Implant Therapy Part 2

This blog is a continuation of the last blog on implant therapy. This time I am going to talk about prostheses supported by implants.

The prostheses that implants can support are a crown, a bridge or a denture (hence called overdenture). The fees for implants and prostheses are usually high because of the expensive costs of the many machines, equipment, instruments, parts and accessories, sundries, sterilization wraps (and pouches) and the charges from the dental laboratories making the prostheses.

At Affinity Dental Care, we use three implant systems: Straumann, Conelog and Molaris implants. All three are high-quality implants that cost over $600 per implant. Additional parts are needed to go onto the implants, like healing caps (the cover screw on the implant) and healing abutment (the long conical cylinder that attaches to the implant and sticks out of the gums). When making the prostheses, there are additional costs for the impression, implant to the crown interface, overdenture attachment, and the making of the crown etc. They can cost at least $750. Not to mention the costs of the numerous sundries like sterilized saline, irrigation tubing, syringes, gauze and protective sheets etc.

The cost can be even higher when bone graft and membrane are involved.

Our expenses to place an implant and a crown onto it can easily be $1,500. Not to mention the special machines and instruments specifically for the procedures in the process.

Implant surgery and placement can be unpredictable, complications can arise, and additional surgeries, remakes and repairs may be needed. Usually, we only charge our patients the costs for the extra supplies and lab bills to our patients.

There can be some inadvertent complications to the prostheses:

An implant involves many procedures. Each procedure requires precisions. Pre-surgical examination and treatment planning is essential. Even with careful preparations, complications can happen. They can be:

  1. Breakage/fracture/loosening
    With time, you may inadvertently break/fracture/loosen the prosthesis, the implant(s), or the implant component(s). In particular, your prosthesis is connected to the implants by small internal screws that you can inadvertently loosen or fracture. Usually, these complications can be fixed relatively quickly, and fractured prostheses can be replaced without further complications.

  2. Implant failure/infection
    Implants supporting the prostheses can fail or can become infected. The treatment may require surgical intervention(s) and may have significant implications for your prosthesis, appearance, and usability. Occasionally, a new prosthesis may need to be made, or the design of the current prosthesis may be modified significantly as a result. The costs of managing failed, or infected implants and a new prosthesis or repairs/modifications to the existing prosthesis are not usually included in the initial estimate. This cost can be high and higher than the initial treatment’s cost. The time needed to manage such situations can also be significant.
  3. Adaptation/acustomization/expectations/realities of your mouth
    Although the prosthesis can come close to the appearance and functionality of your original teeth, it is not a perfect copy or replica of your teeth. However, we seek improvement over your current situation and not perfection. We cannot guarantee the delivery of a “perfect smile” or teeth that feel “just  like your own teeth.”  Expectations can be unrealistic if you expect implant-supported teeth to look and feel just like natural teeth, especially when you have lost the teeth for a long time and the site has severe bone resorption. As a result, the implant-supported teeth will not have the actual gums supporting the implant crown with the natural contour. However, it can appear very naturally with pink gum appearance. Rarely have some patients been unable to become comfortable with their new implant-supported prosthesis.

  4. Changes over time
    Your mouth will undergo slow changes with time. Your gums may shrink, and adjacent teeth may drift, be extracted or change colour. Your prosthesis will also undergo slow changes over the years. The surface may wear and change its colour. The gums around may shrink or grow more prominent. Such changes are very slow but may impact the appearance, functionality or longevity of your implant-supported prosthesis and may lead to a need or desire on your part for modification or remake of the prosthesis.

  5. Temporary prosthesis
    Frequently, a  temporary crown/bridge/denture/retainer is needed to help you cope with the missing teeth until the completion of treatment. These temporary appliances have limitations of fit, appearance, and durability. In particular, they can be brittle, dislodge easily, and wear/disintegrate quickly. There may be treatment times when you are advised not to wear your temporary prosthesis so that the surgical tissues can heal undisturbed. You will usually be informed of this in advance.

    Rarely are some patients unable to wear their temporary prostheses (mainly temporary dentures). There is usually no harm if the patient stops wearing the temporary denture(s). About overdentures

All prosthodontic prostheses require a period of adaptation after their insertion (i.e., when you become accustomed to the new prosthesis), including feel, speech, bite, self-biting etc. The prosthesis may appear foreign, uncomfortable, and annoying during this adaptation period. These issues are typical and will become better with time. Some of the common problems are outlined below.

  • Feel: Your prosthesis may feel big and bulky. You may feel extra fullness in your lips or insufficient space for your tongue.
  • Speech: You may notice that some sounds or speech, in general, are negatively affected. This phenomenon is typically much more noticeable to you than to others. We advise reading out loud to allow for your speech to improve. Some clinical situations are particularly likely to result in temporary (and, occasionally, permanent speech effects). These clinical situations include replacements of upper front teeth and patients who wore upper removable dentures for an extended period before transitioning to a fixed implant-supported bridge.
  • Food impaction: You may notice food annoying getting caught between, around, or under your prosthesis. We will do our best to address this. However, occasionally this problem cannot be eliminated completely.
  • Bite: We will create a bite for your prosthesis that is even, comfortable, and least damaging to your prosthesis and your remaining teeth. However, your implant-supported prosthesis cannot and will not feel exactly like your own natural teeth.
  • Self-biting: Your gums and tongue are not accustomed to the presence of the new prosthesis. You may notice biting your tongue or lip until they become accustomed. This problem can be very uncomfortable. Eating slowly is usually a good strategy until your mouth becomes used to the new prosthesis.
  • Saliva: Excessive salivation is very common after inserting a new prosthesis. Excessive salivation typically resolves quickly as your mouth learns that the new prosthesis in your mouth is not a candy.
  • Denture sores: Patients who receive removable dentures or overdentures should expect that the dentures will cause some temporary gum irritation. This is usually easily improved through adjustments to your denture by the dentist. Several appointments may be needed.

