Below is a list of questions and answers compiled from actual patient inquiries. Click on the hyperlink to find the topic of your choice:

Receding Gums

Emdogain® regenerative material

Smoking and periodontal disease

Gum disease and root canals

Oral cancer

Dental anxiety

Osteoporosis

Dry mouth & implants

Burning mouth syndrome

Diagnosing a toothache

Receding Gums

This past week I went to the dentist for only the 3rd time in the past 10 years. I had my first ever cavity. But worse, I was told that I had four  5 mm recessions and twelve  4 mm recessions. The hygienist was actually amazed that my situation wasn't worse. Will my gums be able to regenerate at all?

-- Submitted by "Nick"

Dear Nick,

Well, that depends. There are certain kinds of recessions that can be fixed or regenerated and some that can't. 

First let's talk about what causes gums to recede. There are situations that set you up for possible recession, called predisposing factors. These are: thin periodontium (referring to the overall thickness of the gums, bone, and connective tissue covering the tooth root ), a prominent muscle attachment (called a "frenum"), and a prominent tooth root.

Then there are the things that can actually cause recession, called precipitating factors. These include: mechanical trauma (like using a hard toothbrush with a horizontal scrubbing stroke or orthodontic movement into an area of thin tissue), and inflammation (like the kind caused by periodontal disease).

Here is the main thing that I look for when determining if a recession is treatable:
Has any tissue height and/or thickness been lost in between the teeth?

This is because the tissue transplant (or graft) that I use to cover the recession needs to get nourishment from somewhere in order to "take." That nourishment (i.e. blood supply) comes from the connective tissue beneath, but more importantly, from the tissue between the teeth (called the papilla). If you see spaces between the teeth where the papilla has "fallen" (often called black triangles), then these may not be graftable recessions.

If they are graftable, then we need to ask more questions to determine if we then SHOULD treat the recession. For instance:
How advanced is it?
Is the exposed root sensitive to hot or cold?
Is plaque accumulating within the recession and causing
inflammation or cavities?
Is it getting progressively worse?
Is it a cosmetic concern?

None of these questions are mutually exclusive. A "yes" answer to any one of those is enough to warrant treatment.

What happens if you do NOT get treatment? 

1. You are exposing the root surface to plaque and bacteria which cause inflammation and progressive periodontitis.

2. This same plaque accumulation can lead to cavities. 

3. The recession can progress to the point where the tooth becomes loose. 

4. If the recession nears the tip of the root, you might need a root canal to save it (along with the graft to cover the root). 

5. Finally, the tooth may be lost. 

The root surface is much softer than the enamel so cavities progress much faster once they get started. In addition, teeth with recessions are harder to keep clean because plaque tends to "pool" at the bottom of the recession where none of us ever think to brush. We only brush the crowns.

We have come a long way in the treatment of recessions. They can be done with different materials and techniques, thereby minimizing discomfort, and maximizing the esthetic result.  Functionally, they work as well as the native tissue you once had - maybe even better.

Here are some links:

Read more in the Cosmetic Gum Surgery section.

See treated cases in our Gallery.

In addition, I have written or am writing a few scientific papers on this very subject.

Please call us for an evaluation or, if you are not in the vicinity of our offices, try to find a qualified periodontist near you by using the directory on the American Academy of Periodontology web site:
http://www.perio.org

Good luck! Let me know if you need any further information.

Sincerely yours,

Ed Lorenzana, DDS, MS

Emdogain Regenerative Material

What exactly is Emdogain® and is it as good as what some people are making it out to be?

--- Submitted by  J. J. Simmons, DDS, Farmington, New Mexico

Quoting from Biora's product description, Emdogain® is a "resorbable, implantable material [that] consists of enamel matrix proteins extracted from developing embryonal enamel of porcine origin... supplied in sterile, lyophilized form."

