Question#3: Porcelain “Fillings”

In your website you describe a replacement for cast gold restorations made with a kind of liquefied porcelain.  Is this the same as ‘Cerec’?  -M.M., Washington, DC

Answer:

The technology for restoring teeth with different kinds of porcelain and using different means of fabrication has grown by leaps and bounds in recent years.  There are now three widely used technologies for creating tooth replacements out of porcelain: stacking, pressing, and milling.  

Stacking refers to taking a porcelain powder, wetting it with distilled water to form a material with the consistency of wet sand, shaping it to the desired shape and then firing it in a kiln so that the porcelain particles fuse to each other to form a solid mass.  It is an old technology that has been used to make porcelain fused to metal or porcelain fused to gold crowns for decades. It is also the technique for making highly esthetic porcelain laminates that are used for enhancing the appearance of front teeth. Because porcelain made in this way shrinks as it is fired, it cannot be made to accurately fit anything that is shaped like a hole (an ‘inlay’) as it always has to be ‘overbuilt’ in size to accommodate the expected shrinking. Any shape that sits on a surface (an ‘onlay’, a porcelain laminate, a biting surface) can successfully be built with stacked porcelain and it is the most esthetic material we have.  In fact it can be combined with other techniques, although labor intensive to do so, for reasons described below.

Pressing refers to taking a porcelain ingot and melting it under high temperature and pressure and injection molding it into a three dimensional pattern of the missing tooth structure.  This technique is explained in more detail elsewhere on this website.  It produces restorations that have an extremely accurate fit, but the process involves many steps to accomplish and the varieties of porcelain that are available for pressing is fairly limited.  Also, for highly aesthetic requirements it can be cut back to allow an overglazing with stackable porcelain.

Milling is the latest technology.  It involves using a computer to create a three dimensional design of a tooth restoration on a computer screen, the data from which is fed into a milling machine that takes a block of porcelain and sculpts it down to the desired shape.  When finished it is baked in an oven to harden the structure.  This technology has become very popular because it involves many fewer steps then pressing and there are a wider variety of porcelains that are available that can be milled.  Lately the most common porcelains to be used are either lithium disilicate or zirconium.  Both of these are much harder than enamel and that translates into less breakage, but it also translates into much more wear on the teeth that come into contact with these restorations.  Therefore an important step in their fabrication is the highly skilled and labor intensive polishing of the surfaces before they are glazed in the hardening step.  Also, for better aesthetics, this material can be cut back to allow an overglazing with stackable porcelain.

Because so much of the work to make a milled porcelain restoration is done on a computer screen, some companies have developed machines different from the ones that they have been selling to dental laboratory technicians that dentists can purchase themselves in order to make these restorations right in their own office. One if these is the Cerec machine.  In these circumstances the dentist or, more likely, a trained dental assistant handles the design work ‘while you wait’.  It is marketed as a convenience to patients because the restoration is made in a single visit, as nothing has to be sent out to a dental laboratory.  But without the oversight of a trained laboratory technician, there is a limit to the refinement that these office made restorations can reach.  In regions of high aesthetic need, the skill and artistry of a trained laboratory technician, plus the additional equipment for cutting back and stacking porcelain, will be lacking in typical Cerec restorations.  In addition, the polishing step is often avoided by painting a ‘glaze’ over the surface and baked.  Studies have shown that this glaze layer wears off in about one year, exposing a microscopically rough underlying surface that can rapidly wear down the opposing teeth.

I want to thank Richard Pavlak, CDT, MDT, FNGS, the founder and director of Porcelain Plus Dental Systems of Cranford, NJ, for his expert help in answering this question.

Question#4: Mercury Toxicity 

Are there peer reviewed published studies on the health effects of the mercury vapor released from amalgam fillings? -G., Wantage, NJ

Answer:

Elsewhere on this website you will find an extensive review of the whole issue of mercury toxicity.  In terms of studies in the peer reviewed literature there are many.  Here are just a few:

 

Summers, AO, Wineman, J, Vimy, MF, et al. Mercury released from dental ‘silver’ fillings provokes an increase in mercury and antibiotic-resistant bacteria in oral and intestinal flora of primates. Antimicrob Agents Chemother. 1993;37:825-834.

 

Siablerud, RL.  The relationship between mercury from dental amalgam and mental health. Am J Psychother. 1989;43:575-587.

 

Lorscheider, FL, Vimy MF, Summers, AO. Mercury exposure from ‘silver’ fillings: emerging evidence questions a traditional dental paradigm. FASEB J. 1995;9:504-508.

 

Eggleston, et al. Correlation of dental amalgam with mercury in brain tissue. J Prost Dent. 1987; 58(6): 704-707

 

Vimy, et al. Maternal-fetal distribution of mercury released from dental amalgam fillings. Exper & Molec Pathology. 1990; 52:291-299.

 

Also, the current issue (September 2015) of the Journal of the American Dental Association includes a cover story on the effects of mercury exposure on US dentists.  As all dentists wear gloves while working, the only route for routine exposure is via mercury vapor.  The research found that there is a correlation between mercury exposure and hand tremor in dentists:

Anglen, J, Gruninger, E, et al. Occupational mercury exposure in association with prevalence of multiple sclerosis and tremor among US dentists. JADA. 2015: 146 (9): 659-668.

Question #5: The Dental/Medical Connection

Have you ever seen a correlation between people with autoimmune disorders and dental issues? I’ve started an immunotherapy medication for my Ankylosing Spondylitis and I have 3 cavities out of nowhere!!! Just wondering if these are related to the systemic issues in my body or more likely to the medications? Would love your insight!   -S.Y., Santa Rosa, Calif.

Answer:

I often see correlations between auto immune disorders and dental issues, so you are not alone.  The connections are many and they run in all directions:

An auto immune disorder can affect the body’s ability to fight infection or it may affect bone metabolism–this can lead to an increase in tooth decay or gum disease, it can also alter the flow or quality of saliva which has a direct influence on susceptibility to tooth decay particularly along the gum line.  

At the same time, dental infections and diseases that are left unchecked can lead to various auto immune disorders.  It is not uncommon, as an example, for a patient with severe untreated gum disease to have adult onset diabetes and when the gum disease is treated the diabetes goes away.  Years ago I treated a patient who had recently been diagnosed with cardiac arrhythmia.  He had not seen a dentist in almost 20 years and needed about 10 teeth extracted as well as other treatment to clean up the rest of his mouth.  His arrhythmia vanished when his dental infections were eliminated. In both cases the heavy bacterial load present in the mouth led to high levels of these same bacteria circulating in the blood stream, leading to inflammation of the pancreas in the first case mentioned and in the heart in the second case mentioned.

Lastly, the medications used to treat auto immune disorders, be they non steroidal anti-inflammatory drugs, steroids, or inflammatory protein blocking drugs can each have side effects that can affect dental health.  When there is a bacterial infection in the mouth, such as tooth decay or some kinds of gum disease, the body must mount a specific kind of inflammatory response to overcome that infection.  If the inflammatory response is being muted by a medication, if will be easier for the bacterial infection to continue on and cause damage–such as tooth decay.  The other issue, and this is common, is that oftentimes there is a side effect from medication that reduces the flow of the saliva, and this can have a dramatic effect on tooth decay.

So it is hard to answer your ‘either/or’ question without saying that most likely the answer is ‘and’–all of the above could apply.  But we can often narrow down the possibilities on the basis of history.  For example, if you have had a long history of being free from tooth decay and if your auto immune condition has been present for a long time then it would be more likely that the recent change in your medication had more to do with the new cavities.  But if the medication is helping you then you would be best served by asking your dentist or hygienist for their advice on prevention.  This often includes issues of diet, daily oral hygiene, and may require the use of a fluoride mouth rinse.  In many holistic circles fluoride has a bad name, and I am not a fan of taking it systemically either in pill form or in treated tap water, but I have no problem recommending it for topical use for my patients who have auto immune disorders or limited flow of saliva. 

Question#6: Receding Gums 

Can receding gums be reversed? What treatments you use to restore gums?  -A., NJ

Answer:

To properly address the problem of receding gums, it is first necessary to determine the cause in a particular person’s mouth.  Gum recession can come about from a number of things and without figuring out why they are receding in the first place, no therapy, including surgically grafting new gum tissue onto the exposed areas, will result in a stable end result.  So, Step One is finding out the cause or there may be a combination of causes in a particular area.  Step Two is dealing with those causes so that the recession process comes to a halt.  Only then, can there be a Step Three–if stopping the progression is not enough then what kind of remediation is possible and/or appropriate?

Gum tissue is largely dependent upon the bone that it sits on top of.  If the bone goes away, often times, the gum goes away also.  The places where this happens the most is on the upper front teeth, especially the upper canine teeth, but it can happen anywhere.  It tends to happen here because the bone can be ‘eggshell thin’ in this region–just covering the upper front teeth with a thin shell of bone.  If anything happens to this bone to break it down, the gum tissue recedes.  So  what can make thin bone disappear?  Here are the most common things:

1.  Gum disease.  This is a bacterial infection of the gums and in its more invasive forms, the infection is not just of the superficial gum tissues (which results in red, puffy, and bleeding gums), but of the deeper parts of the gums that knit into the roots of the teeth and into the bone. If germs get a foothold on these tissues, the bone breaks down and it is often the case that there will be gum recession.  