Your overdentures are retained to the implants by clips with plastic inserts. These inserts will wear over time and require yearly (or sooner) replacements.

  • Relines
    Your gums will continue changing their shape as you age. This will likely cause your overdenture to lose its precise fit to the gums. As a result, it may start feeling loose, and you may notice food collecting underneath after several years. Your removable dentures/overdentures will need regular relines every few years as the need arises. 
  • Retention
    An overdenture is a removable prosthesis. You may discover at your treatment’s conclusion that you wish your removable prosthesis to be even more retentive than possible with the current design. This can often be accomplished where appropriate by placing additional implants and fabricating a brand new prosthesis. 

About crown(s)/bridge(s)

  • Crowns and bridges are held to the implants by small internal screws. These screws fit through small channels in your crown(s)/bridge(s). The very top of the channel(s) is covered with small filling(s) after the treatment. This small filling may occasionally dislodge, leaving the channel open. This represents no danger or risk for anything other than the possible annoyance of food getting stuck inside the hole. The hole can be easily resealed with a new filling.
  • Cleaning
    Your teeth and new prosthesis must be kept impeccably clean by you at home and professionally cleaned regularly at a dentist’s office. Failure to do so may cause the development of an infection and may cause the loss of your implant(s) or the prosthesis. 
  • Monitoring
    You must return for regular recall assessments. These assessments include a clinical exam and radiograph(s) (Xrays). Many problems that may occur with implant treatment will not be noticeable to you at first until it is too late. It is your responsibility to bring to our immediate attention any complications that you may encounter. Failure to do so may cause a simple-to-fix problem to become more extensive and expensive.

This second blog, together with the first one, is the information we at Affinity Dental Care provide to our patients to help them understand the implant therapy and make the right decision on the treatment. Our goal is to give the patients the proper treatments suitable for their conditions and help them achieve healthiness and confidence that will last.


Implant progress continues

In October 2020, I wrote a blog on a patient whose upper front central incisor (tooth #21) had external resorption. The resorption was extensive and rendered the tooth hopeless in prognosis. Different options were presented and discussed – endodontic treatment and extraction with a fixed bridge, a removable denture, or an implant-supported crown as the final prosthesis. Another factor we debated on the challenge in her case besides the time and surgical procedures going to involve – is her oral lichen planus.

Oral lichen planus can present in six types clinically: Reticular (fine white striae cross each other in the lesion), Atrophic (areas of erythematous lesion surrounded by reticular components), papular type, bullous type, plaque-type, erosive or ulcerative type. This disease occurs more frequently in females and is a T-cell mediated autoimmune disease. The ramification is the delayed healing of the gum tissues, leading to a higher chance of infection after surgery.

Despite the higher chance of failure, she elected to have the tooth removed and replaced with an implant-support tooth.

Therefore, the patient had to take a high dosage of antibiotics and rinse her mouth with antiseptic with meticulous oral hygiene before and after the surgery.

The first appointment in October 2020 was to extract tooth #21 and bone graft the socket with mineralized freeze-dried bone allografts (FDBA). The purpose of the bone graft is to create more bone dimensions for the future implant.

Implant progress on incisor Before and after dental implantX-ray of the upper central incisor before extraction, after extraction with the bone graft, and with the implant.

Bone graft particlesBone graft particles

Right after the tooth was extracted, a simple cantilever bridge was fabricated and bonded to the other central incisor to provide a temporary tooth to replace the extracted tooth. The bone was allowed to remodel inside the extraction sockets for over eight months. The healing was non-eventful overall. In August 2021, another course of antibiotic and mouth rinse regimes were initiated for a week before placing a Straumann bone level taper implant (Roxolid SLA) in the grafted site. I attached an immediate temporary crown made of polyether ether ketone (PEEK).

Incisor before extractionThe upper left central incisor before extraction.

Temporary bridge after the extractionA temporary bridge after the extraction

The upper left central incisor replaced with an immediate temporary crown attached to an implantThe upper left central incisor replaced with an immediate temporary crown attached to an implant

A temporary PEEK crown attached to the implant lets the surrounding gums remodel to provide a natural appearance. During the remodelling period, the temporary crown was removed a few times during the six-month healing period to recontour the shape of the temporary crown – 1) to allow the gums to form a natural appearance and 2) to achieve an aesthetically balanced tooth shape that the future permanent crown can model on. Meanwhile, the other upper central incisor (tooth #11) was modified to remove the black triangle (the excessive space between the two front teeth at the gums) and to make the tooth less ovoid in shape. The results are far more natural and harmonious.

