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Should You Replace All Your Amalgam Fillings?

If you watched a recent episode on Dr. Oz, you would initially think that everyone should race to the dentist and have all their amalgam (silver) fillings removed because of mercury vapors that are released from amalgams. Sensationalism makes money on TV, so may I suggest you watch all three parts of the episode before you call the dentist. The tone at the end is very different than the fear at the beginning. The debate about amalgam fillings has been going on since the 1980’s when there was concern raised about the mercury that is part of the silver filling. Studies have been done with suggestions that mercury vapors are released from amalgams and in fact, some countries in Europe have banned the use of amalgams. Research still is not complete and part of the issue is that we don’t know how much mercury is released and how much is too much. The main concern with mercury is that it is neurotoxic – meaning that it affects your nervous system. The following is a list of symptoms that have been associated with mercury toxicity: memory loss, auto immune disorders, fatigue, tremors and the inability to concentrate. Patients who suffer from these conditions may ask to have amalgams removed in an effort to eliminate the symptoms. In fact, over the years, I have had a few patients with multiple sclerosis and others who felt they had metal toxicity, request removal of their amalgams. We developed a plan for those patients and replaced amalgams, but I didn’t see significant improvement in their symptoms. My patient sample in this case was too small and no research study was conducted by me to prove or disprove any theories. As a dentist who has been practicing for 22 years, these are my thoughts on silver fillings: • Amalgams are a solid, dependable restoration that many adults have had in their mouths for 30-40 years. I had a 91 year old patient in recently who had stable silver fillings in place for over 50 years! • Amalgams were a popular material in the past, and are still used by many dentists today, because they are easy to place, hold up for a long time and are inexpensive. • Amalgams require more tooth removal than the new restorations that we have. Because amalgams don’t bond to teeth, you have to cut an undercut in a tooth to hold it in place. In small cavities, that doesn’t normally present a problem, but with larger cavities it can significantly undermine the tooth and lead to fractures later on. • There are alternatives to amalgam that are more supportive to the tooth, look better and don’t come with the suspicions associated with amalgam. They range from bonded composites to porcelain crowns and onlays. Because these materials are more technique sensitive and sometime involves multiple visits and lab fees, they cost more than amalgams. I believe the alternative materials are better, and therefore, I don’t place amalgams. For patients with insurance, many times policies will not cover these restorations and pay an “alternative benefit”, which is the fee of the less expensive amalgam. Personally, I have issues with insurance companies deciding which restoration is the ideal material for my patients….but that’s another topic. • The most exposure to mercury from amalgams is when they are removed and the fillings are aerated. Appropriate suction and isolation are important to limit exposure to patients. Dr. Oz suggests that if you have eight or more fillings you should have them replaced, but I question that because removing eight fillings at once creates a lot of mercury exposure. I would prefer addressing the amalgams as there is a problem, or if there are one or two next to one another, instead of taking them all out at once. Dr. Oz’s guests discuss the reasons why you might be at greater risk and how you can prevent toxicity. The belief is that grinding teeth together and having high acid levels (from coffee, soda, vinegar, oranges) elicit more mercury vapor. They suggest drinking soda and coffee with a straw (I prefer eliminating soda for many reasons). They recommend incorporating garlic, cilantro and Chlorella (a fresh water algae supplement) in your diet because they all help to bind and remove mercury from the body. They suggest removing amalgams if you have eight or more fillings, if you grind your teeth or if there is a sign of corrosion or decay. So, what’s my plan….I have seven amalgams in my mouth! They’ve probably been present for at least 35 years. I actually had eight, but had one replaced in dental school with a gold onlay because of decay around the old filling. I have no intention of removing the others until they break, have decay or open margins. I believing in treating my patients the way I would treat myself or my family. • For me, the biggest reason to replace an amalgam (or any other filling) is because it is no longer doing what it should be doing. If the margins are open, there is a cavity around it or it isn’t supporting the tooth, it needs to come out and be replaced. • Do I worry about amalgams? No, I don’t worry about the existing amalgams that are in my patients mouths. However, I am very careful when I remove them to limit their exposure to the aerated mercury. Which brings up something to consider…if removing the amalgams puts you at greater risk for neurotoxicity, wouldn’t you expect every dental staff member to have issues since they are the ones constantly being exposed? I suggest if you have amalgams present, that you have a conversation with your dentist. I urge you to make decisions based on fact and your individual situation, not television hype. I’ve included the link to Dr. Oz, but be sure to watch all three parts of the episode. http://www.doctoroz.com/episode/are-your-silver-fillings-making-you-sick?video=18173

