1. EXCESSIVE TOOTH WEAR: Many people with worn-down teeth tend to grind more, which predisposes them to fractures, fillings and crowns failing, cracks, and root canals.
2. ABFRACTIONS: Clenching is also associated with gumline recession and erosions, also called “abfraction” defects. One conventional explanation everyone hears is that these are due to a hard toothbrush or a wrong brushing technique. It may well be that these aggravate the condition, but the actual cause of abfractions and recession are clenching and grinding. The thin enamel layer that tapers off at the level of the gums splinters off, exposing dentine. Being softer and more prone to decay, this exposed dentine begins to wear faster, creating a defect that is also prone to cavities.
3. RECESSION: The excessive rocking motion of the teeth being subjected to a dysfunctional bite or grinding causes the thin bone plate holding the teeth in place to recede, thus causing the well-known “tooth recession”. These teeth tend to become more sensitive which is the major cause for people to seek treatment.
4. JAW-JOINT PROBLEMS: In many people, clenching or grinding will lead to jaw-joint (TMJ) damage. Something in the bio-functional triangle of the so-called chewing (or masticatory) apparatus, that is TEETH, MUSCLES, and TMJ, has to give. It is either tooth damage, (including periodontal bone loss and recession), muscle aches (and associated headaches), or TMJ problems.

We see that there is always an underlying reason for most conditions in the mouth and one should go beyond cliché and outdated explanations in order to properly address these.

A nightguard is the first and most conservative way to start addressing these harmful effects. It breaks the cycle of destruction within the chewing triangle.

In cases of excessive tooth wear, a collapsed bite, and a disharmonious bite, permanent solutions should be eventually achieved to restore harmony in the bite, including jaw repositioning, tooth reconstruction, orthopedic bite opening, orthodontics, physiotherapy, etc.

Typical damage caused by tooth clenching and grinding is shown in the following images…

Abfraction lesion with heavy tooth wear and enamel cracks resulting from bruxism and a collapsed bite

Recession with exposed dentine which has started to develop a cavity

Severe recession in a lower incisor as a result of a traumatic bite between the front teeth

The following are two models of a nightguard as used at the dental clinic of  Dr. Joseph Sarkissian…

Click here to view the embedded video.

Click here to view the embedded video.

With the best Holiday wishes and success and prosperity for 2012,
Dr. Joseph Sarkissian and Staff

This is certainly so with cavities in teeth – they hardly ever go away, if we just wait, even though we might at times be tempted to believe that.

Fortunately most parents of small children are eager to handle any cavities they discover in their children’s teeth. But these teeth are often so small and cavities can not be easily discovered by the naked eye, especially if they develop between teeth – and flossing the teeth of a four-year old is not an easy task.

An additional factor in baby teeth is that cavities can develop rather quickly and virtually undetectable under the enamel. Only when this fragile outer shell collapses do they become obvious.

This might then look like this baby molar…

Decayed Primary Tooth: A cavity in a baby molar will look like this only if it is advanced. At this stage it has probably invaded the nerve (pulp) chamber and is in need of a laser pulpotomy.

If this is a tooth that would fall out very soon it could be removed to save the child from any possible tooth ache, but if this tooth is still needed to keep the space open for the permanent tooth to grow into, it need to be saved. Extracting the tooth and then using a spacer to maintain the opening for the new tooth would probably the more costly and way more inconvenient solution.

If we are in the fortunate situation that the majority of the pulp and nerve are still savable, a pulpotomy can be performed (see the graphical explanation).

The following sequence of images shows how this procedure is performed.

1. Decay has been cleaned out with a slow electric drill. There is bleeding from the gums as well as the nerve, which is exposed.

2. The tooth is sealed from the side with a "matrix" to prevent any blood or saliva creeping into the cavity during the following steps.

3. Laser energy is used to remove the nerve tissue from the pulp chamber (Waterlase at 2.25 W).

4. The laser is angled to completely remove nerve tissue from all the recesses of the chamber, to avoid future re-infection.

5. The openings into the canal are now visible with healthy and untraumatized nerve tissue left intact. Mild bleeding is very normal and indicates healthy tissue.

6. A mild 2-3% hydrogen peroxide solution is used to gently disinfect the chamber and stop bleeding before placing the MTA.

7. MTA (Mineral Trioxide Aggregate), a highly biocompatible cement is used to plug the openings to the canals. Very light pressure with a small cotton pellet is used to compact and dry it to avoid trauma to the nerve.

8. After making sure that there is no bleeding seeping through the MTA, this is now covered with a base of glass-ionomer cement.

