Category Archives: Uncategorized

1 or 2 Visit Root Canals?

As you may have noticed in a previous post, dentists sometimes like to argue…and if you’ve ever taken part in an academic debate, it can get pretty intense. Like, insulting your mother or sister tense, which is a little weird considering the crowd (not really classic MMA type people, ya know?). I spent a weekend in Connecticut several years ago, attending an endodontic meeting where the topic of single visit endodontics was discussed. Vigorously. As in, the room quickly divided into “single visit root canal treatment is fine,” or “it’s for total nincompoops!” At the end, I believe the only thing accomplished is that everyone was more entrenched in their a priori view of the subject. For the record, if you ever have the chance to visit Avon, Connecticut, you should go. It’s beautiful countryside.

The question remains: which is better, 1 or 2 visit root canals. There is no shortage of scientific literature on this topic. In fact, PubMed runneth over with articles on this very subject, so what so all of these studies say? Well, it depends on the nature of your question: Are you concerned about post-operative pain? Then 2 visits are probably the way to go as many people report decreased post-operative pain when root canals are performed in 2 visits. I have to point out that, yes, there are studies that show single visit root canals have decreased post-operative pain that 2 visits, but the available evidence, including Cochrane systematic reviews (the highest level of evidence) report that single visit root canals have increased post-operative pain. Are you interested in overall success? Root canals performed in a single visit have pretty much the same success rate as those performed in two. Is the tooth infected? Again, single and multiple visit endodontics have pretty much the same success rate.

The list goes on seemingly forever, so what is a person to do? In my office, many factors dictate whether a root canal is performed in 1 or 2 (3 or 4??) visits. How complex is the case? Teeth with severe curvature, constricted canals, difficult to access areas or someone is severe pain will often be completed in multiple visits. Think of a tooth like a road: straight, wide open roads invite you to hit the gas. Tight, windy roads force you to slow down, take your time and exercise caution, unless you love heartache. Difficult teeth take more time and it’s really hard for most people to remain propped open for more than an hour. Large infection? Maybe consider 2 visits as there will often be drainage. Are you unsure of healing? Multiple visits will offer confidence in your chances of success, so sometimes it’s better to slow down. Everyone would rather have their root canal completed in a single visit than multiple visits, but I like to tell people that I’d rather perform treatment correctly than quickly. On that, I believe, we can all agree.

Ultimately, there is no universally correct answer to this question, because no two patients are exactly alike, no two dentists are exactly alike and no two teeth are exactly alike. Expertise, case complexity, patient compliance, access to the tooth, drainage, treatment goals, time constraints and an almost endless list of factors will drive 1 versus 2 visits.

Sources

Ann Med Health Sci Res. 2016 Jan-Feb;6(1):19-26. doi: 10.4103/2141-9248.180265.

Single Versus Multi-visit Endodontic Treatment of Teeth with Apical Periodontitis: An in vivo Study with 1-year Evaluation.

J Endod. 2018 Sep;44(9):1339-1346. doi: 10.1016/j.joen.2018.05.017. Epub 2018 Jul 24.

Postoperative Pain Intensity after Single- versus Two-visit NonsurgicalEndodontic Retreatment: A Randomized Clinical Trial.

Erdem Hepsenoglu Y1Eyuboglu TF2Özcan M3.

Cochrane Database Syst Rev. 2016 Dec 1;12:CD005296. doi: 10.1002/14651858.CD005296.pub3.

Single versus multiple visits for endodontic treatment of permanent teeth.

Manfredi M1Figini L2Gagliani M3Lodi G4.

Oral Lumps & Bumps

Bumps like the one in the photo above are common in most dental practices. The good news is that most of them are non-cancerous and constitute more of an annoyance that a significant health risk. The bad news is that a small number of these lumps and bumps may be a bit more nefarious than something you will occasionally chomp when eating and this is the rub – how can we tell the difference between them?

The process involves gathering a thorough history, including medical conditions, medications and habits. Is there a family history of oral cancer? Is there a history of diseases like diabetes or Hepatitis C? Is there a history of smoking? If so, how much? Alcohol use? If so, how much? Is there a betel quid habit? Is there a history of HPV infections?

Following this information-gathering exercise, an extra-oral and intra-oral examination is performed to look and feel for anything unusual. If a lump or bump is present, how long has it been there? Does it look like the surrounding tissue? Is it hard or soft? Does it move or does it feel “fixed” or as though it is anchored to the surrounding tissues? Is there an ulcer associated with it? For instance, the tongue lesion in the above picture has the same colour as the surrounding tissues; it is moveable; it has been present for years; it hasn’t changed size; and it is likely the result of trauma. All of that is consistent with a benign growth called a fibroma and it is easily managed with removal and biopsy.

