The Dental Topic Thread: I'd like to be a resource if needed

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Ken M

Mountain climber
Los Angeles, Ca
Dec 4, 2012 - 12:32am PT
On the issue of Sleep Apnea:

I've treated many people with this, and have struggled with it as an issue when I was medical director of a group. Seemed like most everything was a waste of money.

It was accurately said that CPAP is the gold standard of treatment. It is also accurate that >90% that people who start on CPAP stop using it within 9 months.

It's as bad as flossing!

I think there are no great answers. When Niteguards help, that's great and simple.

I'm actually trying to put together a study on a novel approach: Use of Diamox. There is some evidence that it does change the numbers in studies, but not enough evidence to make recommendations. Wouldn't that be ironic?
JOEY.F

Gym climber
It's not rocket surgery
Dec 6, 2012 - 10:35pm PT
How's it going Tarbuster?
I am having all 4 quadrants surgically cleaned, on #2 now.
Effen painful, long overdue.
Question to the Docs.
Do you prescribe/advise a stool softener with the viks?
I know it's kinda gross, but, no one told me....
I have appreciated this thread Micronut and Tooth and your advice since you started it. Thank you.
Crimpergirl

Sport climber
Boulder, Colorado!
Dec 6, 2012 - 11:17pm PT
Okay, a question.

About 1.5 years ago, at the suggestion of my dentist, I had a crown put on my back, lower left molar. It didn't bother me at all, but she said it had a big crack. I thought I'd be a responsible adult and get it fixed before it became trouble.

(I won't do that again!)

After the temp crown was put on, it started hurting. I've had a cracked tooth before that needed a root canal and I know what that feels like. That is what this felt like. So I had to go off to the must surly dentist in Boulder to get the root canal.

After it's done, my tooth still hurts. I get the permanent crown. I tell my main dentist at that time it still hurts. And every time I've been to the dentist since, I tell her that my tooth still hurts. Every time she tells me it can't hurt because it's had a root canal. Frustrating.

Finally, on my own after the pain had worsened greatly, I went to a new guy to get him to look at it and redo the root canal (or what ever needed to be done). The tooth had become increasingly painful. I had to go out of town for 3 weeks in a row and didn't want to get caught on the road suffering. This is about 4-5 weeks ago.

He pokes, he squirts water, pushes air - all that good stuff and announces I have a "complex" case. The tooth I'd had a root canal on was pressure sensitive ("duh" I'm thinking! - I'd pay someone to pull it for the instant relief!). And he says the sensitively (I call it slobber sensitivity since everything makes it hurt) is the tooth in front.

He does a root canal on the tooth in front (he was good!). I think that is tooth 19.

Since them, the very back tooth still hurts and I still feel like it'd be great relief to have it pulled. And the tooth in front of #19 now hurts like a mo-fo: it is now slobber sensitive. Sigh.

Is there such a thing as a chain-reaction tooth sensitivity. I suppose I can go back and get yet another root canal on the tooth in front of #19, but will that make the next one hurt too? I feel the sensitivity all the way into my front left teeth. It is primarily cold sensitively, though wind hurts a lot too.

Would love your thoughts on this. Hope it makes sense.


Tarbuster

climber
right here, right now
Dec 6, 2012 - 11:57pm PT
Joey. F,
I'm following Tooth's lead on Dr. Jim Beck in Pueblo for a detailed workup on bruxism. This means more than sleep studies for apnea. Dr. Beck's wife told me they are no longer taking new patients and furthermore wouldn't do the workup on me without also doing the rest of the work I have slated. Interestingly, she said their 2 visit $1500 sleep and postural studies workup would produce records which may not be readable by another dentist and they're not interested in "teaching" my dentist how to follow suit with implementation according to the findings. Understood. I didn't ascertain the extent of said implementation beyond my need for multiple onlays and an implant. My dentist is a prosthodontist and farms out sleep studies to a lab but doesn't do any postural observance.

I asked Dr. Beck's office (his wife, who was quite helpful) for a referral in the Boulder Denver area for a dentist who does a similar postural workup (you may remember there was some mention by Tooth that a link to my long-term arm problems may be uncovered or elucidated somewhat by these postural studies: i.e. the Holy Grail of my musculoskeletal health issues). Meanwhile, it was suggested I look up dentists who belong to the American Academy of Craniofacial Pain (AACP) in my own area, which I have done and I'm meeting with one next Tuesday, who does some postural workup. Whether or not he'll do the level of detail on the postural side of things which Dr. Beck would do is something I have yet to determine.

