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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.
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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
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Tongue Tie

Tongue Tie

Tongue Tie: There are 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.

A frenum (singular for frena) is a fleshy piece of soft tissue comprised of elastic and striated muscle fibres attached between the gums and the other tissue structures like the lips, cheeks, tongue etc. The primary function of 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.

What is a Tongue Tie?

A tongue-tie is a condition someone is born with that the frenum is too tight that the tongue has limited, overly restricted movements, resulting in ankyloglossia – the frenum is too short, too thick or too broad. Boys have more prevalence for tongue ties than girls.

In neonates, tongue-tie causes the infant to have trouble drinking breast milk because the tongue cannot latch on the nipples. When the infant cries, the tongue appears to have a V shape or a heart shape. Because of not drinking adequate breast milk, the growth and development are impaired and slow.

If gone undiagnosed and untreated, tongue ties can cause many issues to children like small body size, Intellectual disability, ADHD, teeth grinding, dental malocclusion, restricted airway development, dental malocclusion, chronic mouth breathing, speech difficulties, snoring, problems with swallowing, elongated face, small lower jaw, frequent upper respiratory infections. The list can go on and on further.

Adults who have not had the issues corrected before suffer from the signs and symptoms listed in the previous paragraph. Moreover, they also can be experiencing craniofacial deformity, lower self-esteem, lisping and difficult speech, laud snoring, sleep apnea, tongue and cheek biting, soreness in the jaw, TMJ pain, lethargy, gum recession at the site of the frenum attachment (the frenum pulls the gums away), difficult kissing, painful denture (the denture irritating the frenum constantly) etc.

How is it Treated?

A frenotomy is a procedure that releases the tight ligament in the tongue tie by making an incision in the frena. Most laypeople use the term frenectomy, which means the total removal of the frena. Frenectomy is not indicated in most cases.

Frenotomy is simple and adequate for most tongue-tie cases. Since there are few blood vessels or nerve endings, it can be done without any numbing or anesthesia. We just cut the frenum so that the tongue can move normally. After the procedure, the baby can feed without discomfort.

We apply topical numbing gel first for adults and then a bit of local anesthetic around the site. Diode laser is then used to severe the ligament in the frenum with minimal to no bleeding. The laser seals the cut surfaces, so the pain level is usually minimum after the local anesthetic is gone.

Recognition of tongue-tie in babies is essential. The best outcomes from a frenotomy treatment are usually within the first three months after birth. After three months, the infant will take a pregressively longer time to readapt their tongue position during latching after the treatment. Most cases are recognized by a lactation consultation or a nurse at the maternity ward. The mother should look out for it if she is experiencing:

  • pain during or after breastfeeding
  • breasts that feel engorged even right after nursing
  • blocked milk ducts or mastitis
  • fatigue from constantly breastfeeding even though your child never seems to be full
  • colic baby

Should the mothers experience the above symptoms, they should consult with their pediatricians to find out if some issues with the babies affect the feeding.

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Moderate Sedation with Nitrous Oxide and Benzodiazepine

Moderate Sedation with Nitrous Oxide and Benzodiazepine

Moderate sedation: Dentistry has long been associated with pain, fear and anxiety. Fortunately, most of the general population in North America are slightly to somewhat afraid of dentistry, but over 5.5% are highly phobic about dental treatments. 15% of the people are interested in having sedation during a dental visit.

We all know that anxiety affects pain perception, decreasing the pain threshold. The bottom line is that we try to make our patients at Affinity Dental Care feel more comfortable and painless.

How we make our patients more comfortable

The first step is to ensure our patients do not wait too long in our waiting area before seeing them in the treatment area. Our policy is that we do not make our patients wait longer than 10 minutes once they are in the clinic. In fact, 95% of our patients do not need to wait longer than 5 minutes. Besides valuing our patients’ times, we also know that the long wait in a dental office can increase anxiety during the waiting period due to the prolonged activation of the hypothalamic-pituitary-adrenal (HPA) axis in an increase in stress hormone like cortisol release. The longer the patient waits, the more cortisol is circulating in the body, further increasing the signs of anxiety like fast heart rate and heavy breathing.