Emdogain®  (also referred to in the literature as an enamel matrix derivative or EMD) is a material intended to regenerate the supporting tissues of the teeth (i.e. cementum, periodontal ligament and alveolar bone) by grafting proteins (amelogenin and others) derived from porcine (pig) tooth buds. These proteins have been shown to be important in the production of acellular cementum, PDL, and alveolar bone. ¹  

Research has shown these porcine-derived proteins are very similar to human enamel proteins. ^2,3 Experiments in animal models ^4,5 have shown that Emdogain® does what it claims, but does it work in humans? If so how well? Better than the materials and methods we have now?

To answer those questions: Yes, it works pretty well in humans with regeneration of acellular cementum (ac), periodontal ligament (pdl), and alveolar bone (b) as proven with histological sections (Figure 1). ^6-9  Available research comparing Emdogain® to conventional guided tissue regeneration (GTR) using bone graft and a membrane shows that it works as well as present bone graft and membrane combinations.¹⁰

Figure 1. From Mellonig J, 1999.

So is it the be-all, end-all of GTR? The magic bullet? Probably not, but it looks very, very good. In the next year, we will see an explosion in the number of clinical human studies on EMD's in the literature, most with very encouraging results. 

Personally, I think Emdogain® is easier to use during surgery in certain situations than having to manipulate membranes and grafts, but it is very technique sensitive. (I highly recommend reading Dr. Thomas G. Wilson, Jr.'s book on the use of Emdogain® published by Quintessence Publishing for more information.)

Post-operatively, with this product I don't have to worry about exposed membranes and the attendant complications, but I must emphasize that I am not about to throw away my bone grafts and membranes...yet.  

One thing to note: you will not see radiographic changes in bone density and bone levels for about a year so keep that in mind when evaluating cases returned from your periodontist.

I encourage you to ask other periodontists what they think. Visit the Biora web site at www.biora.com to get the company line on Emdogain®. Hopefully, others will e-mail me and give me their impressions that I can pass on to you. 

Thanks for your question and interest.

Ed Lorenzana, DDS, MS

Selected bibliography

1. Hammarstrom L. Enamel matrix , cementum development and regeneration. J Clin Periodontol 1997;24:658-668.

2. Gestrelius S, et al. Formulation of enamel matrix derivative for surface for surface coating. Kinetics and cell colonization. J Clin Periodontol 1997;24:678-684.

3. Gestrelius S, et al. In vitro studies on periodontal ligament cells and enamel matrix derivative. J Clin Periodontol 1997;24:685-692. 

4. Hammarstrom L, Heijl L, Gestrelius S. Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol 1997;24:669-677.

5. Araujo MG, Lindhe J. GTR treatment of degree III furcation defects following application of enamel matrix proteins. An experimental study in dogs. J Clin Periodontol 1998;25:524-530.

6. Heijl L. Periodontal regeneration with enamel matrix derivative in one human experimental defect. A case report. J Clin Periodontol 1997;24:693-696.

7. Mellonig J. Enamel matrix derivative for periodontal reconstructive surgery: Technique and clinical and histologic case report. Int J Perio Rest Dent 1999;19: 9-19.

8. Sculean A, et al. Treatment of intrabony periodontal defects with an enamel matrix protein derivative (Emdogain®): A report of 32 cases. Int J Perio Rest Dent 1999;19:157-163.

9. Silvestri M, et al. Enamel matrix derivative in treatment of intrabony defects. Pract Perio Aesth Dent 1999;11: No. 5.

10. Sculean A, et al. Comparison of enamel matrix proteins and bioabsorbable membranes in the treatment of intrabony periodontal defects. A split-mouth study. J Periodontol 1999;70:255-262.

Smoking and Gum Disease

My dentist told me that my smoking makes my gum disease worse. I have tried to quit before and before I try again I wanted to know if what he says is true.

--- Submitted Anonymously

Your dentist is being very forthright with you about your smoking. He is acting in your best interests by encouraging you to quit smoking. Besides the fact that it is detrimental to your gums,  smoking affects your entire body.  It can increase the effects of aging, destroy lung tissue, increase your risk of lung disease, heart disease, and cancer as well as be detrimental to the unborn fetus, among many others.

