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.


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.


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.


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 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.


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.


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.


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.


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.


Gum Disease

Gum disease is a general diagnostic term used by the public referring to diseases in the gum tissues. We have gum disease when we see our gums are swollen, red, bleeding (when touched or during brushing), receded, enlarged, purulent or painful.

Indeed, gum disease does not only refer to the pink or red gums that are readily visible; it also implies the health status of the supporting bone beneath the gums. People with severe and long-time gum disease would also have long and mobile teeth.

Most of us (over 75%) have gum disease in our lifetime. It is crucial to know that there is not just one form of gum disease; there are multiple forms that can affect your overall oral health and wellness. If untreated, it can increase your risk of developing other cardiovascular system diseases, especially in the coronary arteries, diabetes, dementia, etc.

There are generally two forms of gum disease, gingivitis and periodontitis. Gingivitis refers to inflammation of the gums, which develops when plaque that contains bacteria (germ) and food elements slowly build up on the teeth along the gum lines (where your teeth and your gums meet). Given time, the plaque solidified with the calcium and phosphate found in saliva. The hardened masses are known as tartar or calculus. The tartar and plaque release toxins that trigger body cell reactions to cause inflammation around the unwanted buildups.

If left untreated, gingivitis advances into periodontitis, a much more severe form of gum disease. It can cause an infection that destroys the bone supporting your teeth, leading to tooth loss, bleeding gums, gum abscesses, and bad breath.

Gum disease affects most adults, but it can begin at just about any age. Gum disease often develops slowly and without causing any pain. Sometimes you may not notice any signs until the condition is severe and you are in danger of losing teeth.

A few risk factors can cause or make the person more prone to having it. The first and most common factor is poor oral hygiene. You should brush your teeth at least twice a day using a soft toothbrush to prevent gum disease. It is very important to brush the teeth before bedtime to ensure no food debris or drink accumulates on the teeth and in the mouth. When we are asleep, the salivary flow is slow, and the mouth can be dried up quickly, especially with the mouth open during sleep. The germs in the mouth can exert their disease-causing process unchecked in the long hours of sleep. The brushing should thoroughly reach every accessible surface of the teeth and be gentle (it would take at least two to three minutes to brush teeth each time). Floss at least once a day and see your dentist regularly for oral examinations.

Gum disease is often painless until the advanced stages. However, there are signs and symptoms in the following:

  • Red, swollen, tender, shiny, puffy or sore gums
  • Gums that bleed every time you brush or floss
  • Gums that are receding or pulling away from the teeth, causing the teeth to look longer than before
  • Loose or separating teeth
  • Pus between your gums and teeth
  • Taste of metal in your mouth
  • Sores in your mouth
  • Persistent bad breath
  • A change in the way your teeth fit together when you bite
  • A change in the fit of partial dentures
  • Teeth that are sensitive for no reason

In its early stages, gum disease is tough to see. You may not know that you have a problem. Therefore, it is essential to see your dentists regularly for dental exams and cleaning. We use a tool called a “periodontal probe” to measure where your gums attach to your teeth during the examination. Healthy gums attach to teeth just below the edge of the gum. If your gums attach to your teeth below this point, it is a sign of gum disease. X-rays can also be used to see how much bone you have around the teeth and detect bone loss due to gum disease.

Once the gum disease is diagnosed, we need to find out the causes and underlying factors – poor oral hygiene, improper brushing technique, smoking, malocclusion (bad bite), misaligned teeth (excessive chewing force on the teeth that are out of alignment), lifestyle, life stress level, pregnancy and systemic diseases like diabetes, leukemia, immune suppression, vitamin deficiency etc. If the underlying factors are identified or suspected, the appropriate treatments are presented and discussed with the patient. That could be oral hygiene instruction, diet counselling and referral to our colleagues for further investigation.

Other measures like removal of the plaque and tartar, orthodontic treatments and occlusal equilibration, reduction of germs and toxins on the root surface covered by the loose, inflamed gums (mechanically like root planning and debridement, chemotherapy like topical application of antibiotics and ionizing radiation like a laser), surgically excision of the inflamed gums and recontouring of the defective bone. Systemic antibiotics and mouth rinse can also be part of the treatment protocols.

