Scroll down to see these articles by Dr. Metrick:
Tips on Care of Infants' and Small Children's Teeth
Pregnancy and Teeth (Yours and Your Baby's)
Easy Ways to Prevent Damage to Your Teeth
Four Principles for Saving Money and Having Healthy, Pain-Free Teeth
Everything You're Supposed to Know about Oral Hygiene
All About Whitening Teeth
Nightguards, Anti-snoring Appliances and Sleep Apnea Appliances
Jaw Pain and Tooth Grinding: a Brief Outline
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Tips on Care of Infants’ and Small Children's Teeth Benjamin Metrick DDS
- Nursing your infant at the breast is unquestionably better than bottle-feeding in terms of orthodontic issues down the line. This is because the position of the mouth and the complex sucking/swallowing action required to extract the milk influence the development of the jaw, tongue position, and swallowing muscles. Those in turn will affect the position of the teeth. No commercial nipple matches the breast, but ask your pediatrician for the latest recommendation as to what brand comes closest.
- Avoid leaving an infant alone with a bottle containing anything but water. Anything else, including milk of any kind and juices, can quickly rot the teeth if the child falls asleep with the bottle in mouth, continuously bathing the teeth.
- Use damp gauze or a damp scrap of washcloth to wipe clean baby’s teeth immediately following every feeding. This includes any bit of tooth or teeth visibly protruding through the gums. When baby is cutting a new tooth, quell the pain with a refrigerated cold damp wash cloth or fluid filled pacifier. If this is not sufficient, go to Baby Anbesol. Tylenol drops can also help.
- If you start cleaning your baby’s teeth as soon as they appear, then cleaning is such a normal part of everyday life you are less likely to encounter resistance later.
- When baby begins eating solid food, this would be a good time to switch to a very soft bristled baby brush. The reason is to accustom baby to the brush. Food sticks to the teeth about the same as it does to your dishes and if you clean dishes right after dinner, you don’t need to scrub them; a sponge should do.
- When the child can learn to spit out, a bit of toothpaste may be added.
- A matter-of-fact approach works best with most older children, an attitude that communicates “This is just what we do.” Let your kids see that you brush your teeth too. Do it together; take turns; let them help you the way you help them. Songs and games are great, but huge amounts of praise may backfire with some children, by making the activity “special” when you want it to be “normal.”
- Never give a child soda. Save it for your worst enemies. It is likely a root cause of obesity, diabetes, GI hyperacidity and resulting conditions including gastro-esophageal cancer, as well as dental caries. Why start and have them crave it?
- The topic of fluoride ingestion in newborns and infants has recently become controversial. I will address fluoride in more detail in another article. For now – and keep in mind that the medical thinking on this may change – I personally would not give my own infant fluoridated water, and I would use toothpaste without fluoride until my child was old enough not to swallow it.
- Pay attention to whether your child breathes through his/her mouth or nose most of the time, especially when sleeping. Mouth breathing (we’re talking chronic here, not during the occasional cold) is an indicator of upper respiratory issues. They should be addressed, not only for their own sake but also because they will affect the shape of your child’s face and mouth. If this seems surprising, consider that orthodontia works through constant gentle pressure. So the habitual use of the facial muscles over years certainly does the same.
- We will be happy to look at your child’s teeth at any age for a spot check or to answer a question you may have about anything appearing abnormal. You can call, walk in, or make an appointment for a free consultation. (Calling ahead ensures that you need not wait for the doctor to be free.)
- Typically, we start cleaning children’s teeth at the age at which they can cooperate without restraint or sedation, usually between 3 ½ to 4 ½ years old.
- In our practice, we prefer to be patient and responsive to a child's state rather than coerce, in the rare instances when the child is reluctant to be treated, even if it takes longer. Be aware that pedodontists (specialists in children's dentistry) may have approaches to handling reluctant children that might surprise you. These may include physical restraint (in the form of a “papoose board” with straps) or sedative drugs (commonly chloral hydrate, called in slang a “Mickey Finn”). We do not employ either of these methods but, when necessary, we would recommend the latter alternative. Chloral hydrate has a high index of safety, is short-acting, may be delivered surreptitiously without fuss, leaves the child with no memory of the procedure, and has a minimal risk associated with it in the hands of an experienced pedodontist.
