Dr. Sable Muntean Appointed as Chief Editor of Get Lit Newsletter

October 20, 2023

Get Lit Newsletter Welcomes Dr. Sable Muntean as Chief EditorIgniting Success for New Dentists with Enhanced Content and Expanded Reach [St. Petersburg, FL] – Get Lit Newsletter, the go-to resource for new dentists seeking success in their careers, is delighted to announce the appointment of Dr. Sable Muntean as its Chief Editor. As a young…

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By: Lee Ann Brady DMD I ask the question “Is wear normal?” at almost every lecture I do on occlusion. Usually the response is a small number of mumbled replies. A good follow up question is “How many eighty-five-year-old patients have you seen with mamelons?” I hope you are thinking not many, if any at all. So, yes, tooth wear of some amount is normal. A combination of attrition, erosion and abrasion cause all of us to lose enamel over a lifetime. Is the wear advancing at a pathological rate? The more important question is when is the wear age-appropriate and when is it advancing at a pathologic rate? We don’t have the data to know how many millimeters of enamel loss is appropriate at every decade of life. In order to help with this answer in my office, I play a mental game. With the picture of the patient’s current wear in mind and a knowledge of their age, I imagine if the wear continues at the same rate at what age their teeth will be in jeopardy or need restorative dentistry to be saved. I then reveal this estimate to the patient. You can document wear over time in three ways. I believe it is important that I help my patients understand the process and the options for protecting their teeth. To quantify the amount of wear that is happening, we take a measurement from the CEJ to the incisal edge of several teeth with wear. We take the measurement on the mid-facial and record it on the patient’s perio chart. At subsequent appointments we can now repeat these measurements and have clear data that the process is continuing. Another great way to document tooth wear is with photography. With repeat photographs, we and the patient can see the change over time. Today with digital impressions and software we can scan the arch, and then compare scans months or years later and get a precise measurement of the change. What is causing the wear? I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age. I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression. These are the guidelines for discerning attrition from erosion. Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe: • Matching facets on upper and lower teeth • Facets on tooth surfaces that occlude • Enamel and dentin worn evenly Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe: • Facets that may or may not match on upper and lower teeth • Facets on tooth surfaces that are not in occlusion • Dentin cupped out and wearing faster than enamel • Tooth structure wearing around restorations that remain unchanged Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily. Occlusal Therapy Why Occlusal Appliance Therapy Is My First Step Prior to Ortho, Equilibration, or Restorative Occlusal changes on an appliance are easy and reversible. An appliance can immediately reduce elevator muscle activity and give the patient relief. The patient also experiences what changes to their tooth contacts could provide for them long term. We can test the changes that would be made by ortho, equilibration, and/or restorative. Our goals are to stabilize the joint anatomy and reduce the activity of the elevator muscles because those muscles are what overload the joints and teeth. We also want to slow down the rate of damage to the dentition and move that rate back to a more age-appropriate pace. We also may need to reorganize a patient’s occlusion to manage occlusal forces to ensure restorations that last. Removing Posterior Contacts Does Not Work for Every Patient Over my years of clinical practice, I have found that changing the occlusion does reduce functional risk for most patients. But we all have patients with perfect occlusion who present with TMD symptoms. We have some patients who continue to parafunction after we move them into immediate posterior disclusion. Studies show that proprioception causes the elevator muscles to engage in only 80 to 85% of the population. This means that when the brain receives the signal that teeth are touching, the brain elevates the masseter muscles in 80 to 85% of people. Tooth contact is the trigger. Because this proprioception does not occur for 15 to 20% of the population, it is not the universal trigger for excessive loading. Over my years in clinical practice, I have learned there is nothing I can do that is 100% dependable to stop a patient from para-functioning. Some of my patients continue to excessively load after posterior contacts are removed. Their functional risk does not diminish. If we cannot reduce elevator force and redistribute force enough on an occlusal appliance to eliminate or at least relieve TMD symptoms, then occlusal therapy via ortho, equilibration, or restorative will not satisfactorily help the patient. We will need to turn to other forms of therapy. Other modalities I use are BOTOX to deactivate muscles, massage therapy, and physical therapy. There are also systemic medications, cold lasers, and TENS therapy we can use to reduce the activity of the muscles or reduce inflammation in the muscles and joints. Sometimes one modality will alleviate symptoms for a while and when symptoms return, we can try it again or try another modality. An Exercise to Identify the Patients Who May Not Benefit from Occlusal Therapy You can do what I call a poor man’s EMG on yourself by placing your hands on your masseter muscles. Put your back teeth together, clench and release, clench and release, clench and release to see how much masseter activity you have. Then move your teeth into protrusive edge to edge and try to clench a little bit, making sure your back teeth do not touch. If you now have a posterior tooth touching in the edge-to-edge position, then put a pencil or pen between your front teeth to separate your back teeth. With no back teeth touching and contact on the centrals, try to clench and release two or three times while feeling your masseters. Most of you will find your masseters do not move or move a lot less when no back teeth are touching. Some of you, even with your back teeth separated, can still clench in protrusive and can still increase the muscle activity almost the same amount as when your back teeth touch. I do this exercise with my patients, but when they move into protrusive, I put a bite stop over their front teeth or have them bite on a Lucia jig we have lined for their bite registration. If you do this test with your patients, you can use an EMG or feel the muscle activity with your hands. If the patient can still generate almost the same force or the same force with their back teeth separated, you have identified one of the around 15% of people who might not benefit significantly from occlusal therapy. You’ve also identified someone who might not do well on an anterior-only appliance because, if they can generate that same force on just two teeth, they are at risk for those teeth becoming sore and moving. Interested in Learning More? Join me at The Pankey Institute with The Essentials Series. Starting with Essentials 1, this series offers a comprehensive and structured approach to dental education. Participants will gain essential knowledge and skills, enabling them to build a solid understanding of fundamental concepts in dentistry. From fundamental principles to essential clinical techniques, this series lays the groundwork for a successful dental practice and provides a strong platform for further specialization.