9. After the Glass-ionomer sets in 5 minutes, traces of MTA and cement lining the side walls and the margins are removed with a dry, slow bur. A self-etching bonding agent is applied with a micro-brush and dried after 30 seconds.

10. The cavity is now restored with a bonded composite using proper bonding principles.

11. The final filling completed and polished. This tooth will survive for a few years until it is replaced with a permanent premolar.

The following graphics by Dr. Sarkissian show this development and the treatment of this condition. A permanent tooth would require a root canal treatment at this stage, but for a primary tooth a laser pulpotomy is indicated which keeps the tooth alive.

1. A healthy baby tooth (primary molar). The nerve (pulp) makes up a significant portion of its interior.

2. A true cavity arises when the outer enamel shell of the tooth is penetrated and bacteria invade the interior dentin layer of the tooth.

3. The cavity spreads at a rapid rate.

4. The bacteria have approached the pulp and start causing mild inflammation.

5. Due to softening of the befallen dentin, the outer shell crumbles and exposes the cavity. This is when most parents realize that their child has a cavity.

6. Laser Pulpotomy treatment is initiated. The cavity is excavated with an electric drill.

7. The Waterlase is used to remove, or amputate, the pulp from the chamber. There is no mechanical trauma, heat, or contamination. Hydrokinetic energy is used to break up the tissue without the tearing, crushing and smearing associated with the drill.

8. After mild irrigation with hydrogen peroxide and after bleeding has stopped, MTA (Mineral Trioxide Aggregate) is used to cover and seal the exposed nerves leading into the canals.

9. A glass ionomer cement is used to cover the MTA to allow for undisturbed setting and to prevent its contamination during the multiple bonding steps.

10. The tooth is bonded with resin composite employing the latest techniques in adhesive dentistry.

You can read the article about a real-world pulpotomy to see this procedure performed on a child’s primary molar.

You can find more information on Dr. Sarkissian’s web site under
Services ->Laser Pulpotomy.

But looking at it a bit closer this perspective does not quite hold true. Although the outer shell seems to be hard as an inanimate object the tooth is a living part of the body. Fact is that the inner parts of the tooth contains living tissue that needs to be nourished to stay healthy. Once the root canal procedure is performed, removing nerve and blood vessels and filling the now empty cavity with an inanimate substance, the tooth indeed becomes an object that is no longer connected to body fluids that make it a functioning part of the body. It has become a dead object that is no longer renewed and protected by the body’s defenses. Bacteria entering through the tiniest cracks might cause persistent infections because there are no blood vessels any longer that would bring white blood cells to fight that infection.

Therefore a root canal should be only a very last resort and every effort should be made to save the inner living part of the tooth – the root canal.

The direct cap procedure is such an effort. The following illustrations by Dr. Sarkissian demonstrate this procedure.

1. HEALTHY TOOTH: A healthy tooth is covered by a shell of enamel, the hardest substance in the body. It is a complex organ comprised of all three embryological layers.

2. CAVITY FORMATION – EARLY STAGE: A cavity starts when bacteria in plaque produce acids which eat away at the surface of the enamel.

3. CAVITY FORMATION – DENTINE INVASION: As the cavity penetrates the softer dentine, it spreads like a wave and infects the microscopic tubes of this live tissue.

4. CAVITY FORMATION – DEEP DECAY: Very soon it approaches the nerve chamber, or the pulp, causing an inflammation which at this stage is reversible. This is when one feels mild pain or heightened sensitivity to sweets and cold.

5. DRILLING OUT GROSS DECAY: Treatment is initiated by removing the outer layers of decay with a slow drill.

6. LASER EXCAVATION AND DECONTAMINATION: The deep layers of decay are removed with the Waterlase® at lower settings, to avoid trauma to the nerve. There is no mechanical insult to the nerve, such as vibration, smearing or heat, which is the case when using drills. The infected dentine is thus removed completely, resulting many times in an exposure of the pulp.

7. EXPOSED PULP: If the nerve (pulp) is still healthy, it may bleed slightly. At this stage the exposure is treated like a wound. It is gently irrigated with hydrogen peroxide, followed with an isotonic homeopathic remedy.

8. DIRECT CAP: The exposure is gently covered with MTA, a cement well known for its biocompatibility and ability to preserve vitality of tissues with which it comes into contact.

9. CORE BUILDUP: The remaining cavity is then lined with a self-priming bonding agent without disturbing the MTA. After drying, the whole dentine surface is built up with a core of a flowable composite or compomer.

10. FINAL RESTORATION: The tooth is restored with an esthetic, tooth-colored bonded restoration, preferably an indirect porcelain inlay or onlay. The biomimetic principle is followed, which means that each part of the tooth that was restored, functionally mimics the biological tissue it is replacing.