Biopsy is a scary word for most people. It makes us think “cancer.”
Most biopsied tissue is not cancer, but it is common practice to evaluate anything unusual that is removed from the body even when it looks non-threatening. However scary it may feel, it is ALWAYS better to know what something is, which is why early evaluation is important. Many oral lumps or bumps don’t require removal, but if they do, it is relatively easy and involves some local freezing and a few stitches. There may be some discomfort afterwards that can be managed with medications like ibuprofen or acetaminophen.

If you have questions or concerns about any unusual lumps or bumps and would like to discuss this topic further with Dr. Shackleton, please contact our office anytime.

Sources

Family history of cancer, personal history of medical conditions and risk of oral cavity cancer in France: the ICARE study.
Radoï L1, Paget-Bailly S, Guida F, Cyr D, Menvielle G, Schmaus A, Carton M, Cénée S, Sanchez M, Guizard AV, Trétarre B, Stücker I, Luce D.
BMC Cancer. 2013 Nov 28;13:560. doi: 10.1186/1471-2407-13-560.

Oral conditions associated with hepatitis C virus infection.
Alavian SM1, Mahboobi N, Mahboobi N, Karayiannis P. Saudi J Gastroenterol. 2013 Nov-Dec;19(6):245-51. doi: 10.4103/1319-3767.121032.

Lumps and Bumps of the Gingiva: A Pathological Miscellany.
Brierley DJ1, Crane H1, Hunter KD2,3. Head Neck Pathol. 2019 Mar;13(1):103-113. doi: 10.1007/s12105-019-01000-w. Epub 2019 Jan 29.

Tongue Lumps and Bumps: Histopathological Dilemmas and Clues for Diagnosis.
Allon I1,2, Vered M3,4, Kaplan I3,5,6. Head Neck Pathol. 2019 Mar;13(1):114-124. doi: 10.1007/s12105-019-01005-5. Epub 2019 Jan 29.

Antibiotic Use and Abuse

Antibiotic prescriptions are commonly written in dental offices across the US & Canada every day. We use them to manage infections, reduce pain and prevent possible infections associated with certain surgical procedures. When used properly and where indicated, antibiotics are indispensable in treating infection…when used improperly, antibiotic abuse will contribute to resistance of possible pathogenic organisms to future medical treatment.

The question for dentists and patients alike is often: When to prescribe? This may seem trivial or obvious, but it is critically important to our future well-being. If we, as dentists, prescribe inappropriately, we will not only offer our patients ineffective treatment, but we actually will change the microbial flora (i.e. the bacterial populations) and possibly make future antibiotic use less effective or ineffective. Which brings us back to the question of when to prescribe.

When to prescribe

There are a few clearly defined conditions that warrant antibiotic treatment. These are:

  • Facial cellulitis. This is an infection that has invaded muscle and tissue spaces in the face and can be life-threatening.
  • Lateral periodontal abscess
  • Pericoronitis. This is an infection around a partially erupted tooth (commonly a wisdom tooth) that requires immediate attention and if untreated, may progress to cellulitis
  • An infection where the patient is experiencing systemic symptoms (fever, malaise, or feeling of being unwell)
  • In conjunction with certain surgical procedures where the risk of infection is high
  • Before invasive dental procedures in patients with certain heart conditions, including:
    • A prosthetic heart valve
    • A history of infective endocarditis
    • A heart transplant with abnormal valve function
    • Certain congenital heart defects

The conditions in the above list currently warrant antibiotic coverage because the potential reward or upside of using antibiotics outweighs the potential risks. Potential risks of antibiotic use include: bacterial resistance; allergic reaction; drug interactions and GI complications due to C. difficile infection. A recent study reports 33,000 deaths per year from resistant infections in Europe alone.

When not to prescribe

In short, for everything else. We should never prescribe “just in case.” We should never prescribe for a condition that may be an infection. For years, orthopedic surgeons insisted that antibiotics be used by anyone with a prosthetic joint every time the they go to the dentist, in spite of there being no good reason for this practice. That alone is a tremendous abuse of antibiotic prescription writing. A joint statement by The Canadian Orthopedic Association (COA), the Canadian Dental Association (CDA) and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada suggested that antibiotics not be used routinely for people with “total joint replacement, nor for patients with orthopedic pins, plates and screws.” In spite of this recommendation, they are prescribed for these very conditions every day.