After both the upper central incisors were modifiedAfter both the upper central incisors were modified

At this stage, after the implant has been placed in the bone for over six months, the implant was tested for stability using a resonance device to make sure it has good bone ingrowth into the implant. The result was excellent, with a reading of over 80, which indicates that the implant has pretty good stability.

Trios scannerKnowing that the implant is ready for a definitive “permanent” crown, an impression was obtained using our latest 3-D scanner to make the digital topographic impression. It is a technique to measure the sizes, locations, orientations, depth, morphologies, and angulations of all the teeth and other tissues in the mouth. The scanner can also select the shade and chroma of the teeth that match the standard Vita shade guide. A 3-D printer can print out the digital impression if needed.

A digital impression of upper teeth taken by a Trios scannerA digital impression of upper teeth taken by a Trios scanner

The “permanent” crown for the implant is being fabricated during the writing of this blog. The crown will have three components – the base made with machined titanium, the white zirconia bonded onto the titanium base and a layer of live-like material made with lithium disilicate baked on top of the whiter zirconia.

The “permanent” crown for the implant
Once I have the crown attached to the implant, I will continue to blog on the progress of the final stage of this exciting journey.


Implant therapy, Part 1

There are a few reasons implant therapy is wanted by a patient or recommended by the patient’s dentist. The reasons for having an implant procedure are:

1) To replace a missing tooth

2) To improve the ability to chew

3) To prevent adjacent teeth from drifting

4) To make the removable denture more stable

If you are missing your tooth/teeth and have no concerns about aesthetics, your ability to eat and your dentist have advised you that the likelihood of the teeth drifting is low. A reasonable option is No Treatment and not to replace your missing tooth/teeth.

Besides implants, you should be advised that other options exist to replace their missing tooth/teeth. Among all the options listed below, each has pros and cons. What is suitable depends on an individual’s situation. The possible options are:

1) Removable denture

2) Dental bridge

3) Dental implant therapy

Dental Implant Therapy

Dental Implant therapy consists of two parts

  • Dental implant

The first part is the surgical placement of the dental implant in the jaw bone. The dental implant is made with titanium and looks similar to the tooth’s root. The implant is made with titanium which is a bone-friendly material. When the dental implant is surgically placed into the jaw bone, the bone heals around the implant. Once the bone heals around the implant, this provides a stable foundation for the prosthesis.

  • Dental crown, bridge or overdenture

The second part is the parts above the jaw bone and visible. It could be a crown, which looks like a natural tooth, a bridge and an overdenture. Collectively, they are called a prosthesis which is the component that sits on top of the dental implant.

The prosthesis may be:

  1. Fixed on top of an implant such as a crown or a dental bridge
  2. Removable like a denture sitting on top of the clips of the dental implants. The clips on top of the implants help improve the denture’s stability. Hence it is called overdenture.

Advantages and disadvantages of dental implant therapy

The advantages of having dental implants are:

  • If a prosthesis is fixed on the implant, the prosthesis functions like your natural teeth.
  • If you have a removable prosthesis, the implants provide better stability to your denture.
  • Dental implant therapy often does not negatively affect your adjacent teeth, whereas other non-implant options such as the dental bridge require reduction/shaving of your adjacent teeth.

Disadvantages of dental implants

The disadvantages to having dental implants are:

  • Implant therapy does require one or more surgeries.
  • Compared to the other non-implant options, the treatment time for dental implant therapy is significantly longer because time is needed to allow the bone and soft tissue to heal around the implant.
  • After placement of the dental implant, although the possibility is low, there is always a risk that the bone does not heal properly around the implant. If this occurs, the implant has failed and must be removed. Future placement of a new implant is possible but may require additional procedures such as bone grafting.
  • Some patients may develop inflammation, infection or complication around the functional implant. These do not occur often, but when it happens, you will need additional treatment to eliminate the problem. The worst-case scenario may involve the removal of the implant.
  • The prosthesis is subject to normal wear and tear. As a result, technical complications may arise, such as loosening the screws, cement washout, and fracturing of the porcelain. These technical complications may be fixed, but the entire prosthesis may need replacement.
  • Factors that may be associated with increased risk of implant complications and failure include:
    • smoking
    • diabetes
    • poor care of the mouth
    • not following the dentist’s recommendations
    • not visiting the dentist for regular monitoring and care

Implant surgical procedure

Regarding any risks from the implant surgery, generally, the procedures are minimally invasive and therefore carry little risk. However, there are possible complications that include:

  1. Infection following surgery. This is unlikely if you use the prescribed medications before the surgery.
  2. Implant failure. There is less than a 10% chance that the implant(s) will become unsuccessfully attached to your jawbone.
  3. Nerve damage. If there is minimal bone height in the lower posterior jaw, implants may be placed close to the central nerve of this jaw. This nerve will be identified at the surgery, and all precautions will be taken to protect it from damage. However, occasionally because of post-surgical swelling, the nerve may give altered (generally reduced) sensation for a period of days to months before returning to normal. In rare instances, the change in sensation may be permanent. If nerve function is altered, it could result in tingling, pins and needles, and/or burning sensations. Most commonly, it is a numb feeling on the surface tissue overlying the implants, inside the lip and on the surface of the lip. There would be no effect on muscle movement or facial appearance. In other words, damage to this nerve will not cause any paralysis.
  4. Damage to the roots of adjacent teeth. In infrequent instances, implants placed adjacent to natural teeth may damage the adjacent tooth/teeth during the implant site preparation. If this occurs, further treatment may be necessary to deal with the tooth damage.
  5. Encroachment into the nasal cavity or the maxillary sinus. Although there may be some initial discomfort and minor nasal bleeding, implants that penetrate the spaces typically heal well. In some instances where the pain persists, additional medical treatment may be required later. Rarely it may be necessary to remove an implant.
  6. Failure of the bone graft. In some instances, bone grafting procedures may not provide adequate bone for the subsequent placement of dental implants due to complete or partial failure of the bone graft because of poor healing and graft infection.

Should any implant not properly attach, it will be removed. If the conditions are still favourable for an implant, another attempt to place an implant will be performed; otherwise, other options like a bridge or a denture can be considered.

It is anticipated that the implant(s), if successful, will function for many years if you take care of them. However, the longevity of the implant(s) depends on many factors, including:

  • good general health, excellent oral hygiene,
  • complicating oral habits such as night grinding,
  • regular dental care for your remaining teeth,
  • regular check-ups for the implant(s) and the attached the crown(s),
  • and a smoke-free lifestyle.

Bone grafts and membrane

For successful implant therapy, there must be enough bone. If there is not enough bone, the patient may need surgery to increase the amount of bone. Using bone grafts and membranes is the key to improving bone quantity and quality.

There are potential sources of the bone and membrane:

  • Bone harvest from other areas of your mouth.
  • Bone purchased from a bone bank- The source of the bone may be from human or bovine. These bone tissues are regulated by the strict organ donation criteria, where donors are screened and tested for transmissible diseases. The harvested bone undergoes intense processing and retests.
  • Membranes used are of bovine or porcine origin.
  • The bone grafts and membrane used are safe to use. Specifically with the materials that we use, to date, there has been no documented case of disease transmission (hepatitis, syphilis, blood and tissue infections, and the AIDS virus).

Dental implant therapyThe clips on the implant can hold the denture down

Dental implant therapyA molar crown attached to an implant

This blog is part of the information we at Affinity Dental Care provide to our patients to help them understand the implant therapy and make the right decision on the treatment. Our goal is to give the patients the proper treatments suitable for their conditions and help them achieve healthiness and confidence that will last.


White filling resin with no Bisphenol-A

Like Affinity Dental Care, most dentists nowadays do not use silver amalgam fillings anymore because of the mercury content in this material.

We only use composite resin for the fillings in both anterior and molar teeth to avoid mercury alloy. We like composite resin because of other advantages as well – tooth coloured, translucency that makes it more life-like, less drilling and removal of sound tooth structure before filling with this material, and ease of repair.

However, there are many different brands of composite resin by several manufacturers. They are not all the same in terms of chemistry and their properties.

Unfortunately, many different brands use BPA (bisphenol-A) or Bis-GMA (Bisphenol-A-Glycidyl-Methacrylate). BPA is an endocrine-disrupting chemical that affects your health in a large quantity. Considerable exposure can cause problems in the brain and prostate of fetuses and children. It can also cause behavioural issues in children. Other studies also link this chemical to early puberty, metabolic disorders such as obesity and diabetes, heart disease, high blood pressure, infertility, thyroid dysfunction, and some cancers.

Spermatogenesis impairment and male reproductive abnormalities are related to excessive exposure to this chemical.

Bisphenol-A is a commonly used chemical for plastic materials such as polycarbonate bottles, containers, or coatings of cans. Bis-GMA is not the same as BPA; it comprises only the BPA structure in a tightly bonded ether form. There are traces of BPA in those composites, however.

Suffice it to say. It is a good idea to minimize the amount we are exposed to. In Affinity Dental Care, we use a non-BPA or GMA-containing composite resin made by Kulzer Dental called Venus Pearl. Venus Pearl does not contain any of the two chemicals.

Besides this advantage, there are other benefits of this composite material as it is:

  • easy to be used to fill the cavities – it is not sticky and has a creamy consistency that makes the material easy to be applied to the cleaned cavities,
  • durable – the material’s matrix is a nano-hybrid complex (the filler is from 5 nanometres to 5 micrometres) that resists wear, erosion and crack propagation,
  • strong – It combines high flexural strength with minimal shrinkage stress. The results are long-lasting, and
  • good looking – it offers a wide range of shades and can be applied in single- and multi-shade layering techniques. The material adapts perfectly to the colour of the surrounding teeth, creating an outstandingly natural look.

We do not introduce chemicals that are known to cause harm to our patients at Affinity Dental Care cause we like to consider wellness and health for our patients.

Non-BPA Fillings

Non-BPA Fillings

Top – a molar with a silver amalgam filling. Bottom – the same molar with a white composite resin filling. Dr. Wong at Affinity Dental Care did the filling.


