Dental Professionals

Bisphosphonates and Your Dental Health

 

Question:

There’s a lot of talk about Bisphosphonates, which are used for various medical conditions. Can you explain why this medication is used and how it might affect my dental condition?

 

Answer:

Bisphosphonate drugs come in oral (pill) or intravenous (IV) form. Oral Bisphosphonates are used mainly to treat osteoporosis and osteopenia. The oral (pill) forms are commonly known as Fosomax, Actonel and Boniva.  Intravenous bisphosphonates are primarily used to prevent cancer from spreading to the bones or in cases of multiple myeloma. These IV forms include Aredia, Zometa and Reclast.

 

Although it is rare, these drugs can damage the bones of the upper and lower jaws.  Patients taking these drugs who have a tooth extracted or surgery involving the jaw, may experience death of the bone of the jaw, or Bisphosphonate-related osteonecrosis of the jaw (BRONJ).  In very rare instances, BRONJ can occur spontaneously, without a cause. 

 

Question:

It seems like oral bisphosphonates for treating osteoporosis are creating somewhat of a road block for certain dental surgical procedures. Should these patients consider an increase in preventive care, such as going for checkups and cleanings three or four times a year instead of the usual two times?

 

Answer: 

Yes, preventative dental care should definitely be increased in patients taking bisphosphonate medications.  If a cavity can be treated when it is a small lesion, only a filling is required, while larger ones may need root canals and crowns.  Any of these procedures will often prevent the need for more complex dental extractions and surgeries.  That is why having regular dental exams along with cleanings is the best way to prevent BRONJ.

 

Question:

What is the risk of BRONJ occurring?  Can it happen if a patient cuts their gums due to everyday events like tooth brushing or eating a hard food, such as a taco chip?

 

Answer:

 The incidence of oral side effects from the oral bisphosphonate medications is really very low. Studies show a 1 in 10,000-100,000 risk of occurrence after tooth extraction. Surgery involving the jaw, such as an implant or bony periodontal surgery, could also increase the risk. However, in our practice, we have not seen a single case occur from a tooth extraction.  It is even less likely for BRONJ to result from minor cuts caused by brushing or eating. Patients needn’t be concerned about BRONJ resulting from minor trauma.

  

Question:

What precautions are taken for patients on a bisphosphonate drug who need a tooth extraction or dental implant? Are any extra precautions needed for more routine dental care, such as cleanings or fillings or even root canals?

 

Answer:  

Patients on oral bisphosphonate medications for three years or more, or who have taken even one dose of intravenous bisphosphonate, may require a blood test to determine the risk for BRONJ.  Patients whose results indicate they are at high risk for BRONJ will be asked to discontinue the bisphosphonate medication three months pre- and post-extraction, with approval from their prescribing doctor. If patients are at severe risk, dental extractions are avoided and the tooth is treated with root canal therapy and removal of the crown.

 

No special precautions are needed for routine care, including cleanings, fillings, crowns and other general dental care.

  

Question:

What exactly is the test given to determine risk of BRONJ?  How does the test predict a patient’s risk?

 

Answer:

It is a morning blood test, taken after a patient has not eaten for eight hours.

Those with blood values that indicate a low risk may continue to take their oral medications; patients with moderate to severe risk disease are asked to discontinue the medication for three months before the extraction or surgery and three months afterward.

  

Question:
How is BRONJ treated, and what is the general prognosis?

 

Answer:

BRONJ is not an infection, but a process by which bone is destroyed. BRONJ is treated first by discontinuing the bisphosphonate medication, with approval from the prescribing doctor.  Antibiotics are used to help minimize the amount of bacteria in the mouth and allow the bone to heal itself.  BRONJ is considered successfully treated when the signs and clinical symptoms are gone–pain is resolved, there is no exposed bone in the mouth and the gums are completely healed.  In rare cases, the affected bone must be surgically removed, which may result in a serious jaw defect. 