In the dental setting, we are often pressured by patients to prescribe in situations that do not warrant antibiotic use. This can be a difficult conversation as many people are adamant that antibiotics should be used. I don’t think there is a dentist who has not been pressured by their patients into prescribing. This fact underscores the need for dentists to understand when to prescribe and to take the time to educate their patients on the risks and rewards of antibiotic use.

What to do?

Education is the first, second and ongoing step. As dentists, we have to remain current with antibiotic prescribing standards, including when to prescribe, what to prescribe and when not to prescribe. We have to pass that information along to our patients. When in doubt, we need to consult with our dental and medical colleagues. As a patient population, we have to understand that our dentist has considered antibiotics and if they are not prescribing, understand there is a reason. It is appropriate to ask about antibiotics, to learn about the advantages, disadvantages, risks and alternatives to antibiotics. It is not appropriate to pressure your prescriber into giving you a prescription because you are certain it will make you feel better. Open, clear, honest conversation is the best way toward the best use of antibiotics.

Sources

https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance

https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/aae_systemic-antibiotics.pdf

https://www.cda-adc.ca/en/about/position_statements/jointreplacement/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909496/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5074034/

https://www.heart.org

http://www.cidrap.umn.edu/news-perspective/2018/11/european-study-33000-deaths-year-resistant-infections

Why does my mouth burn?

Burning mouth disorder is miserable. Of course, so are most disorders, which is maybe why this condition is also knows as burning mouth syndrome (not much better), glossodynia (what?), stomatodynia (okay…), oral dysesthesia (this feels made up) and glossopyrosis, to name a few. The good news is that is not too common, around 1% – 6% by most estimates. The bad news, if you’re female, is that burning mouth disorder occurs primarily in women. The worse news is that it tends to occur in the 5th decade of life or older, so while sufferers have this to contend with in addition to the other issues that keep them company as they age.

Burning mouth by any other name still, well, burns. It is characterized as a persistent burning sensation in one or more areas in the mouth, with the tongue being a common site. As you would expect, these people also experience altered taste and dry mouth or xerostomia. The good news is that they often do not have a dry mouth, it just feels that way. The kicker is that to be diagnosed as having burning mouth disorder, you need to experience this sensation for at least 2 hours per day for at least 3 months. Once you have qualified as a burning mouth sufferer, it is important that your health care provider understands if you are primary or secondary. No fear, the distinction is easy: primary burning mouth disorder has no demonstrated cause and secondary burning mouth disorder does have a demonstrated cause. Common causes are Candidiasis, ill-fitting dentures, autoimmune disease such as lichen planus, geographic tongue, atrophic glossitis, nutritional deficiencies, allergies, reflux, certain medications, and endocrine disorders (e.g. diabetes).

Diagnosing this condition and the type requires some questions from you doctor or dentist, a few laboratory tests that include checking for a fungal infection, any nutritional deficiencies, possible autoimmune conditions and a salivary flow rate test. If a primary cause, let’s say a fungal infection, is detected, it is treated and your symptoms re-evaluated. Sometimes, finding a cause for the burning sensation can be time consuming and a bit of trial and error, but with patience you can either confirm or deny the presence of an offending stimulus. If it is determined that the burning mouth disorder is primary (i.e. no identified cause) or secondary (but you cannot change the reason e.g. certain medications), how can you manage the burn? Usually, combination treatments are suggested: supplements such as zinc, alpha lipoic acid are common; swishing certain medications that reduce the burning sensation; sometimes anti-depressant or anti-convulsant medications are used if these other approaches don’t work. Sometimes psychological interventions, such as cognitive-behavioural therapy, are used if a person’s anxiety and stress are increased by having a tongue that is constantly on fire.

One reason for so many approaches is that we are not really sure why some people develop this condition. Of course, hypotheses abound…but they all seem to share some common qualities: essentially, it is (probably) a dysfunction of pain nerves called “c fibres.” This (again, probably) dysfunction occurs at the site of the burning sensation, like the tongue, and (*sigh* probably) where this information is ultimately processed (in the brain). Conditions that have simultaneous peripheral and central sensitization mechanisms are notoriously difficult to manage, which is why the prognosis for conditions like burning mouth disorder are uncertain.

If you have questions about burning mouth disorder or would like to discuss this further with Dr. Shackleton, please do not hesitate to contact our office.