- Preparing your child for a first visit may seem like a good idea; but making too big a deal about it (as in, "This is a BIG DAY!") and reassurance (as in, “Don’t worry, it won’t hurt”) may backfire by planting the idea that there’s something to be reassured about. When a kid comes into our office, the first thing they see is toys. Then they see a guy in a white coat, which is usually intriguing. And while mommy or daddy is chatting with the guy in the white coat, they get to play with the toys. With calm parents, kids need hardly any more introduction than they do to a trip to the store. If you want a children’s book describing a first dental visit, there are two good ones available from our office.
- You may phone Dr. Metrick at 212 795-8989 during business hours or cell phone 917 612-5809 at other hours, to discuss any questions you have about your child’s teeth.
From Sound Dentristy
Dr. Benjamin Metrick, 536 Ft. Washington Ave. ground floor left, NY City 10033,(212) 795-8989
©2008 Benjamin Metrick
Pregnancy and Teeth (Yours and Your Baby’s)
Benjamin Metrick DDS
- If you’re not pregnant yet but thinking about it, get your teeth cleaned and dental work done first. Caring for your teeth in advance is the best way to prevent infections and maintain gum health during the pregnancy.
- Throughout pregnancy, your hormones cause your gums to over-respond to irritants such as tartar and plaque. This means your gums are more likely to swell and bleed. Brush well and use an antiseptic mouthwash to keep this under control, not only for your comfort during pregnancy but to prevent longer-term consequences of chronic swelling.
- If you’re already pregnant, try to postpone dental work until well into the second trimester or, even better, the third trimester. During your first trimester you don’t want yourself and your fetus to be subject to drugs like Novocain or to the temporary surge of germs that are released into the bloodstream by cleanings. However, you also don’t want to have infection or toothache, which also cause the body to produce a powerful chemical response.
- By the same token, do plan to have cleaning and small fillings done after the twenty-first week. Those procedures are safe during that time, according to the results of several recent studies. Don’t put this off, thinking you’ll take care of things after your baby is born – you’ll be busier than you expect, and end up putting it off too long!
- A small number of low-radiation digital x-rays, when necessary, is also considered to be safe after 21 weeks. Conditions in which x-rays are likely to be necessary include: (1) if you’re having sensitivity to hot, cold, sweet, or chewing; (2) if your gums bleed frequently when you brush; (3) if you have swelling of any kind in your mouth; or (4) if your dentist spots a cavity.
- Fluoride is no longer recommended for pregnant women. Yes, the fluoride is taken up by your unborn baby's teeth buds and yes, that does make the teeth stronger. However, some studies currently under way are suggesting that floride may pose risks to the baby's general health.
- If you have morning sickness/nausea, you should at least rinse, preferably brush every time you throw up. Stomach acid is extremely corrosive to tooth enamel. Also use a fluoride rinse before bedtime, which helps protect your teeth by replacing the minerals corroded by the acid.
- When you’re thinking about whether you’re going to nurse or bottle-feed your baby, the main topics you may read about are matters of nutrition and the immune system, etc. Something else you should know is that nursing your infant at the breast is unquestionably better than bottle-feeding in terms of orthodontic issues down the line. This is because the position of the mouth and the complex sucking/swallowing action required to extract the milk influence the development of the jaw, tongue position, and swallowing muscles. Those in turn will affect the position of the teeth. No commercial nipple matches the breast, but ask your pediatrician for the latest recommendation as to what brand comes closest.
- You already know that smoking is bad for you and bad for your developing baby. Add to the list that tobacco is a major culprit in gum disease, and you having gum disease is bad for both you and your baby too.
- Calcium intake is of prime importance for maintaining your own teeth and bones while you create your child’s at the same time. The phosphate in soft drinks actually reduces calcium intake, another reason to eliminate soda from our lives.
- Here is a link to the Center for Women’s Health guide to nutrition during pregnancy: http://www.centerforwomenshealth.com/pregnancy.htm.
A more detailed explanation of my recommendations concerning gum disease, cleanings, and fetal health:
Gum disease is essentially infection of the gums, the result of the bacteria that build up around your teeth. Most people have it to one degree or another. (When it’s bad, the gum seal around your teeth gets looser, allowing the germs to go deeper. Then the body’s defense against the germs starts to eat away at the bone that anchors your teeth.) Gum disease one of the things that I am fighting when I clean your teeth.
When someone has gum disease, the capillaries in their gums become more permeable (leaky). That is not a bad thing in itself: it happens so that white blood cells can migrate out of the bloodstream to attack the offending germs. This permeability works both ways, however, allowing germs in the mouth to pass into the bloodstream. Every time you brush or even eat, there is a brief surge of germs entering your bloodstream – the more advanced the gum disease, the more germs.