Regarding gum disease, these are the findings:

How does this happen? Smoking (specifically nicotine) deprives the fragile gum tissue of blood supply which carries vital nutrients and immune factors. It can mask the effects of gum disease by decreasing the incidence of bleeding while brushing or flossing. This allows periodontal disease to progress until it is too late to save the teeth.

In addition, the type of bacteria that normally reside in the gums is replaced by a more virulent, more destructive kind in smokers. It is tougher to get rid of this bacteria and smokers tend to require retreatment more often than non-smokers.

Worse yet, your response to periodontal therapy (scaling and root planing, surgery, grafting) is on the order of 2-3 times worse in smokers than non-smokers. Again, this is due to the lack of blood supply as well as heat necrosis (where tissue cells are killed due to the heat from cigarettes) and the accumulation of tobacco debris from cigarettes.

Please visit the following sites to learn more about smoking and its detrimental effect on your gums and your health.

Thanks for your question and interest.

Ed Lorenzana, DDS, MS

Gum Disease and Root Canals

I recently had an aching tooth and went to my dentist. He did x-rays and prescribed penicillin to reduce the infection, stating I would need a root canal. A week later I went back and he did another laser-type test. He found the root was still responding and postponed doing the root canal. He stated that it may flare up at any time, however and cautioned me about getting in quickly. I had my teeth cleaned in the meantime but I feel the problem is related more to my gums and the fact I hadn't had my teeth cleaned in 12 months. Have you had any patients experience similar problems?
Thanks

--- Submitted anonymously

This is a  very common situation and unfortunately also a complex one. Your dentist is doing the right thing to err on the side of caution. Periodontal and endodontic (root canal) problems sometimes tend to overlap and are often grouped into what are called "Perio-Endo lesions." What is important is to determine which is the one that is causing your symptoms.

If the sensitivity and discomfort disappeared after your cleaning, you may have had what is called a periodontal abscess. These occur in places where there are deep pockets around the teeth where bacteria and the tissues they destroy (what you know as pus) accumulate and are unable to drain out through the pocket. The abscess (sometimes called a gum boil) develops and causes pain and tooth sensitivity until the area is cleaned and drainage re-established. It appears this is what happened in your case. 

There is another possibility. Your tooth's pulp may have been inflamed or hypersensitive (called a pulpitis) and subsequently the pulp has "died" or become necrosed which would also explain why it is no longer hurtful.  The infection, however, is still present and causing destruction of the bone and supporting tissues of the tooth so a root canal would be necessary. If this situation goes untreated, the pulpal infection may progress along the outside of the root until it drains out the bottom of the gum pocket surrounding a tooth. This process causes loss of connective tissue and bone from around the tooth root and creates a periodontal condition of endodontic origin. 

So what is the next step? See your dentist so he or she can test your tooth for vitality (responsiveness to stimulus). If it does not respond, the pulp is necrosed and you need a root canal prior to periodontal therapy. If it responds normally, have the pockets around your tooth or teeth treated either surgically or non-surgically to eliminate the periodontal infection. 

Remember, just because the symptoms have disappeared, you may still have periodontal disease. Have your dentist either evaluate you for periodontal pocketing or he may send you to a periodontist he is comfortable with. Visit our  About Periodontal Disease... and Your Gums Your Health sections to read more about how periodontal disease occurs, how it is treated, and how it can affect your overall health.   

There is no easy answer. Your dentist will not lead you astray  but you must be patient. The inter-relationship between the teeth and the supporting bone and gums is very complex and problems are often tough to diagnose. Seek second opinions with either another dentist, a periodontist and/or an endodontist if in doubt. Meanwhile, visit the following web sites to learn more about Periodontics and Endodontics.

American Academy of Periodontology - General information on Periodontics, FAQ's, find a periodontist

American Association of Endodontists - Professional Endodontics organization, general information, find an endodontist.

Baylor College of Dentistry - Department of Endodontics - General information, case reports.

Medical Center Endodontics - Ask Dr. Clement your root-canal questions.  

Good luck!

Ed Lorenzana, DDS, MS

*A very special thanks to Dr. Julio Gaitan (Dallas, Texas) who contributed his expertise in Endodontics to this column.