2.  Teeth that hit too hard at bad angles to each other (a.k.a. ‘Bite trauma’, a.k.a. ‘Occlusal disease).  If a lower front tooth happens to come into contact with the back of an upper front tooth before all the other teeth in the mouth come into contact (while in a jaw position where the back teeth ought to be the ones that hit first), then this upper front tooth will suffer from bite trauma.  With repeated hits, this tooth will either move out of the way and look unsightly, or else it will loosen.  In either case, the bone over the root on the front of this tooth will suffer from mechanical breakdown and the gum tissue over it will recede.  This happens mostly on upper teeth and it can happen to upper back teeth as well.  If you go to the place on this website where you can read a selection of my practice newsletters: https://www.centerforintegrativedentistry.com/for-new-patients/practice-news/  and go to the sixth newsletter, “Case 0105MS” you can read more about this cause of recession.

3.  Chemical irritants.  Certain items/chemicals, held between the gums and the cheek will cause gum recession given enough time.  First on this list is chewing tobacco in either loose leaf form or else in the little packets.  Also, though less common these days, some people put an aspirin tablet against an aching tooth (it doesn’t help, but the painful irritation of the aspirin, as it burns the gum, makes it feel as if the pain of the tooth is less).

4.  Mechanical irritation.  Some people brush their teeth with a hard bristled tooth brush and this can abrade and wear down the thin edges of the gums.  A word to the wise: dental plaque has about the consistency of cottage cheese.  A soft brush should be all you need to clean your teeth; it’s not like trying to get rust off of a car fender!  

5.  Systemic irritants.  Any substance that reduces the blood supply to the very tiny capillaries that nourish the eggshell thin bone will cause that bone to die of asphyxiation.  Cigarette smoke contains carbon monoxide, a chemical that binds up oxygen so tightly within the blood that it never makes it to the cells that it should be nourishing.  In places where there is just the smallest, little blood supply–such as very thin bone–it’s only a matter of time.  Marijuana smoke also has this effect as do recreational drugs that cause constrictions of the blood vessels.  These include cocaine and amphetamines.  Folks who use those drugs routinely have horrible gums problems.

So, first, which one or which combination of these five problems applies to any particular site of recession.  Then the cause has to be eliminated, then the question is, what can be done?  Sometimes, as long as the recession has stopped, we don’t have to do anything.  Sometimes we cover the exposed root surface with a tooth colored filling, and sometimes there needs to be a visit to a periodontist for gum graft surgery. 

Question#7:Thermograms for Dental Diagnostics

I recently had a dental thermogram which revealed an infection (which I was not aware of) on my left lower side. Do you believe in thermogram technology and can it be used to figure out the source of the infection?  -B., Doylestown, Pa.

Answer:

A thermogram is a very useful diagnostic tool.  It measures the heat given off by whatever part of the body is imaged.  Today’s thermograms can be very precise, particularly when a structure is imaged  over set intervals of time, the changes in the ‘heat signature’ of that structure reveal alot about what can be going on there.  

In my view, the greatest use of thermograms is in breast imaging, particularly if there is a suspicion of cancer.  Cancerous tumors cause blood vessels to grow towards them, and over time a thermogram will reveal ever ‘hotter’ zones where the blood flow has been made to increase.

How can thermograms be useful in dentistry?  There are a number of reasons why a structure would image as ‘hot’ that have nothing to do with cancer. In the mouth, cancers are easier to detect visually, and a thermogram wouldn’t be as useful, but here, heat signatures most commonly reflect two different phenomena that also heat tissues up: infection and hyperactive muscles. So, if using a thermogram in dentistry it is most important to use other diagnostic criteria to differentiate between these two as both  infection and hyperactive muscles can feel  like the same kind of thing.

 Recently a patient of mine brought me in a thermogram of her lower jaw, and she was told by the doctor who did the imaging that it showed an infection in the bone.  She asked me to evaluate it.  I looked as the history of the teeth and gums in this region of her mouth to see if I had, in the past, noticed any problems that could lead to a future infection.  Finding none I then went to look at the thermograms that had been taken at different angles of her jaw (head on, side view, and looking upward from under the chin).  If the hot spot seen in the side view was from within her jaw bone, it would stay in the same location in each view, but if the hot spot were from a hyperactive muscle, and this patient was a ‘clencher’, then the hot spot would move around more.  To visualize what I mean, think of it this way: if I warmed up a little plastic disk and glued it to your cheek and then took the three thermogram views that I mentioned, the front view would show the hot spot far to the outside of the jawbone; the side view would show the hot spot directly over the jaw bone, and the view from below would show the hot spot at a distance away from the jaw bone.

In this way it is possible to differentiate between heat in a tight muscle, or heat in the jaw bone itself.  That’s the biggest thing that is often missed, but without knowing a history of the teeth, gums and the jawbone in the imaged area it would still be impossible to be completely accurate with just a thermal image alone.  There are tumors that can grow in the jaws, many of which are benign, but they can still register as hot.  There can be unusual blood vessel formations, known as ‘A-V malformations’ that can image as hot without there ever being a tumor or an infection.

Still, I am fond of thermograms as a diagnostic tool.  It can be the deciding factor in pinpointing which tooth is causing pain when a patient can only point to an ‘area’.

Question #8: The Dental/Medical Connection, Part II

About 3 years ago my dentist replaced all of my composite fillings with amalgam. About 2 or 3 months  after that, I developed burning pains in my head, unexplained hair loss, food intolerances, etc. I asked my dentist about this and he said I could have triggered shingles. I still have all of these issues and he is not a very easy person to talk to about my concerns as believes anyone that is against amalgam is clueless, as it has no harmful effects.

 
I am worse off now than before I had this work done. I now clench my jaw while sleeping, my teeth have shifted, and I have cracked a lot of my enamel by doing such things.

Is it even possible to have these amalgams replaced? I am only 26 and my funds are limited.                                                                                       -L., Cliffwood, NJ

Answer:

Elsewhere on my website there is information about dental amalgam.  While it is possible that the symptoms you describe could all be attributable to the mercury that you were exposed to as a result of the placement of your mercury amalgams, it is only a speculation based on the timing of the treatment and the timing of your symptoms.  There are typically two ways to approach this: one way is get tested for mercury toxicity and my office can refer you to a number of healthcare practices where you can get that done.  Yet, I have many patients who, knowing their own body, are quite certain that their exposure to mercury created specific health problems.  I perform autonomic response testing  to gauge the level of stress that mercury fillings are placing on the body (this is an adjunct test in my overall diagnosis and is not the same as the deeper kinds of tests that can be done).

That being said, mercury exposure can cause the symptoms that you describe in susceptible individuals and I have not heard of the shingles virus causing any of them.  Regarding your clenching and shifting of teeth, this could be a result of the new fillings, regardless of what they are made of, having changed your bite in a way that is uncomfortable for your jaw muscles.  That is something that a careful bite evaluation would reveal.  The cracking of your teeth is likely from a combination of the extra bite stress of clenching coupled with the fact that as dental amalgam ages, it tends to expand, thus stressing the tooth structure. But, let me assure you that in almost every case it is possible to preserve teeth, even if there is very little natural tooth structure remaining.

Many of my patients are on limited budgets and I tell all of them that the first and most important step is to get a comprehensive exam and a priority based treatment plan that is designed to address the most serious problems first.  That way, even if the treatment needs to be spread out over a number of years, we are always ‘putting out the biggest fires’. Feel free to call our office if you have further questions about your specific needs.

Question#9: On Root Canal Therapy

I have several old root canal with crowns, some have been treated more than once. I have been recommended to have the teeth removed and replaced with implants. What are your thoughts about this?   –C.O., Denville, NJ

Answer:

Elsewhere on my website you will find my approach to root canal therapy.  It is and can be a valuable way to save teeth and, when done expertly and with non-toxic materials it can be successful, according to studies, about 93% of the time.  This is in line with the success rate of dental implants, so either work well, most of the time.  On some occasions, circumstances favor root canal treatment, in others, the balance goes to implants.  There are too many factors to make general statements in this kind of forum.  In your particular case, the question is: are the current root canal teeth with crowns working well for you?  Or, are you having pain, swelling, or unusual health symptoms that can be traced by various means (acupuncture meridians, muscle testing) to these teeth?  Just because teeth have been treated with root canal therapy, even ‘some more than once’ is not a reason in itself to go through extractions, bone grafts, implant placement and new reconstructions.  But, if there are either ‘signs’–for example, evidence on dental x rays of growing areas of bone loss at the tips of the roots of the treated teeth; or ‘symptoms’–pain, swelling, discomfort chewing, recurrent sinus infections with no apparent sinus problem–then it should be investigated and the treatment you mention could very well be a step towards improved quality of life.

 

Question #10: The Fluoride Question

I have seen on the news that science says that fluoride in the water is good for kids, yet some towns are banning it.  How do you feel about fluoride?  –P.R. Fairfield, Ct.

Answer:

Fluoride is a patch on public health where there is an over consumption of sugar and simple carbs (white bread, crackers, pretzels, cookies, cake, etc). I am not against topically applied fluoride or, if needed, fluoride in toothpaste—but I don’t put it in the toothpaste that I have developed. The problem in my view of water fluoridation is threefold: 1. The dose varies depending on how much water a person drinks and can’t account for other sources of consumed fluoride (fruits and veggies grown in fluoride rich soil), 2. It can’t account for the different rates of absorption—which can be particularly high in ectomorphs (tall, skinny with hyper flexible joints—known in homeopathy as the ‘Calc Fluor type’). 3. Once consumed it gets into the bones of the skeleton and never leaves, ie if you get too much, it’s in there for good, and it does make bones more brittle—something that can be a problem for the elderly with things like hip fracture.

