Just last week I encountered another case of a cracked tooth needing to be extracted. I can’t say this is uncommon. Yet something about this one stuck with me . . . probably because I felt it was avoidable.
Cracked teeth as a result of the grinding and clenching of teeth — also known as bruxism — appears to be reaching epidemic levels. Frankly, that wasn’t the only case of of problems I saw as a result of tooth clenching that day.
The patient I treated right after him had a series of problems connected to clenching as well: among them, bone loss — (with at least one tooth that will have to be removed as a result), front teeth that were chipped, and another that that developed an abscess. Yes, all of these problems had direct connections to the patient’s habit of clenching his teeth.
But let’s return to original patient for a moment. When he first came in and saw me for his initial consultation six months earlier, I pointed out that there was evidence of bruxism. I recommended doing something about it at that time.
The patient looked at me funny — it was clear that he didn’t think he had that problem. I explained why I thought he clenched his teeth and pointed to several things that indicated that condition. He handled a few other problems, but decided to let this one go (“for now”). I’m not going to put a gun to anyone’s head when it comes to my recommendations, but inwardly I wished him good luck.
While conducting my follow-up exam I observed a crack running through his root. Given it’s size and location, his only option is removal. It didn’t hurt him as much as it could have because the nerve had already been removed, but I couldn’t help thinking this was a shame. Had we followed the recommendations I made six months ago, we probably wouldn’t be dealing with this now.
It’s too late for that patient, but the underlying message here is simply this: if a dentist tells you there is a body of evidence suggesting you grind your teeth — don’t ignore it. Most people simply don’t know if they grind because they often do it while they are sleeping. What is more, they don’t do it consistently. Remember, damage can occur in many different ways. It can be slow and steady, like wind erosion wearing down mountains or very quick and short-term, like a bullet to the head. Either way, there is visible change in the end.
Here is a link to an earlier article I wrote about grinding. If a dentist has ever told you that you might grind or clench your teeth, take it to heart. You may be saving yourself a few dollars . . . as well as a few teeth.
I might also give this article the byline: “The Daily Grind.” But I wouldn’t be talking about work. For millions of people, the daily grind is happening to their teeth — and they are often working them to death. I’m not talking about the normal work you would expect, such as that which is associated with eating.
I’m talking about the grinding and clenching of teeth, known as bruxism.
“Bruxism.” It even sounds grating. And, believe me, it literally is. The word itself is taken from the Greek “brugmos,” which means the “gnashing of teeth.” Many people are surprised to learn that it is considered to be one of the most common sleep disorders.
While grinding and clenching can occur either during the daytime or at night, it is bruxism during sleep that causes the majority of dental and health issues — and it can even occur during short naps.
Unfortunately, all of the causes of bruxism are not yet well established or understood. There are several theories, but by most accounts it is classified as a habit. Among the theories that prevail are that some medical conditions such as digestive ailments or stress can contribute to the condition. Others speculate that changes to the bite, such as might occur following tooth loss is a contributory factor. Still other concepts include spinal misalignments (following accidents) or nutritional deficiencies (thought to be calcium, magnesium, and pantothenic acid) as being causative factors.
Some of the activity that occurs when people brux is rhythmic (like chewing) and some is sustained (like holding the teeth together tightly). Both can cause significant damage to the teeth and underlying bone.
It is interesting to note that almost everyone experiences bruxism at one time or another. Until recently, dentists found that only a relatively small percentage of patients would go on to develop symptoms alerting either the patient or the dentist to the problem. Commonly, this would be headaches or jaw pain that might prompt treatment. At other times it might appear as wear patterns on the biting surfaces of the teeth, cracks in the enamel, chipped fillings or crowns, abfractions (notched-out areas of teeth typically found at the gum-line), receding gums or loose teeth.
What is particularly alarming, though, is that over the last several years, bruxism is being reported by dentists as an increasingly common occurrence. One recent report that I read suggested that as many as one in four patients seeking routine dental care grind or clench their teeth.
Most bruxers are not aware of their condition. In fact, many people will insist that they don’t grind their teeth. Spouses or “significant others” often reinforce this by suggesting that they watch the person while they are sleeping and notice the individual snores or has their mouth open. This is difficult to dispute (unless an actual, controlled sleep study is conducted) but it unfortunately can cause dentists to defer intervention while still more damage can occur. And, over time, it usually will. Keep in mind that with sufficient force, the contact does not have to take a long time to do damage. Think of a bullet, for example. It’s a small object and has very brief impact, but the velocity is sufficient to cause harm.