Oral Cancer

This is probably a pretty random question, but I was thinking about how getting a sunburn can potentially lead to skin cancer, and started wondering if when you eat something too hot and you burn the inside of your mouth frequently, and the skin peels, could that ever lead to a form of gum cancer?
I just burned the roof of my mouth by eating pizza that was too hot, and the soreness is quite irritating, but I thought I would ask if something so common could do any long-term damage.
Thanks

--- Submitted anonymously

No question is too random when it involves our well-being so it is a good question.

Basically, at this point, you have nothing to worry about. Oral cancer is most commonly due to things like smoking, dipping/chewing tobacco, and alcohol, especially in combination when the likelihood of oral cancer increases 5 times.

Some other predisposing factors for oral cancer include: age (> 45 yrs), excessive sun exposure (lip cancer), nutritional deficiencies, syphilis, defective immune system (congenital or acquired), metastasis of cancers from other parts of the body (i.e. lung cancer), organ transplant patients, and viruses such as HIV, papillomavirus, herpes simplex virus, Epstein-Barr virus, and cytomegalovirus. Conditions like poor oral hygiene, genetic predisposition, and chronic physical and thermal trauma are very debatable, but watch out the next time you order Domino's, just to be safe.

Depending on the study, 3-6% of all cancers reported each year are oral cancers. Approximately 90% of oral cancers occur in people over the age of 45, with the incidence increasing until age 65, when it levels off. Men are 2-3 times more likely than women to be affected. The most common locations for oral cancer to occur are the floor of the mouth, the sides of the tongue, the soft palate complex (where the palate meets the upper part of the throat), and the lip. 

5-year survival rates for oral cancers are only about 50% because of lack of diagnosis. Oral cancers are usually painless and may be seen as an irregular red and/or white lesion, patch, or sore that persists longer than 2 weeks. Patients should watch for white or red patches in the mouth, tongue, or on the lips;  swellings, growths or lumps anywhere in or about the mouth or neck;  repeated bleeding from the mouth or throat; difficulty swallowing or persistent hoarseness.

If your dentist suspects a lesion may be cancerous, he may refer you to either a periodontist or oral surgeon for a biopsy. If a cancerous tumor is detected, surgery will be needed to remove the lesion and radiation therapy may be required. 

Your best bet for avoiding oral cancers is regular visits to your dentist (at least twice a year) for oral cancer screenings and radiographs, which may detect hidden cancers in the jawbone. The earlier a cancer is detected, the better the prognosis.

Some useful sites to visit:

Baylor College of Dentistry-TAMUS Detecting Oral Cancer Page - A tutorial for dentists including slides showing how to conduct an intraoral cancer screening.

Academy of General Dentistry - Oral cancer fact sheet.

HealthAnswers.com - Explanation of terminology of oral cancer, causes, incidence, signs and symptoms, treatment, etc. 

Oral Cancer Self-Examination - The University of Manitoba shows patients how to conduct an oral cancer self-examination.

Thank you for your question and interest.

Sincerely,

Ed Lorenzana, DDS, MS

Dental Anxiety

My boyfriend hasn't been to the dentist in years. He is frightened and anxious about going again because he thinks he will have cavities. I'm trying to convince him that he needs to go so if he does have dental problems they can be caught and fixed before getting worse. I know he has the whole experience negatively magnified in his mind. I've tried giving him personal experiences to help ease his anxiety. I've tried telling him what goes on and that it's unpleasant but really nothing to be scared about, but I'm worried giving too much detail is only going to scare him further. 

In attempts to cater to his fears, he is making just about every excuse he can think of to avoid going, including mistrust of greedy doctors and the old standby "if I brush my teeth and don't feel pain I see no reason to go." No matter how I try to show him that you need to have regular checkups and cleaning along with daily maintenance, I don't think he's buying it. He says he will go, but not without complaining and only because I want him to go. He says he knows I have more experience in the area than him, so he will just trust my opinion (with a good amount of griping about it). If this convinces him to go, I guess that is good enough to keep his mouth healthy. I want him to go on his own, however, for his own sake, and not just because I say it's a good thing. Any suggestions, words of wisdom, or advice? 