Even when you are not pregnant the implications of such infection are important for you. Among other things, gum disease is a cause of elevated levels of C reactive protein (CRP). CRP is formed by our bodies in response to inflammation and is considered a marker for disease. Elevated levels of CRP in the bloodstream have been linked to diabetes, high blood pressure and heart disease.
When you are pregnant, your own underlying state of health matters all the more. And in pregnancy the likelihood and severity of gum disease actually increases, even if your hygiene remains the same. Higher progesterone levels cause the gums to react to plaque more strongly than usual.
And then there is the matter of the impact on your child. As you know, if you are pregnant, much of what is traveling through your bloodstream reaches your unborn baby. While the placenta is a marvelous piece of evolutionary design and does an amazing job of filtering, it cannot prevent all potentially harmful pathogens, medications and naturally produced chemicals traveling through the bloodstream from affecting the fetus.
CRP has been found in the placenta and in amniotic fluid where it has been associated with adverse outcomes including pre-term birth and pre-eclampsia (high maternal blood pressure). How the CRP gets into the amniotic fluid is a matter still being researched.
It seems intuitive that the germs themselves released into your bloodstream by gum disease are not a great thing for yourbaby either, but we do not know for sure how much of a risk they pose. A study done in Alabama, published in 2004, on over 1,300 women between 21 and 24 weeks of pregnancy concluded that having severe periodontal disease at this stage resulted in births that were early by 3 to 8 weeks pre-term. That conclusion is contradicted by a study published in 2006 in the New England Journal of Medicine on over 800 women in their 21st week, done in four different states, which concluded that there was no connection between the periodontal state and length of pregnancy. So we will have to await further studies for more precise information on that.
However the periodontal health of the mothers who were, safely, treated during these studies did certainly improve. Since just brushing is a disturbance in the mouth that releases germs into the bloodstream, you can imagine that dental cleanings cause a surge of germs too. But that is a very temporary surge and it addresses and limits the disease. So it is absolutely worth doing, especially late in the pregnancy when the baby is well along in its development. At that point, the benefits of the cleaning far outweigh the disturbance.
Bottom line: you should be (1) maintaining your oral health in pregnancy and (2) timing your dental care so that you expose your developing fetus to as few risks as possible from both problems and interventions.
From Sound Dentistry
Dr. Benjamin Metrick, 536 Ft. Washington Ave. ground floor left, NY City 10033,(212) 795-8989
©2008 Benjamin Metrick
- Don't drink corrosive liquids
- sodas... including diet sodas
- bottled iced tea...
- lemon juice, in water or tea or cola, on a regular basis...
- Don't use your teeth as tools
- opening packages...
- pulling off water-bottle seals...
- breaking pills in half...
- cracking nut shells...
- Don’t chew stuff that wasn’t meant to be chewed
- the un-popped kernels at the bottom of the popcorn bucket...
- Don’t let bits of any kind of food stay stuck between your teeth, especially
- citrus fruits (acid)...
- candy (sugar)...
- Don’t subject your teeth to rapid extreme temperature changes
- ice cream with hot coffee...
- ice cream with hot coffee...
- Do you clench your teeth at night? If you do, wear a night guard on your teeth.
- Do you snore or breathe through your mouth at night? If so, you are almost certainly clenching your teeth as well, which is damaging to them. Try a “Breathe-Right”™ strip. Consider wearing an anti-snoring appliance and investigate ways to restore clear nasal breathing. (How to tell? Ask your sleeping partner, if you have one. If you have to get up at night, you’ve probably been breathing through your mouth. And if your mouth is dry when you wake up, you’ve probably been breathing through your mouth. Ask me about the correlations between mouth breathing and tooth grinding/clenching.)
- Just before bedtime is the most important time of the day to brush and floss well. We produce less saliva in our sleep, so we have less of it rinsing our teeth and diluting the acids that bacteria produce as waste products.
- If your mouth tends to be dry, use a fluoride rinse at night, after brushing and flossing.
- Make sure your habitual method of brushing your teeth is actually effective – let’s discuss this at your next visit.
From Sound Dentristy
Dr. Benjamin Metrick, 536 Ft. Washington Ave. ground floor left, NY City 10033, (212) 795-8989
©2008 Benjamin Metrick
FOUR PRINCIPLES for
Saving Money and Having Healthy, Pain-Free Teeth
1. With or without insurance, use your options well.
Dental coverage is different from medical coverage. Sometimes it’s actually cheaper for the patient if the doctor is out-of-network than in-network. That doesn’t make sense, but a lot about the system doesn’t make sense.