Certain sleeping positions will cause more stress than others. People who sleep on their stomachs usually experience the highest levels of stress. Again, remember, one doesn’t have to be in this position all night for damage to occur. People who have broken teeth or dental restorations while sleeping sometimes report hearing a “pop” and then feeling a loose fragment in their mouth. This is a momentary occurrence. Of course, one typically sleeps every night, so if outright fracture doesn’t occur right then, it doesn’t mean physical stress isn’t being applied.
Here are a few other factors associated with bruxing that may be subject to your control:
Relatively high consumption of caffeine, such as is found in coffee, colas, and chocolate
Smoking
High levels of blood alcohol
Drug use, such as SSRIs (anti-depressants) and stimulants like Ecstasy, MDA, and other amphetamines, including those taken for medical reasons.
High levels of anxiety and stress, irregular work shifts, and stressful professions or relationships
Disorders such as Huntingdon’s and Parkinson’s Disease
Keep in mind that other habits in combination with bruxism can accelerate the problem — such as consumption of abrasive foods and acidic soft drinks. These can weaken the enamel mechanically or chemically, thereby accelerating the process of wear.
So far, there is no single accepted cure for bruxism, but it can be reduced or even eliminated if you treat the associated factors successfully. As far as repairing the damaged already caused, typically a dentist will replace the worn natural crown of the tooth with prosthetic crowns. In the event of tooth loss (following cracked teeth) implants may be advised. The materials used will vary by location in the mouth. To protect the new crowns and dental implants, a professionally fabricated custom occlusal guard should be made for wearing while asleep.
Most over-the-counter night guards (while very inexpensive) are deemed ineffective by dentists and in some cases may contribute to problems with the jaw joint, the TMJ. Professional treatment is medically recommended to make sure that the bite has remained stable, to check the device for proper fit and to make any ongoing adjustments, if needed. Monitoring the night guard is suggested at regular visits. It is also important to note that night guards, are simply a first response to bruxism and do not cure it. Their general goals, however, are to:
Minimize the damage to the jaw joint (the TMJ) which at times can be severe and may even require surgery.
Stabilize the wear patterns on the teeth that at first occur gradually, but progressively alter the bite to a point where the change becomes more rapid.
Prevent tooth damage, including damage to existing dental work.
Allow the dentist to evaluate (broadly) the extent and patterns of bruxism by physical examination of the patterns on the surface of the night guard.
Frankly, bruxism can be difficult to diagnose because it is not the only source of tooth wear. Compound this with the fact that the effects of bruxism can be very advanced before the patient is even aware of it, and one has a formula for trouble. In one of the most severe cases of bruxism that I have treated, what brought the patient in to my office for the first time was that he had worn down his front teeth to the point where the nerves were actually exposed. That’s severe. Tooth sensitivity can occur way before then, however.
The most reliable way to diagnose bruxism is through a sleep study performed in a hospital. In my experience, relatively few patients are willing to do this, but the results are difficult to refute.
If you notice changes in your bite or your teeth that you suspect are caused by bruxing, you should point this out to your dentist so that he can evaluate the cause. The sooner the better.
As readers of my blog may know, I have long been an advocate of dietary supplements. While the ideal form of nutrition is always a healthy diet, today’s food is simply not the nutrient-rich, non-chemically altered, or non-genetically engineered food our grandparents ate.
While that might just be a topic for another discussion, I want to point out that whereas supplements have their place, it is always prudent to understand what you are consuming and what potential effects it may produce. This advice holds equally true for vitamins and herbs as it does for medications.
While the side-effects of supplements are typically far less dire than those encountered with many common medications, there can be side-effects nonetheless — especially when used in combination with medications.
As dentists, we are particularly interested in knowing what herbal medications a patient takes that may cause drowsiness, excessive bleeding, cardiovascular problems or that interfere with other drugs.
Here are a few examples:
St. John’s Wort, used as a mood enhancer, can interfere with the effectiveness of many heart and blood pressure medications, as well as blood thinners. On the other hand, garlic, ginseng, ginger, chamomile and gingko, to name a few, can cause bleeding after surgery.
A patient given sedatives by a dentist or oral surgeon before surgery who is also taking Valerian root and kava may experience an interaction that causes excessive drowsiness.
Ginseng has been associated with an increased chance of arrhythmias (irregular heart beats. Patients who take ginseng and also get a local anesthetic with epinephrine (commonly used for fillings and many other dental procedures) may be putting themselves at risk for cardiovascular complications.
Echinacea, while it is widely considered to be an immune system enhancer, may inhibit wound healing and increase the risk of post-surgical infection.