Children, Airway, Snoring and ADHD

I was at meeting of a group of physicians, dentists, speech and physical therapists, other health care providers and the public that works to educate and provide integrated care for children and adults. The focus of the meeting was airway and how it impacts the health and development of children. “What is airway?” Airway refers to the passage by which air reaches the lungs. The issue is that airway can be affected by anatomical issues like large adenoids and tonsils or a deviated septum, congestion, allergies, asthma and a narrow jaw. All these things contribute to a change from healthy nasal breathing through your nose, to mouth breathing. Mouth breathing is not as efficient because of the way the air flows. “Why is airway important?” Quite simply, your airway and the shape of it or anything that interferes with it, prevents good breathing and the flow of oxygen to the lungs, and therefore, the brain. Many children (and adults) who have problems breathing due to allergies or large tonsils and adenoids may snore at night – a sign that their airway is interrupted. Some even have apnea, a situation where the breathing stops for up to a minute at a time, many times throughout the night. The stops in breathing lead to poor sleep. Consider what happens to a developing child’s brain if there are regular interruptions in oxygen. Snoring in children has been associated with problems in memory, language and poor academic performance. The AmericanAcademyof Pediatrics thinks airway is so important that they have issued new guidelines for screening children and adolescents for snoring at routine visits. “What does any of this have to do with ADHD?” ADHD (attention deficit hyperactivity disorder) in children is characterized by impulsivity, hyperactivity and difficulty focusing. If a child is not sleeping well because of problems with their airway (or any other reason for that matter) they will be tired. A sleepy child acts different than a sleepy adult. Adults who are tired become withdrawn, and quiet and consider taking a nap. Children, on the other hand, try to keep themselves awake! To do this, they try to move around a lot, seem impulsive or talk to themselves to stay awake. Many doctors believe that children are mistakenly diagnosed with ADHD when really they are suffering from sleep apnea and are just tired. “What are the signs that my child may have an issue with their airway?” There are both medical and physical changes that may occur with airway issues. Medical Allergies or asthma Snoring Large adenoids or tonsils Bedwetting Hyperactivity Physical – because breathing uses so many muscles, visible physical changes are common, many related to tooth and jaw position. Narrow upper arch Long, narrow face Poor tongue posture Crossbite Small, poorly developed nostrils Gummy smile Open mouth posture (anterior open bite) Short and turned up upper lip “What do you do to treat airway issues?” Removal of adenoid and tonsils helps resolve about 90% of the issues. Speech and myofunctional therapy that retrain tongue position and encourage nasal breathing. Orthodontic intervention that expands the jaw and the airway. Medication to treat allergies or asthma The most important step in this process is diagnosis. If you suspect airway issues in your child, see their pediatrician, an ear-nose-throat specialist or a dentist who understands airway problems. Remember to be an advocate for your child. You know them better than anyone else so it is your responsibility to find a professional who understands and can help you.