In some cases, guided tissue regeneration, bone grafting and the use of enamel matrix derivative (Amelogenins) may be considered to arrest disease progression and regenerate lost tissues.

The best medicine is always preventative medicine. The patients need to get their teeth checked and cleaned regularly to maintain oral health and total wellness.


Dental cosmetic issues – overbite and overjet

The terms overjet and overbite are commonly coined to describe a dental cosmetic problem. They are often used to express misalignment of front teeth; while both conditions are similar, they are not the same. Patients can have both or one of them that stands in the way of a great smile.

A beautiful smile can work wonders on your confidence and, in turn, your success. My patient came to my office for orthodontic treatment using the clear aligner technique frequently told me that their reasons for seeking orthodontic treatment were overbite. Some are right with their diagnosis, but some have other malocclusion issues.

Overbite is when the upper front teeth excessively overlap the bottom front teeth when back teeth are closed. It is also called a deep bite or a closed bite. An overbite is typically measured in millimetres. Suppose the edges of the top and bottom front teeth line up at the same level when the patient closes their mouth, 0mm overbite. If the top teeth overlap the bottom by 10mm, there is a 10mm overbite. The ideal overbite is generally in the range of 2-4mm.

With overjet teeth, the front teeth protrude outward in a horizontal direction. Overjet teeth happen when the upper front teeth push outward. This condition is also known as buck teeth. When the alignment between these teeth is normal, the upper front teeth sit roughly 2 mm in front of the lower teeth. So overjet describes a condition where the horizontal separation is greater than 2 mm.

In summary, overbite describes the vertical misalignment between the upper and lower front teeth. At the same time, the overjet depicts the horizontal distance between the upper and lower front teeth.

Deep overbites and overjet are a common condition – about a quarter of the population in the world.

Patients with deep bites are usually not noticeable when they smile. However, they are generally associated with retruded or short lower jaw and short lower face height. Because the front teeth excessively cover the lower teeth, the patients who have deep bites tend to have jaw joint or orofacial musculature issues. Other issues are bad bites and misaligned teeth with crowdings. The gums behind the upper front teeth can be irritated if the lower teeth are touching the gums during full mouth closure.

Patients with mild overjet teeth are hardly noticeable, but more significant cases, especially when the front teeth stick out, can change the look or shape of your face. Protruded front teeth make it difficult for their lips to close, leading to difficulty chewing and swallowing. They may have jaw pain as well.

Besides the common problems like crowdings (crooked teeth) and malocclusions (bad bite), speech problems, frequent tongue, cheek or lip biting, both conditions are likely associated with craniofacial deficiency (small and narrow maxilla and mandible) and, subsequently, lack of nasal breathing (more mouth breathing and sleep-breathing disorder).

Overjet and overbite teeth can occur for numerous reasons, including genetics (although I believe it is to the very least extent). They are likely the results of trouble with breastfeeding, infant soft diets, thumb sucking and pacifier usage for a long time as a child.

There are several established treatment options available for an overbite and an overjet that include:

  • Braces – align and correct the bad bite.
  • Teeth removal – gain space for alignment.
  • Appliances for growth modification (Herbst and Bionator etc.) – promote the jaw’s growth and development in 3D dimensions.
  • Aligners (ClearCorrect and Invisalign etc.) – align and correct the bad bite, like braces.
  • Biomimetic devices (Vivos Therapeutics) – promote the width and forward growth of the upper jaw
  • Crowns and bridges – mask the overjet and overbite or restore the vertical dimension of occlusion for the cases with severe enamel wear and missing teeth
  • Veneers – mask the overjet and overbite.
  • Bonding – mask the overjet and overbite.
  • Oral surgery –reset and align the jaw to face or jaw to jaw relationship.

The severity of your case and several other factors will determine the best treatment options. The options can be a single one or a combination of two or more.


Holistic and Wellness Dentistry

Holistic and Wellness Dentistry:

Dentists were traditionally regarded as teeth doctors. However, I believe dentists are oral and maxillofacial physicians for the following reasons:

  • We have education in general medicine, surgery and pathology in dental school.
  • We have training in recognizing (and sometimes diagnosing) diseases in the said areas. At the same time, we can see manifestations of some illnesses in another part of the body in the head and neck area.
  • Like osteopathic medicine, dentists base diagnosis and treatment on the theory that the body’s systems are interconnected. They combine disease prevention and health maintenance with conventional medicine.