This list is by no means exhaustive, and the simple message here is just because an herbal remedy is considered “natural” doesn’t mean you should neglect to inform your dentist that you are taking them. Neither he nor you want to risk negative effects or complications that can come about as a result of interactions.
More likely than not, your doctor will simply ask you to stop taking a particular supplement before surgery or modify the anesthesia accordingly.
Good communication is the key.
Here is another example of this point. Not uncommonly, patients take “baby aspirin” as a blood thinner. Of course, this is not an herb, but many people feel it is not worth mentioning because it is just a “baby” aspirin. That is, until they fail to stop bleeding after an extraction.
You should always be sure to tell your doctor about ALL of the substances you are taking, including prescriptions and over-the-counter drugs. Even doctors aren’t always fully aware of every potential interaction between herbs and drugs, as new drugs are constantly being developed and introduced into the market. It is in your best interest to let your doctor “know before you go.”
No matter how you slice it, tooth problems can be a pain. Among these, cracked teeth stand out for their confusing and erratic nature. A cracked tooth can be painful, annoying, and an exercise in frustration for patients and dentists alike. While there can be many factors that contribute to cracked teeth, the bottom line is that if your tooth is cracked the solution is often involved, potentially expensive — and, despite best efforts, tooth loss is still a very real possibility. Clicking on the picture below will take you to a compilation of questions and answers about cracked teeth. It covers a lot of ground, but if you think you may have a cracked tooth, it is worth reading so that you can know what to expect.
The treatment of cracked teeth can be one of the most complex — and frustrating — experiences for any patient, or dentist, for that matter. Symptoms can be erratic, elusive and the solutions can range from simple to very involved. It is not uncommon for patients with cracked teeth to visit several dentists stating symptoms that can’t be reproduced or even seen by the dentist.
If you suspect you may have a cracked tooth, read this carefully. It pays to be fully informed and prepared for any and all possibilities.
Q: My teeth aren’t cracked. Why should I care?
A: Cracked teeth are becoming a growing problem in the adult population. What used to be encountered by most dentists only occasionally is now a common occurrence in almost every dental office. Just a few short years ago dental journals were reporting near “epidemic” findings of as many as one-in-four patients that grind their teeth. (One of the principal causes of cracked teeth.) Today, those estimates approach one in three. If it doesn’t affect you now, it just might down the road.
Q: Why do teeth get cracks?
A: Traditionally, one of the most common causes of cracked teeth had to do with teeth that were heavily filled. Decay and subsequent filling cause a weakening of remaining tooth structure. Any new decay that a patient develops after a tooth has been filled can weaken it still further. Since teeth — filled or not — are used for chewing, they are subject to physical stress. All materials subject to stress can suffer from stress fatigue. After many bites on the tooth and filling (stress cycles), a hairline fracture can develop. And that’s just the “normal” stress. If a person is under mental stress, they may grind or clench their teeth (usually when sleeping). This can, and does, result in even higher levels of tooth stress.
Q: Why does the tooth sometimes hurt to hot and/or cold?
A: The nerve of the tooth becomes aggravated by the crack and by the bacteria being forced into it through tubules of dentin. The nerve then gets inflamed because of the toxins in the bacteria. A classic symptom of nerve inflammation is hot and cold sensitivity.
Q: Why does it hurt to bite on my tooth?
A: As your tooth flexes (yes it does bend to a very slight degree!) your nerve becomes stimulated by fluid that backs up in the tubules of dentin. Dentin is the inner layer of tooth structure, below your enamel. The tubules run down to the nerve and the fluid moves in them. You perceive that as a sharp pain.
Q: What will happen if I just ignore it?
A: Typically, the crack continues to progress slowly until, like a crack in a car windshield, it spreads throughout the glass or, in this case, the tooth. Sometimes, the crack travels sideways and a piece of the tooth breaks off. At other times, it runs deep into the root — possibly reaching the nerve itself. Teeth can often go for months in a stable, but inflamed condition. Sometimes they seem to get better, only to suddenly get worse. It is hard to predict the course of an untreated tooth, but it is usually a slow degeneration as the crack gets deeper. If caught early enough, a small crack will usually respond well to treatment, but a bigger one can lead to root canal treatment or even extraction. The nerve can be attacked by the bacteria, which tends to make the tooth very sensitive to hot and/or cold. The ache can be persistent as the tooth dies and the pain can range from moderate to severe. Subsequent infections can spread into the underlying bone causing an abscess. In this case, the pain is usually severe, and is not effectively controlled by pain killers.
Q: What is the best way to treat a cracked tooth?
