Connecting with Dr. Risbrudt, DDS

The biggest single thing that gives you the most bang for your dental buck??  DIAGNOSIS!

Thought I was going to give you something really profound, right??  The usual “diagnosis” is what’s causing the short term problem, like:  toothache, sore bleeding gums, broken tooth, filing fell out–you know, the usual stuff!  But wait!  There’s more……

Making a diagnosis means finding the underlying CAUSE of the problem.  That requires an astute practicing professional.  One who can notice subtleties that translate into bigger problems later if not addressed early on.  One who thinks about things, not just mindlessly fills holes.  One who has many tools “in the drawer” so to speak, in their armamentarium, so that creative solutions to subtle problems can lead to long term stability and predictability later.  One who can take the proper records to identify hidden problems and small problems that can turn into bigger problems later.

There’s nothing worse than an unpredictable dental future, in my view.  It’s what causes patients/clients to lose faith in dentistry and stop looking at dentistry as a long term investment, and instead goes from one crisis to the next with no significant return on that dental investment.  I hear new patients to our practice say:  “Every year, I max out my insurance, and the next year I have to start all over!  I never seem to get caught up–it’s always something!!  What’s up with that??!”

If you were going to build a custom house for yourself, would you just start putting boards in the air??  I don’t think so!  If you’re going on a vacation, do you just show up at the airport??  Plan your work, and then work your plan!!

Developing a PLAN leads to a more predictable future.  With economics the way the way they are these days, planning is crucial!!

So, that begs the question:  What kind of dentist are you looking for??

Something to think about!!

Ever had a C-Reactive Protein test?  Know what it’s for???  The test itself measures the presence of inflammation in the body.  Chronic inflammation has been associated with numerous diseases, including Alzheimer’s disease, Parkinson’s disease, arteriosclerosis, heart attacks and strokes.

Recent studies have shown that Alzheimer’s dementia and other degenerative diseases are associated with chronic inflammation and that most people with these diseases have elevated C-reactive protein levels.

So, how come we’re interested in how your C-reactive protein test came out? One of the major sources of chronic inflammation can literally be right under your nose.  If you are a person with chronic gum disease, or gums that bleed easily, that’s inflammation.  Our goal around here is to help you keep the gums intact around your teeth, so the gums act as a membrane, or natural barrier to prevent the bacteria from the oral environment from finding its way into your bloodstream.  The gums should keep the blood in and the bugs out!!  That stops inflammation!

So, how to do that?  We’ve talked about various home care aids in this column before, so you know that we are partial to ultrasonic toothbrushes and ionized water irrigation devices.  Those are the obvious tools to use to curb localized inflammation in the mouth.

If you are into using nutritional supplements, as more and more of our patients are, here’s a list of useful supplements to curb inflammation:  Aged garlic extract taken twice a day lowers not only C-reactive protein levels but also cholesterol.  In addition, quercitin, curcumin, gamma tocopherol (a form of Vitamin E) magnesium and Vitamin D can all lower C-reactive protein levels.  Lower C-reactive levels=lower inflammation!!

Most can be purchased without a prescription.  Most impressive is the extract called curcumin, extracted from the spice turmeric.  Curcumin not only lowers C-reactive proteins, but also inhibits cancer development and spread, protects the brain and is a very powerful antioxidant.  The dose is 250 milligrams three times a day with meals.

It’s no secret that we’re into personal responsibility for health around here.  That’s why we suggest judicious supplementation to support the body’s chemistry for more optimum health.  As usual, do your own research on these things to make sure their use is appropriate for your  unique circumstances.

A word to the wise is prevention!!

So we’re going to talk about testing for snoring and sleep apnea diagnosis in this thread.  The gold standard is PSG, which is an anacronym for polysomnography.  This study is typically accomplished in a designated sleep center under the supervision of a medical doctor.  We have some qualified sleep medicine centers that we like in our area.

Alternative testing can be done by a device that can be worn in the comfort of your home.  Sometimes a screening with one of these devices can provide the information you need to further test in a sleep center.

Another useful screening formula for probability of sleep apnea from adjusted neck circumference (ANC) which you could easily do at home goes like this:  ANC=NC (cm) +H(4) + S (3) + C/G (3) To convert your neck size from inches to centimeters, remember that there are 2.54 centimeters to an inch.  So if your neck size is 16 inches, for instance, your neck circumference is 2.54X16″=41 centimeters.  H is for hypertension, so you add 4 if you have it.  S is for snoring present, so add 3 if you snore.  C/G stands for choking or gasping so add 3 if you experience it.  (Ask your sleeping partner)  So in the above example, if we take 41 centimeters, add 4 for hypertension present, add 3 if snoring present, and 3 for choking or gasping (ask your sleeping partner!), it gives a total score of 41+4+3+3=51.  (Less than 43=low probability, 43-48=intermediate probability, and more than 48=high probability. )  How did you do?  Do you need to investigate further?