 

 

Dr. Barry Cherny received his Bachelor’s degree in Biology from the University of Illinois, and a Bachelor’s degree in Dentistry and Doctor of Dental Surgery from the University of Illinois.  His internship and residency in Oral and Maxillofacial Surgery were completed at the University of Illinois Hospital and Clinics, Michael Reese Medical Center, West Side Veterans Administration Hospital and Cook County Hospital. He is a Diplomat of the American Board of Oral and Maxillofacial Surgery, a Fellow of the American Association of Oral and Maxillofacial Surgeons and a Fellow of the American College of Oral and Maxillofacial Surgery. He is also a member of the Illinois Society of Oral and Maxillofacial Surgeons and the Chicago Society of Oral and Maxillofacial Surgeons.

 

Dr. Cherny is in private practice with his partners, Dr. Bruce Hochstadter, Dr. Richard Isaacson, Dr. Leo Dumanis, Dr. Nick Katris and Dr. Michelle Pashley. They practice the full scope of Oral and Maxillofacial Surgery at their three office locations:

 

Westfield / Old Orchard Professional Building

64 Old Orchard Rd, Suite 229

Skokie, IL 60077

847-675-6868

 

444 N. Northwest Highway, Suite 325

Park Ridge, IL 60068

847-296-6100

 

600 W. Lake Cook Rd, Suite 101

Buffalo Grove, IL 60089

847-229-1300

 

Question 1
When is a gingival graft needed?
 
Answer 1
There are two basic reasons to perform gum grafting: to preserve a tooth’s bone support and ultimately its function, or to cover exposed roots.
Exposed root surface in the gums means there is already a loss of bone that supports the tooth.  We know from research that a tooth with one millimeter or less of gum tissue is much more likely to lose additional bone support in the future. Also, muscle pulls on thin gum and can further aggravate the problem, leading to additional loss of gum and bone. Placing a soft tissue graft helps to build up the amount of gum around a tooth and prevent further loss of gum and bone.
Gum grafts can cover most, if not all, of the exposed root surface.  A patient may want to cover exposed root surfaces to either improve the esthetics or to reduce sensitivity. Newer root coverage procedures also protect teeth with too-thin gums by increasing the amount of gingival tissue.
The most advanced procedures combine several technologies that enable rebuilding of both gum and lost bone.  

Question 2
How long does the gum grafting procedure usually last?

Answer 2
Total time is approximately 60-90 minutes, which includes: pre-treatment preparation, time for you to choose music to listen to during the procedure, anesthetic, treatment and post-treatment instructions. 

Question 3
What are the different types of ways to do grafts and the advantages of each?

Answer 3
There are two types of basic treatments for soft tissue grafting, each used successfully for many years.

The first procedure, developed in the early ‘60s, is called a soft tissue graft. This graft technique prepares a graft bed below the existing gum. This means that the increased gum tissue is directed away from the tooth and placed into the looser mucosal tissue. The grafted tissue is usually obtained by peeling a small and very thin sample of tissue from the hard palate or roof of the mouth. Some clinicians use tissue bank material that is processed to leave only a freeze-dried protein sheet. This material acts as a scaffolding and allows your own tissue to eventually grow over it. While this material does eliminate the need for a second surgical site in your mouth, as in the procedure detailed below, it does not appear to work quite as well as your own tissue.
 
The second, and newer procedure, is called a root coverage gum graft. The gum tissue surrounding the tooth in question is peeled away from the tooth, and deeper gum tissue is taken from the roof of the mouth. The site is stitched closed, leaving virtually no open wound. The graft material is then sandwiched between the peeled gum tissue and the tooth, closed with stitches, and hiked over the previously exposed root surface. This overlying flap of gum provides vital nourishment to the graft while the area heals.  Both sites heal within a few weeks and mature to a protective gum tissue.  Careful chewing is required to protect the graft while it heals. While this procedure does not cover the root surface of the tooth, it does protect the tooth against further gum recession.

Question 4
Which type of grafting is preferred?

Answer 4
The root coverage gum graft procedure is preferable in several ways. Since there is no open wound, the graft site is much more comfortable. Root coverage is more esthetically pleasing as the color match of the donor tissue is generally excellent.  Most important, the procedure protects the tooth against further breakdown. The only limitation is the need for neighboring teeth to have substantial levels of bone in order to ensure 100% root coverage.
 
