A large number of people do not have room for wisdom teeth. This may be the result of an evolutionary change because our diet has changed over thousands of years and we don’t eat as many greens and nuts and our jaws are not as big as they used to be. We are seeing more and more people in the past few generations did not even form some of their wisdom teeth. Those who do have wisdom teeth and don’t have room for them will get impacted teeth. When a tooth becomes impacted it can do damage to the tooth in front of it.

Depending on how it’s sitting in the jaw bone(or what happens in most cases) the wisdom tooth will come part way out of the jaw and then the gum tissue surrounding the enamel covered crown of the tooth can’t adhere to the enamel and a pocket forms. Food can get trapped in the pocket and cause an infection caused periocornitis. This infection causes swelling and pus from around the wisdom tooth that will come and go but become more frequent and severe over time. Quite often it is necessary to remove those wisdom teeth and, in many cases, it is a surgical procedure to extract the tooth.

In our office, we provide IV sedation so that the patient isn’t aware of the treatment while it is going on, and will recover better than with just using a local anesthetic. Taking out wisdom teeth is sometimes an elective thing but it is usually best to do it when the patient is younger before the bone becomes dense. Early extraction also gives less likelihood of the wisdom teeth causing damage to the other teeth, caused by the patient’s bite or resorption of the tooth in front of it. If extraction of wisdom teeth is ignored and it is growing into the molar in front of it, the patient may get almost like decay but its resorption similar to the resorption you get when permanent teeth come under the baby teeth and resorp the roots. Sometimes if you ignore it, you will end up losing multiple teeth: the wisdom tooth and the one in front of it, and then the one above it because it doesn’t have a tooth to function against. For these reasons, extraction of wisdom teeth is an important thing to evaluate at an early stage.

What are some symptoms of a TMJ disorder?

Headaches:

There are many, many causes for headaches, but the majority of headaches are muscle related. We hear a lot of patients talking about their headaches caused by stress. In many cases, people get headaches because of stress because they are clenching and their bite is not in harmony with their joints. Certainly not in all of them, but that is a big part of it. And when their bite is in harmony with the jaw joints and the muscles are relaxed, they are less prone to get headaches.

Earaches:

Many people complain of earaches when it may be TMJ pain. The physician may tell them that there is nothing wrong with the ear. Often times its an inflammation in or around the jaw joint that is making it feel like an ear ache. A lot of jaw pain is transient. It is exasterbated or brought on by stress and once the stress is gone then a lot of the symptoms will subside. That doesn’t necessarily mean their bite is really great but it does mean they can adapt to it…except during times of stress…and if they get their bite and jaw in harmony then it takes a lot more stress to bring on those symptoms.

What is TMJ?

The Temporal Mandibular Joint is the joint where the jaw meets the skull. Within that joint is a thin disc that sits between the jaw and the skull. And a lot of the problems occur when the ligaments or muscles attached to that disc are damaged or not functioning properly and then the disc starts popping out of place. That’s when people hear the clicks and the pops and the grating noises. Often times our goal is to get the muscles relaxed so they will release their abnormal pressure on the disc so it can go into place and get the inflammation in the ligament space behind the disc and the joint healed. A major goal of our treatment is to get that back in place. In a few cases, it is necessary to do this surgically.

Temporary pain relief:

Something someone can do in the event that they have an acute muscle problem is to use ice packs: 20 minutes on one side and then 20 minutes on the other side…for the first day or two of the acute episode. And then change that over into using more moist heat after that and gently exercising their muscles…stretching, making sure they relax and don’t clench their teeth, get on a soft diet, and take mild anti inflammatory such as Advil.

A healthy TMJ requires finding the right solution:

In a comprehensive approach to dental care, making sure that you have a healthy TMJ has to be the starting point. You cannot restore a bite, restore a smile, or have anything that is going to function well long term for the patient, if the joints aren’t healthy. Fortunately, the majority of jaw pain is muscle pain that is often related to the bite. And if the bite is corrected and in harmony with where the muscles need to function, and the muscles can be calmed down and comforted. And a very small percentage of patients with jaw pain can actually be a problem within the jaw joint itself and many of these can be treated through splint and bite therapy but some of them have to be surgically corrected to get the comfort that’s needed. And all of that needs to be done prior to doing any major restorative work such as crowning teeth, changing bite, and other restorative work. So the foundation has to start with the joints that are healthy and comfortable and in good position. Then the bite can be constructed to be in harmony with that.