The colour tone of our walls is calm and soothing. We have windows in all our treatment areas that allow natural light to come in and a nice view of the outside.

We like to tune in to lovely scenery of different countries or videos of fish swimming in the coral reef on our TV while playing soothing music instead of radio stations playing loud music.

Having patients take pain killers right before the appointment can positively reduce pain and soreness. We always apply a topical numbing gel to the injection site before freezing. The freezing technique is crucial, giving the freezing steadily, slowly with acupuncture/vibration, reducing or eliminating the pain from the needles.

We help our patients understand the process

Patients not knowing the treatment process and what to expect can add more anxiety to an already stressful situation. In light of this, a preoperatory consultation can help assess the patient’s medical conditions, previous history of dental treatments tolerance, and psychological conditions. The proposed treatment process can be shown and explained during the exact consultation. When the patients understand the process and feel confident about the dentist, they feel more comfortable and less anxious. It is equivalent to sitting in the dark versus in a well-lit environment.

Our office has no experience with and does not offer other anxiety-reducing modalities like acupuncture and hypnosis. According to our research, both are unpredictable in achieving the end goal – only works sometimes.

Notwithstanding the earlier armamentarium, certain patients may need moderate sedation either because they are petrifying with dentistry or have cardiovascular disease that cannot be stressed further during the dental procedure.

The cornerstone of moderate sedation

The use of benzodiazepine and nitrous oxide is the cornerstone of moderate sedation. We use one of those agents or both together to help to calm and sedate our anxious patients. Nitrous oxide, also called laughing gas, can be used alone to reduce stress and analgesic effect during the treatment.

The gas is non-irritating, sweet-smelling, colourless. It has a high margin of safety, and it is safe for patients who have impaired liver or kidney functions. The gas is delivered via a nose piece sitting on the patient’s nose. Despite its high safety level, there are specific contraindications for using the gas on some patients who are:

  • Inability to tolerate a nasal hood for an extended time
  • Un-cooperative children
  • Claustrophobic patients
  • Inability to breathe through the nose
  • Patients with severe COPD (Chronic obstructive pulmonary disease)
  • Pregnancy in the first trimester
  • Bleomycin chemotherapy within the last past year

Oral sedation with a benzodiazepine can be used alone or in conjunction with nitrous oxide gas. The drug of choice in Affinity Dental Care is Triazolam (Halcion) for adults and Midazolam (Versed) for children. Both are sedative and anxiolytic (anti-anxiety). They both have a short effect and are relatively safe to be used in patients with compromised liver function.

The patients cannot eat or drink anything eight hours before the oral sedation. Because of that, we usually book the patients in the morning for sedation. The patient cannot drive or engage with activities with attention and sobriety for at least 24 hours after.

When both oral sedation and nitrous oxide are combined, the patients become very relaxed and can fall asleep. However, we only administer the medications to the level that the patients remain conscious when they are in the office. Besides following all the conscious sedation protocols closely, other safety measures like vital sign monitoring of the patients are on when the patient is under treatment.

At Affinity Dental Care, we want to ensure our patients are safe and have the least amount of anxiety during dental treatments.

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Gum Disease Treatment

Gum Disease Treatment

The goal of gum disease treatment is to control the infection and restore the health of the gums and bones. There are two approaches to it – allopathic and holistic. The two approaches are not mutually exclusive and can be employed together to achieve “wholistic” results.

When I say holistic approach, I do not narrowly mean detoxification or using natural products to fight gum disease in toothpaste, rinse, capsules or ointment. I am more referring to treating the underlying causes or exacerbating factors of gum disease.

Examples of how treatment should be dealt with

In my previous blog talking about the risk factors, there is a factor of nutritional deficiency in Vitamin C or D. We need to make sure the patient is getting the proper nutrient for the building and maintenance of the supporting tissues. If you are a smoker or social drug user, it makes sense to stop smoking and substance abuse to achieve better oral health.