New Dental Implant

Modern dental implants are almost all made of titanium metal inserted into the jaw bone to support artificial teeth made with tooth-like materials. The material could be porcelain, lithium disilicate, composite resin, acrylic or zirconia. There are a few implants made with zirconium oxide, however. The titanium implants are usually greyish metallic, and the zirconium oxide ones are white. Titanium implants have a long history of success. The first titanium dental implant was placed in a human volunteer in 1965 by an orthopedic surgeon named Dr. Branemark. The white Zirconium oxide implant has a shorter history; it was first introduced in 2005.

Dental implants function like roots in the jaw bone to solidly support structures like crowns, bridges and dentures in the mouth that the patients would otherwise could not have. In order to place the implant in the bone, several surgical procedures may involve. After the implant is placed in the bone, a few months is needed for the bone to heal tightly around the implants before the implants can support functional teeth.

There are many other benefits of having the implants besides having new teeth that do not move:

  • Maintain jaw bone by reducing bone resorption of the jaw bone where the implants are located. Without the implants in the bone, the bone will gradually become smaller in dimension and density.
  • Can confidently chew more solid food without pain from the otherwise sliding, painful and unstable dentures.
  • Improved appearance and smile because implant-supported teeth can look and feel like your own teeth, having the appearance of pink gums around the teeth naturally.
  • Improved speech with the spaces having teeth and no more unstable, loose dentures
  • Improved comfort because the implants become part of you; implants eliminate the discomfort of removable dentures.
  • Improved self-esteem because dental implants can give you back your smile and help you feel better about yourself.
  • Improved oral health because implants can be placed in the bone where the teeth are missing, either immediately or after extractions. Implants do not involve other teeth as a tooth-supported bridge does. Individual implants also allow easier access between teeth, improving oral hygiene.
  • Implants are very durable and will last many years. With good care, many implants last a lifetime.
  • Convenience because implants eliminate the embarrassing inconvenience of removing dentures and the need for messy adhesives to keep them in place.

There are many shapes and sizes of implants. Conventional implants usually have a width between 3.3 mm to 6 mm. Mini-implants are long and narrow and have a width of between 2.2 to 3.00.

Lately, Keystone Dental has developed wide-body implants ranging from 7 mm to 9 mm. The wide-body implants are for immediate replacement of a molar tooth in the same sitting after a tooth is removed. A conventional implant is often not suited for immediate placement in the molar extraction socket because the smaller size cannot effectively fill up the wide of the socket of the molar after extraction. On the other hand, a wide-body one can fill up the space of the molar socket much better and, therefore, have more stability. Better stability means a better outcome in the healing process.

Wide body dental implant
Wide-body implant
Conventional dental implant
Conventional dental implant

Another nice feature of these wide-body implants is the shorter lengths than conventional implants. They only need shorter lengths because they have much wider diameters that provide more surface area for bone to heal into them. Frequently, there is not enough bone depth for a conventional implant to be inserted before it encroaches into vital structures like the sinuses, inferior alveolar nerve, lingual nerve, and blood vessels. A shorter wide-body implant can be a good option in cases like these.

The other benefits of the broad platform of the wide-body implant allow for an emergence profile suitable for a molar restoration, less food trap and more aesthetic. Because they are ideal for immediate placement in a multi-rooted molar extraction socket, therefore they require a less surgical procedure, shorter treatment time and maximized bone preservation.

At Affinity Dental Care, we provide implant treatments using conventional implants and the new wide-body implant to restore teeth with crowns, bridges and secured dentures for our patients.

Image courtesy of Keystone Dental
Courtesy of Keystone Dental

Kids’ teeth grinding during sleep

Sleep bruxism in children is characterized by grinding and involuntary teeth clenching. It is natural to be concerned if you hear your child grinding their teeth in their sleep. Bruxism in children lasts about four seconds and can occur up to six times per hour. Typically, the parents notice the condition first because they can hear the grinding noises at night.

Many kids have it, but most outgrow it without lasting problems.

If your child is around 3 to 5 years old, I would not be overly concerned about it because some scholars have indicated that sleep grinding at that age could produce physiological wear to allow the growth and development of the jaw. It can become more of a concern if you hear or notice your older children grinding their teeth at least three times per week for two months because repetitive masticatory muscle activity can cause serious health complications. Typically, the incidence of sleep grinding decreases from ten years old onwards.

Causes of Sleep Bruxism in Children

Kids grind their teeth for a few reasons:

  • pain, such as from an earache or teething
  • temporomandibular joint disorder (TMD)
  • erupting adult teeth in the mixed dentition period, typically between 6 to 12 years old
  • misaligned teeth
  • stress (worry about a test or a change in routine) and social anxiety disorder (arguing with parents and siblings can cause enough stress to prompt teeth grinding or jaw clenching)
  • medical reasons like hyperactivity, cerebral palsy, attention-deficit disorder, gastroesophageal reflux, sleep apnea or hypoxia secondary to airway obstruction
  • taking some types of medicines like antidepressants and psychotropic drugs for anxiety
  • frequent snoring and mouth breathing, which could be a sign of upper airway obstruction
  • daytime bad habits and parafunction like lip, pen and nail-biting
  • frequent nightmare
  • second-hand smoke
  • genetic reason and personality trait (it runs in families). Studies have indicated a positive correlation between the concentration of catecholamines in the urine and sleep bruxism. Disturbances in the GABAergic and glutamatergic systems of the brain also have a positive correlation with sleep bruxism

Many times, bruxism is not noticed and does not cause problems. Often, it’s more bothersome to other family members because of the grinding sound.