Tooth: you following this?
I'll have some feedback next week.

(Good luck with that Callie)
micronut

Trad climber
Topic Author's Reply - Dec 7, 2012 - 12:24am PT
Callie,

Oh man, what a bummer. Nobody should have to go through that kind of scenario. It really sounds like you probably have a vertical root fracture on that tooth that is still hurting. We often cannot see these on radiographs but most of the teeth that I extract with suspicion of a vertical fracture end up having a visible crack I can see once the thing is out.

AND YOU BY ALL MEANS CAN HAVE PAIN associated with a root canal'd tooth. The microscopic ligaments that hold the tooth in place, the PDL, can transmit pain as the broken root "pumps" up and down. Even a hairline crack, like a crack in a windshield can do this. Happens all the time. No dentist should give up on somebody who says "this thing still hurts!".

The problem is, we don't have a fix for a tooth with a vertical root fracture. They usually need to be extracted, grafted, and restored with an implant, which if done right should be a smooth and fairly painless process that ends up in a tooth that lasts a lifetime.
micronut

Trad climber
Topic Author's Reply - Dec 7, 2012 - 12:31am PT
JOEY F.

"Vitamin V" can really beat up the stomach. If he Vicodin is really jamming you up, can you get by with just 800 ibuprofen/motrin/advil twice daily? If so that's your best bet. And rinsing with warm salt water thrice daily. The warmer the better. And some moist hot compress a few times a day if you are past the first 24 hrs, wherein I usually like ice on the jaw.

Tylenol III could be a better alternative for you if the Vico tears you up. Or Ultram. Its not quite as strong but really cuts the breakthrough pain down.

For the next quadrant. Take 800 ibuprofen 45 minute pre op. And hit the ice packs hard for the first 12 hrs post op. I rarely, rarely have patients need the heavy stuff if they follow the post op recommendations to the T.

Also, no real talkin or yappin or working out or jogging or nothin' for the first four hours. Moving the jaw and the surgical site around tends to get it all inflammed. Sleep elevated on a few pillows to let gravity help, and stick to really soft foods. Its a drag, I know, but saving them teeth is a major lifesaver for quality of life down the road. You'll be really glad you did it if you do your daily chores and brush and floss well from now on out.

Hope you feel better soon,

Dr. J
JOEY.F

Gym climber
It's not rocket surgery
Dec 7, 2012 - 01:20am PT
Yikes, The first round of meds wore off ouch....Thanks for the ice advice...Throb throb...Good luck tarbuster and crimpie...
tooth

Trad climber
B.C.
Dec 7, 2012 - 08:39am PT
Yes I'm following Tarbuster. I spent many trips learning from Dr. Beck, what he does won't be followed by just anyone. I've continued to study more about this area, but it isn't just drilling a hole and filling it in!



Crimpergirl, I can think of many reasons why that tooth started to hurt after... perhaps a 3D x-ray would show 1. if all 5(?) of the canals were filled 2. cracks 3. IA nerves/proximity to extruded sealer from the RCT which may hurt for a couple weeks 4.....etc Your local endodontists should be able to help you out.
Crimpergirl

Sport climber
Boulder, Colorado!
Dec 7, 2012 - 09:40am PT
Thanks to both of you.

The most frustrating part is being told repeatedly by many people that the tooth can't still hurt. Pisses me off as it's my tooth, in my head, and it hurts!