Sources

A Population-Based Study of the Incidence of Burning Mouth Syndrome
John J. Kohorst, Alison J. Bruce, Rochelle R. Torgerson, Louis A. Schenck, Mark D. P. Davis Mayo Clin Proc. Author manuscript; available in PMC 2015 Nov 1. Published in final edited form as: Mayo Clin Proc. 2014 Nov; 89(11): 1545–1552. Published online 2014 Aug 28. doi: 10.1016/j.mayocp.2014.05.018 PMCID:  PMC4532369

Burning Mouth Syndrome: Aetiopathogenesis and Principles of Management
L. Feller, J. Fourie, M. Bouckaert, R. A. G. Khammissa, R. Ballyram, J. Lemmer Pain Res Manag. 2017; 2017: 1926269. Published online 2017 Oct 18. doi: 10.1155/2017/1926269 PMCID:  PMC5664327

Botox

What is Botox?

Botulinum toxin A (BoTnA), commonly known as Botox, is mostly known for esthetics. It can smooth wrinkles, often giving people a younger appearance. It is a purified protein that has several mechanisms and so has it also have many uses. It should be pointed out that Botox, Dysport and Xeomin are all proprietary names for botulinum toxin that can be used esthetically or therapeutically.

What does it do?

It works by relaxing the muscles it contacts and by calming nerves that relay pain messages to your brain. Wrinkles form because certain muscles contract thousands and thousands and thousands of times. As we age, our skin becomes less elastic and so little lines or creases form. By relaxing certain muscles, we can soften the lines in your face, creating a more youthful appearance.

Many people have pain conditions that do not respond well to conventional treatment. Also, some conditions (e.g. neuralgias) are often managed with medications that have undesirable side effects. If a person cannot tolerate these medications or they have stopped working, Botulinum toxin may offer some pain relief.

Where do we use it?

For esthetics, most people use it in the upper face (i.e. the eyes and forehead), but it can be used just about anywhere wrinkles appear. Certain injection patterns have been established, making this a safe and predictable procedure for most people.

It is also used to manage many pain conditions, like neuralgia (postherpetic neuralgia and trigeminal neuralgia), chronic migraine and many muscle pain disorders. It can be used in the jaw muscles to minimize the pain from temporomandibular dysfunction or “TMD.”

Why do we use it?

We use it for esthetics and pain management. If you think you may benefit from botulinum toxin, talk to your doctor or dentist. Ask questions, lots of questions and approach it with realistic expectations.

Why CBCT For Endodontics ?

What is CBCT?

Cone Beam Computed Tomography (CBCT) is an x-ray technology that allows dentists to see your orofacial structures in 3-D. Traditional dental xrays are 2-D and are usually our first approach when evaluating teeth, but they have inherent limitations, making some diagnoses very difficult. For instance, you may have pain in a tooth that sounds like an infection, but there may be no sign of it on a conventional 2-D x-ray. Additionally, your symptoms may not be clear-cut, leaving your dentist with the following 2 options: guessing (never, ever, ever, ever a good approach) or waiting. Waiting is the best thing in this circumstance because dentists should, at the very least, do no harm. But that leaves you in ongoing pain, which, well, sucks…….it sucks a lot. Enter CBCT…

This technology will often show your dentist which tooth is infected, why it is infected and how extensive the infection is. The diagnostic power of this technology alone is fantastic, but wait – there’s more: it will often guide your dentist’s treatment plan based on these findings. It will show your dentist how many roots/canals a tooth has; it will show your dentist if a previous root canal treatment has any shortcomings; it will tell your dentist if a previous root canal has a perforation; it can even sometimes tell your dentist if a root is cracked. This is invaluable in treatment planning, because your dentist can then discuss the best approach and then proceed, without wasting your time and money on procedures that are doomed to failure (e.g. trying to retreat a root canal that has a cracked root).

Like everything else in a dental office, it is a tool that provides information. It cannot replace the skill or judgment of your dentist, but simply can help them arrive at a more accurate diagnosis and the most effective treatment for you. Please contact our office or your dental office with further questions about CBCT.

Meditation And Pain

If you suffer any chronic pain, it is likely that somewhere along the line someone suggested you try meditation. Perhaps they oversold it (“it will cure everything!!”) or used a softer approach – either way, you may have been left with some questions like “Does this really work?” or “Isn’t this for aging hippies and new-age weirdos?”