I can help you get through the insurance maze – then you make the choice.
2. Watch out for hidden costs.
Some options at other offices or clinics may seem cheaper, but they may require more visits to get the same thing done or make use of less durable materials.
I can help you think big-picture about cost-effective care – then you make the choice.
3. Don’t do unnecessary procedures.
It’s important to know the costs and benefits, both long- and short-term, of each procedure. I advocate a level of care that makes practical as well as medical sense.
I can help you understand what procedures are worth doing – then you make the choice.
4. Take care of the teeth you have.
The maintenance I recommend saves you pain and money – big money over your lifetime. Pretty smiles and fewer dental visits are great things, but I’m talking about even more than that.
I’m talking about the quality of your life, and your ability to stay healthy and make ends meet at the same time.
I can help you sustain your health affordably– with choices you make.
All About Whitening Teeth Benjamin Metrick DDS
Sparkling white teeth aren’t just for TV and movie stars these days. Many people are realizing a boost in attractiveness and self-confidence that a whiter smile brings, as well as improving personal and business prospects. This article examines the pros and cons of various tooth bleaching methods.
When you are ready to whiten your teeth, have your teeth cleaned well and use this opportunity to consult with your dentist about the best method for you.
One basic fact is that no bleaching method will change the shade of existing dental material in and on your teeth. If you have porcelain crowns, bondings or tooth colored fillings that show in your smile and they match now, bleaching will make them relatively darker than your teeth. But if you are ready to replace the dental materials, bleach first-then replace. It’s nearly impossible for the dentist to guess what shade your teeth will bleach to.
If you have numerous restorations that show or if you have somewhat crowded teeth or gaps, you may want to invest in porcelain veneers. Done well, veneers can immediately improve your smile and they will retain their lighter shade for many years.
If you are a young adult and your teeth are only mildly stained, you may want to try an over–the-counter (OTC) method of bleaching. Whitening strips work well within their limitations. They need to be well adapted to the curved surfaces of your teeth or the edges between the teeth may look dark. If your teeth are wider than average, the strips may not go all the way across the teeth that show when you smile. Bleaching strips can also cause tooth sensitivity-as can any bleaching method-if kept on too long. The sensitivity is usually temporary and subsides within 24 hours.
Older adults or people with darkly stained teeth will want to see their dentist for power bleaching, take home custom trays or both. Custom trays are clear flexible slipcovers made on plaster casts of your teeth. Your dentist will have to take impressions of your teeth to make the molds. Bleaching gel is placed into the trays and placed onto your teeth. There are OTC “boil and bite” tray kits on the market but they don’t fit well enough to be efficient or to keep you from ingesting the bleach so I’m not in favor of them. One company has a non-custom tray pre-filled with a very thick gel that you can’t swallow but these are available only from dentists and are about as expensive as custom trays.
Power bleaching (examples are Zoom and Britesmile) is usually about a one hour procedure in which your lips and gums are protected by barriers and gels. Then a bleach is placed onto your teeth and either a special light or laser is shined onto your teeth to activate the bleach.These powerful systems will lighten most teeth several shades in one visit. If your teeth are deeply stained however, you will have to use the take home custom trays to finish the job. Most dentists give you the trays and bleach along with the power bleaching for no additional cost.
Using custom tray bleaching alone can give you the same results as power bleaching if you use them for a week or two. The amount of time for each wearing can be 30 minutes to two hours or even all night, depending on the strength of the bleach and your tolerance for sensitivity.
The composition of all of these bleaches is either hydrogen peroxide or carbamide peroxide. They are available in different strengths but the sensitivity of your teeth is the factor limiting both strength of bleach and the amount of time you can have it on your teeth at one time.
Sensitivity varies from person to person and can be relieved by any OTC pain reliever such as aspirin, Advil or Tylenol, just to name a few. Some power bleaching methods recommend taking two Advils prior to the bleaching session. Some tray methods recommend Tylenol before sleeping with the trays on. Some power bleaching methods include application of desensitizing medication onto your teeth and/or take home desensitizers.
All of these methods are effective if used enough, the formula being:
Strength of peroxide x Length of time on the teeth
Severity of the stain
In older persons as well as heavy tea, coffee and red wine drinkers, the stain takes longer to bleach but it will if you keep at it.
There is no evidence that prolonged use of peroxides will permanently damage the enamel of your teeth. They can, if you overdo it make the edges of your teeth look like a translucent grey but this is reversible. They can discolor your gums and cause a burn if bleach stays on them long enough but this is usually gotten over. Poorly fitting or poorly trimmed trays are the usual cause of burns.