The best is not to fluoridate the water and eat healthy and practice good hygiene. But I admit that in the face of poverty and ignorance— in regions with historically high levels of decay from poor diets including drinking a lot of soda (in Appalachia they like Mountain Dew, which has a very low pH, making it a more potent destroyer of teeth), then water fluoridation is better than kids losing their teeth by the time they are 20! In ‘war zones’—different measures apply.

Question #11: Dental Detective Work

I had two mercury fillings replaced by a holistic dentist. They were replaced with some kind of amalgam I believe. They are my two upper back molars. I also had a lower molar root canal extracted (same side). This was about 2 years ago. Recently I started tasting metallic taste in my mouth. It seems like it’s coming from one or both of the replaced fillings. It’s very extreme when I’m around sheetrock or plaster dust (we are renovating a home) and it almost feels as if there is some kind of metallic chemical reaction happening. Have you heard of this or know how i can address this? Thank you!  –C.L., Glen Ridge NJ.

Answer:

It will probably take some detective work to answer this question, so this will not be the final word.  Yet, this question raises some interesting issues that are worth sharing in this kind of forum.  First of all, if you had a holistic dentist replace mercury fillings, he or she would not have used an ‘amalgam’, as that is just another word for mercury fillings.  More likely would be replacement with ‘composite’–which is a kind of high strength plastic material.  If, in fact, all of the mercury fillings were removed, not leaving in any of them this material in the deeper parts of the tooth (with, for example, just a replacement of a ‘veneer’ of composite on the surface), then neither of these fillings could be the cause of the metallic taste.  Also, if you had a tooth treated with root canal therapy and that tooth was extracted, it could not be the cause of this taste either.  This leaves many, many open questions… Do you have any other mercury fillings in your mouth?  Do you have any other metals in your mouth as a result of crowns, bridges, removable appliances, orthodontic wires, etc?  The first place to look would be any metal in your mouth.  If you don’t have any metal in your mouth, then there are some dental conditions and some medical conditions that can lead to a metallic taste. Poor oral hygiene is a common cause–so, are you good about brushing and flossing daily?  Any sinus infection can cause a metallic taste.  Certain prescription medicines and certain nutritional supplements can cause a metallic taste.  Certain medical problems can also cause a metallic taste.  But the clue that you give about this being triggered by work with drywall or plaster adds an interesting twist.  Drywall and plaster contain calcium sulfate and the sulfur component can vary in concentration, sometimes in drywall being quite high.  It was discovered some years ago that as the sulfur outgassed, it caused copper pipes near to it to corrode.  Sulfur is a highly reactive element that causes the breakdown of other metals, so if there are metal ‘things’ in your mouth and you are inhaling a sulfur containing dust, you could be getting a chemical reaction that would give you this taste.  That’s about as far as I can go with just this information–good luck! 

Question #12: Recent Cold Sensitivity

I recently developed some severe sensitivity to cold on my teeth.  Cold air and cold drinks really set them off.  I brush my teeth daily and try to take really good care of them and I have not had a cavity in years.  What could be causing this?   –A.S. Union, NJ

Answer:

Although sudden cold sensitivity can indicate tooth decay near a nerve and even be an early warning sign that root canal therapy is needed.  Far more often the cause of this problem is a combination of two separate processes.  Either may be the culprit alone or there may be both at work.  The processes are: Abrasion and Erosion.

Abrasion happens because there is a mineral called ‘silica’ that is a component of every toothpaste on the market (except my new toothpaste, “Dr Shuch’s Remarkable Edible Toothpaste“) and it is harder than tooth enamel and tooth dentin, the two minerals that make up every tooth.  Because it is harder, every time you brush your teeth with a silica containing toothpaste, you are doing the equivalent of ‘sanding’ your teeth with very fine sand paper.  It is used to abrade off stains, but particularly if you have gum recession and have exposed roots, they abrade at a much faster rate than does enamel because they are softer than enamel.  It is not an unusual story for me to hear that a patient comes in and tells me, “My teeth were becoming sensitive, so I worried that I was getting a cavity and began brushing my teeth five times a day, but the problem is only getting worse!”  Well, the answer to this kind of sensitivity is to stop brushing with a silica based toothpaste.  Even if you don’t have my product, just brushing for a few days with just warm water will keep the teeth reasonably clean and allow the naturally calcium rich ions in saliva to harden up these root surfaces and the sensitivity should go away.  Likewise, there is silica in chewing gum, that gives it a stiff, rubbery consistency.  It can wear the biting surfaces of teeth down to the point that any biting pressure will give a sudden, sharp pain and these teeth will also become sensitive to cold and air.  Here, the answer is to stop chewing gum!

Erosion happens from eating or drinking foods that are acid (sour).  The common ones are vinegar, like what is in salad dressing or in pickles; citrus, such as lemons, grapefruits and oranges; or with some stomach conditions where there is gastric reflux or vomiting.  Also, some soft drinks have a low pH that makes them taste ‘tart’ and these will cause alot of enamel erosion!  Here, the thing to do is to identify the cause and reduce your consumption of it or your habit.  An interesting combination of these two processes comes about when people chew citrus flavor chewing gum.  It contains citric acid to make it a bit tart and it contains silica that wears down enamel.  For those who chew this kind of gum for hours every day, they can can a very particular kind of wear on the teeth that can be extremely sensitive.  It will look like the cusp tips of the lower teeth all have little indentations at the tips.  Here, the enamel has been abraded down so that the cusp tips just contain exposed dentin, and this dentin then wears down faster than the surrounding tooth structure.  So the cusp tips each will have a little cupped out area that can hurt like a knife when biting on sweet or sour foods.  Sometimes we have to fill these ‘potholes’ in to make the sensitivity go away, other times, stopping the erosion will allow the teeth to absorb calcium in these areas and they will become free of symptoms all by themselves.

Question #13: Dr. Shuch’s Remarkable Edible Toothpaste

I would like to order Dr Shuch’s Remarkable Toothpaste, how can I get it?  -N.A. Aurora, Co

Answer:   

If you’d like to order a single tube, please use this link that will take you right to the page on Amazon.  As most people have “Prime,” its less costly if you are buying a single tube to get it there and for that reason my office does not ship single tubes.  But for bulk orders in multiples of 9, our office sells and ships them directly at a substantial discount from what is offered on Amazon.  If you wish to order in bulk, feel free to call our office at 973-579-7400 on Mondays, Tuesdays, or Thursday’s. Pam or Suzanne will let you know what the current bulk discounts are and can help you with your purchase. 