12 Rules to Sleep Hygiene

Last week I discussed children and sleep and mentioned something called sleep hygiene. I promised I would give a list of sleep hygiene rules. When speaking about it at the office this week, someone looked at me like I was crazy when I said “sleep hygiene.” So, let me explain: Sleep hygiene is anything that helps you maintain a restful sleep pattern. Sleep is as important as eating and exercise in staying healthy, and many people have developed bad habits over the years that lead to poor sleep. Sleep hygiene “rules” are just guidelines. They are mostly common sense, but like most things in life, we forget or ignore what our mother used to tell us. 12 RULES TO BETTER SLEEP HYGIENE Sleep hygiene is a way to develop healthy sleep habits that lead to consistent, restful, restorative sleep. 1. Sleep as much — at night – as needed to feel refreshed and healthy during the following day. Aim for a standard number of hours of sleep every single night. Excessively long times in bed seem related to fragmented and shallow sleep. 2. Avoid daytime napping. If needed, nap for less than an hour and before 3 p.m. 3. Have a regular wake-up time in the morning. This seems to strengthen circadian cycling and leads to waking up in the morning on your own without the use of an alarm. 4. A steady daily amount of exercise helps deepen sleep in the long run, but occasional one-shot exercise does not directly influence sleep during the following night. 5. Give yourself a wind-down time each day. Use this time to tie up the day’s loose ends and organize tomorrow. It is better to do this when you are awake and alert than to wait until the lights are out and your head has hit the pillow! Anxiety about things you can do nothing about at night interferes with sleep. Give yourself a scheduled, routine 30-60 minutes to do this end-of-the-day. 6. Create a structure to your day (even week-ends) that requires you to do certain things at certain times. Eating and taking medication at the same time helps to maintain your body’s internal clock. 7. You should associate your bed with sleep. Avoid using your bed to watch TV, eat, talk on the phone or work on a laptop. 8. Avoid sleeping pills or use them sparingly. They may be of some benefit, when properly prescribed by your physician, but the constant use of sleeping pills is ineffective at most and detrimental in some insomniacs. It is better to understand why your body is not sleeping, and to correct the root cause. 9. Avoid caffeine and alcohol before bed. Be aware of the many hidden sources of caffeine, ex: Mountain Dew, chocolate. Alcohol does help tense people fall asleep fast, but the ensuing sleep is then fragmented. Alcohol also suppresses REM (dreaming) sleep. 10. If you’re not asleep in 20-30 minutes, get up and do something that will relax you, but definitely with very dim light. 11. Your bedroom should encourage sleep. Everyone has their own image of comfortable – just be sure your bedroom is ideal for you. Regarding temperature, don’t have the room too hot or too cold. 12. Think about light and dark: Get as much exposure to light as you can during the daytime and as much darkness you can during the nighttime. Look at the amount of “extra” light in your bedroom from things like alarm clocks and consider wearing an eye mask to block out all light. Adapted from the 2012 American Academy of Dental Sleep Medicine Annual Meeting

Children and Sleep

Don’t get too excited – I don’t have the answer for getting a baby to go to sleep. This is part two of my report from the recent American Academy of Dental Sleep Medicine conference. There was actually a lot of interesting discussion on children and teenagers sleep patterns and snoring in children. Here are the interesting things that were reviewed: 1. There are an increasing number of infants, children and teenagers being diagnosed with obstructive sleep apnea (OSA), a disorder where breathing is interrupted during sleep. Many of these children may have been incorrectly diagnosed with ADHD. The reason for the increase in OSA is unclear, but the following things may help identify those who have it: *snoring more than three times a week *allergies, frequent colds or habitual mouth breathing *large tonsils and adenoids *being born prematurely *obesity *long narrow faces and crowding in the front teeth *daytime sleepiness *bedwetting If your child snores, you should discuss the situation with their pediatrician, an ear-nose-throat specialist or a dentist who understands sleep disturbances. Many times a combination of tonsillectomy and adenoid removal along with jaw expansion is successful at eliminating snoring, creating changes in the jaw and face, expanding the nasal passages and reducing daytime sleepiness. 2. There was discussion about teenagers and how their natural sleep patterns vary from adults. The average adolescent requires 10 hours of sleep per night, however, at least two-thirds of those adolescents get less than an average of seven hours of sleep. Many sleep very little during the school week and then make up their lost sleep by sleeping extra hours on the weekend just to get to seven hours. 3. One reason teenagers suffer from sleep disturbances is because their circadian rhythms (their internal clock that regulates sleep) does not coincide with their school pattern. Teenagers are naturally programmed to sleep late in the morning and not go to bed until very late at night. However, when school starts early, it requires teenagers to wake before their final REM phase has completed. This final REM phase is critical because memory consolidation and other important functions occur in it. This constant interruption in sleep can cause issues with school performance, lead to daytime sleepiness and affect growth and development. While many of the signs of lack of sleep like excessive irritability, mood swings and difficulty concentrating can be mistaken for just being a teenager, it is important to be aware of the signs. When the previous signs are coupled with a craving for carbohydrates, sudden shifts in feeling hot and cold, or odd sensations of having things crawling on their skin, you might begin to suspect a sleep disturbance in a teenager. 4. OSA, narcolepsy and delayed sleep pattern are the three most common sleep disorders found in teenagers. As with snoring in children, if you suspect a sleep problem, seek professional help. There are many local sleep centers with specially trained sleep physicians that diagnose and treat sleep issues. 5. The final topic that is worthy of mentioning is sleep hygiene. While it sounds like a strange term, it refers to developing and following healthy sleep habits. Many teenagers, and adults alike, sleep poorly due to overstimulation from TV, phones and computers prior to sleep. For example, the light from computers is a stimulant that wakes you, like mimicking daylight in the morning, so using a computer or texting before bedtime can interfere with the time it takes to fall asleep. Next week I will post 12 Rules for Sleep Hygiene. Remember, if you or a loved one snores or suffers from daytime sleepiness, speak to a professional to determine possible causes and treatment.