The pulps of your teeth can be adversely and permanently damaged (think root canal)
by bleaching the root surfaces of your teeth if you have receding gums. The rule is: keep bleach off of those root surfaces.
People with tetracycline stained teeth which have a grey caste or horizontal banded coloration will require weeks or months of bleaching with take home trays but eventually the peroxides penetrate and the stains break up. More likely the dentist will recommend veneers for such cases.
How long the bleaching lasts will vary by how deeply bleached the teeth were, the foods and liquids you eat and drink, and if you use a bleaching toothpaste. Two or three touch up periods with your trays every year or two can restore that white smile.
If you smoke-stop it! If you can’t or won’t stop, try Topol toothpaste but don’t expect your teeth to hold the effects of a bleaching for long.
“Whitening” is sometimes used as a code word for tooth cleaning product formulated to clean tough stains off of the surface of the teeth, not a bad thing but they do not actually bleach.
One final note: swallowing peroxides is not healthy. They release oxygen. They are oxidants-the opposite of the anti-oxidant vitamins that we are supposed to take in. This goes for bleaching gels, toothpastes and mouthwashes that contain peroxides.
Type of Bleaching --Duration-- Best For--Typical Cost
Whitening strips-- 2 weeks-- mild discoloration, young adults--, $30.-80.
OTC gels-- 1-2 weeks-- mild discoloration, young adults-- $25.-120.
Power bleaching with light or laser-- 1-2 hour(s)--all cases-- $500.-1000.
Take home custom trays-- 7 days-more-- all cases-- $250.-500.
Combination of power bleaching and trays--7-14 days-- difficult cases, bleaching to "ultimate white"-- $500.-2000.
Night guards, anti-snoring appliances and sleep apnea appliances
This article will attempt to explain the uses of, differences between, and overlap of function among various types of appliances worn on the teeth during sleep.
Why wear any appliance?
You clench or grind your teeth.
What damage can occur by grinding or clenching?
Wearing down tooth enamel on the chewing surfaces
Loss of support of the teeth, bone and gums—leading to loosening of the teeth
Loss of tooth structure near the gum line
Damage to the jaw joints
Spasm of the chewing muscles, also affecting muscles of the neck and shoulders
What problems can snoring cause?
Loss of sleep for one’s bed partner
Sleep apnea episodes
Snoring has been linked with fatigue, depression, memory disturbance, irritability, loss of libido, erectile dysfunction, night time urinary frequency, chronic bronchitis and reflux disease.
What are sleep apnea episodes?
You should first know what snoring is and why people snore.
OK. What is snoring and why do people snore?
Funny you should ask! We know it is noise. The noise is caused by vibration of the soft palate and uvula, usually, and sometimes other loose tissue of the throat. Most people who snore are breathing through their mouths due to blockage, partial or complete, of the nasal passages. When the base of the tongue occludes the throat, incoming air forms a narrow stream with a great enough force to make the loose tissue in the throat vibrate and make noise.
One can snore while breathing through the nose but the incidence of nasal snoring is estimated at roughly 5% of all snorers. Nasal snorers can largely skip this article unless the noise bothers their bed partners. If so, go straight to the ENT physician.
Apnea means “absence of breathing,” A sleep apnea episode occurs when the tongue and soft palate, and sometimes other structures as well, moist-stick together, causing total cut off of air to one’s lungs. After 10-20 seconds, the body’s reflex mechanisms, recognizing the lack of air flow to the lungs, cause the jaw to jut forward, moving the (attached) tongue forward and unblocking the throat. Others sleeping in the same house are treated to the characteristic snort that signals resumed breathing.
Sleep apnea can also be caused by failure of the nervous system to respond to the cut off of air. This is referred to as central sleep apnea to distinguish from common obstructive sleep apnea (OSA). One of the main functions of sleep labs is to rule out central sleep apnea.
OSA has been linked to the same problems as snoring as well as increased risk of heart attack and stroke.
Why are sleep apnea episodes harmful?
Every episode is accompanied by a mini-arousal, not remembered, that knocks one out of whatever stage of sleep so that regular episodes will prevent necessary, psychologically and physiologically, restorative deep sleep. Even people with mild OSA have 5 or more episodes per hour. At the very least, OSA causes its sufferers to feel fatigued earlier in the day and especially after dinner when so many of us are resigned to couch potato existence. It is likely that more traffic fatalities are caused by fatigued drivers than by intoxicated ones.