Question 5
How long does it take to heal from the procedure?  Is there a lot of discomfort?

Answer 5
With either procedure, the vast majority of patients need mild pain medication for only ½ to 1 ½ days afterward.  While healing, patients need to take extra care while brushing and eating to protect the graft and allow it to bond with the underlying root surface.  Tooth brushing should be done gently.  A soft diet is required for the first few days while the graft begins to mature, and for one to two weeks after the procedure, patients should not allow more substantial foods to get into the graft site.
 
Question 6
Can gum grafting help a patient whose smile is affected by receding gums?

Answer 6
Yes, it absolutely can.  Receding gums can impact a smile as they cause an uneven frame to the teeth. When a patient has a high lip line, the gums will become a greater part of their smile.  If one or more teeth have changes in the height of their gums, this draws attention to the part that is different. Additionally, the tooth can appear longer than the rest of the teeth. That is why restoring the position of the gum back to its original position will also help restore a pleasing smile.

Question 7
Can any amount of exposed root be covered with grafting? What are some of the limits of grafting?
 
Answer 7
To answer this properly requires a bit of technical explanation. Placing a gum graft means you are relocating tissue that has been removed from its blood supply, which is its source of nutrition.  To keep this tissue alive until it can reconnect with the new area’s blood supply, it must be placed into an environment that can provide nourishment. A root surface has no vessels or blood supply to offer the graft, so we are dependent on the blood supply present in the bone neighboring the treated tooth. The better the bone support, the more blood supply is available to help the graft survive. That is why teeth with more severe bone loss around the sides have a poorer prognosis for root coverage. As the gum defect size increases, the chance for 100% root coverage decreases. 
The same is true for dental implants, made of titanium.  The material presents the same challenges as a root surface and offers no nourishment, but tissue can be grafted over the top portions of an implant.
 
Question 8
Is grafting always necessary to treat receding gums?

Answer 8
No, it is not absolutely necessary except in cases where preserving the tooth’s bone support is necessary.  If the gums have receded to the point where there is no gum tissue surrounding a tooth, grafting is recommended.  You can choose not to graft if your concerns are cosmetic or you are experiencing hypersensitivity to temperature or pressure.

Question 9 
What factors increase gum recession, and what can I do to prevent it? 

Answer 9
I am so glad you asked! Factors that lead to receding gums include improper brushing techniques (aggressive tooth brushing, horizontal tooth brushing, or using medium and hard brushes), and clenching and grinding teeth.  A good first step toward prevention is to ask your dentist or hygienist for oral hygiene instruction.  They can show you how to brush in a way that reduces stress to the teeth and gums.  If you grind your teeth, ask about custom made acrylic appliances known as night guards, which will protect your teeth and gums from stress while you sleep.

Information courtesy of:
David Barack, DDS
University of Illinois Dental School
Diplomate of American Board of Periodontology

www.ooperio.com

Crack Tooth Syndrome:

 

Question 1

What are some signs and symptoms of a cracked tooth?

 

Answer 1

The most common symptom of a cracked tooth is a quick, sharp pain when chewing something such as a bagel, bread, crust or similar food.   The pain lasts only a second, but can be very startling at the beginning.  The most commonly cracked tooth is the lower second molar, but can be on many other teeth.  It is one of the most difficult dental problems to diagnose and, in fact, is very often diagnosed by a process of elimination.  Clinically, the tooth may show a tiny surface crack, but not always.  The x-ray usually is normal in appearance and the tooth may have a large filling or even no filling at all.  

  

Question 2

What is the treatment for a cracked tooth?

 

Answer 2:  The treatment, like the diagnosis, can vary. If your symptoms are minimal, nothing may be done. If pain occurs with hard chewing only, the tooth can be prepared for an onlay or crown to see if binding the structure together eliminates your discomfort.  If the tooth is sensitive to heat or cold, or you feel a dull ache or pain with even light chewing, nerve tissue may be involved and endodontic treatment is recommended. If infection has developed or the crack is extreme, extraction of the tooth may be the only option.