From the time babies are born, their growth and development are subjected to nurturing. Genetic makeup may control their traits, but what they eat and what environment and conditions they grow in can stifle or modify the expressions of the genes.

Nurturing or nature? There are numerous studies by Dr Robert Corruccini and Dr Jerome Ross, both are malocclusion anthropologists, showing modern humans have more malocclusion, small upper and lower jaws with teeth overcrowding than the population a few years ago in Western society. They also studied isolated rural peoples, and they found that the peoples do not have a malocclusion. But, once they were exposed to the western prepared-processed foods and culture, the malocclusion started to show in their children.

Animal studies demonstrated that animals fed with a soft diet always end up with smaller body mass, less dense bone and more petite, weaker oral musculature, narrower maxilla, smaller mandible, thinner jaw bone and weaker TMJs.

Today, babies are bottle-fed and have soft food come in a jar like the Gerber. In ancient times, infants drank milk from their mothers’ breasts and started chewing tough meat and vegetable soon after weaning.

Breastfeeding results in proper training and development of the tongue; a functional tongue, in turn, promotes the appropriate mouth and airway developments. Then the early hard diet continues the process. We get ideal growth when the tongue postures, swallows, and speaks properly.

Babies who use pacifiers tend to have improper arch form, small arch width, narrow and high vaulted palate, underdevelopment, and airway compromise.

Dietary consistency and toughness promote proper oral and maxillofacial muscle strength, bone growth and permanent teeth eruption.

According to Dr Jerome Rose, 95% of all malocclusions is acquired. Genetics plays only a 5% role.

As a family dentist who treats patients for their overall wellness, I pay more attention to the signs and symptoms of craniofacial dysfunction in my patients. During an examination, I look for black eyes (venous pooling). Dark circles can tell us a lot about a patient’s airway health. Children with less optimal development due to poor nutrition and restricted airflow through their noses would have a “droopy” appearance in their eyes or visible sclera (the white part of the eye) below the iris.

Before I even look at the teeth, I look for the cue of proper nasal breathing in my patients – lips together and at rest, tongue at the roof of the mouth, teeth are invisible and silent. When the patient sits upright in my dental chair, I check their subconscious swallowing. Patients with healthy nasal breathing should show no movement of lips and cheeks during subconscious swallowing.

The patient’s facial shape and face height, whether the lower jaw is short or not, can indicate their overall health.

Inside the mouth, I look for the symptoms of constricted arch forms, deep overbite, large tongue size, scalloped tongue lateral borders, large and inflamed tonsils, long and flappy soft palate, and tongue and lip ties.

Our teeth do not typically touch between chewing. Our teeth only contact for less than 10 minutes a day, including the time for chewing food. So, the patients with excessive enamel wear based on their age can indicate teeth grinding or clenching during their sleep. They are part of the risk factors for sleep-breathing disorder (SBD).

All the signs and symptoms mentioned above are related to SBD and chronic mouth breathing.

Mouth breathing can lead to malocclusion, increased upper respiratory infections, ENT infections, and asthma. Craniofacial deformity, snoring and obstructive sleep apnea (OSA).

Patients with OSA often have increased face height, decreased nose prominence, decreased nose width and retrognathic mandible. Narrow arches, high vault, elongated soft palate, retrognathic maxilla, retruded mandible are also the results of OSA and mouth breathing.

Chronic mouth breathing increases nasal airflow resistance, sympathetic nervous system activation and altered biochemistry and physiology during sleep. Whereas nasal breathing –diaphragmatic breathing leads to optimal CO2, O2 and Nitric Oxide balance.

Nitric oxide is a compound in the body that causes blood vessels to widen and stimulates the release of certain hormones, such as insulin and human growth hormone. Nitric oxide supplements are a category of supplements that includes L-citrulline and L-arginine.

Snoring is associated with straight profiles, V-shaped palatal morphology, increased neck circumference, decreased upper arch length and shorter inter-first upper molar distance. Significantly narrower maxillary and mandibular arch widths when compared to control groups. – inadequate space for the tongue. As the space in the oral cavity is inadequate, the tongue gravitates to the back of the oro-pharynx when the patient is lying down during sleep. Hence snoring and SBD.