Tooth ache usually means that the nerves in the center of the tooth – the pulp – are being attacked by an infection. This is mostly caused by a cavity that remained too long untreated so that it penetrated the enamel, the underlying dentin and is now approaching the pulp.

The following illustrations show the progression and treatment of this condition.

Nerve dying: A cavity arising in a tooth, if not addressed in time, will eventually approach the nerve (pulp) and cause an infection. At some point the infection will irreversibly damage the nerve and cause it to die. Usual symptoms characterizing this stage are pain, pain to hot drinks and throbbing.

1. The necrosis (death) within the nerve chamber will spread to other parts of the root canals. Soon the whole tissue within the nerve chamber and the canals will die and degenerate into pus or a gangrenous mass.

2. The toxic tissue within the canals now spreads out through the small opening at the end of the roots into the bone. A localized bone infection sets in also known as apical periodontitis or local osteomyelitis. The bone at the tip of the roots dissolves away. Symptoms at this stage include throbbing pain and extreme tenderness to touch. Sometimes the tooth feels as if it is longer. This is due to mounting pressure from the pus beneath it that pushes the tooth outwards.

3. Root canal therapy is initiated. An access hole is made and the chamber is drilled out.

4. Special files are used to clean out the canals and widen them. Disinfecting solutions are used to loosen the dead tissue and kill germs. The canals are widened at least four-fold in diameter to make sure all the dead tissue lining the toxic walls, its recesses and irregularities are removed.

5. A laser is used with a special flexible tip to irradiate the canals and further disinfect its walls.

6. After it is disinfected and dried, the canals are filled with a paste that seals the empty space and prevents bacteria from growing.

7. After the paste sets, and commonly in a separate session, the top section of the root canal material is removed, and a space is prepared to accurately accept a fiberglass post. This is bonded inside this space with a resin cement, which also fills the void in the tooth and reconstructs the core for the future restoration. This is called "post and core buildup".

8. The top part of the tooth is now prepared and shaped to accept a porcelain crown or onlay. An impression is taken and the tooth temporized.

9. In the final session, the tooth-colored porcelain is bonded to the tooth. It is important to understand that the tooth is now essentially bonded from the post all the way up to the top restoration, acting as a single unit, as close to an original tooth as one can get. Therefore the stability and function of the tooth is reinforced.

Metals are good conductors of electricity and it does not take too much imagination to suspect that when they are placed in our bodies, they will create electrical currents that may not only cause the release of toxic corrosion products, but also interfere with the body’s subtle energy fields.

Since many dissimilar metals, such as silver amalgam and gold are used as fillings in our teeth, and are present in a moist environment, a battery effect is produced. This electrical activity is measured as “galvanic currents” between different fillings, or between fillings and body tissue. Electricity may cause corrosion of the less noble metal component, releasing harmful metal ions, or it may have neurological effects as it travels though our bodies.

Some people may perceive this as a “metallic taste” in the mouth or a spark of electricity when they have metal utensils or aluminum foil touch their metal fillings. It may also cause fatigue, sleep disturbances, irritability, skin lesions, etc.

It is easy to measure the battery effect. We do that regularly on our patients. A regular voltmeter will typically measure values of 20 to 300 millivolts between a mercury filling and the body. Mercury fillings hiding under or placed adjacent to gold crowns is of major concern because the electricity generated is much more profound.

Mercury released through galvanic corrosion enters the bone and gums surrounding these teeth in concentrations 20-100 times normal values. Other components of amalgams, such as tin and copper, also are released as salts which have a highly toxic effect on the body.

As we age, or in some cases following certain aggravating conditions, the vertical relationship between the jaws is diminished, and an “overclosed bite” results. The “columns” are shortened and worn down. As an analogy, the “roof” of the mouth is lowered. In the space inside the mouth, or the “room” that is now smaller, the tongue has less room to fit and function, and the airway, our life channel, is diminished in size and volume.

“Bite opening”, a simple layman’s term to describe the orthopaedic gain in vertical space between the upper and lower jaws,  is a method to restore the vertical relationship between upper and lower jaws to the original, or to a dimension that the body physiologically was meant to have, or once had.

What are oral and dental signs of an overclosed bite?

Many people who have an over-closed bite have:

1. worn-down teeth, man times so extreme that the teeth are flattened and have no enamel covering. There may also be other signs such as small craters caused by erosion on the chewing surfaces of the back teeth.
2. Fracturing of fillings, ceramics, or outright teeth, especially if they are root canalled.
3. thinner lips, as these get pushed together and collapse inwards, (just like in the elderly) when the vertical is reduced.