What about lack of oxygen to the brain?
While there have been deaths attributed to sleep apnea they are so rare as to be considered freak occurrences and are likely due to central sleep apnea.
There are two recent studies asserting that OSA causes gradual progressive damage to brain cells that may be linked with depression as well as memory, mood and increased blood pressure. Newer technologies have only recently been able to detect changes within cells signaling damage prior to wholesale cell death. The studies may be purchased online but here is a link to a secondary source: http://www.medicalnewstoday.com/articles/114146.php.
More to the point is that almost all people who snore are breathing through their mouths all night long and are depriving their lungs of the nitric oxide naturally produced in the nasal passages. Nitric oxide opens one‘s lungs to better oxygen exchange. Thus, mouth breathing has the effect of lowering the body’s blood oxygen level by about 10 to 20 percent. The chronic damage to the body is considerable and the topic of much current research. Those who breathe through the mouth during the day as well sustain even greater damage, and more quickly.
What about the appliances?
OK. First, the appliances to stop damage caused by grinding:
1) Simple horseshoe shaped plastic night-guards have been used for decades and I believe them to be more harmful than beneficial in some cases so we rarely recommend them. While protecting the biting surfaces of teeth from attrition, they do not prevent the grinding and clenching which cause periodontal disease, tooth degradation at the gum-line nor jaw joint damage.
2) In its place we recommend the NTI appliance which is a custom-made, hard plastic bit which fits onto the (usually) lower front teeth and prevents the back teeth from being able to meet. You can get an idea of the principle by placing a toothpick, cu-tip, or wooden match between your upper and lower front teeth and closing, without bending or breaking the stick. Just having something in front to prevent the back teeth from meeting prevents loss of tooth structure but also halts the heavy muscular forces that cause all of the other problems. Worn regularly, this appliance will act as a habit breaker, stopping clenching and enabling the muscles of the jaws, neck and shoulders to relax. This can be a life-enhancing change. Not incidentally, this appliance was developed to stop chronic headaches, including migraines, without the use of drugs. Its inventor uses it as a night guard and so do I. Find out more about it at this site: http://www.headacheprevention.com.
Not coincidently, clenching and grinding have the same cause as snoring and sleep apnea—nasal obstruction. Anti-snoring and sleep apnea appliances also prevent grinding and clenching. So before you choose a night guard, you may want to seriously investigate whether you snore. A recent study has shown that 44% of men and 28% of women who snore don’t know that they do. Your spouse may be trying to be kind to you by not saying something about it.
Now appliances to stop snoring and sleep apnea, what is the difference?
In order for a dentist to provide an appliance to lessen OSA, the patient must be certified by an approved sleep lab (also called sleep disturbance centers or any of several variants). These labs will interview you to determine whether to have you stay for an overnight study. If you go for an overnight, they will determine the number of sleep apnea episodes per hour and determine the relative severity of your problem. You need to have 40 episodes in an 8 hour period to qualify as having ”mild” OSA. Fewer than 5 episodes/hour means you don’t qualify. This saves the insurance companies millions—(see “trickle down theory.”)
If you are apneac they will offer you their one and only cure—the CPAP machine. This is a small box which pumps air through a hose to something that inserts into your nose. The continuous positive air pressure (CPAP) overcomes any resistance of your soft tissues and affords you good sleep and good health, if you can tolerate it. If not the dentist can make you an appliance which will posture your lower jaw forward, thereby pulling your tongue just enough to keep it from sticking in your throat and blocking air.
If you are a certified as having OSA, your medical insurance may cover the cost of the appliance. If you are not certified, you may have an anti-snoring appliance made. It’s really the same thing but your dental insurance will have to pick up the bill, or you may need to pay out of pocket if your dental doesn’t allow for snoring appliances.
Neither appliance will cause you to breathe through your nose. This is a problem for your physicians. You will need to have an allergy test to rule out the most common causes of nasal blockage, airborne allergens and food allergy. The cures here are medical—sprays or pills as well as avoidance of offending foods. Then you will need to have an ENT (ear, nose, and throat) specialist check you out for physical blockages—deviated septum, adenoid tissue, polyps, thickened nasal lining. If you have any of these the cure is surgical.
So, in short, an appliance will not cure your nasal blockage but will eliminate most of your sleep apnea and that is the best you will do unless you go to a sleep lab or manage to be able to breathe through your nose more at night. Night guards can stop the damage caused by clenching and grinding.
What about other cures for snoring?