Question #14: A Bite Problem with Pain

I have had excruciating pain in my right ear for four months. I believe it’s because my bite is not correct. It almost feels like I have a cavity that was never smoothed down and I only bite down on my right side. I have gone to the dentist and got an appliance and it just made it worse.  I am  desperate to find a solution. Can you give me some advice?  Who I should go to for help at this point? Thank you so much,  -D., Murrieta, Ca Answer:  This could be a few different things so it will need to be looked at by a dentist who has some understanding about this; more about that in a minute.  Here are the most likely possibilities: If the tooth was recently filled then the most obvious thing might be that the bite on the filling is  high.  This is most common when the tooth is the upper last molar, as it is the tooth that is closest to the jaw joint and pain in this tooth can feel like pain in the joint. But there are other reasons besides being close to the joint why this tooth can feel like or lead to what we call ‘TMD’ or ‘tempro-mandibular dysfunction.  When the bite is high on a tooth this close to the jaw hinge, then even a tiny bit of excess height can be a huge pain generator.  The mechanics of this are kind of like a nut cracker.  If you want to exert the maximum pressure on a walnut shell, you want to get the nut as far into the jaws of the nut cracker as you can, because that is where you’ve got the most leverage.  Just like that example, you can exert the highest amount of biting pressure on the teeth furthest towards the back of the mouth.  So if you have a high bite back there, you’ve got the strength of all of your most powerful muscles clamping down on that high spot.  Here is how that problem can get worse in a hurry.  Every tooth sits in a bony socket and is connected to the bone by millions of very short fibers, not unlike how a peach pit in a ‘cling’ peach is attached to the flesh of the peach.  These fibers are actually ligaments that hold and suspend the tooth and cushion it during chewing, but if they get over-compressed they swell.  This has the effect of raising the tooth up in the socket, which makes the bite problem even worse!!! The bite does not necessarily have to be high in a straight up and down bite; it can be high when you go through a chewing motion.  In that case the lower tooth that engages with it will contact not the deep valley in the center of the tooth, but the slopes of the valley walls.  Many dentists only check the bite in an up and down motion and don’t check to see if side-to-side movements are ‘premature’ or ‘free.’  There are other possibilities also.  The problem tooth may have an infection and may need root canal therapy or the jaw hinge could have been strained from holding your mouth open for an extended period of time.  These other issues would need to be ruled out, but my bet would be on first looking into the bite issue.  My recommendation would be for you to go to a website run by the L. D. Pankey Foundation (www.pankeydentist.org).  This is a post-graduate educational organization that teaches dentists the the art and science of getting patient’s bites correct.  Unfortunately, this is not an area of education that is given much emphasis in dental school, so it is up to dentists, after they graduate and if they have this interest, in getting post graduate training in this area. They also teach dentists how to properly make bite appliances as there are many different kinds and the wrong kind can make a problem worse.  There are a few “schools of occlusion” that teach these skills, but Pankey is the best!  I went on their site and plugged in your city and there are four dentists all within about one hour of you.  Good Luck!!! Question #15: Thermography Part II Do you use thermography in your practice?  I have not been able to find a single dentist in Central Europe who is even familiar with it.  I tend not to trust normal x-rays.   -M.L.  Germany Answer Thermography is a valuable diagnostic tool especially when it comes to evaluating areas of inflammation or infection.  It captures the ‘heat signature’ of muscles and bones and in this way I can often use it to differentiate between pain coming from a jaw infection or pain coming from an overlying inflamed muscle.  It gives different information than an x-ray; one does not replace the other.  Most dentists are not familiar with them and don’t know how to read them.  But I have encountered MD’s that also do not understand how to interpret head and neck thermograms properly.  I don’t have a thermography camera, but I send patients to local medical offices that typically use them for breast imaging in lieu of annual mammograms.  You could likely find an office that can image your head and neck that way, but finding a practitioner who can interpret it may be a challenge and again, the imaging does not replace x-rays. Question #16: Careful Mercury Removal Protocol Do you follow a protective protocol for amalgam removal?  -J.  Montclair, NJ Answer I’ve developed and refined a amalgam removal protocol that has patients coming to me from all over the country.  On this same website, go to this page to view my approach:  and go to this page to view my recommendations for patients prior to having their amalgams out.  Question #17: On Laser Assisted Gum Surgery      Do you think LANAP (Laser Assisted New Attachment Procedure) surgery is good for bone loss and gums?  -D.D.  Montclair, NJ Answer In dentistry, there are many things that the various types of lasers that are now available to dentists, can do.  Some of these things simply duplicate what other technologies already do and, depending upon the application, the laser may do that job better or worse than an existing technology. LANAP is an exception.  There is no other technology that can do what LANAP can accomplish when it comes to rebuilding the connections between gum tissue and teeth. But….and it is a very big ‘But,’ what is called, ‘case selection,’ is all important.  What this means is that a dentist who typically does alot of these procedures…who will most likely be a periodontist…must examine a patient and examine the particular gum defects and judge if the tool of LANAP would be appropriate, useful and would stand a good chance of success.  In the right hands and with  appropriate case selection, LANAP is nothing short of magic!   Question #18 Recent Tinnitus May Be A Bite Problem Can my tinnitus go away once my jaw clicking has been fixed?  Two months ago I had LASIK surgery and it was very painful.  I started clenching my teeth and grinding at night; I’ve developed ear pressure and popping and the tinnitus has only gotten worse.  Some have recommended SSRI’s [a type of anti-depressant].  Can you point me in the right direction?  -K.M., El Salvador Answer Your question seems simple, but with the background you give it becomes more complicated.  The short answer is that based on what you have said, the cause of your tinnitus and the cause of your jaw clicking are both likely caused by the same thing: your clenching and grinding.  Clicking is caused when the disc that separates the ‘ball’ and the ‘socket’ in the jaw hinge gets pushed out to the side.  This most frequently happens when the biting and chewing muscles get over stressed and start to work out of harmony with each other (earlier, on this message board–see above–I have given a more thorough answer to the question about clicking).  Tinnitus is caused by many things including being too close to loud noises!  But in your case, where it seems to have begun only after the clenching and grinding, the cause is again that same excess muscle pressure compressing structures around the ear canal including the blood vessels that supply nutrients to the cells of hearing.  In your case, the precipitating event seems to be the continuing pain from the LASIK surgery.  That would be the first place to seek help as it sounds to me as if the pain from that is making you clench your teeth and the anxiety over being in chronic pain is contributing to your grinding.  At this point you may need to treat the symptoms of the pain and the anxiety before you can address the cause of the post surgical pain.  In that case I would recommend starting with ibuprofen for the pain.  If you need a pharmaceutical that is useful for helping break the cycle of clenching at night leading to lack of sleep, leading to more clenching from being over-tired and anxious, then you ought to see a physician who can prescribe a low dose of Valium, which is a great muscle relaxer, or Elavil, which is also effective as short term therapy.  I must emphasize that both of these medications should only be used short term to break the cycle of spasm and lack of restful sleep; both can be addictive and lose their effectiveness and Elavil is a medication that can not be stopped abruptly but needs to be tapered off.  Of course, at  some point, it would be good for a dentist to evaluate you to see if you have dental triggers to these kinds of muscle spasms.  When tooth surfaces meet in less than harmonious ways, they can serve to trigger episodes of TMD syndromes.  Elsewhere on this website I cover the issues of an unbalanced bite.  But be aware that most dentists are not trained in diagnosing and treating this problem.  To find one who is, go to www.pankeydentist.org.  Question #19: When Root Canal Therapy Fails A year ago I was diagnosed with multiple autoimmune diseases. I came upon some research on root canals being the problem. I had a root canal on 1 tooth many years ago. About 6 months ago, the crown fell off and the remaining tooth was black and tasted rotten. My dentist felt that there was too much decay to build it up and put another crown on. He wants to do a dental implant. I read that the tooth needs extracting but holistic dentists have a procedure for cleaning the root canal area. Can you explain what that procedure is as I am concerned that it may very well be contributing to  my autoimmune diseases. Also, after it is extracted what do you do to fill the space-it is the tooth in front-the lateral incisor.  S.C., Alabama Answer First off, I’d like to say that multiple autoimmune diseases likely have multiple causes and to believe that there is any one thing, a bad root canal or any one other thing will cure your condition may not be realistic.  I have had cases where auto immune diseases got drastically better when all dental infections were cleared up, but in a scenario such as what you describe I would look very closely at when the root canal therapy was originally done, if there were any symptoms of pain or signs of infection after it was completed, and importantly, what was the timing of the onset of the autoimmune disease relative to the root canal therapy.  For the sake of your question, assuming that this old root canal treated tooth is unrestorable and a viable option is putting in an implant, the important thing from a holistic point of view is that once the tooth has been removed, that the tooth socket is carefully and thoroughly scraped clean, so that any trace of bacteria or toxins are removed from the tooth socket walls.  In addition, I am of the opinion that an implant ought not to be placed into this socket on the same day as the extraction in order to give the body time to detoxify the wound.  Many of my colleagues will disagree with me on this point as it then requires a second surgery to re-open the area and place the implant at a later date.  But when there is a question of an autoimmune condition, it is best to err on the side of caution.  Because this tooth is in the front, it will be important for your dentist to have a plan in advance of how to send you back out into the world on the day of your extraction so that you will be able to smile and speak!  Here, the options are some kind of removable appliance such as an orthodontic retainer with a tooth on the appliance, or a bonded composite bridge attached to the teeth on either side of the lateral incisor.  Lastly, depending on many factors…esthetic, biological, condition of the teeth on either side of the lateral incisor, and a few others, it may be in your interest to consider rather than an implant, the placement of a permanent all porcelain bonded bridge.  Good Luck! Question #20: The Healing After an Extraction [This is a question that I received privately from a former patient of mine, who now lives far away.  I usually don’t answer these kinds of questions in this format, because I can’t give advice to patients that I don’t know.  