Thanks in advance,
Sara

Your boyfriend is a lucky man to have someone so concerned about his well-being. Unfortunately, his fears are probably due to a traumatic childhood experience or just fear of the unknown. Many of my patients have told me they were brought up not knowing they needed to go see the dentist and now they regret it.

The longer he goes without seeing a dentist, the worse his problems are going to be and the more the work may end up costing him. In this day and age of shoddy dental insurance, if the work he needs entails seeing a specialist like me, the cost is often not completely covered by insurance. 

Forgetting cost for a second, here are the things a dentist can do for you with routine visits and cleanings: (1) catch cavities before they become too large for a simple filling (you'd then need root canals, crowns, and possible surgery), (2) screen you for oral cancers (especially if a smoker or snuff user), (3) keep your teeth clean to prevent having to see someone like me for gum disease treatment (which usually includes surgery), (4) keep your teeth clean to prevent tooth loss (which would then require a bridge or implants - all pretty expensive).

Your boyfriend must remember, by the time you feel pain in your teeth, gums or bone, it usually TOO LATE to treat! Cavities sometimes won't cause pain until it reaches the pulp (the nerve) which means he'll need a root canal and crown. Gum disease won't cause pain until the teeth become loose or an abscess forms. Then he would need either gum surgery or extractions of hopeless teeth.

As you can see, going to the dentist regularly is COST EFFECTIVE and will SAVE your boyfriend money in the long run. Most insurance today covers two visits per year for cleanings and enough coverage for several fillings and/or crown. Use your coverage if you have it otherwise, the insurance company thanks you and just takes your money, laughing all the way to the bank.

Regarding his fear of dentists, I would suggest he go to someone his friends go to and like, then have him set up a consultation and make sure he tells the dentist he has fears. That way they can talk first and get to know each other and get comfortable. If he's not comfortable, then have him try someone else.

Also, for routine treatment, the dentist will use local anesthetics to prevent discomfort and can use nitrous oxide (laughing gas) and/or prescribe an anti-anxiety medication (like Valium) to make him more comfortable.

If you do not know anyone in particular, visit the American Dental Association web site (www.ada.org) and he can look up someone that fits his needs.

Some useful sites to visit:

Dental Phobia and Anxiety - Dr. Stuart M. Ellis offers many helpful hints for overcoming fear of the dentist.

Overcoming Dental Dread - Some helpful techniques to deal with dental phobia.

Conquer Your Fear of the Dentist - A great article from the Dental Zone.

Share Your Fears (Group Therapy) - The site beyondfear.org allows you to share your fears about dentistry or just read others' experiences - you are not alone!

I am confident your boyfriend can find someone out there to take care of him. 

Good luck!

Ed Lorenzana, DDS, MS

Osteoporosis

I am an older college student writing a paper on osteoporosis. I am wanting to know if periodontal disease and osteoporosis have anything in common? Do people who have osteoporosis have a greater risk factor for this gum disease? 

Thanks.

Great question - this is an area of ongoing research and a topic for debate.

A risk factor is defined as an environmental, behavioral or biologic factor confirmed by temporal sequence, which, if present, directly increases the probability of a disease occurring and, if absent or removed, reduces that probability.

Risk "factors" for periodontal disease that have been recognized by the American Academy of Periodontology include smoking, diabetes, and certain periodontopathic bacteria.

Risk "indicators" (a.k.a. probable or putative risk factors) are often detected in cross-sectional studies. They have yet to be confirmed in longitudinal studies. These include aging, gender, genetic predisposition, systemic diseases and conditions (i.e.
immunosuppression), stress, nutrition, and osteoporosis.

Osteoporosis is characterized by low bone mass (osteopenia) and deterioration of skeletal tissue which leads to increased risk of fracture. Osteoporosis is most common in females; people over the age of 50; Caucasians; people with no exposure to sunlight; people with excessive alcohol consumption, tobacco smoking, or coffee drinking; chronic use of corticosteroids; and people with diabetes, hyperthyroidism, and rheumatoid arthritis.