There are a couple of other written instruments that can help educate yourself whether or not there might be a problem cramping your lifestyle.  ESS:  Epworth Sleepiness Scale, for instance, and SAQLI: Sleep Apnea Quality of Life Index. These are available in our office.  You might even find them on the web.

Believe it or not, it is sometimes significant to find out if fatigue and daytime sleepiness are NOT sleep apnea.  If it’s NOT sleep apnea, further investigation is necessary by a skilled sleep medicine doctor.  It could be a central nervous system condition called IFL:  Inspiritory Flow Limitation.

Suppose you have made your mind up that you are not going to do a sleep study.  If you’ve spoken to friends who have done a sleep study, many of them will complain that they didn’t think they slept a wink in a strange bed in a lab, but I digress……What options are there?

HST: Home Sleep Study–a portable device worn like a headband that will record most of the same elements found in a PSG or sleep center study.

PulseOximetry: another portable device that can be worn in the comfort of your home that will indicate the probability of sleep apnea.  It is also used in follow-up studies after oral appliance therapy to measure the efficacy of the treatment.  Not as much info with this as an HST, but useful nonetheless.

If you’re going to get your medical insurance involved in the investigation or treatment, some kind of study will have to be done.  They just won’t throw money at a problem unless they have proof that it exists.

The question is:  Is snoring effecting the quality of your life, either through loss of intimacy with your partner, or fatigue and daytime sleepiness?  Could be that some health issue that you’ve just chalked up to “old age” is really related to snoring and sleep apnea.  In that case it’s VERY treatable!!

Don’t waste another day wondering!!

THR

So, you suspect you are experiencing a sleep disturbance problem.  You’re probably wondering:  “Why am I snoring, anyway, and if I snore, does that mean I have sleep apnea as well?”  Or:  “All I know is my sleeping partner is really bummed, and is about to move into a separate bedroom, or banish me to the couch–not my idea of an intimate relationship!”

Snoring is an airway issue.  For some reason, the airway is closing off to some degree, as in snoring,  or in the case of apnea, closing off entirely, if only briefly.  If you’ve awakened yourself out of breath in the middle of the night, it can be pretty scary!  The question becomes:  How many times per night is that happening, and can it cause long term problems?

What conditions can affect airway?

-Tonsils and adenoids problems.

-Blockage due to sinus conditions or allergies.

-Deviated septum problems as a result of injury.

- Extraction-type orthodontics, especially if you wore a headgear or neckgear.

- Grinding or clenching the teeth, and TMJ/TMD problems can be the body’s way of trying to enlarge the airway.

- Local factors such as weight gain which effects neck circumference.

- Alcohol or sugary desserts consumption close to bedtime can cause throat tissues to enlarge and become congested, effectively constricting the airway.

So, what’s next??  How can I find out conclusively if snoring or sleep apnea is a problem?  We’ll talk about testing in the next issue of this thread.

THR

Used to be snoring was just an embarrassing social problem, but now……..Lots of stuff in the media and the literature these days!  You might be thinking to yourself:

“So I know snore sometimes–what’s the big deal??”

“I occasionally get tired in the afternoons.  Isn’t that pretty normal??  After all, I’m not getting any younger!”

“High blood pressure?  Yeah, I’m taking some medication, but it’s just a low dose.  So what??”

I took my first week-long course on snoring and sleep apnea back in the winter of 2003.  I felt like wow, this is something pretty exciting!  I wonder, though, is this something that patients will relate to?  And, what will it take to make my patient base aware?  Well, the media has pretty much taken care of the awareness thing for sure!

During the ensuing eight years, several sleep centers have appeared in our immediate geographic neighborhood, and several of our medical colleagues have become certified in sleep medicine.  That pretty much makes this more than just a passing fad, medically.  The studies keep pouring in, and the evidence is rather irrefutable.  Snoring and sleep apnea are closely related to a host of other medical phenomena, like high blood pressure, diabetes, heart attack and stroke.  And, TMJ/TMD problems as well.

In this segment, we’ll talk about common signs or symptoms of sleep apnea.

