health Myths Busted!
Myth 1: Bleeding gums are normal.
Busted: If you washed your hands and they bled, would you be concerned? Of course! The same goes for your gums. Bleeding is the first sign of infection. Gums bleed because plaque, which is full of disease-causing bacteria, is accumulating where a toothbrush cannot reach to remove it. This is why flossing daily is so important. It reaches these areas, about 35% of your tooth surface, that tooth brushing misses, no matter how well you brush. The longer the bacteria accumulates, the stronger it gets, which causes more than just bleeding and inflammation. This bacteria can cause your gums and bone that hold your teeth in place to break down, and they don’t grow back. Also, when plaque sits undisturbed it can harden, causing more irritation to your gums and providing a home to this virulent bacteria. At this point it is called calculus or tartar, which can only be removed by a dental hygienist. This is why regular dental appointments are more than just checking for cavities! Not great at flossing? Be honest with your dental hygienist about it. Your hygienist can show you other options such as interdental brushes, water flossers, or simply showing you the correct flossing technique. Once you begin flossing, your gums may continue to bleed for a while; this is your body’s immune response trying to fight the infection. So keep at it daily!
Myth 2: If Your teeth don’t hurt, they are healthy.
Busted: Many dental problems, such as chronic gum disease and cavities, don’t hurt in the beginning stages. It’s once they have progressed to a point where treatment is quite extensive, not to mention expensive, that you actually feel them. For instance, a cavity tends to only hurt once it has reached the center of the tooth where the nerves are located. At this point, a filling won’t simply take care of the problem. Most times you may need a root canal and a crown, if the tooth can be saved at all. This is why detecting problems early, with X-rays and regular dental visits, is so important. Dentists and dental hygienists are highly trained to know when you need X-rays. Dental X-rays are imperative to diagnose potential problems, to check for cavities, and to monitor your bone level holding your teeth in place, among other things. Without them your dentist and hygienist are working blindly. You wouldn’t want a broken arm to be set without an X-ray to determine the extent of the fracture, right? Same goes for your teeth.
Myth 3: Oral health doesn’t affect overall health.
Busted: Your mouth is connected to your body! In fact, many diseases can show their first symptoms in your mouth. This includes some autoimmune diseases and even HIV. Further, you are swallowing the bacteria in your mouth every day, all day. If you have gum disease, this bacteria can be harming more than just your mouth. Bacteria can enter your bloodstream and affect other organs in your body. Research is emerging every day showing links of bacteria from the mouth contributing to heart disease and stroke risk to rheumatoid arthritis, pre-term and low birth weight babies, even Alzheimer’s disease and the ability to control blood sugar levels in diabetes. Infection in your mouth = problems for your whole body, so take care of your mouth!
Lacey McAvoy, RDH
Brushing Before or After Food And Drinks
Have you ever been told to brush your teeth before you eat? Probably not, but according to a recent article it is suggested that it would be better for your teeth (Nathan J). One of the biggest reasons to brush before you eat would be to avoid enamel or dentin erosion. When you eat most foods, or drink beverages like coffee, soda, or juice the pH of your mouth becomes more acidic. The more acidic your mouth is, the “softer” you tooth surface, the more likely tooth erosion happens when you brush. Brushing before you eat removes the plaque and biofilm that is made up of bacteria waiting to be feed by the food you eat. Once that bacteria starts to metabolize the food in your mouth, the acidity of your mouth is increased (Pradhan D, Jain D, Gulati A) leading to “softer” tooth surface.
One reason that most people might not want to brush before they eat is the taste of food from brushing with toothpaste. Brushing without toothpaste could be an option for some, although I would recommend using fluoride mouth rinse not only to keep fluoride in your oral hygiene routine but to aid in removal of food particles. If brushing before you eat doesn’t sound like something you would want to try, waiting at least 1.5 hours after you eat or drink before brushing your teeth can help minimize tooth wear (Nathan J). I believe that for those with gum recession, worn enamel such a toothbrush abrasion, or even those who have tooth sensitivity, brushing before you eat might really be beneficial.
Nathan J. Toothbrushing in Relation to Food Consumption. Access. 2015;29(8):18-19,33.
- Pradhan D, Jain D, Gulati A, et al. Effect of the presence of dental plaque on oral sugar clearance and salivary pH: an in vivo study. J. Contemp Dent Pract. 2012;13(6);753-5.
Tasha Melendez, RDH