A: Unless the crack is stabilized and splinted together, the tooth is likely to deteriorate. Although various methods may be attempted to bond the crack together, this is only likely to work if the crack is very superficial. Chewing forces are quite strong, though, and if the tooth has been sensitive these “patch-up” efforts tend to be unpredictable and may not work at all. The only real solution is to bind the entire tooth together with a crown so that any chewing force is transferred to the entire tooth, rather than acting to split it apart.
Q: What color will the crown be?
A: Most people seem to prefer that their teeth have a natural appearance. We can manufacture one of several types of crowns — many of which are metal-free — and which are extremely strong. Because many cracked teeth have large black mercury-amalgam fillings, your tooth is likely to look much better after being crowned. At least there is some small benefit to the time and expense involved.
Q: Are there any other advantages to having a full crown?
A: The crown is bonded over the entire tooth. This seals the cracks and the various sources of bacterial leakage that can result from the patchwork of fillings typically found in these teeth. The nerve is now provided with its best chance of recovery since there is a hermetic (airtight) seal, and the crack has been immobilized. Still, it is not necessarily completely immobilized. You still use it to eat . . . .
Q: Is there any guarantee that the nerve will recover?
A: No! Despite the best treatment and efforts, at least 10% of cracked teeth have nerves that will die. The tooth can (and does) still move slightly within the bone, and this slight movement can flex the crack from the opposite site — despite a crown on top.
Sometimes, the existing bacterial damage is already sufficiently advanced, and the damage to the nerve so severe that the nerve goes on to die regardless of what is done. This is the main reason why early treatment is recommended to minimize the size of the crack and bacterial invasion.
Q: What happens if the nerve doesn’t recover?
A: Generally, the nerve will die and you run the risk of developing an abscess. The traditional therapy is a root canal (also called endodontic therapy). Usually, a small hole is made in the crown in order to treat it. The hole is later filled with a permanent tooth-colored filling.
Q: Will this weaken my crown?
A: Possibly, a little. But it is a quick and uncomplicated way to handle the problem, with few long-term problems. The white filling usually matches the crown well, but don’t expect it to be invisible. For most people, it’s not a problem, but if having a filling in your crown bothers you, a new crown can be made if you don’t mind the additional expense.
A second option is to cement the crown with a temporary cement. If the nerve dies, the crown can be removed for the root canal treatment. This prevents a need for drilling through the crown, but has other down-sides. You have to decide if you are prepared to accept them: First, if the crown is put on with a temporary cement, it will come off one day. Depending upon the type of cement and inherent retention of the crown, this could range from months to years. In most cases, if the crown loosens, you will notice it, retrieve it, and all is well. However, it is possible to bite on it, break it, or accidentally swallow it — so you need to take this into account before making your decision, because you may be have to face the cost of a repair or a new crown.
Q: What if the crown loosens after it has been temporarily cemented and nothing else bad happens?
A: Well, then, you can choose to re-cement it temporarily or with a final cement. If enough time has elapsed so you are pretty certain your symptoms are gone and the nerve is doing well, you may elect to use the stronger cement. Talk this over with your dentist, because that zone of evaluation can range from three months to three years. Sometimes it is simply a matter of clinical judgment. Every case is different and complex individual case factors need to be taken into account. Even with the best efforts some nerves will go on to die (even as long as ten or more years later). You should also note that most dentists include the cost of cementing your crown only once. If you elect to cement it with temporary cement, an extra expense will be involved (either re-cementation, office visit, or both — depending upon your doctor’s policy) unless your dentist has told you otherwise.
Q: How successful is endodontic (root canal) therapy?
A: Pretty successful. Though 5 to 15% can still fail (even without a crack) according to various studies. Having a crack pushes this number toward the higher end. Some of these root canaled teeth – especially those with a history of a prior crack – will continue to get pain when bitten on or, sometimes when pushed from the side. This is due to the crack movement irritating the tissues around the tooth (the periodontal ligament). At this point, there is no treatment other than extraction for these cases.
Q: So I can go through all that time, discomfort, expense, and still lose the tooth?
A: Yes.
Q: What then?
A: There are several options for replacement.
An implantplaced into the bone, which supports a new tooth.
A conventional bridge (which caps teeth on either side of the missing tooth).
Or, a partial denture.
Many of the advantages and disadvantages of these options are discussed elsewhere on this site.
Please remember, information provided on the internet is not a substitute for clinical evaluation by a licensed professional.
Your situation is unique to you and deserves proper attention and treatment.
Dr. Richard Walicki is a dentist practicing general and cosmetic dentistry. While we hope you find the information contained herein interesting and useful, this blog is for informational purposes and is not intended to diagnose any oral disease. Dental conditions should be evaluated by your dental health professional or a qualified specialist.
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