The connection between periodontal disease and osteoporosis has been difficult to establish due to a variety of study designs. Some have found associations between skeletal bone and mandibular bone. Studies are in the literature that prove or disprove the connection between the two conditions, depending on the study and its design.

What we do know is this: osteoporosis occurs most frequently in older adults, as does periodontal disease. The presence of either of the two conditions or in tandem should send warning flags to both physicians and dental professionals alike. Cooperation and communication is the key not only to maintaining the patient's well-being, but also preserving their quality of life.

Women in particular should be cognizant of possible complications of osteoporosis, including periodontal disease. They should also consult with their physicians as to the use of hormone replacement therapy which has been shown to have a protective role in terms of tooth loss.

We must bear in mind that the primary etiology of periodontal disease is bacterial plaque. Therefore, if good oral hygiene is combined with regular check-ups, the effects that any of the aforementioned risk factors or risk indicators may exert on the periodontal tissues can be minimized.

Some useful sites to visit that focus on osteoporosis:

The Osteoporosis Center - Pages geared towards making osteoporosis understandable to patients. Highly recommended.

The National Osteoporosis Foundation - Probably the most comprehensive site on the net if you are a patient, dentist, physician, or just curious. 

The American Medical Association Health Insight Article - Covers osteoporosis, women's concerns, menopause, and how hormone replacement therapy can help. 

Hispanic Women and Osteoporosis - From the National Institutes of Health (NIH), an important article to raise awareness of osteoporosis in the Latin community. A must for the San Antonio and Rio Grande Valley communities.

Thanks for a great question.

Sincerely,

Ed Lorenzana, DDS, MS

Dry Mouth and Dental Implants

Hello I am a young, 55 year-old woman. I have rheumatoid arthritis (RA) and Sjogren's Syndrome (dry mouth and dry eyes). Because of this, my doctors tell me all my lower teeth just broke off over a 1 month period. Now I need to have my lower teeth extracted. I am very heartsick about this. I cared for my teeth and yet from the inside they just decayed - is that right? My question is this: can I have implants as individual replacement teeth or can I only get a denture plate? I am not psychologically prepared for this as my teeth were not "bad" until this happened. Also is there any treatment to keep the upper teeth from doing the same thing? I am on methotrexate and steroids for the RA. Could that affect my teeth? Thank you.

Dear Anonymous,

I am so sorry to hear of your situation. As if the RA and Sjogren's wasn't bad enough, right? Unfortunately, Sjogren's affects more than just making for a dry mouth and dry eyes. The lack of saliva prevents the body's own mechanical and immune defenses from preventing periodontal disease and caries (cavities) on the teeth. Mechanically, saliva washes away much of the plaque that accumulates throughout the day. Immunologically, the immunoglobulin IgA, part of your immune defense, is in saliva. Therefore, lack of saliva often results in the growth of plaque and the lack of IgA to help fight it.

This results in root caries, which weakens teeth right at the gumline, and periodontal disease, which weakens the support around the teeth. It is not uncommon to have teeth fracture in folks with Sjogren's due to these conditions. Other complications of Sjogren's include increased abrasion/erosion of teeth, increased sensitivity of teeth, corrosion of metallic restorations, altered taste sensation, burning discomfort, oral candida infection, and halitosis. 

Some helpful hints: Drink lots and lots of water to help with saliva and tear production and lubrication of the oral tissues (it's good for you, too). Avoid tobacco, alcohol, and caffeine which tend to dry them out. Also, switch to Biotène brand fluoride toothpaste. It is specifically made for dry mouth sufferers, as is their mouthwash. Oral Balance is a moisturizing gel lubricant that is very helpful, especially for denture wearers. You can find these at any large chain drugstore like Eckerd's or Walgreen's. (See the links below). Chewing sugarless gum is also good for stimulating salivary gland production, as long as you do not experience jaw pain. Make sure you floss daily and/or use an interdental brush to clean between teeth.