Well, yes, but it’s been around for a long time, so others have also found it useful – other people besides onks or bald tambourine-playing Krishna worshipers you may have seen at an airport. Or Santa Monica. The scientific literature has been gaining some steam for the past few decades about the benefits of meditation, for no small reason because of the efforts of Jon Kabat Zinn. A former MIT molecular biologist, Jon Kabat Zinn created

mindfulness based stress reduction and went on to form the Stress Reduction Clinic at the UMass Medical School, which is still functioning today as the Centre for Mindfulness, still at UMass Medical School. Essentially, what he did was to take Buddhist meditation techniques, stripped them of all mysticism and begin employing it as a tool to reduce stress in, well, anyone who was interested.

So, great, but what does this have to do with pain management? It seems the short answer is that it helps reduce pain, but there are some caveats. First, though, the data: Several systematic reviews (the most reliable kind of report) show evidence that mindfulness mediation helps sufferers deal with the psychological aspects of their chronic pain and that it has some effect in reducing the physical sensation of pain.

Additionally, Yoga (a mindful physical practice) seems effective at reducing chronic pain. Essentially, this data shows that if you have chronic pain and a meditative practice (and perhaps a mindful physical practice like yoga, tai chi, etc.), you will likely experience a reduction in the stress and depression associated with the pain and you will have a reduction in the pain itself. This is not unlike medical marijuana which does have some benefit in pain reduction, but also has the complimentary benefit in making you not care so much about the pain. And like medical marijuana, more research is needed with meditation and chronic pain.

It should be underscored that meditation is not a panacea, no matter what some advocates say. If you require pain medication, you will likely still require pain medication, perhaps less. If you require therapy, antidepressants and other treatments, don’t expect meditation to obviate the use of these other treatments – meditation should be viewed as part of your pain management protocol, an adjunct to treatments that have provided benefit.

If you are interested in meditation, please ask us about resources that are available.

Sources

Curr Opin Obstet Gynecol. 2017 Sep 28. doi: 10.1097/GCO.0000000000000417. [Epub ahead of print]
Does mindfulness meditation improve chronic pain? A systematicreview.
Ball EF1, Nur Shafina Muhammad Sharizan E, Franklin G, Rogozińska E.

Cochrane Database Syst Rev. 2017 Jan 12;1:CD010671. doi:
10.1002/14651858.CD010671.pub2. Yoga treatment for chronic non-specific low back pain.
Wieland LS1, Skoetz N2, Pilkington K3, Vempati R4, D’Adamo CR1, Berman BM1.

Cochrane Database Syst Rev. 2017 Jan 3;1:CD010802. doi:
10.1002/14651858.CD010802.pub2.
Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer.
Cramer H1, Lauche R2, Klose P1, Lange S1, Langhorst J3, Dobos GJ1.

Ann Behav Med. 2017 Apr;51(2):199-213. doi: 10.1007/s12160-016-9844-2.
Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis.
Hilton L1, Hempel S2, Ewing BA2, Apaydin E2, Xenakis L2, Newberry S2, Colaiaco B2, Maher AR2, Shanman RM2, Sorbero ME2, Maglione MA2.

Dental Trauma

Canada. Land of hockey, skiing and falling down. We’ve all done it, right? Sometimes we lead with our backside, sometimes with out face. And don’t forget the never-ending list of those who’ve been on the receiving end of a hockey stick. Or a puck. Or a rock. Teeth are broken, loosened, lost or just go black. If you’re lucky, you may just need a small filling to repair the damage, but many aren’t so fortunate.

Dental trauma from, oh, I don’t know – eating a hockey stick, can lead to many problems down the road if left untreated. Persistent infections, bone loss, resorption (i.e. the tooth “dissolving” from the inside-out or outside-in) and tooth loss could be in your future if you don’t deal with these issues. I mean, you wouldn’t leave a broken finger alone, would you?

If the answer was yes, please stop reading now….

Your dentist can assess the damage from whatever your flavour of trauma, offer treatment options and usually provide the necessary care so that you can keep smiling without drawing unwanted attention. Immediate attention (preferably the day of trauma) can offer the best long-term prognosis. Here are some tooth-saving tips:

  • If you knocked your tooth right out, see your dentist in less than 1 hour (preferably with your tooth). hile on your way, place the tooth in milk or even your own saliva. Remember, the clock is ticking, so be fast. The sooner it goes back into your jaw, the better – longer than 1 hour is usually bad news
  • If your tooth is fractured, but the nerve isn’t exposed, a filling may do the trick
  • If your tooth is loosened, it can usually be “snapped” back into place by your dentist. Don’t be a hero – go to your dentist.