The patient with tongue-tie leads to restricted tongue mobility. The results were associated with narrowing the maxillary arch and elongation of the soft palate – affecting maxillofacial development.

Craniofacial deficiencies started with bottle feeding and a soft diet in the infants. They caused airway deficiency/compromise, resulting in mouth breathing and sleep breathing disorder. With imbalanced oxygen, carbon dioxide and nitric oxide exchange, compounded with sleep fragmentation, mental and physical health and development deteriorate, resulting in a broad spectrum of disease from day-time-lethargy to cardiovascular diseases.

I am a family dentist in Burlington practicing wellness dentistry for all ages – from infants through adults to seniors. I encompass wellness dentistry into every aspect of practice – from the office location, setup, and airflow to lighting, from the materials to the equipment, from the diagnoses to treatment planning. It is very rewarding for me to be able to help my patients who have the issues and symptoms mentioned to improve their health outside their mouths.


Omicron Sar-Cov2 versus Influenza

When the world started to regroup and gather together, as the number of COVID cases dropped, in late November 2021, there was news about the new Omicron variant first reported in South Africa that this variant has been shown severely contagious. 

At the start of the COVID province-wide lockdown on March 23, 2020 (right after the march break), there were about 78 new cases that day. That lockdown included dental offices as we were not allowed to do elective dental treatments like fillings, cleaning, implants, examinations etc. We were only allowed to treat dental emergency cases for severe toothache or painful dental infection with swelling. At that time, we were encouraged to do teledentistry to triage the patients and prescribed pain killers or antibiotics over the phone. For those severe cases, we were only providing emergency root canals, extractions or some palliative dental procedures like smoothing the sharp edges of a broken tooth and rebonding the loose orthodontic wires etc. Eventually, on May 27, 2020, the province announced that chiropractors, dentists, massage therapists, optometrists, homeopaths and psychologists could see patients under their respective governing bodies’ guidelines and strict IPAC protocol, especially for COVID.  

As the provinces continued reopening in different stages, the number of cases had spiked at 3945 on January 9, 2021, and 4812 on April 15, 2021. The number of cases died down during the spring and summer to as low as 119 cases on July 15, 2021. The Omicron made the peak at 4383 new cases on December 22, 2021, but then it peaks further on December 24, 2021, at 9,571 new cases in Ontario. The day before, on December 23, it was at 5,790. December 24, we had 10,412 cases, and today, January 6, 2022, we have 13,3339 cases. It epitomizes the super contagiousness of the disease. 

The numbers are truly sensational! However, it could be very deceiving to look at the daily numbers for just a few days. There could be unusual events preceding the upticks, reporting bias, overreporting, and “diagnostic bias.” Fortunately, the symptoms of this new variant are generally less severe, and the hospitalization strictly due to COVID has not shot up proportionally. The number of deaths due to the disease remains low. 

Meanwhile, after hitting a high of nearly 27,000 new cases nationwide on December 15, 2021, the numbers dropped to about 15,424 on December 21, 2021, in South Africa and continue to fall to 12,978 cases on December 30, 2021. This downtrend appears to continue to the future.

So will Ontario or Canada see a downtrend soon like what we see in South Africa? According to epidemiology, it is possible to see a steep increase followed by an abrupt decrease. This trend may be happening in Ontario; we had a peak on January 4, 2022, at 18,828 cases, and in the last few days, the numbers have been down to about 13,500 a day.

We are familiar with the Novel Covid as it first started and the two variants, namely Delta and Omicron, that have gained a lot of publicity. Indeed, a few more variants are less famous than their relatives. Alpha, Beta, Gamma, Mu, R.1, Epsilon, Theta and Zeta variants. There likely will be more in the future.

Compared to flu viruses, COVID viruses can spread further because the consensus among scientists and doctors is that transmission of COVID-19 is primarily airborne, while the flu is via droplets. That means that COVID viruses can travel further in the air.

Why is this Omicron so much more contagious than other COVID variants? Scientists are still working on the reasons for the Omicron’s fast transmissibility; one of the theories is that this variant can evade our immune system effectively once it enters our bodies.