But sometimes, it can cause:

  • headaches
  • worn down tooth enamel or chipped teeth
  • sensitive teeth
  • face, ear, or jaw pain
  • sleep disturbance that can cause behavioural problems and medical issues because they are not getting the rest children need

It can be challenging to pinpoint the cause of bruxism. I may use a method of elimination to determine the cause. I need to examine the patient systematically to determine the causes and risks, then provide treatment to the patient accordingly if the reasons are a concern.

Treatment for Bruxism

Most kids will outgrow sleep bruxism, but they still need to be monitored by the dentist. Grinding can damage both primary and secondary teeth and affect current and future oral health. The treatment approach can include monitoring and

  • a nighttime mouthguard
  • an examination by a pediatrician if medical reasons like tonsilitis and airway obstruction are suspected
  • reduction of the stressors – parents’ roles are vital because they could be the ones who can help to eliminate the stressors like high expectations and excessive extracurricular activities like piano lessons or sports
  • referral for mental health counselling
  • improve your child’s sleep hygiene by making sure their room is dark and quiet, limiting their time on cell phone and computer
  • Soothing bedtime activities like brushing teeth, taking a warm bath, cuddling together with your child, reading stories and soft music
  • provision of nutritious diet low in added sugars but avoid hard snacks like corn chips, popcorn and chewing gum
  • stretching exercises and facial massage techniques
  • orthodontic treatment to align the teeth and create proper arch forms that can help healthy orofacial development
  • elimination of parafunction and bad habits like nail and pen biting
  • acupuncture and photomodulation of the (acupoint) trigger points
  • Stop using a pacifier if the kid is still using it after 2.5 years
  • Hydroxyzine medication before bed for two months for older children

Combining the above treatment modalities is often needed if the condition is severe. We love to see children at Affinity Dental Care.


Safe Mercury Fillings Removal

Dental silver filling is a filling material used to fill cavities. It is also called dental silver amalgam filling.

Dental amalgam is a mixture of metals consisting of liquid mercury (about 50%) and a powdered alloy composed of silver (about 25%), tin (about 14%), zinc (about 8%) and copper. The liquid mercury reacts with the three metals to form a paste. Before the chemical reaction is completed, dentists can pack the paste into a cleaned cavity, then carve out the shape and anatomy before the paste becomes hard.

It is a strong, cheap, and durable material for cavity filling. It has been in use since the early 1800s. The silver amalgam has an antibacterial effect with a self-sealing property that contributes to its longevity. However, there are potential risks with mercury fillings.

Potential Risks:

  1. It contains elemental mercury that can release in the form of a vapour that can be inhaled. Exposure to high levels of mercury vapour, which may occur in some occupational settings, has been associated with adverse effects on the brain and the kidney.
  2. Fetuses and young children whose developing neurological systems are more sensitive to the neurotoxic effects of mercury vapour. In light of this, there are concerns about using mercury fillings in pregnant women with their developing fetuses, women planning to become pregnant, nursing women, and young children.
  3. People with pre-existing neurological diseases and people with impaired kidney function.
  4. People with known heightened sensitivity (allergy) to mercury or other dental amalgam components (silver, copper, tin).

In July 2018, the European Union prohibited amalgam for the dental treatment of children under 15 years and pregnant or breastfeeding women.

Due to the “potential risks” and the poor cosmetic results, I have not been doing silver amalgam fillings for over two decades. In fact, my office does not have mercury amalgam materials at all.

Suppose you fall into any of the greater risk groups listed above; both Health Canada and the Food and Drug Administration (FDA) recommend not to use mercury amalgam filling in those groups mentioned earlier in this blog.

I do not recommend anyone remove or replace existing amalgam fillings in good condition unless necessary – patients with medical conditions mentioned, physiological reactions to this material, or holistic propensity. Removing intact amalgam fillings can result in unnecessary loss of healthy tooth structure and a temporary increase in exposure due to additional mercury vapour during the removal process.

The International Academy of Oral Medicine and Toxicology (IAOMT) has provided guidelines on a safe amalgam removal protocol dubbed Safe Mercury Amalgam Removal Technique (SMART). At Affinity Dental Care, we closely follow the guidelines and have the following equipment and protocols.

  • An amalgam separator filters all the wastewater from our dental high volume suction to collect mercury waste such that no mercury is released in our effluent into the public sewer system. A certified medical waste disposal company safely disposes of the amalgam separator once full.
  • The operatory is equipped with a MedEVAC Airflow chairside unit that can remove mercury vapour from the air during amalgam filling removal. The nozzle is placed close to the operating field.
  • A non-latex rubber dam isolates the teeth from the rest of the oral space to keep the amalgam pieces from entering the mouth before a high-volume waste suction removes them.
  • The patient’s face and head are covered with a disposable sheet to prevent accidental contact with the mercury alloy during the removal.
  • A high-volume evacuation suction is used thorough the removal and cleanup procedure. After completely removing the amalgam filling, the area will be thoroughly washed with water and then with a slurry of charcoal before removing the rubber isolation dam and head/face cover.
  • A saliva ejector is placed under the dental dam to reduce mercury exposure to the patient.
  • The amalgam is to be sectioned into chunks and removed in as large pieces as possible, using a small diameter carbide drill under a copious amount of water.
  • We avoid any amalgam filling removal for women who are pregnant or breastfeeding.