How Well Do You Sleep?

I just got back from the annual American Academy of Dental Sleep Medicine conference and was amazed at the amount of new research being done regarding sleep. I took a ton of notes and want to share everything I learned with you, but I think it will be too overwhelming for one blog so I am going to divide it up over the next few weeks. I'm going to do a series that addresses the following topics: • general information related to sleep • children and sleep • geriatrics and sleep • diseases associated with sleep disturbances First, I'll answer the question that many people ask me: why, as a dentist, do you even care about sleep? Very simply, we all need sleep and when it's interrupted, for whatever reason, it affects our overall health dramatically. Because our practice focuses on prevention and education, we discuss sleep with our patients. Additionally, dentists are in a unique position to work with sleep physicians in making oral appliances that eliminate snoring and treat obstructive sleep apnea (OSA). One of the most common sleep disorders is obstructive sleep apnea, a condition where breathing is interrupted many times a night due to a blockage or collapse of the airway. People may stop breathing for 10-60 seconds, hundreds of time a night. This stoppage leads to problems in many areas of the body and is linked with an increased risk for: high blood pressure, depression, stroke, diabetes, metabolic syndrome, heart failure and impotence. OSA is treated with either a mask called CPAP that blows air and prevents collapse of the airway or an oral appliance that repositions the jaw and opens the airway. Interesting new research shows: • OSA patients treated with either oral appliance therapy or CPAP were able to reduce their high blood pressure medications after one year of use. Because high blood pressure is common with OSA, I always suggest that patients with it evaluate their sleep to determine if they have OSA. • Custom-made oral appliances to treat both snoring and sleep apnea fit better and, therefore, are more comfortable. The reason this is important is because the more comfortable the appliance, the more compliant a person will be in wearing the appliance. • People who suffer from sleep disorders are more sensitive to pain. This is especially important for chronic pain sufferers - perhaps correcting sleep patterns will decrease pain levels. • Excessive wear on front teeth can happen at night while a patient is struggling to sleep. Many people deny being aware of grinding their teeth but still have wear. OSA may be the cause. OSA is not the only sleep disorder that exists and without an evaluation by sleep physician, and many times an overnight sleep study, it is impossible to diagnose what is wrong. Other sleep disorders include restless leg syndrome, insomnia, delayed sleep response and chronic partial sleep deprivation. Some signs that point to a sleep disturbance are: • Difficulty falling asleep or staying asleep • Daytime sleepiness • Depression • Loud snoring that disturbs the sleep of others • Difficulty concentrating • Gasping for air during sleep • Waking up with a bad taste in your mouth • Chronic morning headaches If you believe you have issues with sleep, I suggest contacting a sleep physician or discussing your concerns with your doctor. For more information, visit: http://www.aadsm.org/whatisdentalsleepmedicine.aspx, http://www.ahsleepcenters.com/ For any additional questions, please contact our office at 973-377-6500 or info@adamsdentalnj.com.