The findings are that the Omicron is milder in its symptoms than the Delta. The most common symptoms include:

  • Muscle aches.
  • Fatigue.
  • Scratchy throat.
  • Night sweats.

Other symptoms may also include:

  • Runny nose.
  • Headache.
  • Sneezing.
  • Sore throat.

The symptoms are generally milder than the other COVID variants, But one symptom appears to stand out above others — scratchy throats.

Traditional COVID has the following symptoms:

  • Fever or chills.
  • Cough.
  • Shortness of breath or difficulty breathing.
  • Fatigue.
  • Muscle or body aches.
  • Headache.
  • New loss of taste or smell.
  • Sore throat.
  • Congestion or runny nose.
  • Nausea or vomiting.
  • Diarrhea.

Indeed, the traditional COVID symptoms are very similar to Influenza. Both can lead to death and complications, including long-term damage to the lungs, heart, kidneys, brain and other organs, and a variety of long-lasting symptoms is possible. At present, the mortality rate of COVID is thought to be substantially higher (possibly ten times or more) than that of most strains of the flu. Fortunately, the mortality and morbidity of this new Omicron are somewhat below the flu viruses. Because of the lesser symptoms, some scientists and medical experts are optimistic that this variant may help end the COVID pandemic sooner than later by improving the herb immunity after contracting and recovering from Omicron. Despite the large number of people getting COVID, we are not “in the same place as we were last year.” Dr. Theresa Tam told CTV National News during a year-end interview.

The  Omicron is causing an “enormous” number of COVID infections, but severe illness is not rising at the same pace.

There may also be a shift to the conventional vaccine using an inactivated piece of the COVID virus to stimulate our bodies’ immune systems against the virus. The mRNA vaccines as the immunity do not last long. 

How is it going to affect my practice? According to the guidelines, we practice infection prevention and control protocols (see the blogs on this topic before): frequent surface disinfection, continuous HEPA air filtering and UV light air disinfection, barrier and doors between different areas, social distancing, new PPE between patients, vaccination and frequent rapid testing. Etc. We make sure our patients and staff are safe when they are here in my dental practice. Let us ride this out together and continue to enjoy total health.


Manual or Electric Toothbrushes

Toothbrushing is the most effective way to remove food debris and plaque from the teeth, which helps prevent cavities, gingivitis, periodontitis, candidiasis and bad breath.
There are manual and electric toothbrushes. Within each type, there are a few options available. So, what kind of toothbrush is best?

Let’s look at manual toothbrushes first.

There are two major types of manual toothbrushes.

The first type is made of natural wood sticks from miswak, neem or babool trees. All three are traditional chewing sticks prepared from the roots or twigs. Studies have demonstrated that they all have an antibacterial effect against Streptococcus mutants, a cavity and gum disease-causing oral bacteria.

The sticks needed to be prepared by chewing the end to create the bristles. However, the strands tend to be hard. The filaments can be difficult to effectively brush the areas between molars and the backs of the front teeth because the filaments are in a straight line with the stick and cannot be bent to reach those areas. Despite its potential antibacterial and anti-inflammatory effects, the sticks can cause damage to the gums, which leads to gum recessions. It is also challenging to get the tips of the bristles to effectively scrape the plaque and food debris away from the tooth surfaces.

Photo courtesy from the article “A review of the therapeutic effects of using miswak (Salvadora Persica) on oral health.” SaudiMed J.
Authors: Mohammad M. Haque, BDS, MPH and Saeed A. Alsareii, SB (Surg), JBGS

The other type is made with a plastic, wood or bamboo handle with nylon bristles at about 90 degrees to the long axis of the handles. That configuration allows better contact with the molars and other difficult-to-reach areas. Dentists only recommend using toothbrushes with soft bristles to prevent “brushing” the gums away. There are a few different shapes, sizes, arrangements of the toothbrushes for diverse needs and purposes.

There are two major types of electric toothbrushes too!

The first type is the oscillating rotary heads, which are circular heads that spin and move back and forth. The exemplifying one is by Oral-B. The newer one has a blue tooth connection to your smartphone that can monitor your brushing in terms of time spent, pressure on the teeth, power level, etc.
The second type is the sonic brush heads which vibrate back and forth extremely fast. Philip Sonicare is the best-known brand using this technology. It also has a blue tooth connection to an app on your phone to monitor the brushing like the Oral-B.