The information is very helpful!
jopay

climber
so.il
Dec 7, 2012 - 09:46am PT
Alright I have a few questions and just let me say I appreciate you dental professionals doing this. I'm 66 and still have all my wisdom teeth, over the years dentists have mentioned it being a good thing to have them removed, but I'm kinda of a "if it ain't broke don't fix it " kind of guy, and they were never any trouble.That is until about a year ago thatI began biting my cheek and of course once bitten the cycle starts, so my dentist says that I'm squeezing my cheek tissue between my lower wisdom tooth and the tooth above. The lower wisdom tooth is visible and actually used for chewing. So I made an appointment with an Oral Surgeon and he concurred with my dentist but wants to take the upper wisdom tooth on that side out as well and an extraction appointment is set, however after perusing the vast data on the Inter web it seems that older folks have more concern with this procedure as the roots are fully formed and some bone might have to be removed, yikes. Is it ever a possibility that they can't be removed due to attachment to the bone or jaw? There is even mention of harming ones jaw bone or some type of sinus area, is any of this an issue or am I just being too well read.
Tarbuster

climber
right here, right now
Dec 7, 2012 - 10:32am PT
Side note/question about anti-inflammatory and pain meds:

Last year I was being treated by a spine Dr. for herniated disc at C6 (clinically determined not the root cause of my particular long-term forearm issues) and was taking Gabapentin/Neurontin for nerve compression pain and also Diclofenac (said to be much stronger than ibuprofen) and their protocol was to include an antacid along with the Diclofenac. They are saying some micro-bleeding always occurs in the stomach with ANSAID use so they are recommending Ranitidine/Zantac as a prophylactic for that insult (reducing stomach acid in the presence of micro-bleeding).

Also had both hips resurfaced this year and the surgeon/hospital instituted the same program, prescribing Ranitidine along with OxyContin and Oxycodone/Vicodin. (And of course with those painkillers also laxatives, SENNA is a good one (sennosides 8.6 mg, simple vegetable extract).

Tooth, Micronut: are you perhaps familiar with the prophylactic use of acid reflux drugs for mid/longer-term use of anti-inflammatories and painkillers? I'm suspecting this has something to do with the longer-term use (i.e. 5 to 6 weeks following joint replacement), as distinct from dentistry wherein it's usually short-term use following the work, (i.e. acute pain).

Perhaps of interest, acute dental pain is just about the ONLY pain in which ibuprofen has been effective for me. It never does anything for chronic musculoskeletal issues in my case.

Thank you.

BTW & off-topic:
Here's a heads up dissuading the use of ibuprofen in a ROUTINE prophylactic capacity for sports related pain, these studies have been coming out for some time:
http://well.blogs.nytimes.com/2012/12/05/for-athletes-risks-from-ibuprofen-use/
tradmanclimbs

Ice climber
Pomfert VT
Dec 7, 2012 - 10:54am PT
50yrs old. Currently under employed carpenters helper. tooth in the back lower right sometimes but not always very heat/cold sensitive. how long can I put off dealing with this?
Spanky

Social climber
boulder co
Dec 7, 2012 - 01:13pm PT
Hey Micro,

Just wanted to say thanks for the advice.

cheers
TwistedCrank

climber
Dingleberry Gulch, Ideeho
Dec 7, 2012 - 02:26pm PT
My teeth are ok but I need to know why it hurts when I pee.
micronut

Trad climber
Topic Author's Reply - Dec 7, 2012 - 11:36pm PT
Tarbuster,
Thanks for the Ibuprofen article. Pretty good read. I'm not a big fan of chronic use of anything, including NSAIDS, especialy for athletes (I swam on the US team in the 90s) but if you are really suffering as an athlete for a season/phase of tear down, I've always told folks to mix it up with Aleve, Tylenol, Ibu..etc. Not sure this helps, but they are metabolized slightly differently and that might help a bit in my humble opinion. But yeah, long term anything is gonna get you somehow.

And your thoughts on antacid use with long term NSAIDS, interesting. I don't have much experience with that concept, because, as you alluded prior, my surgeries are usually pretty intense for only 3-5 days, and 800 ibu twice daily does wonders. Rarely do my patients take narcotics for more than a couple doses, if any. I believe this has to do with the fact that I tend to try and be really gentle with the tissues and a maniac about micro-suturing to "perfection". My assistants hate me because I dink around closing things up, making em look like stitching on an ArcTeryx Gamma SV.

I really wish you had a way to see my guy in Fresno who is really good with cases like yours. It's over my head and not in my specialty to deal with the dental scenario you're dealing with, but keep your chin up and let me know if you are ever in central California. I can get you in to see a real genius when it comes to dentitions like yours.
micronut

Trad climber
Topic Author's Reply - Dec 7, 2012 - 11:38pm PT
Spanky, you're welcome.