Are you green?

I had a new patient in yesterday who works at a big pharmaceutical company and is involved with sustainability at their company. It made me think about what, if anything, we do to support sustainability. At first, all I could think of was recycling our paper and plastic, and I was a bit embarrassed. But the more I thought about, I realized that small changes we’ve made over the years have been “green”: • Digital x-rays – I think this is the single biggest change because it is such a win-win for everybody. Using digital allows us to dramatically reduce radiation exposure for patients. Also, the system has a reusable sensor which eliminates the need for film and its lead lining. Finally, no chemicals are needed to develop the film. • Appointment reminders – we decided a few years ago that we wanted to reduce the amount of paper we use at the office, so we switched to an email or text appointment reminder system. We no longer send out postcards which saves paper and printer ink. • Communication – let’s face it, no office will ever completely eliminate paper use, but little changes make an impact. We use email now to communicate with doctors, labs and patients. All referral letters and x-rays are sent over the internet instead of being printed and mailed. The additional plus side is that I’m amazed at how little stationary I need to purchase! • Plastic containers – our sterilizers require distilled water and each week we would go through at least five plastic jugs. Installing an automatic distilled water system in the office has eliminated the waste of plastic (and makes my assistants happy because they don’t have to lug jugs of water around). • Construction – we recently renovated a building for our office and although we made big changes, I tried as much as possible to reuse or maintain building materials. Windows and wood trim could have been replaced, but we chose to keep them. When we purchased things for the building, we looked for sustainable or energy efficient supplies like fluorescent lighting, Energy Star® products, and products made with recycled materials. While I’m sure there are more things we could do at the office, I’m pleased that we’ve done some things to make an impact. I encourage everyone, home and business alike, to spend some time recognizing the changes you’ve already made and considering the additional things you can do to improve sustainability.

The Four-Minute Exam That Can Save Your Life

Most people don’t think their family dentist could save their life, but the truth is that they can. This year over 52,000 Americans will be newly diagnosed with oral and throat cancers. When detected in the early stages of disease, these cancers have an 80– 90% chance of survival. However, the reality is that most of the cancers won’t be diagnosed until later stages the person will not live longer than five years after the initial diagnoses. Since April is national Oral Cancer Awareness month, I thought it was important to review the risks and signs of oral cancer. It is important to know the risks for developing oral and throat cancers. The most obvious of risks are smoking and drinking alcohol over a long period of time. Another risk is the HPV-16 virus (human papilloma virus). This is the same virus associated with cervical cancer in women. If you or your partner/spouse has a history of HPV, your risk for developing throat cancer may increase. It is known that men have a three times greater chance of developing throat cancer due to the HPV virus than women. There are a small percentage of people (about 7%) who develop oral and throat cancers with no apparent cause. In these cases it is believed that a genetic predisposition may exist. There is no age discrimination when it comes to oral and throat cancer. These cancers can affect anyone at any age. The following list contains the signs and symptoms that can be associated with oral and throat cancer: - A sore or lesion that does not heal within two weeks - A white or red patch on the gums, tongue, tonsil, floor of the mouth, inside of the cheek - A lump or thickening of the cheek - Difficulty chewing or swallowing - Persistent sore throat, hoarseness, or changes in your voice - Difficulty moving the jaw or tongue - Swelling of the jaw that can cause a denture to fit poorly - Persistent swollen lymph nodes under the chin and along the sides of the neck Each year the death rate for these cancers continues to grow. By raising awareness and knowing your risks for developing the disease we can decrease the death rate and increase the survival rate. Please know your risk for developing oral and throat cancer. Discuss your risks with your dental team and ask your family dentist for a head and neck cancer screening at every visit that may include use of the VELscope, a special non-invasive light that evaluates the cells below the surface. Your dentist should exam your lips, tongue, throat, gums and feel your lymph nodes. It only takes 4 minutes and it could save you life.