 

Question 3

Does a crack ever heal itself?

 

Answer 3:

Unlike bone, the cracked tooth never heals. That is why we recommend beginning restorative work immediately.  Delaying treatment can allow a minor crack to worsen and require more extensive treatment. 

 

Question 4:

How does root canal treatment eliminate pain in a cracked tooth?

 

Answer 4:

It eliminates the pain coming from the pulpal (nerve) tissues inside the tooth. The fibers around the tooth (the ligaments and bone) can still create some discomfort, but not the intense pain caused by the nerve tissues. While creating a completely normal-feeling and pain-free tooth can’t be guaranteed, eliminating those pulp tissues, along with restorative work, can bring very satisfactory results. 

Question 5

What is an endodontist and how would they treat a cracked tooth?

 

Answer 5:

An endodontist is a dentist who specializes in treating diseases of the pulp (the nerve and connective tissues inside the tooth) and the periapical tissues (the tissues around the root end such as bone and periodontal ligament).  The endodontist frequently sees dental patients in emergency situations, as the most severe dental pain occurs from the root canal system. For a cracked tooth, an endodontist would perform root canal treatment to eliminate the affected pulp tissues, easing discomfort and pain.

  

Question 6:

If a patient has cracked tooth syndrome and root canal treatment is indicated, what can be expected?

a) is it painful?

b) how many visits will it take

c) how long is each visit

d) how effective is root canal therapy in treating cracked tooth syndrome?

 

Answer 6:

We understand that patients are frequently in pain by the time they visit the endodontist and should not have to endure any additional discomfort during treatment.  We use local, injectable anesthetics that are incredibly effective in ensuring there is no pain associated with a root canal treatment. Treatments can take one or two appointments of 45 minutes to one hour each, with the anesthetics lasting about four hours to ensure a pain-free treatment. Root canal therapy is very predictable, with some of the highest success rates for medical/dental procedures.  However, the long term success in treating cracked tooth syndrome is more unpredictable because we don’t always know the extent of the cracks in each individual case. While there are many excellent techniques available today for replacing teeth, none are as good as your own natural tooth.  That’s why our number one priority is always to help you keep your teeth for a lifetime.

 

Question 7:
So a combination of restorative dentistry and root canal therapy is the best long-term treatment for most cases of cracked teeth?

 

Answer 7:

Absolutely, the prognosis for these cases is very good. The key is early diagnosis and prompt treatment.  Our ability to diagnose gets better every year due to more advanced techniques for visualization (cone beam and CT scans), while treatment discomfort has been virtually eliminated.  

 

Question 8

Is it possible to prevent cracked tooth syndrome?  What precautions can you take if you’re at greater risk–a history of a cracked tooth, a weak-looking tooth or are a heavy teeth clencher or grinder?

 

Answer 8

Prevention is not always possible, but it makes good sense to take precautions in higher-risk situations.  Patients with deep anatomical pits and fissures, who may have previously had cracked or fractured teeth, should be watched more closely for crack detection.  In addition, consider doing restorations such as onlays or crowns to protect the cusps on those teeth—and do it early.  Older restorations  should be examined thoroughly for early signs of cracks or fractures. If your  teeth show excessive wear patterns, protect them with bite guards or proper bite adjustments as needed.   Other teeth to watch: those with fractured cusps, cracked teeth, split teeth (the pieces have separated) and vertically root fractured teeth (fractures that start below the gumline, such as when a posted tooth has split from the root end toward the crown). Don’t be concerned if your teeth have “craze” lines—these are tiny cracks that affect only the outer enamel of the teeth and do not need to be treated.

 

Information courtesy of:

Lester B. Chernick, DDS

Loyola Univ. School of Dentistry

Northwestern University Endodontic Resident and Specialty Certificate
Clinical Associate Professor of Endodontics for 11 years

Partner: Water Tower Endodontics

www.Watertowerendo.com

info@watertowerendo.com

Chronic kidney disease (CKD) presently affects one in 9 Americans, according to the National Kidney Foundation. Debilitating effects from CKD can lead to heart disease and /or kidney failure. A recent article in the journal of Periodontology suggested that edentulous patients are more likely to have CKD than those with a full or partial dentition.