Of course, when it comes to sports, the best treatment is a mouthguard. This goes for all sports where you come into contact with other humans or fixed objects, like goalposts or fences or the ground. As always, if you’re not sure, talk to your dentist. They want you to keep your teeth as much as you do.

Controversies In Dentistry, Or, A Case For Conservative Treatment

Dentists are funny – we usually think we’re right about, well, everything. I’m not especially proud of this, but as one who often suffers this affliction, the first step towards a cure is admitting the problem exists. Believe it or not, there are many, oh so many controversies in dentistry. Some examples are: do we treat root canals in 1 visit or 2? What causes nighttime tooth grinding? How and why do we treat it? What causes jaw pain (also known as TMD, TMJ, TMJD and so on)? How do we treat jaw pain? Who needs braces? When do you start? Should you remove teeth to treat crowding? Root canal or implant? Who should do root canal? When to gum graft? Is “cosmetic dentistry” ethical? Should all wisdom teeth be removed? When? Who does it – an oral surgeon? A periodontist? A general dentist? Fluoride in the water? Amalgam? Is conventional 2-D x-ray good enough or do we need more 3-D? If more 3-D, when do we do it? And on and on and on it goes. I once sat in a room full of dentists (mostly Endodontists) for a weekend listening to 2 differing factions argue about 1-visit versus 2-visit root canal therapy. It was heated, the room was equally divided and each side passionately advocated for their position and each side was adamant that they were correct and the other side was dumb.

This highlights a few issues: firstly, scientific advancement in healthcare is messy in realtime. When we view progress through the lens of years, decades and centuries, the achievements are easy to see. Unfortunately, we don’t live in decades or centuries, we live now, here, today and seeing progress on a daily basis is virtually impossible. Secondly, we are humans and so we have biases. We make a decision, often emotionally charged, and then doggedly defend that position in spite of any evidence to the contrary. 90% of my colleagues disagree with me? They’re idiots. They’re biased. They’re morally bankrupt. They’ve been bought off. We’ve all seen this and, if you’re human, you’ve likely accused others of polluted thinking, unable to see the facts clearly as you do through your Spockesque viewfinder.

What’s one to do? In my line of work, the standard operating procedure is: study the literature; look at all arguments; understand what is and what isn’t a scientific study (hint: if you’ve seen it on Facebook, it likely isn’t science); studies should be randomized and double blinded with placebo treatment; read systematic reviews of the literature; DO NOT RELY ON GOOGLE TO TELL YOU WHAT IS RIGHT OR WRONG. Reliable and accessible sources are PubMed and Evidence-based Dentistry (American Dental Association & Nature). Do you remember the adage of questioning things that sound too good to be true? Extend that to EVERYTHING you research.

When considering what treatment is best-suited to address someone’s pain or disease, we must consider so many things, including their expectations, nature of treatment (how invasive it the treatment?), timing of treatment (do I need to start now or can it be delayed?), length of treatment (1 visit? 2 visits? Will it take several months or years to achieve the desired result?), alternatives (what else is there that may achieve the same result? A better result? A worse result?), cost, and prognosis (including best and worstcase scenarios). The good news is that many things we recommend in dentistry are straight-forward. Take the following example: You have an infected tooth. You want to keep your tooth and cost is a factor. Root canal is predictable (90-95%, but there can be complications) and you will likely keep your tooth. Extraction is predictable (100%, but there can be complications), but you will lose your tooth. Doing nothing is predictable, but predictable in that we can be certain that your condition will only worsen. Allow me to summarize:

Do nothing

  • Initial cost: antibiotic and analgesic prescription (approx. $100).
  • Long-term cost: extraction, possible hospitalization, time off work, tooth replacement, etc. (approx. $500 – $7000+).
  • Ultimate tooth loss (remember, your goal was keeping your tooth).
  • Timing: uncertain, but the chickens will likely come home to roost sooner than later.
  • Prognosis: long-term is uncertain because of bone loss due to infection.
  • Number of visits: again uncertain, but plan for 4+ if you plan on replacing the tooth. If not, then as few as 1 visit.
  • If you have an infected tooth and elect to do nothing about it, please know you are only delaying treatment – you will be forced into a decision in the future and the experience will not likely be a pleasant one.