The Topic No One Wants to Talk About

I recently sent an email to my three children (ages 18, 19 and 26) with the subject line “An important topic no one wants to talk about” that had them jokingly saying they were going to mark future emails from me as Spam. The unpleasant topic was related to the correlation between HPV (human papillomavirus), oral cancer and oral sex. HPV is the broad term for a group of viruses, some of which are considered “low risk” and others which are “high risk” and cause genital cancers. HPV-16 is the strain that causes both genital and oral cancers. In the past, the “model” for oral cancer was an older man who had spent a lifetime of smoking and drinking. But now, young people without the risk factors of smoking and drinking are being diagnosed with oral cancer. It is suspected that oral sex, considered by many young adults to be “safer” than intercourse, is considered the culprit. According to the Journal of the American Medical Association, about 7 percent of men and women between the ages of 14 and 69 living in the United States carry HPV in their mouths. Advances in diagnosis have allowed researchers to test for viral DNA and have found HPV in many oral cancers. Even the location of HPV related oral cancer varies from the “traditional” oral cancers, with lesions being found primarily in the back of the throat and in the crypts, or crevices, of the tonsils. I advise all my patients to be aware of the potential signs and symptoms of oral cancer: A unexplained white or red lesion in the mouth that is present for more than two weeks. A swelling in the throat Difficulty or painful swallowing A change in your voice If you notice any of the above, call us for a complete evaluation. Oral sex is not the only cause of transmission; HPV infection increases with the number of partners you have and is transmissible by skin to skin contact. Not all infections with HPV will lead to cancer. Of the 150 related viruses, about 40 are sexually transmitted and only some of those will cause cancer. Most infections with HPV are cleared by the body without any long term consequences. If you would like additional information about HPV and cancer, visit our website at www.adamsdentalnj.com or contact our office at 973-377-6500. Additional information is available on the websites below. http://abcnews.go.com/Health/ReproductiveHealth/hpv-oral-cancers-rise-oral-sex-popular-spread/story?id=11916068#.T2Ozo8WPUTY http://www.cancer.gov/cancertopics/factsheet/Risk/HPV http://oralcancerfoundation.org/facts/index.htm

Diabetes and Gum Disease

For years, dentists have known that oral health and overall systemic health are linked. Now, more and more research recognizes the significant link between diabetes and periodontal (gum) disease. Diabetes is a disease that affects the body’s ability to fight infection and diabetics are more prone to develop gum disease. Inflammation, and the destruction that occurs as a result of it, is a key factor in the development and progression of both diabetes and gum disease. Diabetics may have difficulty controlling their blood sugar levels, even with medication, if they have uncontrolled gum disease. Conversely, patients with gum disease, even those who are undergoing treatment for it, may find their efforts unsuccessful if they lack glycemic control. If you are diabetic, you should see your dentist regularly. You may need to have cleanings done more frequently depending on the condition of your gums. Signs of gum disease: • Red, swollen gums • Gums that pull away from the teeth • Bleeding gums with brushing and flossing • Bad breath • Teeth feel like they don’t fit together properly If you have any of the above signs, regardless of whether or not you are diabetic, you should see your dentist for an evaluation. The good news is that both physicians and dentists are aware of the relationship between these two diseases and will work with one another to co-manage a patient’s care. For more information, please visit our website at www.adamsdentalnj.com or email us at info@adamsdentalnj.com.

Halloween Isn't All About Candy!

Madison's first, second and third graders received Halloween toothbrushes in preparation for next week's candy. Central Avenue, Torey J. Sabatini, Kings Road and St. Vincent Martyr schools were all visited by Kelly Olsen and Andrea Ceresa of Adams Dental in Madison. They delivered children's toothbrushes with orange handles and black bristles along with instructions on how to brush their teeth. The brushes will be handed out to all first, second and third graders during their Halloween festivities. Kelly Olsen, hygienist, felt it was important to put a different spin on Halloween. She said: "I know that children will eat candy on Halloween and it's not realistic to tell a second grader to turn down a Tootsie Roll. But at least we can encourage good brushing habits afterwards."

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