At Case Western Reserve University 4,053 adults aged 40 and older were evaluated for kidney function and periodontal health. After elimination of risk factors such as age ,race/ ethnicity, and smoking, results indicated that edentulism was found to be “significantly associated” with CKD. Participants who had lost all there teeth were more likely to have CKD than those who had kep their teeth. Edentulism in this study was linked to evidence of past periodontal disease and chronic inflamation.

CKD is considered an inflamatory disease that now may join other adverse systemic conditions with a common link to oral health status.

At The Dental Professionals, you’ll find the widest range of cosmetic dentistry services available today, performed by Chicago dentists with years of professional experience. Whitening, laminated and bonding cosmetic dentistry services at The Dental Professionals utilize the latest technology and products to make your smile a winning one: brighter, whiter and completely natural. Let us give you something to smile about.

Tooth Whitening. You can have this smile transforming cosmetic dentistry service done at our offices or in the comfort of home. A chairside power bleaching at our Chicago or Skokie office can be done in just an hour. We’ll apply a protective gel or rubber shield for your gums, apply bleaching agent to your teeth and use a special light to enhance the bleaching agent action. One session is generally enough to significantly whiten teeth. If you opt for home use, we’ll provide everything you need: a custom-made bleaching tray and whitening cosmetic products. Just wear the tray for up to 3 hours per day and you’ll see great results in two to four weeks. Keep your new white smile for years by visiting us for regular professional care.

Porcelain Laminates: Using advances in modern dental materials and techniques, The Dental Professionals offers the most up-to-date ways to repair or replace teeth. These ultra-thin, high-strength facings made out of advanced porcelains can replace or cover part of the enamel of the tooth. The color and translucency of all porcelain restoration mimic natural tooth enamel, creating a pleasing, natural-looking smile.

Bonded Composites: Composites can improve the appearance of teeth that are chipped, broken, cracked, stained, or have spaces between them. Special tooth-colored cosmetic dentistry materials are applied to the tooth surface to smooth out roughness, change colors, alter contours or close spaces. The Dental Professionals uses materials that are stronger and more durable than ever before.

Everyone wants it: a brighter, whiter, more winning smile. Tooth whitening can help you get it. Is going white just right for you? Following are seven simple answers to help enlighten you about our Chicago tooth whitening services.

1. Is tooth whitening right for all teeth? Ask us to evaluate you and your teeth before whitening. Yellowish, hued teeth respond well to bleach, but brownish-colored and grayish-hued teeth do not. Whitening does not whiten caps, veneers or bonded teeth. Finally, if you’re nursing or pregnant, we do not recommend brightening.

2. Can brightening be done in your Chicago and Skokie offices? If you prefer, chairside power bleaching can be done in one hour at our Chicago and Skokie offices. We’ll apply a protective gel or rubber shield for your gums, apply bleaching agent to your teeth and use a special light to enhance the action of the bleaching agent. One session is generally enough to significantly whiten your teeth; some patients may require an additional session.

3. Is bleaching safe? Yes. Be assured that brightening will not soften enamel or existing fillings. The primary ingredient is hydrogen peroxide, used safely in brightening procedures for over 100 years.

4. How does brightening work at home? Take-home brightening is available to be done anywhere and anytime. We’ll give you a custom-made bleaching tray filled with a mild bleaching agent. Just wear the tray _ to 2 hours per day for two to four weeks for great results.

5. How much whiter will my teeth look? Most people see a significant change in the whiteness of their smiles; but results will vary by individual.

6. Is bleaching painful in any way? The majority of patients experience no pain or sensitivity during the process or after.

7. How do I keep my teeth white after the bleaching? To maintain your new bright smile, brush your teeth twice daily or after each meal and floss once a day, visit us regularly for cleanings and check-ups and do a touch-up bleach at home. With regular professional care and use of after-care products, you can maintain your new whiteness for many years.