 

Extraction

  • Initial cost: $150-$300.
  • Long-term cost: $0 (no tooth replacement) – $800 – $7000 (implant + extensive bone grafting). You should discuss replacement options with your dentist prior to removing your tooth to obtain a more accurate cost estimate.
  • Tooth loss.
  • Timing: sooner is better.
  • Prognosis: good/favourable (that is, favourable in that it addresses the tooth infection, but this prognosis does not address any other treatment).
  • Number of visits: 1 (extraction is finite), additional visits to replace the tooth may range from 3-8+, depending on how you elect to replace your tooth.
  • Again, please discuss all options with your dentist before removing a tooth so you can proceed with confidence.

 

Root Canal Therapy

  • Initial cost: $800-$2200 (this depends on number of canals, complexity, number of visits, additional diagnostic procedures involved, etc.).
  • Long-term cost: plan on either a simple filling ($150-$300) or a post/core/crown ($1500-$2000) in addition to the root canal cost. Additionally, some teeth also require gum surgery to adequately repair.
  • You keep your tooth.
  • Timing: sooner is better.
  • Prognosis: typically, good/favourable (RCT succeeds 90-95%; retreatment succeeds 80-85%; apical surgery succeeds 80-90%).
  • Number of visits: typically, 1-3, but may require more if surgery is required. Also, this does not account for the visits required to have a crown made for the tooth.
  • Please discuss all options with your dentist before having with root canal therapy so you can proceed with confidence.

I have to emphasize that this is a fairly watered-down version of this scenario and will probably necessitate a longer conversation with your dentist before you can arrive at a decision. Ask questions. Ask lots of questions….

Root canal, while a complex procedure, has a straight-forward decision tree. There is a pretty well-established diagnostic protocol and then generally accepted treatment that flows from these diagnoses. You treat it or you don’t. The end. But let’s investigate another example that may not be so straight forward: Temporomandibular dysfunction.

To be continued next week

A Case For Conservative Treatment, Or, Controversies In Dentistry: Part II TMJ Treatment

“I have TMJ.” Dentists hear this every day. The good news is, not only do you have TMJ, you have two. TMJ stands for TemporoMandibular Joint, more commonly known as our jaw joint, which resides just ahead of your ear tragus. You know the tragus – it’s the part of the ear that the kids love to pierce. It’s also handy for holding in earbuds. Place your fingers just ahead of your tragi, open and close a few times and you will have successfully identified your temporomandibular joints. About 1 in 3 of you will notice a click or pop in 1 or both of your joints when you open and close and if you’re lucky, it won’t cause any pain.

In the dental profession, we usually refer to TMJ as TMD or TemporoMandibular Dysfunction, which is an umbrella term for a collection of problems with the jaw joints, muscles, tendons, cartilage and ligaments. It’s the most common orofacial pain and is experienced by men and women, young and old. Some estimates suggest over 10 million Americans experience some form of this condition. Diagnosis can be difficult and often takes time, possibly requiring multiple visits with multiple clinicians. If you’re unfortunate enough to have experienced this, you no doubt have heard many different treatment approaches, from not chewing gum to wearing a splint, to crowns, orthodontics and even jaw surgery. It can be confusing and overwhelming because in the midst of all this advice, you are in pain. You can’t eat, laughing hurts, your head aches, you don’t want to work or socialize and all this begins to weigh you down. Like other chronic pain sufferers, depression and anxiety are common in those with TMD.

And those who suggest treatment A vs. Treatment B or C are almost always certain they have the answers and that everyone else is nuts. Or dumb. Or misinformed. It gets pretty heated and causes rifts in professional and personal relationships. Seriously.

So, what are you to do? You want treatment that is effective, right? And if you’re like most people who experience chronic pain, you will do just about anything to have some pain relief. Let’s take 2 treatment approaches, but please remember, there are many other treatments that I am not going to discuss here. I am using 2 very real-world examples that occur every day in many dental offices and both claim to effectively treat TMD. The 2 treatment approaches are: Occlusal and non-Occlusal. You may now be wondering “What is Occlusal??” which is a good question. Occlusion is how our teeth come together, so in simpler terms, the treatments are a bite-centred approach and a non-bite-centred approach.