We do not stock any mercury materials and restore teeth with composite white fillings to avoid mercury exposure. We use porcelain, lithium disilicate (Emax), and Zirconia materials for crowns and bridges.

If you are interested in having the silver amalgam fillings removed safely and holistically, please call our office to book a consultation appointment.


Airway Dentistry

I recently heard the term airway dentistry, and I was curious about what that exactly is. I have been researching and noticed that it is just another term for dentistry that focuses on the mouth’s structure and how those impacts breathing. It involves looking for signs of sleep breathing disorder like tooth wear, the position of the tongue and the condition of the soft tissue. The goal is to recognize signs and symptoms of breathing disorders that could lead to obstructive sleep apnea.

I have been practicing dental sleep medicine emphasizing sleep-related disorders like obstructive sleep apnea. I have also been looking for potential developmental issues in children who show signs and symptoms of craniofacial discrepancy that can cause nasal obstruction and mouth breathing habits.

Essentially, wellness and holistic dentistry encompass airway dentistry. I practice my dentistry by looking beyond the teeth, nose, throat, muscles of the tongue, face, neck, and rest of the body. Our entire system and organs are interconnected. I mentioned in my previous blog about the effects and the subsequent diseases that can arise from a single disorder – a breathing disorder. The compromised airway should be treated rigorously and as soon as it is diagnosed, as it can lead to many other conditions. The list of the conditions is long, ranging from poor facial aesthetics and hunched posture to debilitating congestive heart failure. Please see my previous blogs on Nurturing, Sleep Apnea, Tongue-tie and Lip-tie.

Sleepiness and narcolepsy during the day despite 7 to 8 hours of the sleeping time the night before can be the sign of obstructive sleep apnea or hypoxia for adults. Snoring, teeth grinding, and excessive enamel wear are signs of sleep-related breathing disorder. Infants who have trouble breastfeeding could have tongue and lip ties or even upper nasal airway obstruction. Tongue and lip ties can themselves lead to the craniofacial discrepancy that, in turn, causes a narrow upper airway.

There are many reasons you should breathe in through your nose instead of the mouth. You can take deeper breaths, which provides more oxygen to the body. Chronic mouth breathing causes teeth to crowd and narrow, long faces. Mouth breathers are more likely to have sleep-related breathing disorders, dry mouth, swollen gums and other gum diseases.

Airway enhancement is part of holistic wellness dentistry. The recognition and referral to medical colleagues to make the diagnosis of the underlying diseases and related treatments could be the first step in helping patients. Besides the recognition and proper referrals, dentists can provide treatments like palatal expansion, mandibular advancement, oral myofunctional therapy, air-centric orthodontic treatment etc. Dentists can help lactating mothers understand the importance of breastfeeding and proper unprocessed diets for their infants to enhance airway development and immune system development. If the infants have tongue and/or lip tie problems that affect breastfeeding, frenectomy or frenotomy should be done.

Integrative Dental Medicine is a term to describe the modern-day dentistry that dentists should be practicing to provide the best outcomes to our patients. It comprises airway dentistry, air-centric orthodontics, wellness and holistic dentistry.

At Affinity Dental Care, we practice dentistry the way I blog.


An Implant Case

My patient had a tooth in his lower right side, the first molar, that was very mobile due to advanced gum disease with severe bone loss. The tooth was deemed hopeless in prognosis, so I recommended the patient have the tooth extracted. The patient has presented the different options with the would-be space left behind in detail: leaving the space empty, replacing it with a removable partial denture, fixing a three-unit-dental bridge, and placing a crown supporting by an implant. After all the fees, procedures and other questions were answered, the patient elected to have the tooth removed and replaced with an implant-supported crown.

Severe bone loss in the first molar
1. Severe bone loss in the first molar

After having a cone-beam computed tomography taken (CBCT) to determine the adequacy of bone volume and quality for an implant, treatment plans were made to place a tissue level Biohorizons implant immediately after the extraction using a surgical template to guide the placement of the implant.

Treatment planning using 3D imaging
2. Treatment planning using 3D imaging

The patient was instructed to take an antibiotic and rinse his mouth with an antiseptic for a few days before the surgery.

On the day of surgery, a local anesthetic was first administered, and when the numbing was profound enough, the tooth was atraumatically extracted. The inflamed tissues inside the socket were cleaned out carefully and meticulously. Immediately, an implant was placed inside the prepared socket. Due to severe bone loss from his advanced gum disease, ground bone particles from a human donor were grafted and packed around the implant. A special collagen membrane was placed over the bone graft to ensure that the patient’s bone cells migrated among the bone graft particles to form new natural solid bone around the implant.