–Daytime fatigue

–Loud snoring, followed by choking or gasping for breath

–Waking up with a racing pulse and out of breath

–Inability to control high blood pressure

–Lack of dreaming

–Morning headaches

–Memory loss

–Large neck size  (17″ or more for men, 15″ or more for women)

–Acid reflux

–Frequent nighttime urination

So, what to do if you suspect snoring and/or sleep apnea are a problem?  That’s for Part II

THR

So you’re suffering with migraines??  We’ve talked about migraines that may be related to occlusion (bite) issues before in our “Got TMJ?” series.  A bite splint or orthotic can be very helpful with pathological bite relationships.  Often, TMJ/TMD problems can be misdiagnosed as migraines. ( I invite you to read the complete series:  “Got TMJ?” in previous posts on this blog.–ed.)

But wait!  There’s more!!  Many people overlook the importance of diet and exercise when it comes to migraines.   Food is becoming more and more processed these days, so it’s harder to find food without additives.  It’s a nutritional minefield out there!!

So let’s list some of the common “excitotoxins” found in food additives which act as triggers  that rile up the immune system in susceptible individuals, leading to migraines:

Chocolate, aspartame, sulfites, nitrites, alcohol, caffeine, MSG, “natural flavoring”, carrageenan, hydrolyzed proteins, isolated soy proteins and soy protein concentrate, whey protein, sodium or calcium caseinate, stock, broth, meat gravies, pureed tomatoes or tomato paste, beans nuts, (peanut butter) mushrooms, (especially portabella), cheeses, (especially parmesan) and dried or condensed cow’s milk.  Start reading labels–you won’t believe it!!

The other factor not previously mentioned–reactive hypoglycemia.  Sugar shock!!  When sugary foods are eaten, there is an immediate spike in blood sugar (sugar high) followed by a precipitous drop in blood sugar which triggers the release of glutamate from the cellular stores–often enough to precipitate a migraine attack.  Got migraines?  Try a sugar-free diet.

Yeah right–simple, but not easy!!  Guess you have to ask yourself these question(s):  Why would you want to change your diet?  How would you do it, if you decided to?  How important is it for you to change your diet?  How would your life change with fewer migraines?  What are the three best reasons for making diet, exercise or lifestyle changes to manage migraines??

Something to think about!!

THR

Perimolysis? Sounds ominous!!  Perimolysis is a phenomenon of tooth wear that is accelerated by erosive dietary or environmental factors.

For instance:  A person likes to drink soda, swishing it between the cheeks and teeth, or eats a lot of citrus and grinds their teeth during the day or at night.  Perimolysis,   or wear accelerated by chemical factors occurs.   The chemical factors literally demineralize the enamel, and then it is rapidly worn away by the abrasion which occurs with grinding or clenching.  Add the grit from an outdoor construction job, and it’s a recipe for disaster!!  (See image below.)

GERD, (Gastro Esophageal Regurgitation Disease)  for instance, creates a highly acidic erosive environment, particularly at night.  Grinding in the presence of a highly acid environment accelerates the wear on the tops of the teeth.

What’s up with soda?  Guess what?? HIGHLY acid!!  Phosphoric and citric acid acid are added to soda to increase the tartness.  Add in 10+ teaspoons of sugar in a soda, and over a period of time, that can be a “money pit mouth” factor.

Sucking on lemons, oranges, or grapefruit on a regular basis will do the same thing.   The citric acid demineralizes the enamel, and grinding or clenching does the rest.

Incidentally, 95%+ people grind or clench to some degree, depending on stress levels, so it’s just a fact of life.  It’s about stress relief.  If you look at your high school graduation photograph and your teeth are significantly shorter now than they were then, perhaps it’s time to investigate.

What to do?  Intervention:  What’s that look like??  It all depends!  Where the wear is occurring, how much wear, creating sensitivity, compromising your smile??  Best to have us take a look to determine your options.

A word to the wise is:  Prevention!

THR

Perimolysis

Does your dentist have a philosophy?  Why would that be important?  For instance, if your dentist’s philosophy is:  “The Bottom Line,” that would be different than, say, if “The Dentist’s Philosophy” was the bottom line?  A subtle but powerful difference!

When “The Bottom Line” is the prevailing philosophy of a dental practice, the patient experiences “up-selling” and “bait and switch, ” two of the most often mentioned complaints from the consumer/patient’s point of view.

On the other hand, when “The Dentist’s Philosophy” is front and center, that begets a whole different dynamic.  That means good old-fashioned professionalism, in my view. “Professionalism,” my mentor Dr. L.D. Pankey used to say, ” is that quality of conduct which accompanies the use of superior knowledge, skill and judgment toward the benefit of another person or society prior to any consideration of self-interest.”