Stress can be a factor that decreases the immune system and increases the amount of chemo messengers for inflammation in our bodies. This factor needed to be recognized, and appropriate professional help should be initiated.

Diabetes-induced gum disease can be severe. It is usually caused by poorly controlled diabetes – either no knowledge of having diabetes, noncompliance with the medications, indulging in sweet consumption, and simply inadequate or wrong medications. Once the diabetes is under control, allopathic and other holistic treatments can be effectively employed to manage the disease.

Those are just a few examples of how gum disease should be dealt with. A good medical history is essential in guiding the treatment modalities of gum disease.

The importance of patient’s education on gum disease

The patient’s education on gum disease processes (causes and results) is the epitome of the whole treatment. Knowing the importance of brushing and flossing, brushing the teeth properly, the frequency of brushing, etc., is the first stage in helping us have better oral health.

The allopathic approach, comprising biomechanical scraping and chemotherapeutic treatments, eliminates the direct causes of gum disease – the oral pathogenic bacteria and their products, including plaque and tartar.

The biomechanical scraping includes scaling and root planing. It involves physically removing the obnoxious toxin and bacteria embedded in the plaque and tartar sticking on the teeth and roots using fine instruments that dentists and hygienists used to scale the substances out. In some cases, for the patients to feel comfortable during the procedure, local anesthetics can numb the gums and teeth. When the gums and teeth are frozen, cleaning can be done to the root underneath the sensitive and inflamed gums without feeling pain by the patients.

In some cases, gum flaps are raised (gums covering the diseased roots are detached away from the roots with the surgical procedure) to have good visualization of the tartar and disease. The scraping can be performed more effortlessly and more thoroughly. After the thorough cleaning is done, the gums are sutured back onto the roots to heal and seal.

Removal of the redundant, inflamed and frail gums covering the deep gum pocket (space between the teeth and the surrounding gums) can be performed as such that the depth of the pocket can be reduced for easier home care/brushing. This procedure is called gingivectomy or gingivoplasty.

Grafting sound healthy gums to cover the exposed root with receding gums can be performed to enhance the healthiness of the area.

The dentist can prescribe antibiotics like amoxicillin for chemotherapy treatments to fight acute gum infection. If the disease is chronic, low dose doxycycline like periostat can help the body regulate the inflammatory mediators.

Place antibiotics into the deep pockets underneath the gums releasing medication slowly over time can help avoid having the other system exposed to the drug.

Emdogain (a natural protein growth factor) that promotes the healing process of soft and hard tissues is one of the chemo agents that dentists can use to battle gum disease. It is used locally in the defect after the area has been cleaned and disinfected.

Using a dental laser to target and kill the harmful bacteria in the infected gum pockets can be an effective choice of treatment in conjunction with other therapies.

Besides killing the harmful germs, the photons emitted by a particular dental laser can be a biomodulation agent (photobiomodulation) that stimulates the mitochondria (the powerhouse) in our good body cells. The energized cells, in turn, make the healing process a lot faster.

The use of natural botanical products like turmeric, cinnamon, Beswick, etc., in mouth rinse or toothpaste, can help suppress bacterial counts and modulate our inflammatory mediators.

Like I said before in my previous blog. The practice of mindfulness of our body and our health status is quintessential to maintaining our well-being. Periodic checkups with our family doctors and dentists are essential to stop any disease processes from progressing. Prevention is the best medicine. Early detection will ensure the disease is curable and health and wellness can be maintained and last for a lifetime.

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Gum Disease Risk Factors

Gum Disease Risk Factors

Gum disease risk factors could affect your overall health. Gum disease is classified by stage and grade – like cancer staging. After conducting a thorough assessment of your gum health and bone status, dentists/periodontists assign a stage ranging from initial to severe, localized to general, that describes the acuteness of the disease. We also give a grade that indicates the disease progression rate and anticipated response to treatment.