Immediately implant and bone graft placement after the extraction.
3. Immediately implant and bone graft placement after the extraction.
An implant case
4. The implant with a cover after six months of healing.

After six months of healing, a resonance test, a device that gives out a measurement in number, was done to determine how well the implant had been embedded in the jaw bone. The measurement indicated a well-integrated implant with the bone; therefore, the implant was ready to support a crown. A Trois digital scanner was used to take an impression of the teeth and implant. The digital data were sent to a dental laboratory. A digital model was printed with the implant analogue embedded in it in the same way as the actual implant in the month.

A crown made with Zirconia material was made that fit onto the implant. The crown was then secured to the implant with a screw in the mouth that must be tightened with a torque wrench.

After the crown was securely screwed onto the implant, a composite resin was used to fill in the screw hole. In this case, it is a screw-retained crown. A screw-retained crown is desirable because of its ability to be removed easily from the implant if the crown is chipped and requires removal for repairs. If there is periimplantitis (bone loss around the implant due to infection), the crown must be removed for proper treatments.

The implant without the cover.
5. The implant without the cover.
The crown was made on the digitally printed model.
6. The crown was made on the digitally printed model.
The crown was tightened onto the implant with a special wrench.
7. The crown was tightened onto the implant with a special wrench.
The crown was secured onto the implant and became functional.
8. The crown was secured onto the implant and became functional.

Lip Tie

About lip-tie: In my last blog, I mentioned seven frena (also called frenula) in the mouth, found in the top, bottom, sides of the mouth, underneath the upper and lower lips, and below the tongue. The primary function of the frena is to keep the different structures together with flexible but restricted movements. The flexible and yet controlled movement of the organs (lips, cheeks, tongues etc.) allows proper food capturing, swallowing, speech, and mouth movement.

Babies born with lip-tie can have Issues with breastfeeding, inadequate weight gain, colic, sore mother’s nipples. If untreated, it will affect speech, instrument playing, kissing, etc., in adulthood. It will further generate space between the two upper front teeth (diastema), gum recession, painful dentures etc.

What is a lip tie?

A lip-tie occurs when a baby born with the frenulum attaching the lip, upper or lower lip, to the gums, is very short and tight. The lip-tie may make it difficult to move the lips. Lip ties are less common than a similar (sometimes co-occurring) condition: tongue tie. There is reason to believe that lip ties and tongue ties are genetic.

Lip tie has not been studied as much as tongue-tie, but treatments are similar.

Common symptoms

Related symptoms in babies may include:

  • Struggling to latch on to the breast. The baby may make clicking or smacking sounds while nursing because of poor latching or constant losing the nipple.
  • Difficulty breathing during feeding.
  • Falling asleep often during nursing and prolonged feeding time.
  • Acting extremely fatigued by nursing.
  • Slow or lack of weight gain.
  • Colic.
  • Failure to thrive.
  • Breast milk leaking from the mouth as a result of a poor seal.

Related symptoms in mothers may include:

  • Pain during or after breastfeeding – blocked milk ducts or mastitis.
  • Breasts that feel engorged even right after nursing
  • Fatigue from constantly breastfeeding even though your child never seems to be full

Lip tie complications

Babies with a severe condition may have trouble gaining weight. They may have an easier time drinking from a bottle, so you may need to supplement breastfeeding with formula or breast milk-fed from a bottle if that makes it easier for your baby to get nourishment. They will keep your baby on the right track, growth-wise, while you figure out if your child needs a lip tie revision.

Babies who have a severe lip or tongue-tie may have difficulty eating from a spoon or eating finger foods. Some pediatricians believe that an untreated lip tie can lead to a higher likelihood of tooth decay for toddlers.

How is it Treated?

It all depends on the severity of the tie: a small, string-like appearance on one end of the spectrum, a broad, fanlike band of connective tissue on the other. Babies with the severe condition can develop a callus on their upper lip.

The Kotlow classification system uses four grades to rate the frenulum based on appearance. With this system, the higher the grade, the higher the ‘severity’ of lip-tie, and the greater the likelihood of breastfeeding problems.

Level 1 and Level 2 lip ties are typically left alone and do not require revision. If there’s a tongue tie as well as a lip tie restricting your baby’s ability to feed, a pediatrician may advise you to “revise” or “release” them both, even if the lip tie is considered to be Level 1 or Level 2.

Level 3 or Level 4 lip ties may require a frenotomy procedure. However, most people equate frenotomy to frenectomy as they are two different procedures.

A frenotomy neatly severs the membrane connecting the lip to the gums. It can be performed using a laser or a sterilized surgical scissor. In comparison, a frenectomy involves total removal of the frena, including its attachment to the underlying bone, which requires more surgery than a simple frenotomy incision.

Besides frenotomy or frenectomy, the mother can try a therapy technique to loosen a lip tie and make it easier for babies to breastfeed. Sliding your finger along the top of your baby’s lip and practicing lessening the gap between the lip and gumline can gradually improve the mobility of your child’s lip.

Lip-tie with gum recession
Lip-tie with gum recession
Frenotomy using diode laser – minimal bleeding and pain right after
Frenotomy using diode laser – minimal bleeding and pain right after
Healing after a week – fast healing
Healing after a week – fast healing