Get frequent cleanings (3-4x per year) to prevent periodontal disease. Also, have your dentist start you on fluoride therapy (Prevident 5000 is good - prescription only) to prevent caries, and don't forget to use the Biotène and Oral Balance products. They will help you keep your teeth clean and lubricate your dry mouth. Home care combined with professional cleanings and support is essential in cases of Sjogren's. Chlorhexidine rinse (Peridex or Periogard) can also be used ( by prescription  only) but be aware that it can stain teeth temporarily and alter taste sensation. In your case, I think the benefits far outweigh the drawbacks.

As far as saving your upper teeth, the methotrexate should not do anything to your teeth. However, the dry mouth will, especially without professional help.

As far as the implants go, you can have made what is called a fixed-detachable restoration. Sounds like a contradiction in terms, right? The way it works is that you need no fewer than 5 implants (6 + are better) with good spacing and position along your arch. Once they heal, a one-piece porcelain-fused-to-metal restoration is fabricated that screws directly onto the implants (picture a continuous bridge). In this
manner, the whole thing is fixed, but it can be detached, if needed, by the restorative dentist.

I won't kid you: it is time-consuming and expensive and usually only prosthodontists (specialists) can pull this off successfully. Don't get me wrong, they are done every day but the planning is very important, as is experience and teamwork (communication) with the surgeon. If you are interested in this, speak with the prosthodontist FIRST because trust me, you will be together for a long time. Implant work is not one of those things you have done and then forget about.

Also, there is NO information in the literature stating that implants do not work in Sjogren's patients. On the contrary: they work about as well as in patients with normal salivary flow. Watch out if someone throws you that line.

I have seen my share of patients with this condition. It can be quite debilitating. Visit the following web sites for more information on Sjogren's and for support discussions:

The Salivary Dysfunction Clinic - From Baylor College of Dentistry in Dallas, this page provides information for dry mouth sufferers and information on the clinic. It is run by Dr. Ibitsam Al-Hashimi.

The Sjogren's Syndrome Referral Center - Also from Baylor College of Dentistry, it is a joint collaboration between dentists and physicians that helps coordinate efforts aimed at helping patients with Sjogren's. Read about a patient's personal story.

Biotène and Oral Balance Products -  Home page for products for dry mouth sufferers. Find where these products are available according to where you live or order them directly.
List of Medications - Medications that have been linked to dry mouth symptoms. Provided by the California Dental Hygienists Association.

Good luck. I hope this has been helpful.

Sincerely,

Ed Lorenzana, DDS, MS

Burning Mouth Syndrome

I was diagnosed with burning mouth syndrome (BMS) 2 1/2 years ago. Do you know of any non-drug treatment that will help with the burning which can be every day? I have tried additional hormones, vitamins and anti-fungal medications. My doctor suggested trying klonopin at low dosages. Everything I read about klonopin leads me to believe people can get addicted to the drug. They suggested low doses starting at .25 mg. I have been using tabasco rinse which has helped the most. 

Thank you for your input.

Laurie

Dear Laurie,

What I would suggest be a starting point is having a complete evaluation by a periodontist and physician, if needed, to determine the cause of your condition.

There are numerous causes, including:
Certain medications
Food allergies
Lichen planus or other desquamative conditions
Oral yeast infection
Diabetes
Nerve damage
Vitamin deficiencies (B vitamins primarily)
Dry mouth (a.k.a. xerostomia)
Hormonal fluctuations (i.e. menopause)
Metal allergies

It is also frequently associated with depression or anxiety.

This is a very frustrating condition that requires a practitioner with lots of patience. I trained at Baylor College of Dentistry in Dallas where they have a Stomatology Center and Center for Salivary Dysfunction. If you ever have the means, it is the BEST place to get a full evaluation. Visit the College web site at http://www.tambcd.edu

As far as nonprescription help, I would recommend you make sure you are receiving the RDA of B vitamins. Don't overdo it like some do with vitamin C. I would get a full evaluation to determine whether you have a deficiency to begin with.

I cannot imagine a tabasco rinse helping any. Some medications that are known to help are topical corticosteroids (they are not systemically absorbed), also what is called 1-2-3 mouthrinse (a combination of Dimetapp elixir, Kaopectate, and distilled water), and antidepressants, if indicated by your physician.