Besides poor oral hygiene home care like neglecting teeth brushing, poor techniques and improper toothbrushes, gum disease can be related to or exacerbated by a litany of other factors that have nothing to do with brushing your teeth.

The litany of other factors includes:

Smoking and Recreational Drug use

Tobacco users often see an increase in disease as they are 2x more likely to develop gum disease. Vaping and smoking marijuana also increase the severity of the disease. Patients addicted to methamphetamines often develop meth mouth, characterized by rampant decay with black teeth and severe periodontal disease.

Diabetes

Diabetes is one of the most common endocrine disorders. People with diabetes are at risk for poor healing due to poor blood circulation and greater risk for infections. Gingivitis in diabetic patients can be more challenging to treat because of poor healing capabilities.

Leukemia

Gingivitis can be an early symptom of leukemia, especially in children. Twenty-five percent of children with leukemia develop gingivitis as the first sign of cancer. Data from studies of childhood leukemia have shown that about 25 percent of children with leukemia develop gingivitis as the first sign of cancer. In leukemia patients, leukemia cells infiltrate the gums, and gingivitis can become severe because leukemia reduces the body’s ability to fight the infection.

Pregnancy

During pregnancy, blood flow to the gums increases, causing gum swelling. The gums are also more sensitive and reactive to the bacteria in the plaque. Sometimes, lumps and nodules develop in the gums between teeth that are red and swollen.

Dry Mouth

Certain medications or medical conditions, Sjorgen disease, may cause dry mouth, leaving your mouth more vulnerable to gum disease. Since saliva often helps to wash away plaque and neutralize the pH in the month, when dry mouth occurs, plaque bacteria have a better chance of causing damage, including tooth decay and gingivitis.

Chronic or nocturnal mouth breathing (due to constricted airway, habit, large tongue etc.) often causes dry mouth and desiccated gums.

Menopause

Patients with menopause often experience dry mouth. Sometimes they may even have burning mouth syndrome. Desquamative gingivitis can occur due to the endocrinal imbalance. This type of gingivitis can be excruciating because the outermost layers of the gums pull away from the underlying tissue and expose nerves. That painful gums lead to more neglected oral hygiene.

Nutritional Deficiency

Poor nutrition, especially vitamin C deficiency,  results in bleeding gums that can develop into gingivitis if left untreated. Vitamin C also helps the body perform maintenance and repair on bones, teeth, and cartilage, and it also helps wounds heal. Vitamin B and D, calcium, magnesium, zinc, and iron deficiency can also impact gum health.

Neurological Diseases

Patients with Parkinsonism, Lou Gehrig’s disease (ALS), have difficulty holding a toothbrush and performing proper brushing and flossing that we all normally can do.

Dementia and Alzheimer’s diseases are other neurological disorders that make regular home care challenging as they are too senile and forgetful to perform brushing regularly.

Misaligned Teeth and Missing Teeth

Crooked teeth are often tough to clean by brushing alone, and plaque accumulates around quickly; as a result, causing gum disease. The misaligned teeth can often suffer from excessive force during biting and chewing, which will accelerate the breakdown of the supporting tissues.

Clenching or Grinding Your Teeth

Excessive force on the supporting tissues of the teeth could speed up the breakdown of periodontal tissues.

Systemic Inflammatory Diseases

Patients with chrons disease or rheumatoid arthritis often have poor gum tissues due to the systemic inflammation also manifested in the gums, possibly triggered by the same inflammation agents like cytokines and prostaglandin in the body.

Stress

Chronic distress can lead to hypertension, headaches, upset stomach, chest pain, restlessness, and insomnia. It can bring on or worsen specific symptoms or diseases. Stress causes the body to be weaker in fighting infection, including periodontal diseases.

Genetics and Immunompromised Diseases

Patients born with compromised immune systems or those who acquire immunocompromised diseases are likely to have severe gum diseases.

Cancer treatments often involve chemotherapy or radiotherapy that suppresses the body’s disease-fighting mechanisms.