Courtesy of Oral-B and Philips Sonicare

Overall, electric toothbrushes are more effective and efficient in removing plaque and debris simply because they have much faster strokes/vibration per minute than manual toothbrushing. The brush heads of the electric toothbrush are usually smaller than the manual toothbrush heads, especially the Oral-B one; therefore, the bristles can effectively contact the hard-to-reach areas like the molars, the spaces between teeth and the back of the front teeth.

Using electric toothbrushes needs less hand movement and requires less hand dexterity. Hence elderlies with poor hand coordination, patients with muscular dystrophy, multiple sclerosis and parkinsonism can benefit from the do-it-for-you movements of electric toothbrushes.

Patients with braces may also find it easier to clean their teeth with electric toothbrushes.

Despite the superiority of electric toothbrushes in food debris and plaque removal, they do have some factors that some patients may find to be unacceptable. For example, the sound and vibration may be too uncomfortable for certain patients. The initial cost to purchase an electric toothbrush is higher than the manual one. So as the cost of the replacement heads for the electric one is more expensive.


Management of Stressors in Dentistry

Last week, I blogged about dentists’ stress in their clinical lives.

Stress can never be eliminated from a dental practice. However, it must be minimized as much as possible to avoid the many stress-related physical and emotional problems that it causes.

The key to successfully managing stress is recognizing and understanding its causes. Once the causes have been identified and understood, preventive steps can be taken.

Stress can lead to dysthymia, anxiety, loss of appetite, physical health deterioration and depression. Dentists with excessive stress constantly can end up with alcoholism and drug abuse, unstable family life, divorce, burnout, mental breakdown and suicide.

Statistically, divorce dentists are three times more likely to commit suicide than divorced people in the general population.

The cause of these mental health issues can stem from various things. Many dentists work long hours and can get burnt out quickly. There is a lot of pressure on the job to do things perfectly. Plus, you might not always have the most pleasant patients to deal with.

Some of the preventive measures that could minimize the stress of dental practice are as follows:

  • Confinement

I like to have large windows in all my operatories in my practice. I like the operatories to be large and not fully enclosed with drywall and doors. There are a lot of dental offices in a shopping plaza which provides a limited view of the outside world with windows.

However, the average dentist spends most of their life confined to a small, sometimes windowless operatory. Besides adding windows, most of the time is impossible; there are other ways to improve the working environment; dentists can hang photos or pictures on the walls, install glass wall partitions instead of solid wall partitions, and enhance the lighting by adding more warm light (2700K – 4000K) to the bright daylight lighting.

The dentist should sit upright on the dentist’s chair with easy movement around the patient’s head. The dental equipment and instruments should be easily reached without excessively straining the dentist’s head, neck, back and shoulder. It is all about ergonomic with good design and layout of the treatment cabinets, patient’s chair and dentist’s chair.

  • Isolation

When dentists practice alone, there is less opportunity to share and solve problems with their colleagues. Dentists need to have a broader network of fellow practitioners to share issues and frustrations. Through peer support, problems can be solved easier.

I recommend joining the local dental society, which regularly provides social networking and seminars. I, for one, am a member of the Burlington Dental Academy, which allows me to have more venues to communicate with my colleagues.

We should communicate more with colleagues, health care practitioners, friends, and staff about issues and concerns.

Having more than one dental practitioner in practice, with associates or partners, often can alleviate the mental stress with isolation and lack of understanding.

  • Long hours

I have been there and done that; I worked seven days a week with extended hours each day. Long hours put a lot of stress on my mental and physical health.

Working more sensible hours and taking time each day for a leisurely lunch break;

Have a longer buffer time between each patient and ensure enough time for the lunch break.

  • Lack of exercise

Adopting a program of physical exercises, such as regular walking or working out at a local health club;

Take a leisure walk during lunchtime.

  • Stress of perfection

The relentless pursuit of perfection and permanence in an inhospitable oral environment is a significant cause of stress and frustration for dentists. The emphasis on perfection is instilled in dental school. However, it must be tempered with the realization that a perfect restoration will ultimately be rendered imperfect by time and patient neglect, despite the dentist’s efforts.

Most important, being kinder to yourself and less critical and demanding of your efforts.