It would imply a more collaborative relationship between doctor and patient, revolving around making informed decisions which are in the best interests  of the patient.

Does the word “virtue” even come up in today’s modern vernacular??  “Virtue,” Webster says, “is conformity to a standard of right; a particular moral excellence.”

To the extent that the dentist “does the right thing” and “does the thing right” is a reflection of ethical and intellectual virtue, something that Aristotle, Socrates, and Plato felt very strongly about!  When a professional person knowingly does something that is either unscrupulous or incompetent, ethical virtue is lacking.  When the same mistake is made out of ignorance, it is a lack of intellectual virtue.

My heartstrings got twanged when I first heard Dr. Pankey talk about these concepts. They have been my moral compass for many years in practice.  I constantly ask myself:  “Am I doing my best for this patient?” It is the framework for my continued growth and development on behalf of the people who present themselves for care in my office, because they deserve it!!  The road to excellence is always under construction!!

Something to think about!!

THR

How do you know if you’re a candidate for dental implants?  These days, there’s almost no impossible situation for implants.  Adequate bone to support these titanium root forms is a must.  That being said, there’s one rule of thumb that’s pretty important:  If the teeth have been missing for a long time, some heroics may be necessary to get enough bone to support implants.

With the advent of three-dimensional CT scans, it’s now much easier to locate areas of sufficient bone to support implants.  On the other hand, these scans prevent choosing an unsuitable site, even though clinically it may look terrific.  For instance, I had a long term patient who wanted to replace her conventional denture with an implant- supported prosthesis.  The bony ridge on her upper jaw looked very adequate, but wait–the scan showed the bone was at best marginal!  Long story short–the implants were placed, but required significant bone grafts to support them for healing.

One of the criteria we use to select a surgeon to help our patients requires that they have mastered immediate-placement surgery.  Immediate placement means that the implant is placed at the same time that the hopeless tooth is removed.  When bone is adequate this can be done in about 75% of cases.  Hastens the overall healing time by several weeks.

What if the tooth that requires an implant is in the front of the mouth?  And, you’re concerned about how you’re going to look while the healing is going on.  That requires some precise planning and temporary types of restorations, but it can be creatively managed.

Let’s say you had some implants placed, and the location is less than stellar in terms of restoring it adequately.  Even situations like that can be managed by the use of careful planning and an astute surgical/restorative team.  What we typically do to prevent this kind of scenario is to use the 3-D imaging and mounted study casts of your mouth to create a surgical stint to guide the surgeon’s placement for the very best functional and aesthetic result.

Got an implant question??  Call our office for a no-charge second opinion today!

THR

Appliances sound like something you install in the kitchen, but there are numerous mouth appliances out there, so let’s explore the uses and descriptions:

Mouthguard: Usually used for protection of the teeth in contact sports.  Function:  Pretty much injury prevention.

Snoreguard: A specially constructed oral appliance for use in treating mild to moderate snoring and sleep apnea.  Function:  to hold the lower jaw forward enough to open the airway, thereby curbing the noise of snoring, and also preventing the throat from closing and cutting off normal breathing.  (Apnea)

Bite Splint: Used to alleviate pain, dysfunction and wear from noxious biting habits that can endanger the teeth and muscles. Function: It’s purpose is to allow muscles to calm down and relax from hyperfunctioning.

Nightguard: Usually a hard plastic oral appliance made on either the upper or lower jaw to protect the teeth from gnashing together at night.  Function:  Great for prevention of fracture of delicate porcelain veneers, for instance.  Properly made, usually promotes more restful sleep in non-snorers.  A must following any kind of porcelain veneer esthetic dentistry.

Orthotic: Another word for bite splint.  Indicates “splinting” of muscles to calm them down in the case of cranio-facial pain, headaches, earaches, range of motion problems, etc.  Can also act as a nightguard when finally balanced.  Wearing orthotics in your shoes?  Why not use the same idea to keep things in balance with your jaw, particularly at night? 

Which one is best for you?  It all depends!!

Often, if there is snoring/sleep apnea, it is usually accompanied by grinding or clenching, so a snoreguard is a good bet.

In the case of chronic head and neck pain, a splint or orthotic is indicated.  Once the orthotic is balanced, it also acts as a nightguard.

If you have had extensive dentistry done to include veneers or all-ceramic crowns, a nightguard is an absolute must to protect your dental investment.

Confused?  How about a no-charge opinion??  A word to the wise is prevention!!

THR