Teeth Repair With Composite Material
People visit a dentist characteristically to treat a problem in the mouth, usually pertaining to the teeth or the gums. No surprise there. Would you consider a dental evaluation if you had chronic sinusitis, ringing in the ears, chronic back pain or neck cramping or migraines or persistent waking up headaches? Most will not. These conditions traditionally fall under the purview of various medical specialties. Yet these are conditions that might be the result of a mouth that is hyper activated by the state of mind of that person. It is the often missed link in the differential diagnosis.
The essence of dental practice is ostensibly to eradicate the scourge of dental disease and also to educate and train the patients to take care of their mouths so well that they would not need a dentist anymore. In other words, unlike medicine, the field of dentistry has been working hard to work itself out of business. If one were to ignore, for the moment, the hereditary and congenital defects that affect the mouth and discount for the misfortunes of accidental injuries, then almost 90 % – 100% of dental issues people are battling are self-inflicted: those of personal abuse, inadequate maintenance or psychologically induced damage.
What constitutes an ideally maintained mouth?
If these five conditions are met then the oral health will be at its optimum and be maintained in that condition almost to perpetuity (or at least until age related issues require attention). Of these the conditions of No. 1 are largely a matter of genetics and luck of having the right hereditary heritage. No. 2 through 4 are inter-related and largely dependent on personal responsibility and due diligence. No. 5 is the subject I plan on exploring in more depth here.
Stress is a manifestation of our lifestyles and life choices we make. We have a perfunctory awareness of the effects of stress on ourselves. Minor afflictions such as headaches, muscle tension, disturbed sleep and mood alterations are easily connected to enhanced stress one is enduring. The more subtle manifestations of stress we acknowledge are exemplified by events like tics or changes in the medical status as demonstrated by development of high blood pressure, weight gain or loss and sometimes skin eruptions or rashes etc. There is yet another area where stress plays out its effects and that is in the mouth.
The mouth has been categorized as having some very definite functions namely, it is the organ responsible for communication – verbal and non-verbal, entry route for food and liquids, breathing and last but not the least, a finely tuned sensory receptor for taste, temperature and smell in conjunction with the nose. But the role that the mouth plays in mirroring the condition of the mind or the psyche of the individual gets ignored and yet appears to be a much more prevalent and persistent than given allowance for.
We often believe that stress is a uniquely modern experience. The way we grind away our teeth or seek out qualified specialist to handle TMJ (joint) related problems and the fact that most of us lead such busy and time strapped and sleep deficient lives, leads us to believe that we are living in unprecedented stressful times.
As dentists we are, from a very early stage, disabused of the notion that teeth wear is the result of our chewing food habits. The common and oft repeated trick question is: When do our teeth meet? To which the answer is: Never. Which is true, in that for the normal functions of the mouth the teeth of the opposing jaws do not have to come in contact with each other. Even when eating, the teeth come closing to gnashing into one another and just short of contact they separate. One of the admonishments we as dentists are encouraged to give the patients is: Teeth apart, lips closed. So then why do we have worn out teeth? The answer appears to be, habitual clenching or grinding or rubbing of the teeth against one another in a non-functional manner. This is the first clue of a mind to mouth link wherein there is a chronic and sometimes constant use of a body part for no definite functional purpose.
The other clue to its insidious origins is that fact that most people who tend to rub their teeth together are blissfully unaware of it. Some learn of this habit when secondary symptoms begin to rise such as, teeth sensitivity, chipped and cracked enamel, fillings cracking or popping out, or simply a vanishing set of smile line teeth. Some might have muscular issues, such as neck cramping, upper and lower back issues for which they seek help from the chiropractor or a massage therapist. But the real majority of people find out about this habit from a visit to the Dentist who notices the characteristic wear patterns. A well trained dentist will help connect the dots of various apparently unrelated conditions to the havoc origins in the mouth. We, the dentist then add to the notion that modern day stress is responsible for most of the non-bacterial dental damage.
Therefore by inference the people in ancient times should have had fairly pristine dental conditions afflicted only by conditions of poor hygiene and results of eating a hardy fibrous diet. Yet look at the example below:
Fossils of human skulls dated to be approximately 12000 years old. Note the heavy wear patterns on the teeth with loss of tooth anatomical morphology. This person is showing signs of extreme tooth wear only possible by deliberate rubbing of his maxillary with his mandibular teeth. If grinding teeth is a habit related activity and is subconsciously driven, then did this ancient human also live through a life of chronic stress?