In this case I know this patient well and her question was such a good one that I chose to answer it here]… I am 76 years old and chemically sensitive. One week ago I needed to have a wisdom tooth extracted. It was next to a dental implant and the surgeon told me that he needed to take it out a different way from ‘usual,’ and he warned me of a number of complications, including a dry socket, which, with my health I am very afraid of.  He cut the tooth into pieces and it seemed to go fine.  But now, I am starting to feel pulsing in the area.  Not pain but an energy emanating from the site and around it.  I had a bit of this feeling shortly after the extraction, but it went away and now it is back, but more pronounced.  I have been alternating Tylenol and Advil as per the advice of the surgeon.   Could this be dry socket?                                         S.D., Delaware First, it sounds like your oral surgeon did the right thing.  The standard way to extract a back tooth is to use the tooth in front of it as a fulcrum in order to get enough leverage to lift the tooth out.  An implant is never something to use as a fulcrum, so it was better that he sectioned the tooth into pieces and didn’t put that kind of stress on the implant.  Now, to your question.  If you can imagine that once a tooth is extracted, the open socket becomes, for the body, a ‘construction zone.’  Over a period of days, weeks and months the socket first fills with blood that clots into a plug and serves the purpose that a scab would serve on the surface of your skin.  Once the bleeding stops and the clot is well lodged in the socket, then your body starts the long process of converting that plug into new bone and new skin.  To do this, your body has to open up the blood vessels nearby to permit all the raw materials to reach the site.  This creates a feeling of heat and a pulsing feeling, particularly if you exert yourself.  For weeks, if you exercise, you will feel your heartbeat right in this area and that won’t go away until it is all healed and all the ‘construction vehicles’ go away.  So your symptoms sound completely normal for a normally healing extraction site.  A dry socket feels entirely different.  It HURTS!  It is a deep bone ache that doesn’t come and go.  It results from the blood clot plug washing out of the socket before real healing has begun but after the time when the socket will bleed easily.   The bony walls of the socket need to be covered during healing and that is the function of the blood clot.  If you lose that, you will know!  And then your oral surgeon will need to see you every few days and pack the socket with a special paste that serves the purpose of a substitute clot.  But, rest easy.  From what you describe, you are feeling the healing process!   Question #21: On Gum Treatments for Pocketing What is your view on deep teeth planing for early gum disease (some 5’s on wisdom teeth that never fully came in). Dangers and alternatives.  -A. McAllen, Tx Answer: Root planing and scaling is a time-honored treatment for removing the hardened deposits of tartar that form under the gumline.  When tartar forms there its name changes from tartar to “calculus,” although it is no relation to higher math!  Gum pockets typically form when the knitting that links the gum tissue that hugs the root surfaces of teeth to the teeth themselves.  Think of how the underside of your fingernail is attached to your finger, or how the peach pit in a cling peach is attached to all of the fibers of the peach.  Both of these examples are fairly good approximations of how the periodontal ligaments knit into the root surfaces.   Calculus is like a living coral reef–a hardened structure that houses thousands of bacteria.  Elsewhere on my website you will find much educational information about gum disease and I encourage you to review it.  These bacteria take in “food”–from the debris left behind after you eat or, when gum disease gets bad, from damaging the cells of your gums to get at the proteins inside of them.  Typically there needs to be a multi-pronged approach: the pockets need to be cleaned out, so root planing is a good start, then a good system of oral hygiene needs to be put in place so that these deposits don’t return.  I recommend using a water pik daily where an alkaline form of Vitamin C is added to the water (sodium ascorbate powder 1/2 teaspoon into the water pik tank).  Sodium Ascorbate powder looks like and tastes like salt.  It quickly dissolves in room temperature water and I recommend that after you put the water into your water pik, that you add the 1/2 teaspoon of this powder and stir it until it completely dissolves. Also, after you have finished water pikking your teeth and gums, refill the water pik tank about 1/3 full with plain warm water and with the hose pointing into your sink drain, turn it on and flush the tubing so that the vitamin C will not build up and leave a residue that might otherwise shorten the life of your water pik.  Sodium Ascorbate powder is available from the ‘Now’ vitamin company.  You will need to use a water pik as just rinsing your mouth, even with the vitamin C added, will not get this solution down into a 5mm pocket.  You need the horsepower of the water pik to power wash the roots of your teeth under your gumline. Also, my toothpaste: Dr Shuch’s Remarkable Edible Toothpaste, available on Amazon, has nutritional components in sufficient quantities and proportions to help the gum tissue to be more resistant to bacterial infiltration while also strengthening the collagen fibers that form the periodontal ligaments.  If you use a water pik, and brush with my toothpaste, you will go a long way to helping your mouth to be more resistant to gum disease.  Other factors that can also affect your gums are if your bite is applying too much pressure on specific teeth.  See on this website what I have to say about an unbalanced bite.  Two more things: don’t smoke or use any tobacco products as the toxins upset the balance of the ‘good bacteria’ in the mouth that otherwise crowd out the ‘weeds’ of the gum disease bacteria–and exercise!  Oxygenating your body with aerobic exercise also makes it harder for the ‘anaerobic’, oxygen-hating bacteria that cause gum disease to survive…make their life hard! Question #22: On A Recent Crop of Cavities My dentist said I have 11 cavities and I feel they are trying to scam me. Can you take a look at my x-rays and tell me your professional advice?  –P.A. New Jersey Answer: Diagnosing any kind of dental disease requires more than looking at a set of x-rays. It requires an in-person exam, because some areas of decay show up better on x-rays–for example cavities on the flossing surfaces of teeth, but other areas of decay show up better during a clinical exam–for example cavities on the biting surfaces or those at the gumline.  I do these kind of exams, we call them, ‘second opinion exams,’ all the time.  If you wish to travel up to northwest NJ, just call Suzanne or Pam at 973-579-7400 and they will give you instructions.  But if you can’t come, let me offer these words of advice for anyone receiving this kind of diagnosis. There are things that can happen in life that can lead to a ‘crop’ of cavities all showing up at the same time and if you fall into any of these categories, your diagnosis may very well be correct.  For example, if you have not been regular in seeking dental care and if your daily oral hygiene routine is not very thorough, then the first time you go to see a dentist after a long hiatus may show alot of decay.  Also, if you have been regular about your dental care and your home care, but you have changed your diet to include more simple sugars and starches, particularly if you are also fond of sour tasting foods or beverages (lemonade or citrus fruits, vinegar, pickles, mustard, etc.)  then you could easily have set up conditions for widespread decay.  Also, if you are taking any medications that can lead to dry-mouth, like certain heart medications or certain Parkinson’s Disease medications, these can lead you to being much, much more vulnerable to extensive decay.   An additional factor that I have seen over the past few years is due to the overwhelming popularity of digital dental x-rays.  There are many advantages to this new technology including faster viewing of images, no need for darkroom chemistry and easier image storage and retrieval.  But there remains a down side and it has to do with diagnosing subtle changes in the calcification density of teeth and bones.  Unlike conventional radiographs, digital images are not truly ‘images,’ they are data sets that use algorithms to convert those data sets into images.  Many times those algorithms get it right but sometimes they get it wrong and convert what should be a slightly ligher ‘grey’ into a slightly darker ‘grey.’  This is a huge issue in a case just like yours as a dentist may very honestly and unknowingly read a digital image and ‘see’ what any dentist would recognize as tooth decay, but when double checked using a conventional radiograph, there is no ‘area’ of decay.  I have seen about a half dozen cases like this.  One time one of my regular patients had intermittent pain in a tooth and I took a conventional pain and it was clear to me that he had a root end infection and needed root canal therapy. I referred him to an endodontist who took a digital film and told the patient that he did not see any reason to do root canal therapy.  I spoke with that endodontist by phone and we clearly had a professional diagnostic disagreement.  He sent the patient home and I called him and we spoke about the two different diagnosis.  I informed him of my certainty, but I told him to wait and see, but I felt that his symptoms would be getting worse.  Two months later he was back in the endodontist’s chair getting the root canal therapy.  It took that long for the bone physiology to degenerate sufficiently for it to show up with the digital imaging. More recently I had a patient who used to live locally but has since relocated to central Pennsylvania who was told by her local dentist that she had over 10 cavities.  This was very unusual as her oral home care had always been excellent and she had a good diet and was not on any medications.  I had her send me the digital images and had her come in for a consult at which time I took a few films to double check what I saw on her digital images.  As it turned out, she did not have 10 cavities at all, it was just a less than perfect algorithm that had skewed the gray scale of the digital images.  Note, this is not any kind of ‘adjustable’ feature of digital x-rays.  Doctors can manipulate images after they are taken to lighten or darken them, but the essential algorithm that determines these things is set at the factory to be as accurate as it can be.  The thing is, as mathematicians might say, it is precise, but not necessarily accurate.   As you seem to be doubting the diagnosis that you have received, it would ease your mind to get yourself a second opinion.  Even if it is not with me, I encourage you to do so.  Good Luck! Question #23: On Bite Balancing I am suffering from a bite imbalance caused by recent dental treatment.  I had 10 crowns placed on some of my upper teeth.  I have many of the symptoms you list on your website for bite imbalance.   I want to ask about what you called “superbone” and also gum inflammation that started right after the work.  I have been grinding and clenching at night I never had this before and I believe that I have an abscess and needs root canal therapy.  Also, my bite may have shifted.  My question is, can the “superbone” be fixed? Lastly, do you know any dentists in Los Angeles that could help me?  -M.Z., West Hollywood, California Answer: Here in my practice my patients know that occasionally I get up on my ‘soap-box’ and give a 30 second rant about how dental schools don’t adequately teach dental students what they really need to know about the subject of occlusion.  But as it turns out there are some excellent post-graduate centers for dental education that do.  It is just that we dentists, like everyone else, ‘don’t know what we don’t know,’ and even taking my own example, once I graduated dental school I thought that I knew all that I needed to know to put somebody’s mouth back together.  What I found out in my early years of practice, in the mid-1980’s and early 1990’s, was that there was a whole body of knowledge that had to do with how the teeth fit together, function against each other and how all of that works with the chewing and positioning muscles and the jaw hinge itself.  