Occlusal Wear: Is It Advancing? How Fast?

October 17, 2023

By: Lee Ann Brady DMD I ask the question “Is wear normal?” at almost every lecture I do on occlusion. Usually, the response is a small number of mumbled replies. A good follow-up question is “How many eighty-five-year-old patients have you seen with mamelons?” I hope you are thinking not many if any at all.…

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times of transition

Facing Times of Transition in Your Dental Career

October 2, 2023

By: Savannah Craig Throughout our lives, we all face times of change and transition. While reflecting on the completion of my dental residency program and the end of my formal education, I’ve been thinking about how many periods of change I’ve encountered on my journey. The big milestones of life were met with celebration but…

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apply to dental school

You Want to Apply to Dental School, Now What?

September 25, 2023

By: Dr. Bri Torgerson Hi! I’m Dr. Bri Torgerson and this month, I wanted to touch base with those applying to dental school. My background in applying to dental schools is that I applied three times to dental school. Now, I ended up getting in on my second application cycle 10 days before orientation, but…

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Is Strength Training the Key to Your Dental Career Longevity?

September 5, 2023

By: Savannah Craig One of the many things associated with a career in dentistry is back and neck pain. Finding ways to protect yourself is crucial to being able to have a long career. Since dental school, I’ve been trying to find solutions for managing and preventing back pain. I’ve tried stretching, massage therapy, and…

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Dental Fuel Episode 12: Expert Advice with Dr. Shannon Johnson

August 18, 2023

In Dental Fuel Episode 12, Dr. Shannon Johnson wraps up our last episode with her by providing some expert advice. If you haven’t met her already, she is a clinical rockstar and an amazing person. We all can learn so much from her and I hope you will get the opportunity to meet her in…

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Tips When Looking for a Dental Associate Position

August 15, 2023

By: Dr. Bri Torgerson Navigating associate positions can be intimidating. If you’re like me, you can be confused and lost in the vastness of contracts and office nuances that exist for Associate Dentists. I’m excited to walk you through everything I have come across in the many offices I have worked in. I’ll expand on some…

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Dental Fuel Episode 11: Team Mistake with Dr. Shannon Johnson

August 11, 2023

Working in teams can be tough! Shannon Johnson knows the ins and outs of working in a team but also working in a practice alone!  In Dental Fuel Episode 11, Shannon talks about some team mistakes that are commonly made and how she has come to appreciate team members in her practice of dentistry. Shannon…

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as a dentist should you change your name when you get married

DDS or MRS: Changing Your Name When You Get Married

August 8, 2023

By: Savannah Craig There are seemingly one million different questions to answer and decisions to be made while planning a wedding. You have to make a decision on everything from what types of flowers you want, to who will be invited. As a dentist, doctor, or someone who holds a professional license or publication you…

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dental fuel

Dental Fuel Episode 10: Financial Mistake with Dr. Shannon Johnson

August 4, 2023

Dr. Shannon Johnson has wisdom in dentistry and experience in the field. She knows firsthand about financial mistakes and how to overcome them! In Dental Fuel episode 10, she shares just that– a financial mistake and the steps she took to overcome it! 🎙️ Listen to Dental Fuel Episode 10 on Apple Podcasts Dental Fuel…

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