If they work, great! If all you need is a spray or a Breathe-Right strip than your case is very mild. Some people will not be so successful. Advice to lose weight requires actually losing the weight and hoping much fatty tissue in the throat is lost first. Not drinking before bedtime will prevent some flaccidity of throat muscles but is not a major factor. Add to this that the more years one snores, the more flaccid the soft palate becomes, and you can understand why older snorers are louder than younger ones.
Ridding your bedroom of allergens can help and will make you healthier even if it doesn’t stop your snoring altogether.
What if my child snores or grinds his teeth?
Parents should know that all of the above goes double for children. If you tell me your child just can’t breathe through the nose and there is nothing to be done about it—I pity your child. Untreated mouth breathing children will have poorly developed faces, jaws and crooked teeth. They will need years of braces, have dental problems their entire lives, and suffer ill health, shorter lifespan and possibly migraine headaches in the bargain.
Both grinding and snoring in children are indisputable signs of nasal blockage. Nasal blockage in children is due to allergies and or adenoid tissue blocking the nose. If your child snores and/or wears his teeth down, I am talking to you, mom and dad!
If you say your physician doesn’t recommend removing enlarged tonsils and adenoid tissue unless breathing is almost totally blocked, I say find another physician.
But my child can’t breathe through the nose due to asthma.
Asthma is brought
on by the mouth breathing usually started by allergies. Nasal breathing will
alleviate the symptoms of asthma. Mouth breathing exacerbates asthma. If your
child suffers from asthma, check out the nearest branch of the Buteyko Society
at this web site: http://www.buteykonyc.com. Buteyko didn’t know about nitric oxide but
his techniques of stopping asthma symptoms through progressive nasal breathing
training still work well. Other sites to view include: http://www.breathingcenter.com and http://www.buteykoeducators.org.
Copyright May 2009 by Benjamin Metrick DDS
Jaw Pain and Tooth Grinding: A Brief Outline
The situation: Your jaw joint hurts. Your teeth are visibly and significantly ground down.
What has happened?
Short answer: Over time you have worn down your teeth, to the point that the angle of your jaw when your teeth are closed is different, and the jaw joint is damaged.
Your jaw muscles and also the joint itself are under abnormal stress. Joints can tolerate only so much stress for only so long before they begin to break down.
There is a disk suspended between your jawbone and your skull by two thin ligaments. The disk is made of cartilage and concave on both sides. The distorted position of your jaw forces the disk out from between the bones. You feel or hear this as clicking or popping in the joint.
In early stages, the disk pops back into place immediately. Eventually, in later stages, the ligaments can be stretched out or worn through and the disk stays in the wrong place. Then bones rub together and arthritis sets in, changing the shape of the end of the jawbone. At the same time, the jaw muscles are shortened by these changes, and the muscles tend to spasm, which also adds stress on the joint complex – a vicious cycle.
Pains in the joint can occur in children as young as twelve. In adults, pain can occur at any point of joint derangement, especially in the later stages. How long you can ignore the developing symptoms and increasing pain is a function of how tough and/or how stubborn you are. But you need to take care of it and the sooner the better.
Short answer: This situation is not likely to resolve itself and will get worse.
Your jaw joint is almost certainly arthritic and will become more so. Only correcting the position of the jaw joint will stop the deterioration and give you relief.
Some people end up so miserable that tens of thousands of jaw joint surgeries are performed in the U.S. every year, despite an appallingly poor success rate.
Besides, you will also continue to lose tooth enamel and
exacerbate gum problems. Gum disease (which is really gum and bone disease –“
periodontitis”) is not just a matter for your mouth. It leads to higher blood
pressure, and greater incidence of heart disease and stroke. These periodontal
issues are more easily remedied than the jaw joint problem but are preferably
Make the teeth even shorter?
Short answer: I do not recommend this.
There is a school of thought in dentistry that says, the biggest problem for the jaws is the fact that the wear on the teeth has occurred unevenly. Their recommendation focuses on filing down the teeth selectively, to improve the bite.
I wish this relatively simple solution worked, but I don’t
believe in it and won’t perform it in cases of severe tooth wear due to
grinding. (There are other situations
in which it is useful to adjust the bite in this way.) In my opinion it won’t
stop the jaw joint from deteriorating and so it can only provide temporary
relief, when it works at all.
Move the teeth with orthodontics?
Short answer: For children, teenagers and young adults this is the best solution.
Sometimes an underdeveloped jaw or badly positioned teeth are part of the cause of jaw joint pain in addition to, or as a cause of, tooth grinding.