We cannot meet all patients’ unrealistic expectations. We need to tell the patients who demand such expectations that we cannot provide such treatment and recommend the other options. Be prepared to refer the patients to specialists or colleagues for a second opinion.

  • Economic pressure

The cost of dental education can easily be over $250,000 to complete if the dental education is in Canada. For those who got their education done in the United States or overseas, the cost can easily be over $500,000 in us dollars.

In addition, the cost of setting up a new dental office can easily be over $500,000. The cost of buying an established practice is even higher – it can easily be two million dollars or more.

Once in practice, the dentist soon learns that office overhead rises to meet income. The overhead often surpasses the revenue in the first few years.

The financial burden is whopping! The dentist who works all the time and never takes time off might make a few dollars more, but there is a high price to pay — BURNOUT! And when dentists burn out, they become emotionally and mentally exhausted, develop a negative, indifferent or cynical attitude towards their patients and their staff, and negatively evaluate themselves.

We need to manage our overhead well, do the expansion with caution, and know the return on investment. We need to be careful about our expenses on professional social media management, the cost of marketing, the cost of equipment updates and acquiring newer technologies.

We need to have a spreadsheet showing the expected incomes versus the cost of the purchases and expenses, including your time and health.

We may want to start as an associate first to pay back the student loan and then consider the ownership of a practice.

Much of the stress that dentists experience is self-inflicted and a product of acting out their strivings and ambitions. In other words, dentists themselves often are the source of most of the stress they experience.

  • Staffing pressure

Keeping a supportive and stable staff has been extremely difficult through the history of practice ownership. The situation is worse nowadays with the COVID.

Hiring and keeping the right staff is an art that no single course can teach you.

An excellent dental management consultant can provide you with some advice and management, but they can be very costly.

There are a few basic principles that the staff will more likely want to work with you and stay working with you. Take home money is essential, but it is not all. All staff want a non-stressful environment where they feel comfortable performing their required duties and responsibilities with respectful recognition and acknowledgment from their employers.

If you do not provide enough training, direction, and communication of your expectations, the staff will feel stressed out when performing their duties. It is a vicious cycle that will perpetuate and multiply. They want respect and recognition.

We need to lower our expectations and recognize that each person has a different level and scope of capabilities. We need to make professional development a Top Priority and encourage a conduit for all-way communication in the office.

  • Time pressure

Attempting to stay on schedule in a busy dental practice is a chronic source of stress. As we all know, once we are behind schedule, there is no way to catch up. It is important to book enough time for each procedure, provide buffer time between patients, and ensure enough sterilized instruments and supplies for the day.

Make sure there is a time for emergency patients, and do not be afraid to turn away some patients or rebook the patients back for further appointments. You cannot see everyone and make every patient likes you.

  • Compromise treatment frustration

Most important, being kinder to yourself and less critical and demanding of your efforts.

Invite the patient back for the remedial work with no charge. Do not count the cost but gauge the degree of satisfaction

We need to know our limits and refer out for additional care if the case is too challenging. Engagement with continuing dental education can also help us to improve our skills and knowledge.

  • Patient anxiety

The psychological stress of working with apprehensive and fearful patients can be devastating to the dental practitioner. There is now considerable evidence that dentists experience patterns of physiological stress responses (increased heart rate, high blood pressure, sweating, etc.) that parallel the patient’s responses when performing dental procedures that evoke patient fear and anxiety. We need to learn how to handle patient anxiety and hostility better.

If you have an extremely fearful and anxious patient, suggesting things like rescheduling or offering general health and wellness tips can help.

Sedation like anxiolytics and nitrous oxide can be very helpful for certain patients. Referral to a dental specialist who can provide the needed sedation or general anesthesia can save the grace.

  • Processing a good dentist’s personality:

We should show compassion to ourselves and know our limitations. Besides managing the daily operation of the office, managing stress in the office is equally essential.

Things like mindfulness, leisure walk and meditation can help you throughout the day.

We need to be mindful of ourselves, our stress, lives, and families. Harmonious family life will reduce stress at work. Being content leads to security, and security leads to happiness.

Managing your stress every day is crucial to getting through some of the things listed above. Be mindful, relax and seek help if the stressors start to cause problems to you.