Without that knowledge it is still possible to put someone’s mouth back together with multiple crowns, but there is always the chance that there will be problems. Here you have several questions and I will take them one by one.  First, the ‘superbone’ that I mention is more accurately referred to as ‘bossing’ of the bone and it only comes about after many years of having a grinding habit.  So it is unlikely that this is what you have.  But you mention an abscess that needs root canal therapy and the abscess can easily cause a hard swelling on the bone above the tooth (for an upper tooth). This swelling is due to an infection in the bone and typically, once root canal therapy has been completed–or even once it is started–this kind of swelling disappears.  You also mention gum inflammation.  There could be many different causes of this following the kind of dental work you describe.  Off the top of my head I can think of four possibilities: it may be related to the abscess and will clear up when the root canal therapy is done, it may be related to the bite issue and will only clear up when that has been addressed, it may be related to the fit of the crown or crowns on the stumps of the teeth or if there is any excess cement at the margins of the crowns that could be irritating the gums or if there is an allergy to any of the dental materials that were used.  You will need a dentist to do some detective work to uncover exactly what the gum problem is and to see if the current work can be salvaged–i.e. if the bite can be adjusted on this new work to make your mouth comfortable, or if it will have to be replaced.  I don’t personally know of any dentists in the Los Angeles area, but I want to encourage you to go to the website of the Pankey Institute, one of the finest post graduate dental training centers in the world, and go to the place where you can key in your zip code and it will list for you dentists who are graduates of its programs.  Click here for the link, and good luck!    Question #24: Can Lost Gums Come Back? Is it possible to regrow gum? –G. Washington State, USA Answer:  The short answer is no; once gum tissue is lost, the only way it can “come back” is if it is grafted in place through a surgical procedure where some gum can be harvested from a donor region and sewn into place where the gum is missing.  But in many instances, it can be just fine to leave well enough alone if the underlying condition that caused the gum loss in the first place has been addressed.  If there was gum disease and the underlying bone has been lost to some degree, the gum tissue is merely reflecting what the underlying support tissue now looks like.  Also, if there is a bite issue that is causing the tooth with the receding gum to be bumped at a bad angle, this can be a mechanical cause of bone loss and gum loss. Gum tissue derives much of its nourishment from the bone under it and if that bone is lost, the gum line often, but not always, recedes to reflect the new ‘reality.’ In cases where this doesn’t happen, the result are gum pockets that can be hard to keep clean and that can be a safe harbor for the kinds of bacteria that make gum disease and bone loss worse!  So, from a health point of view it is not always bad if the gums have receded.  Yet, it can result in an unsightly smile, with long-looking teeth and sometimes the exposed root surfaces can be sensitive or a bit more susceptible to decay.  In those circumstances, a consult with a good periodontist would be your best bet.  Good Luck! Question#25:Dr Shuch’s Remarkable Toothpaste Part II I have purchased Dr. Shuch’s Remarkable Edible Toothpaste for one of my relatives who is bedridden and unable to spit out.  It tastes good! Please clarify: (1) How to use (cotton gauze, tooth brush, using finger?)   (2) When eating after brushing, bacteria remaining won’t create any problem?  (3) Calcium carbonate won’t make a problem when eating?  Thank you for your reply.  –John,  Kochi, Kerala, India Answer:  Hi John!  It is great to know that my toothpaste is being used and enjoyed in India!  Here are the answers to your questions: My recommendation is to use Dr. Shuch’s Remarkable Edible Toothpaste just like regular toothpaste–in other words, put it on a toothbrush and use it to brush the teeth, except at the last step, just swallow it, don’t rinse it or spit it out.  It can be applied with any method, but the action of brushing helps to clean food debris off of the teeth and it also makes sure that the toothpaste vitamins and minerals are pushed into the crevasses between the teeth and the gums.  This is very important as this is the area where gum disease starts and one of the things that my toothpaste does is that it makes the gums tougher, so that it is harder for debris to get lodged under the gum line.  In terms of eating the toothpaste, the bacteria and debris– we are swallowing this every minute of the day!  Any food debris that remains on the teeth is just stuff that wasn’t swallowed while eating and the mouth is normally filled with bacteria–most of which are FRIENDLY AND HELPFUL! And our mouth and entire digestive system would cease to function if it were not for these inhabitants.  So fear not!  In terms of calcium carbonate, the form in my toothpaste is the same as what it typically used in cookies, breads, nutritional bars, and baked goods of all kinds.  It is actually a well-absorbed source of calcium, which we all need!  Namaste! Question #26: Mercury Removal Protocol Part II  Do you think that using a dental dam is necessary for safe mercury amalgam removal?  –M.M.  New Jersey Answer:   When removing mercury amalgam it is important to control the debris which is composed of 50% mercury. While it is being pulverized, it creates an airborne cloud of dust and a liquid mixture that is called a slurry.  The cloud must be controlled through high speed suction placed right next to the work area to vacuum off the cloud.  In addition in my office I use bipolar ionization to put a static charge on the cloud particles so that they are electrostatically taken out of the air.  The slurry is also evacuated by the high speed suction tip, but without a dental dam it can and does flow all over the mouth and part of the cloud, in the form of an aerosol, stays in the mouth and this is an easy way for the mercury to get directly absorbed through the mucus membranes of the mouth.  A dental dam is the single best way to control the slurry and also keep the aerosol from gaining access to the mucus membranes.  To be extra cautious I also put my patients on oxygen during the removal process just so that they are kept from breathing in any of the aerosols.  Only in rare cases where there is not sufficient room for a rubber dam, such as removing a large amalgam from an upper wisdom tooth, am I forced to resort to a different method of isolation: a device I import from Sweden called ‘Clean -Up’, which is an attachment to the high speed suction apparatus that focuses the suction most directly on the tooth being worked on.  But in my opinion the gold standard for safe mercury removal will always be the dental dam. Question27: Enamel Hypoplasia My twelve year old son has his permanent teeth erupting with what his dentist calls ‘enamel hypoplasia’.  The dentist is recommending fluoride treatments; is that the best thing?   –Ali, London, UK Answer:  This is a big subject as enamel hypoplasia is a spectrum disorder, meaning it can be mild, moderate or severe—and the need for treatment and the kind of treatment depend on how bad the problem is. Then there is the issue of is the problem functional…ie pain on chewing on surfaces denuded of enamel or greater tendencies for tooth decay, or is the problem more esthetic…ie the upper front teeth look bad and your son is embarrassed about smiling? Sometimes hypoplasia doesn’t need any treatment, sometimes it will eventually require a lot of dental restorations (if the weak enamel keeps breaking off) and sometimes it needs something in-between… like some upper front teeth bonding for deeper lines or spots and fillings on back teeth if they get cavities or if the surfaces crumble. Fluoride is a tool, but only useful if there is a continuing problem of tooth decay. What I mean by that is that just because enamel is thin or weak or non existent, does not mean that teeth will certainly get cavities, as dentin can be nearly as hard as enamel through a diet without a lot of sugar or junk foods, low in acidic (sour) foods, and high in vegetables and meat (including bone broth or dishes made with marrowbones). Question #28: Dental Diagnostics  If an x-ray indicated an infection under a crown & a root canal was done years ago, would you recommend  a retreatment of the root canal & therefore prepare a new crown for the patient?  This is a patient that has not been in much distress & thought she woke up with discomfort because of teeth grinding in her sleep, although x-ray showed some darkness under tooth. –K.M.  Newton, NJ Answer:  This is an interesting question and it requires a somewhat complicated answer.  First of all, a single dental x-ray is a snapshot in the middle of a ‘movie’–a situation that can be changing over time….or not!  So in order to work towards an answer to this question, the first part is to see if there have been prior films taken of this same tooth, taken at different points in time.  There should, for example, be a film that was taken at the original completion of the root canal therapy years ago.  There may also have been subsequent films taken, including the one taken most recently.  If these can be arranged chronologically, then it will become clear if there is a clear and obvious infection or not.  When an infection first becomes obvious on a dental x-ray (and some infections are too new, and show pain, swelling, etc, but no changes on an x-ray initially), there will be a dark grey zone at the tip of one or more of the roots of the tooth.  This is referred to in dental jargon as a ‘peri-apical pathology’ or ”p.a.p.” for short.  Sometimes these are picked up on a dental x-ray as an incidental finding—because the patient has absolutely no symptoms that anything has ever been wrong with the tooth, even if the problem might have been present for years.  But let’s say that originally, this tooth hurt, and the dentist years ago took a film and found a p.a.p. and it was clear that the tooth needed root canal therapy.  Let’s also assume that after that procedure was done and a crown was made for the tooth that everything felt fine.  Now we come to the situation of the questioner.  There were some non-specific symptoms and a dental visit revealed that there was a p.a.p. at the tip of one or more roots of this tooth.  The series of films ought to be able to reveal if this area is: (1) slowly enlarging–indicating a growing infection, (2) stable in size–indicating that the original p.a.p., despite root canal treatment, never completely went away as can happen when these areas form scar tissue rather than revert to healthy bone, or (3) That the area initially healed normally, i.e. that the original p.a.p. completely disappeared and healthy bone re-formed at the tip of the root or roots and that now, in the latest film, there is a clear ‘return’ of an infection. Once we can establish the pattern, it becomes clearer if there may or may not be a need to retreat the tooth with additional root canal therapy or a different procedure called an ‘apicoectomy’ which is a small surgical procedure done to remove the infection through the gum. You mentioned that the patient was not in not in great distress, but woke up with some discomfort that might have been a result of clenching or grinding at night.  Well, welcome to the world of Covid related dentistry in 2021!  So many people are clenching, grinding, breaking teeth, developing TMJ problems, etc as a result of the stresses of our ‘new-normal’ that there was even an article in the NY Times about this phenomenon.  So, the x-ray will give some information, and maybe it is clear or maybe it is still unclear if the root canal needs more treatment, but if it is not crystal clear then the next step ought to just be adjusting the bite on the crown to make sure that this is not just a ‘bite-aggravation’ of this tooth.  If it was just a bite aggravation–the equivalent of a sprained ligament (yes, teeth have ligaments that can easily get sprained from over-use), then adjusting the bite may solve the problem or at least enable the dentist to eliminate the possibility that the entire problem was bite related.  