The bite-centred approach involves changing how your teeth come together and is often achieved by one or many of the following methods:

  • Full-time splint wear
    • Wearing a splint or “orthotic” full-time will change how your teeth come together. By doing this, you will commit to either braces to move your teeth to a new position as determined by the splint or crowns on many or all of your teeth. This is costly, time consuming and is often not without complication
  • Orthodontics (braces)
    • If you have worn an appliance full-time and have experienced a bite change, it may be recommended that you have braces to “stabilize” your bite to the new position. This is costly and time consuming, but is probably the most conservative of the bite-centred approaches
  • Multiple or full mouth crowns
    • If you have worn an appliance full-time and have experienced a bite change, it may be recommended that you have crowns on multiple or all of your teeth. This is expensive (often over $50, 000. Yes, you read that correctly), and often has complications, including root canal therapy and possible tooth loss. Never mind that it involves shaving down healthy enamel. And crowns will need to be replaced in around 10 years, which will cost another $50,000 (or probably more)
  • Jaw surgery
    • This may be on the joint alone or may be recommended in conjunction with orthodontic treatment and/or multiple crowns. It is costly, demands recovery time and is often not without complication

It should be noted that throughout most of its history, organized dentistry advocated the bite-centred approach. With the advent of evidence-based dentistry in the 1990’s (yes, we were a little late to the evidence-based party), it became glaringly clear that most (over 85%) of TMD cases had NOTHING to do with a faulty bite or “bad jaw position.”

Non-bite centred treatment does not try to change your bite. Instead, it takes the following approaches.

  • Home-based physical therapy
    • Passive stretching
    • Heat/ice
    • Avoidance of painful triggers (e.g. hard/chewy food)
    • Relaxation therapies
    • Posture awareness
  • Part-time splint wear
    • Worn only at night, this will likely not result in any permanent changes to your bite. The idea is that it will decrease your tooth grinding (initially) and hopefully reduce some of the stress on your jaw joints
  • Medications
    • Non-steroidal anti-inflammatory drugs (NSAIDs), like Ibuprofen; steroid anti-inflammatory drugs; medicated topical creams; short-term antidepressant use; short-term anti-convulsant use
  • Trigger point injections and needling
    • Pioneered by Dr. Janet Travel (President JFK’s physician), a small amount of lidocaine (i.e. “freezing”) is injected into the painful part of the muscle, which typically offers pain relief for days, weeks or months
  • Joint injections
    • If a TMJ is not responding to the above therapies, we may inject a joint lubricant or a steroid, similar to someone with knee arthritis
  • Physical therapy
    • Some people also require treatment with a physical therapist to manage their neck and jaw pain
  • Botulinum toxin injections (i.e. Botox)
    • Botox has been shown to treat chronic migraine, nerve pain and muscle pain. If other, more conservative treatments are not effective, some people require botulinum toxin to manage their pain

Most people who pursue the non-bite approach may spend $1000 – $5000. If botulinum toxin is required, treatment may cost up to $10,000 (unfortunately, Botulinum toxin is very costly to provide). It should be underscored that no enamel is sacrificed with the conservative, non-bite change approach; there is very little in the way on long-term follow up; and there are few, if any, treatment complications.

The Evidence for TMD treatment: Well, that’s a good question. According to the American Dental Associations Evidence-Based Dentistry site, bite changes are not recommended. According to Nature’s Evidence-Based Dentistry, bite changes are not recommended. According to the Canadian Dental Association, bite changes are not recommended. According to every provincial dental association, including the Alberta Dental Association and College, bite changes are not recommended. Most (all?) Oral Medicine/Orofacial Pain graduate programs in the USA, Canada and the UK recommend no bite changes.

So, conservative non-bite-centred treatment has the endorsement of most (all?) organized dental bodies, NIHB research and graduate dental programs the manage TMD with no irreversible changes to your teeth or jaws. Bite-centred treatment is not endorsed by any dental organizations like the Canadian or American Dental Associations, is very costly and requires extensive ongoing follow up.

Considering this information, can someone please explain to me how there is still a controversy?

References

Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005514.
Occlusal splints for treating sleep bruxism (tooth grinding). Macedo CR1, Silva AB, Machado MA, Saconato H, Prado GF.

J Oral Rehabil. 2010 May;37(6):430-51. doi: 10.1111/j.1365- 2842.2010.02089.x. Epub 2010 Apr 20.
Management of TMD: evidence from systematic reviews and meta-analyses. List T1, Axelsson S.

Quintessence Int. 2004 Mar;35(3):211-21.
Association of malocclusion and functional occlusion with temporomandibular disorders (TMD) in adults: a systematic review of population-based studies. Gesch D1, Bernhardt O, Kirbschus A.

Angle Orthod. 2007 May;77(3):542-8.
TMD in relation to malocclusion and orthodontic treatment. Mohlin B1, Axelsson S, Paulin G, Pietilä T, Bondemark L, Brattström V, Hansen K, Holm AK.