How we address TMJ disorder:

The first thing we do is a true assessment with each of our patients to find out if the joints can be loaded without pain, which they should be, similar to the knee or any other joint in the body. We do measurements of range of motion, such as how far can they open and move their jaw from side to side, is it even, do they open without their jaw deviating from one side to another Deviation would indicate a problem within the joint in most cases. We also listen to the joints with a Doppler ultra sound to give us an indication of the health of the joint itself, It all starts with a good assessment. Once we’ve got the assessment its going to give us a good idea in most cases whether the problem is a muscle problem (which it is most of the time) or if it is in the joint. Each are handled/addressed a little differently. In a lot of cases it is wise to utilize a full arch splint where we can recreate an ideal bite that fullfils all the criteria for a good bite in harmony with the joints without doing anything to the teeth until we verify that we can get them comfortable and get the joints in a good place and everything is healthy…And then and only then, should you start on any restorative treatment.

The splints we use are often diagnostic as well as therapeutic. Many of the problems have occurred over long periods of time. While many of them resolve instantaneously, many others take an extended amount of treatment to get them healthy. A joint with abnormal pressure over an extended amount of time may have inflammation or a change within the joint itself that have to change back as you get a proper bite. This is one reason splint therapy sometimes takes some time: the joints themselves will heal and remodel and you want to wait until that remodeling has completed before you start restoring the bite. If you restore the bite where the joint is when it’s not completely healthy that bite is going to change as the joint heals.

Because we are taking care of decay at an earlier stage and using filling that bond to the tooth that have a coefficient of expansion that is more similar to the tooth structure, there are fewer cracked teeth caused by the restoration, the fillings are smaller so they last longer, and cosmetically they blend to look more like part of the teeth.

When fillings get to be a certain size, regardless of the material, you are exceeding the limits of that material for it to be an effective restorative product. In this case, porcelain restorations can be shaped and cast to fit in or on the tooth and bond to the tooth. This solution can be effective for teeth that need full coverage to protect where they have been cracked or broken. Often times now we don’t have to do a full crown when we can do different shaped restorations that bond to the teeth and maintain more structural integrity to the tooth.

Some individuals are reluctant to even just have their teeth cleaned because of fear. For these individuals we have oral medication that can be taken 45 minutes to an hour before their appointment that will alleviate their anxiety. The medication is strong enough to really do an effective job so these patients will need a designated driver after treatment.

If we are going to be doing significant dentistry on an individual who is not comfortable sitting for an extended amount of time or has an extreme fear, IV sedation is available. This is a safe method of sedating the patient so that they will not have an unpleasant memory of the treatment. They will not be unconscious, as with general anesthesia, so there are not extreme dangers associated with this sedation. Patients can still respond and inform us if something is bothering them so that we can respond accordingly.

Sometimes there is dead or dying tissue in the canal that holds the roots of the teeth which can cause an abscess, sometimes it is painless but many times it can be a painful experience for the patient. A solution is making an opening into the canal that is in the roots and then removing the diseased tissue from the tooth all the way to the tip of the root and cleaning, shaping, and disinfecting the inside of the canal and then sealing with a plastic material and cement so that bacteria can’t get from the bloodstream back into that space again. In the canal, when it gets infected, the first thing that happens is an increase in blood flow, which causes swelling. The swelling cuts off the blood supply and then the blood can’t fight the bacteria. This causes dead and diseased tissue which becomes a continuous source of food for the bacteria. They grow and then an abscess occurs when the bacteria start getting out to the end of the root and that is when a patient will experience a throbbing pain.

Some symptoms can be sensitivity to hot and cold that lingers afterward, spontaneous throbbing pain, and pain upon chewing. These symptoms do not necessarily mean that the patient needs a root canal. For example, cold sensitivity, if it goes away immediately, may be a sign of an irritated but healthy nerve. However, if you have hot on a tooth and it lingers for a long period of time, most of the time that will be a tooth that needs a root canal.

The most common scenario where it is necessary to do a root canal is if there is infection in the root from decay. Occasionally a root canal is also necessary due to trauma, a cracked tooth, and in rare instances during tooth restoration if the canal is to close to the surface of the tooth.