Then, if the problem persists, regardless of equivocal x-ray findings, the root canal will likely need more treatment. Lastly, none of this speaks to whether or not the tooth will require a new crown.  Retreating a root canal conventionally or through an apicoectomy does not automatically mean that the tooth will need a new crown.  Only if there is an issue of decay under the crown or if there is a question of how the crown fits or if by redoing the root canal therapy the crown will become unserviceable, will it become necessary to remake the crown.  If the crown is beautiful in every way and if the root canal therapy needs more treatment, then this would argue for an apicoectomy as the better treatment option as in that case, the top of the tooth is left alone. Question #29: Thermography Part III  Do you integrate thermal imaging along with normal x-ray techniques? If so have you seen cases in which the latter could not confirm the findings detected by IR thermography?  –M. Switzerland Answer: X-rays reveal different densities of hard tissue such as bone or tooth.  For example, tooth decay is tooth structure that has had its calcium removed by acid reactions with bacteria.  This results in a dental x-ray that shows a relatively darker grey region compared to a normally calcified tooth.  Thermography shows different quantities of heat in a tissue, be it hard tissue or soft tissue.  So they image different things and some of the things that they image may happen to coincide and other things will not.  Tooth decay does not have a particular heat signature, so a dental x-ray will show an issue and a thermogram will not.  But his doesn’t mean that there is no decay!  A place where these two types of imagine will coincide are active infections in the bone.  For example, if a tooth has an actively infected nerve, there may be a sign on the dental x-ray of a hollowed out area at the tip of the root of the affected tooth and there will be a corresponding ‘hot spot’ on a thermogram taken of the same area. But chronic infections may not be ‘hot’ at all and will show up on a dental x-ray but not on a thermogram.  Thermograms can be useful for spotting rare but serious problems in the jaws, such as a cancerous tumor or a arterio-venous malformation, and these may not image well with standard dental x-rays (but would show up on an MRI).  The greatest misinterpretation of dental thermograms comes when a ‘hot spot’ is interpreted as a tooth or bone infection, when in fact it is just a chewing muscle that has been over used.  We see this alot in TMJ patients or in those who clench or grind their teeth.  Thermograms will show lots of hot spots but they need to be properly interpreted so that these are not mistaken for bone infections.  This can be done by comparing front and side view thermograms.  If the hot spot is a muscle, a side view will show that the hot spot is positioned laterally to the jaw bone itself. Question #30: Can Teeth “Regrow”? Is it possible to regrow enamel on teeth?  I had a piece shear off after clenching. Is there anything healthy that I can apply or a vitamin taken by mouth? –R.R., Skokie, Ill Answer:  Enamel doesn’t re-grow.  If enamel is present and has started to decay it is possible to reverse that process, but that requires that the enamel be present.  Once it has been physically lost there is no longer the internal protein matrix (collagen) that orients the minerals to crystallize into the proper shape and size.  What is left though is dentin, and this structure can almost be made into an enamel substitute, except that the surface will not “grow.”  So if the fracture is small, and if you have not  lost so much of the tooth that it is no longer functional (when you close your teeth together that tooth should still make contact with its opposing tooth),  and it it is not unsightly when you speak or smile, then you are left with a simple task of just making sure that the newly exposed dentin is not sensitive to air, cold, or sour (acid) foods.  That can be accomplished with topically applied fluoride–one of the times that I do recommend its use.  OTC products such as ‘Gel-Cam” can be applied with a Q-Tip to the exposed surface after brushing and flossing.  Used daily after about two weeks the dentin surface should have absorbed sufficient fluoride so that the exposed surface is no longer sensitive.  But if the fracture was large–so that the tooth is no longer functional or if it has affected your smile, or if the fracture was deep–so that a highly sensitive pink spot is visible or if there is pain and a pinpoint of blood coming from the tooth, then you are going to need the services of a dentist.  In those scenarios you could need something a simple as a bonded composite filling, a porcelain onlay or as complex as a root canal treatment and a crown. Question #31: On Integrative Care of Gum Disease I have been told by a dentist that I have gum disease and bone loss and I am wondering what kind of treatments that might be considered ‘unconventional’ that you have seen help. – O., Cliffside Park, NJ Answer:  Gum disease is a category that includes many conditions, so without more information it would be impossible to say what may work for your particular condition, but for the most commonly occurring kinds of gum disease, please see the section of my website that goes into this in detail by clicking this link: https://www.centerforintegrativedentistry.com/what-is-homeopathy/our-approach-to-gum-disease/  In terms of ‘unconventional’, the factors that I take into consideration have to do with localized areas of bite stress that can contribute to focal areas of bone loss, making sure that my patient’s have adequate vitamin support through diet and supplementation, making sure that the oral ecosystem is set to favor the friendly, healthy bacteria rather than the ‘bad actors’ that contribute to disease, and making sure that my patient understands the importance of aerobic exercise to maximally infuse their gums and jawbones with high levels of oxygen.  As always, my many decades of research has led to my developing and recommending that my patients brush their teeth with the toothpaste I developed specifically to help gums, Dr Shuch’s Remarkable Edible Toothpaste.  You can click here to find that product.  Please note, none of what I have just mentioned replaces such standard gum disease treatments as deep cleaning, root planing and scaling, etc, these are adjuncts that help improve the outcome. Question #32: On Gum Tissue Health Thank you for your website!  I have been using sodium ascorbate powder and coenzyme Q-10 and I can feel my loose teeth tightening up!  My question is: Can gums regrow?  –R., Park Ridge, NJ Answer:  Dear R, Good for you!  These are important steps that anyone can do that make the gum tissues healthier and firmer and that can translate into loose teeth tightening up.  Gum tissue never re-grows.  Occasionally it can be added to surgically through a procedure called ‘grafting,’ but this is not done to tighten teeth.  Gum tissue simply grows or is lost where there is underlying bone.  If you have had gum disease for a while, you may have lost bone around your teeth and the height of the gum tissue may be reflecting the reality of where the remaining bone still exists.  But this is not the most important thing.  The most important thing is that the gum tissue that remains is very firm, like leather, rather than fragile like the skin of a ripe tomato!  Also what is important is that the surface of the gum that sits against the roots of your teeth is attached to those roots.  Gum tissue when it is healthiest is attached to teeth in a similar way that your fingernails are attached to the skin of your fingers.  There is a kind of attachment that knits the two together.  The things that you can do on your own to help this along include things that you are already doing with the vitamin C and the coenzyme Q-10, but also include keeping you mouth very clean and keeping the ecosystem of your mouth in balance.  For this I recommend that you use Dr. Shuch’s Remarkable Toothpaste!  Also, make vigorous exercise a part of your life to get your blood well oxygenated and moving deeply into your jaws and gums.  With those things as a start, it will make it easier for any dentist or periodontist to help you.  Good Luck! Question #33: “Sleep Hygiene” I’m wondering if I need a nightguard; I wake up in the morning with my jaw muscles sore and stiff, so maybe I’m clenching while I sleep?  –R.T.  Bloomingdale, NJ Answer: Whenever I get this question I first educate my patients on what I call, “Sleep Hygiene.”  Simply put, there are ways that we can habitually sleep that actually encourage the jaw muscles to clench and grind and, if you know a few secrets, there are ways that tend to make the muscles more peaceful.  If these no-cost measures don’t work, then we can always resort to a nightguard. By the way, in my practice I often diagnose bite related issues that we address through bite balancing (also known as ‘occlusal equilibration’), that we treat pretty much before any other dentistry.  So this answer applies best for those who have already been equilibrated.  The principles spelled out here apply to everyone, but if there are bite discrepancies, they can make the jaw muscles sore no matter what.  With that being said, here are the secrets of good sleep hygiene for establishing a peaceful jaw musculature:      First, if you are a back sleeper, just before you doze off to sleep, do a bit of a meditation where you are to focus your awareness on where the weight of your head falls.  In the picture above, all of the weight of the head is being supported by the pillow.  This is a common thing for back sleepers and frankly, nothing could be worse for jaw and head-support muscles.  The proper support for the weight of the head is demonstrated by this next picture: The weight of the head should be supported by the back of the neck.  A neck pillow, a rolled up towel, a bolster…whatever works.  I don’t care if the back of your head is actually floating in air an inch off of your mattress!  What is KEY is that you feel the weight of your head being supported by the back of the neck. Second, if you are a side sleeper, the circumstances are different.  And here, the key is to again do a bit of meditation just before nodding off with the purpose of sensing if, your head is on straight!” See the following pictures: Note here that between the firmness of the mattress, the breadth of the shoulders and the loft of the pillow there will be a relationship that either does or doesn’t keep the head oriented in line with the rest of the spine.  Here, those factors create a tilted neck that creates tension on this person’s neck on the right side–all night long!  Compare that to this next picture: Here, the pillow is too high and there will be tension all night long on the muscles of the the neck on this person’s left side–all night long.  A further variation on this is pictured next: Here the head isn’t tilted, but it is twisted, creating tension in different neck muscles, but tension nevertheless that can last all night.  And, below, is the opposite: Here the head is turned the other way, and the opposite neck muscles will stay in tension all night.  What side sleepers need to be mindful of, just before nodding off, is that their alignment looks like this: Then then neck muscles can relax!  And if they are relaxed, then at least they will not be contributing to the accumulation of tensions that can highjack other muscle groups of the head, neck and shoulders to also hold tension.  One more thing…. it is perfectly OK for the head to be held and supported in a slightly forward posture that is akin to the fetal position.  The next secret applies to both side and stomach sleepers and is perhaps the most important secret of sleep hygiene: With your eyes closed and your head nestled snugly into your pillow, do a bit more meditation and sense where the weight of your head is being supported.  The goal here is that ALL of your head’s weight should be borne by any part of the head EXCEPT your lower jaw (mandible).  Any weight pressure against your lower jaw will result in an equal and opposite force that your jaw muscles will exert all night long in order to stabilize your jaw and keep it from being “pushed” off to the side by the weight of your head.  Another way to visualize this is shown in the next picture: The weight of your head can be spread out on any of the areas highlighted by the green dots, but none of your weight should be on any of the areas marked by the red dots!  