If that’s your case and if the wear on your teeth is not yet severe, correcting the problem with orthodontics could be your best alternative. This kind of orthodontics may involve the use of braces and/or appliances, the kind worn inside the mouth.
Young adults should especially consider this option and it is the best choice for children and teenagers. Invisalign clear aligners are not generally suited for this purpose.
Build the teeth up with something you wear?
Short answer: This is a solution that satisfies many adults, if they are willing to wear an orthotic device full-time.
An orthotic device can be made to fit your teeth, usually on the lower jaw, that provides a new chewing surface and a better bite. A first orthotic is made of clear acrylic (plastic), possibly with some metal reinforcement, so that it can be adjusted for the most comfort. You wear it full-time for at least six to eight weeks, and it should significantly lessen your jaw joint pain as soon as it is properly adjusted to correct your bite, creating the proper amount of space for your joint disk(s).
After this period, a permanent version can be made out of denture-like materials. It will clip onto the teeth. This solution can last for years before the orthotic itself is worn down and needs to be reconditioned or replaced.
When well made, it should be nearly invisible. There should be no problem getting used to it, since you have already been wearing the initial orthotic for weeks.
The orthothic is worn full-time. You take it out only when you are cleaning your teeth and the appliance.
Even with a removable appliance such as an orthotic, full-time use will be an “irreversible procedure”, permanently altering your joints, presumably for the better. This is without question preferable to surgery. Some articles use this fact of “irreversibility” as a negative for the patient and the dentist. If you are suffering, there is no downside to changing to a more pain-free bite position. This is supposed to be a negative for the dentist because afterwards, his responsibility to the patient is greater.
Restore the teeth themselves?
Short answer: This solution is the longest-lasting, most esthetic and ultimately the most comfortable. Unfortunately it is also the most expensive.
First a simple acrylic orthotic, as described above, is made to determine the best position of the jaw. Then, instead of wearing a permanent orthotic, your back teeth are individually built up with onlays or crowns in a way that precisely matches the bite you have with the orthotic in place.
In many cases, building up the lower back teeth, and sometimes also the canines, is enough to maintain the corrected position and alleviate joint pain for the long haul. In other cases, additional teeth may need to be restored.
Frequently asked questions:
“Couldn’t I just wear a night guard?” While we are all in favor of using a night guard, if you are having chronic jaw joint pains, it’s probably too late for that. The jaw joint has already undergone arthritic change and needs to be repositioned to prevent worsening pain and further damage to the joint. An orthotic should be worn at all times except during oral hygiene.
“How much is this going to cost?”
First, correcting the jaw position with a temporary orthotic requires examination, treatment planning, taking necessary x-rays of the joints and molds of the teeth, and creating and adjusting the orthotic. Those fees likely range from $3000 up (and can reach $7000 in midtown).
After the initial orthotic has been worn for several weeks and found to be satisfactory, it is possible to identify more precisely the complexity and costs of a permanent orthotic vs. crowning. A permanent orthotic is likely to cost at least $2500 (up to $5000). Crowning done precisely enough to duplicate the bite position of the temporary orthotic is likely to cost $1500 to $2500 per crown. Typical cases require a minimum of eight crowns.
Orthodontic fees are highly variable, especially for changing jaw position in adults. Expect a starting fee near $5000 and up.
There are many variables depending on the case but among these three options,
· A permanent orthotic will require only 3 to 5 dental visits following the period of wearing the initial orthothic. Crowns are also relatively immediate, say within one month following the initial period. Orthodontics will take most time, perhaps 12 to 15 months of treatment and numerous visits.
· A permanent orthotic is likely to cost the least, then orthodontics and crowns the most.
Fees vary with the complexity of the case. The rates identified here are, to my knowledge, bottom-line. Fees among dentists vary widely not only by experience but also by location. Dentists who limit their activities to correction of jaw problems will charge more.
“Will my insurance cover it?” Probably not. (Contact your insurer to check.)
“Why not?” Insurance
companies pay only what the law demands that they pay. Jaw joint problems are
not currently recognized as a covered disease by medical or dental insurance
companies in most states, even though the pain wrecks your life. Some cases
have been paid in a few locations but only after lengthy litigation and appeals
to higher courts. New York
State is among the worst
for the medical/dental consumer because many insurance companies are
headquartered here and politics plays a large part in our health care
Contact your congressman.
More information? Next steps? Feel free to call for an appointment to discuss your problem with me. There is no fee or obligation.
©Dr. Benjamin Metrick 2009
phone 212 795-8989