Twisted Crank, send Tooth a urine sample.
micronut

Trad climber
Topic Author's Reply - Dec 7, 2012 - 11:46pm PT
Tradman,

It depends on a lot of things. The most important is WHY are you having the sensitivity. If its a little bit of gum recession, and it isn't moving quickly, you may be fine for quite a while. Put it off too long and you might need an expensive gum graft.

If its decay, and it's moving toward your pulp, it can become a big dela quickly and you don't want to put it off unless you want to risk an expensive root canal, and crown, etc...

If its a microfracture in the tooth, same thing.

If its a bigger fracture (though you still won't be able to tell yourself, I'm not talking about a crack you can feel), it can be a real time bomb and you can end up with a costly extraction.

YOU NEED A GOOD DIAGNOSIS TO ANSWER THIS ONE CORRECTLY.

The bottom line is that all of dentistry is easy to fix when its a small deal (and costs accordingly, and that things almost always progress to bigger procedures and more expense. Its just the way it goes. Just like a car. That sensitivity is your "check engine" light. Ignore it, and the consequences tend to grow with time. I hope its a small fix, you just gotta get in there now and have it looked at. Its worth the couple hundred $ to have it looked at, diagnosed, and cost estimated. If you end up there on a Saturday with a jaw swollen up or a cracked tooth you'll kick yourself and your wallet will get dinged even harder.

Hope it works out,

Scott

Tarbuster

climber
right here, right now
Dec 7, 2012 - 11:51pm PT
Tooth, Micro!
You guys rock. This thread needs to be a "sticky", one that sits always at the top like on other forums.
...(OK, maybe on the side, but handy).

Floss the ones you want to keep.
JOEY.F

Gym climber
It's not rocket surgery
Dec 8, 2012 - 12:16am PT
Micro, your advice for ice was the bomb. Did that and pain/swelling went down and finally slept. Also, today did IB and rinse. Just a sore jaw now, nbd.
You and Tooth are the best and can't thank you enough.
A long time ago a dentist told me,"I'll trade you 2 flossings for 1 brushing"...
Thanks again.
tooth

Trad climber
B.C.
Dec 8, 2012 - 12:19am PT
Jopay,

I wouldn't worry much at all about an oral surgeon removing that top wisdom tooth. They will go over risks with you, but even if the roots of the tooth entered the sinus, (I've seen that a lot) you are at an oral surgeon's, they can more than handle that. They place 50mm implants through the sinus into the cheekbone (zygoma) and do other things to it more invasive than simply removing a couple root tips from under it.

So often what you see on the internet about anything is similar to two blind guys describing an elephant while one is hanging onto it's tail, and the other it's tusk.

Most of the wisdom teeth I remove are fully-formed teeth. Very rarely is it stuck to the bone, this week I did one that was, I cut up the tooth into pieces, removed the pieces from within the bone, and today the patient told me that the needle was the most he felt with the procedure.


Those things you mention are issues that can arise, but I haven't seen it with an errupted max wisdom tooth.


Tarbuster, I haven't had any experience with the drugs you are talking about - I was kinda surprised to find out that they don't have Vicodin in Canada - T3's is the strongest I have prescribed while up here, and most people don't even fill it out.



Tradman,

50 year old stick frame house. Sagging roof. You can't look in the attic or behind the drywall. How long can I leave it?

I guess I would have to know what your "leave it" means to you. "Leave it" before you lose the tooth? Before you need a filling? Before you need a root canal/crown? Before you need crown lengthening as well? Before you need an implant/denture? Before you need SuperSeal treatment or gingival grafting to cover the exposed cementum or dentin? Before it blows up with an abscess? Before the abscess rots the nerves in your bone and causes nerve damage?

Even if we knew any of the problems that could be causing these symptoms, we can't predict how fast the problem will progress with you -- everyone is so different. When my patient has a problem I can only recommend treatment, I can't recommend waiting at all because I see too many problems blow up overnight.

If your roof is sagging how do I know that it won't fall in tomorrow, or that it won't snow heavy tonight and then thaw tomorrow and start dripping inside?



TwistedCrank, if it hurts when you pee, urine trouble.




edit: this took me 6 hours before i posted, so I didn't see the last 6 posts or replies from Micronut. Best save the sample for him -- postage to Canada is too expensive and it would arrive as a solid right now.
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