Compare that to the idealized dentition:
This is the ideal that dentists are taught to aim for while restoring teeth and mouths. The stark difference in the ideal from what is encountered in real life in majority of the mouths today as well as in the ancient past, leads us to believe that gnashing teeth to cause significant tooth wear is not purely a consequence of our modern stressed lives but that stress has always existed in our lives and we have taken it out on our teeth and in our mouths.
Stress is a consequence of our capacity to think and imagine. Our identities are largely the creation of our minds some based on practical truth and some on our hopes and aspiration to be something else, something better. We are not satisfied to just exist, we have to make an impact however small. This leads us to constantly be in a mode of self evaluation, which can be stressful. Furthermore since we are aware and curious of our surrounding we are very cognizant of our weakness and susceptibilities to the vagries of life which can sometimes be hazardous. Survival is always in the back of our minds. Since the earliest days of our evolution into the human species the fragile nature of our existence has been amply emphasised. The modern day human and the ancient early humans might had different standards of living but are and were affected by the same existential quandaries. Therefore it should not be a surprise that we have always been a stressed out species.
The question is why then do we have to manifest our stresses in the mouth? People handle stress differently. Some are prone to more open displays of stress such as uninhibited exhibition of anger or crying. Some try to work it out by physically burning the pent up energy by indulging in rigorous exercise or by being constantly in motion, either the enitre body or parts of the body as in sustained shaking or developing incessant tics. But these are socially not very appealing and therefore those who can will try to internalize the stress as much as possible to put on a sanguine countenance. If pent up stress does not find resolution or an outlet it results in conditions which might manifest as skin lesions eg: psoriasis, urticaria ( these are called psychosommatic conditions) or sleep issues and if stress becomes chronic it will affect the health by causing changes to blood pressure, immunity etc. Mouth therefore becomes a convenient area to be used to mitigate the stress cycles one goes through in life as it is a discreet part and the mouth can be subject to sustained and continuous use as a stress reliever without it becoming socially awkward.
What are the common manifestations of stress in the mouth. It can be anything from apthous ulcers, which are extremely small but painful eruptions that appear to coincide with high stress times, or conditions like Lichen Planus in which there either localised or generalized sloughing of skin in the mouth. Dry mouth and its associated complications can occur. But by far the most common area of effect seems to be on the Teeth, Bone, Muscle, Joint complex as a result of constant and chronic grinding of teeth or clenching of teeth.
Chronic clenching or grinding can cause the obvious loss of tooth structure but the less obvious effect is the transference of that chronic load to the supporting tissues. The upper molars invariably have their roots sitting in close proximity to the sinuses. If these teeth are irritated by traumatic overload it will cause the sinus tissue to respond by getting inflammed resulting in sinusitis. Through keeping the teeth and mouth in constant motion, the muscles tasked with this activity eventually begin to get tired and get filled with Lactic acid causing inflammation. Now the stage is set for the occurrence of muscle cramps, headaches and even migraine attacks. The neck muscles have to work overtime too in tandem with the muscles of the mouth and as a result they become prone to cramps which is why grinders sometimes wake up with stiff necks. Neck muscultaure blends into the sheet of muscle that run all the way down the back to the tail bone. If neck muscles go out of wack they will eventually feed that loss of equillibrium down the muscle sheet in the back and they will begin to function in a compromised manner. In this environment if by chance the individual happens to mistime a turn or picking up of an object, it might precipitate a muscle tear anywhere along the back resulting in upper and lower back muscle and joint issues. In some individuals this hyperactivity in the mouth plays out at the level of the jaw joints and when inflammation sets in, it might mimic an ear problem, ringing in the ears or even pain. Most people who seek help because of these symptoms are at the tail end of a process that had a silent beginning quite a few years ago in the mouth.
As a result of all this, the present day dentist finds their work becoming more defined by the management and maintanence of mouths which show progressive and continuing destruction from being used as stress breakers. Patients have to therefore be made aware that the treatments being proposed are heavily dependant for success on the patient’s ability to find a way to manage the stress cycles. Mouth guards help, but stress management through other alternate methods are welcome, be it by meditation, hypnosis or in extreme case even medication. As long as we humans insist on stressing ourselves out and then taking it out on our teeth and oral structures, it appears the field of dentistry is not about to fulfill its goal of erradicating dental problems and fade into oblivion.
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Patient F presented to the office for her 6-month Re-care appointment, when it was noticed that # 24 had a facially draining abscess. Radiograph below shows mandibular anterior teeth with extensive bone loss with periapical lesion on # 24.
I have always wondered, that skilled as we might be to work magic with the modern day dental materials, are we really comfortable in prognosticating the results of our work?
Male patient in late 40s with extreme wear and awareness of habit of heavy teeth grinding. The patient is interested in repairing the damage but does not have the financial resources to take on this large a reconstruction all at once.