I would also switch to Bioténe toothpaste and mouthwash. They are designed for dry mouth sufferers but I recommend them to anyone with burning mouth, dequamative gingivitis, or a suspected cinnamon allergy (cinnamon being the primary flavoring agent in toothpastes and colas). You would perhaps benefit.

Visit the Bioténe site at: http://www.laclede.com/biotene.html

If you would like to read an article about your condition that you can take with you to your treating dentist or physician, send me your address (privately) and I will be happy to send you a copy. It was written by Dr. Terry Rees, Chairman of the Dept. of Periodontics and Director of the Stomatology Center at Baylor College of Dentistry in Dallas, Texas. You may not get much out of it because it is intended for practitioners as a guideline for diagnosis and treatment. However, you may get some understanding as to the condition's complexity.

Good luck!

Sincerely yours,

Ed Lorenzana, DDS, MS

Diagnosing a Toothache

I have been having a toothache for 2 weeks now. The pain starts with a headache, an earache and a toothache. The whole right side of my face is a constant throb. The pain comes and goes like contractions. It starts off as a slight pain, then it goes to a pain as if someone is sticking a pin in my tooth. I don't know which tooth it is but one side of my face hurts. Please someone tell me what this is. I really need an answer or a suggestion.

--- Submitted Anonymously

Dear Anonymous,

My first suggestion is to take ibuprofen (Advil, 3-4 tabs, every 4-6 hrs.) to help manage the pain.

Then get to a dentist quickly. Go to someone you know or someone a friend or relative knows and trusts. Tell them it is an emergency and you will come ANYTIME. This is important, otherwise, they will not think it is urgent. Most dentists set aside time for emergencies but you must be willing to go at the time they have available. If they offer it, take it.

Now for the things to look out for that will help your dentist make a diagnosis:
1. Is the tooth/teeth sensitive to hot or cold?
2. Does the pain come and go on its own - without stimulation (i.e touching it, tapping on it) or only when you touch/bite on it?
3. Does the pain wake you up at night?
4. Have you recently lost a filling in the tooth/teeth in question?
These four questions, if answered in the affirmative, may point to a possible root canal.

5. Have you eaten anything hard or crunchy recently like hard candy, nuts, etc.?
6. Have you had any dental work recently - a crown, fillings, etc.?
7. Do you clench or grind your teeth?
8. Are you under a lot of stress at home or at work?
9. Have you had any trauma to the area recently?
10. Does the tooth/teeth hurt when you clench (bite down) or when you let go?
These questions try to narrow down the possibilities, including clenching, grinding, or a cracked tooth.

11. When was the last time you had your teeth cleaned and/or examined?
12. Have you ever been treated for periodontal (gum) disease?
13. Have you ever noticed any swellings or gum boils (abscesses) around the tooth/teeth in question?
14. Are any of your teeth loose or have they become loose recently?
These questions try to determine if the problem is periodontal in nature.

Your dentist may come up with other questions but thinking about these questions in advance will help the dentist tremendously in making a proper diagnosis.

Other nuggets of advice:
1. Go to see the dentist ASAP.
2. Don't take antibiotics lying around or from your friend/mother/girlfriend/etc. They may feel like they help in the short run, but they do NOT take care of the problem. In addition, if you do not take the full course, you are creating resistant strains of bacteria
which may make it tougher to fight off infection with the antibiotics we have in the future.
3. Don't take anyone else's pain meds unless under the direction of a dentist or doctor. You don't know if the meds and their dosages are right for you.
4. Go see a dentist ASAP. Get the idea?

I wish you luck. I hope this has been helpful.

Sincerely yours,

Ed Lorenzana, DDS, MS

DISCLAIMER: The views expressed in AP Interactive are strictly those of the individual periodontist responding to the question(s) submitted and should not be construed to reflect the opinions of all of the periodontists and staff at Advanced Periodontics of Texas. Advanced Periodontics of Texas does not seek nor accept financial contributions from any of the products or companies mentioned in AP Interactive.

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