Can a history of orthodontics (braces) cause an overclosed bite?

According to our experience within our patient pool, most of those who have had braces with 4 sound premolars extracted also have over-closed bites, which is not only erosion-caused, but also due to an abnormal constriction of the size of the jaw and the inward tilting of the teeth.

Many dentists and orthodontists who have a deeper understanding of the way the jaws and jaw-joints works, frequently open the vertical in order to avoid relapse, or to prevent fracturing of tooth restorations.

What are other TMJ symptoms of loss in vertical?

The vertical collapse ultimately reflects in the jaw-joint. As the teeth wear down, the joints gets pushed back and jammed into their socket in the skull, and the delicate tissue behind the joint space, as well as the disc between the cartilage faces are damaged. Clicking, jaw tension and headaches ensue, which are common signs of Jaw-joint dysfunction (TMD).
How does one identify a loss in vertical at first glance?

If the lower incisors are worn down and crowded, facets appear and the dentin shows through, that indicates that at least 2 mm of vertical has been lost.

How is vertical bite opening achieved?

This is achieved in two phases:

• PHASE I: One option is to add some temporary material (composite) to lower teeth at a pre-determined opening, as dictated by the jaw-joint and neuromuscular function.
  Another option, especially in patients who have TMJ symptoms, is to have them wear a splint on the teeth to train the jaw to function in the new position for a few months. This allows for healing of the jaw joint.
  Phase I is an interim phase that is fully reversible and lasts 3 months.
• PHASE II: If the new jaw position is drastically different and the teeth are crowded or angled incorrectly, braces are placed to have the teeth move to a new position in space as dictated by the jaw.
  If many teeth have failing fillings or crowns, or are worn down, they are restored with porcelain crowns, overlays or onlays to the new dimension dictated by the jaw.

What are other benefits of restoring the vertical?

• Improved jaw-joint health
• less headaches
• less clenching and grinding
• stable tooth relationship
• more conservative tooth drilling for crowns and onlays (which are built with proper tooth anatomy thanks to the increased clearance between teeth)
• better lip support, reduction of wrinkles around the corners of the mouth, larger airway
• increased scope of jaw movement (range of motion)
• improved esthetic profile

There is a common misconception that because of the controversy surrounding root canals, many people avoid treatment of dead teeth despite the fact that these dead nerves act as a mini gangrene made up of the utmost toxic material. These teeth have to be treated at all costs.

Alternative treatment includes extraction of the tooth, which then necessitates the placement of a bridge or an implant to cover the space of the missing tooth and to restore the bite.

Root canal risks:

• Some roots, which are thin, bent, flat, or decayed may be perforated or fractured by the root canal procedure. This compromises the outcome of the treatment and the tooth might need to be extracted.
• Root canalled teeth are more brittle because they are dead and do not receive nutrition from the pulp. This makes them more vulnerable to fractures.
• Vertical fractures may develop in a root canalled tooth due to the propagation of an existing micro-fracture already present in a tooth that has had a previous root canal, due to a post placed to build the tooth up for a crown, or due to a heavy bite.  Because a root canalled tooth is dead, the ligament surrounding it and suspending it in the bone is prone to inflammation, which may cause long-standing tenderness to biting.

Disinfection and canal treatment protocols:

• Laser disinfection by the Waterlase laser
• Ozone injection into the canals
• Irrigation with antiseptic liquids

Materials:  We rarely use gutta percha in our office. The permanent filler materials we use are one of four options (three general and one special):

1. ENDOREZ:  a resin-based material. This material is known to seal the canal systems thoroughly and even bond to the walls with resin tags.
2. ENDOSEQUENCE: A bioceramic material that is also very biocompatible and sets to a hard consistency.
3. MTA: Mineral Trioxide Aggragate is extremely biocompatible, but we only use it for canals that are of certain size and accessibility.
4. ENDOCAL: a calcium-oxide, zinc-oxide based material. Highly biocompatible, and known for diffusing through the canal systems and disinfecting large portions of the root structure. Due to its multiple drawbacks, however, Dr. Sarkissian uses it only in special circumstances, or only for the purpose of medicating the canals for 2-4 weeks prior to being replaced by another material.

Drawbacks of Endocal:  it is not as visible as Gutta percha in x-rays, making it harder to distinguish between filled vs. non-filled portions within the root canal complex.  This means that future dentists may mistake it as an insufficiently filled root canal, and many insurance companies may deny claims for reimbursement. The American Association of Endodontists disapproves of its use due to claims of a higher incidence of root fractures.