Your lower jaw should feel as if it is floating in space, without pressure or tension of any kind.  And lastly: Your last meditation before drifting off to sleep is simple.  Confirm for yourself, “Lips together, Teeth apart.”  You should not have your jaw in a tooth to tooth supported position as it will encourage clenching.  The lower jaw should ‘float’ in the musculature and be suspended there, loose and free!  If beyond these measures of sleep hygiene, you are still suffering from symptoms of night clenching or grinding, then it may be time to get a well made, precision nightguard. Question #34: Cracked Tooth Options What are the options if I have a cracked molar?  –B.D., Andover, NJ  Answer: Molars can crack in a variety of ways and the treatment really depends on the kind of crack.  Here’s a rundown of the most common variations: 1. If the crack is very superficial, like a sliver of enamel that might look like a little piece of a contact lens, with no sensitivity to cold, sweets or sour foods, then it can just be polished so that it isn’t sharp to the tongue. 2. If the cracked off part is deep enough so that the tooth structure under the enamel, the dentin, is exposed and sensitive to cold, sweets or sour foods, or if the broken off part involves a flossing contact area such that now there is a food trap between two teeth, then the options will include either a tooth colored filling, a porcelain filling called an ‘onlay,’ or a crown. 3.  If the cracked off part has exposed a tiny red dot that may bleed or in any case will be extremely sensitive to touch, then the tooth will need root canal therapy before it can be restored. 4.  If the cracked off part is large enough so that part of the break is under the gum line, the tooth will need a porcelain onlay or a crown. 5.  If the tooth has cracked in a major way but is completely without symptoms of discomfort then an x-ray may reveal that the crack formed from previously undiagnosed deep decay or previously unknown trauma that caused the dental nerve to die some time prior to the crack. And depending on the extent of the decay or the extent of the low-grade chronic infection that is associated with old, dead nerves, the tooth may be salvageable with root canal therapy and a crown or it may just need to come out. 6.  If the tooth has no obvious signs of a fracture, but gives a symptom of feeling a sharp spike of pain when biting down on something hard and then a second spike of pain when the biting pressure is released, then this means that there is an internal crack in the tooth and that biting down causes the two halves of the tooth to flex apart and then spring back together when the biting pressure is released, causing the enclosed nerve to be first stretched and then squeezed.  In this case it is possible that a combination of root canal therapy and a crown will save the tooth, with the crown acting as a tight belt around the circumference of the tooth and holding it together against biting pressure despite the crack, but here the prognosis will always be guarded.  In my practice I will often first shape the tooth for a crown and put on a temporary crown just to judge if the “belt” makes the tooth feel OK, before committing to any other step as there is no way to know for sure with an internal crack whether it is superficial, deep, or through and through. 7.  If the molar is actually split, so that there are two pieces that are independent of each other then the chances are that it will have to be extracted and replaced with either an implant supported crown, a permanent fixed bridge or a removable partial denture.  But there are circumstances when even this situation can be salvaged.  If, for example, the crack is through and through on an upper molar–in some of these cases the anatomy of the roots of that tooth look like a three-legged stool and if the crack involves one of the smaller roots and if the bone support on the remaining two roots is strong, then a partial extraction of the small, loose root with root canal therapy and a crown on the other two roots may still be possible.  There are other variations on this option that depend on the root anatomy and strength of remaining root or roots, but this gives you a general idea. Question #35: On Infected Teeth, Meridians, & Muscle Testing Hi! I have two root canal done many years back and have few chronic conditions. Some of them might be connected with meridian chart. Is it possible to make sure through muscle testing or other technique that extraction of root canal is my best choice? -I.K., Long Island City, Queens NY Answer: Muscle testing can certainly be part of an evaluation for this question.  But not as a stand-alone test.  First, as far as a timeline goes, is there some relation to the onset of symptoms and having had one or both of these root canals done?  Are there any local symptoms of pain or sensitivity related to either or both of these teeth when chewing or when waking up in the morning?  What is the gum condition around these teeth and how does this compare with the gum conditions around the rest of the teeth in the mouth?  Are there bite issues (see section of this website on the problems of an unbalanced bite).  Are there root canals done elsewhere in the mouth that are otherwise fine?  And these are just the general questions!  A thorough exam may reveal other potential issues such as mixed metals or materials sensitivities.  My feeling is that it is important before recommending taking out any teeth to have a pretty clear sense that doing so will be beneficial enough from a health point of view to justify not just the extractions, but the costs of replacing those teeth once they are missing.  Question # 36: On Homeopathics in Complex Cases I have an embedded wisdom tooth, which lies horizontally and is close to a nerve. In a recent x-ray, my dentist discovered that a cyst has formed around the crown. I’ve been advised to surgically remove the cyst and the embedded tooth. The risk is a 1% chance of permanent numbness in my lower lip, tongue and chin. I am 52, female and have an autoimmune condition (rheumatoid arthritis – in remission. Is there a homeopathic remedy to dissolve the cyst without surgery? -L., Singapore Answer: Here’s an example of how homeopathics can assist in a complex situation and a bit about what it can and cannot do.  Homeopathics can be used in two very different ways: Acute prescribing and Constitutional care. It is easy to find remedies for acute conditions–it’s kind of like having a first-aid kit!  And there are remedies like Silicea for things like splinters–to help the body expel them, and remedies like Hepar Sulph for acute infections that cause these to rise up to the surface like a pimple.  But what you describe is not an acute situation, but rather one that has been ongoing in your body probably since you were about 15 or 16  years old, when this tooth was first forming in your jaw and before it became aligned in its now impacted position. For whatever reason you body has built a capsule (the cyst) around this wisdom tooth.  Ordinarily this is no cause for alarm as most teeth develop something like called an “eruption cyst” that actually helps it to break through the gum (this can’t happen if the tooth is impacted like yours). So in your case the significance is only if on subsequent x-rays of this same area the cyst shows a steady enlargement.  That would trigger a need to intervene.  Now to your question of a homeopathic remedy that might assist in the draining or the re-absorption of this cyst. THAT would require the skill of a homeopath trained in constitutional prescribing.  The homeopathic interview would have to take into account all of the factors that you brought up: your auto immune disease, the history of this growing cyst as well as maybe a dozen other factors, in order to find the appropriate constitutional remedy.  And from this distance I couldn’t say even if that would be your best option as constitutional care can take quite a bit of time and if the cyst is growing quickly you may be better off opting for surgery and then using homeopathics to help support your body as it goes through and recovers from the operation. For acute care for surgery there are tried and true acute remedies that will help you heal faster, feel better sooner, and maybe even help heal damaged nerve endings.  Look on my website  (Here) for the section about helpful acute homeopathic remedies for dental conditions. Good Luck! Question #37: On Treating Complicated Root Canals I have had some teeth treated with root canal therapy in the past and now I need another one.  But things have not always gone smoothly.  I need one tooth retreated owing to a returned infection and now I have a second tooth that needs root canal.  I’m thinking of seeing an endodontist instead of a general dentist who does root canals and this endodontist uses something called, “Endocal-10.”  I have also heard about ozone therapy as a help.  Can you comment?                                                                                  -N.H., Montreal, Canada Answer: Elsewhere on this website I have written extensively about root canal therapy (click here).  When done well, it is an exceedingly successful treatment.  With your history, it is clear that the internal anatomy of your teeth is more complicated than average and so it is an excellent idea for you to seek out and have treatment in the hands of an endodontist–a specialist who main focus is root canal therapy.  In terms of specific materials or techniques such as the ones you mentioned, I would be more concerned if I were you in just finding a good endodontist in your area and to trust him/her to use what they have found to work best in their hands.  There are lots of new technologies and materials out there that make cleaning, shaping and filling the root canal spaces much more predictable and successful than what has been possible years ago.  For example, I often refer my patients to an endodontist who uses a instrument/technique called the “Gentle Wave.” procedure and the results are extraordinary.  It shouldn’t be for you to pick materials and methods; but find someone you trust who has a good recommendation and rest assured that you are in good hands.  Good Luck!  Question #38: Toothbrush Varieties  What kind of electric toothbrush is best to clean teeth and clean under the gum line without harming the enamel? Also, are brush heads with embedded charcoal acceptable?  -L.M., San Francisco, California Answer: A few things to keep in mind when evaluating any toothbrush.  First, it is important that the bristles, or at least the tips of the bristles are very fine. The reason being that the most important place for the bristles to reach is just below the gum line, and if the bristles are too thick, they will not be flexible enough for entering this tight, narrow space.  Second, if you are going to use an electric toothbrush then please use one that oscillates rather than spins.  While it is OK for your dentist or dental hygienist to use a spinning style polisher a couple of times per year, the spinning motion is much more aggressive and depending on the abrasiveness of the toothpaste, this can result in serious abrasive wear at the gum line.  Third, when it comes to “harming the enamel” –the more important problem is harming the parts of teeth like the root surfaces that don’t have enamel covering them.  Brushing even in a hugely aggressive way won’t do much to harm enamel, but the “dentin”—that is what is just under the gum line.  And the key to not harming the dentin is to make sure that the kind of abrasive particles within your toothpaste are not physically harder than dentin, otherwise every day you will be scratching away another layer of the dentin.  The main culprit in this problem is “silica” which is like powdered quartz or beach sand.  It has a hardness rating of about 7, where dentin has a hardness of around 4.5.  A better choice is using a toothpaste where the abrasive particles are softer than dentin, with the best choice being calcium carbonate.  It has a hardness of about 3.5.  Having trouble finding a toothpaste without silica and that uses calcium carbonate as the only abrasive?  Feel free to look for my own invention, Dr Shuch’s Remarkable Edible Toothpaste. Oh, and as far as bristles embedded with charcoal, this is a marketing gimmick, the particles will surely separate from the bristles after just one or two brushings and if they are so adherent to the bristles that they stay attached, their pores will become hopelessly clogged with toothpaste residue that they won’t do much for you!