The Davis Clinic for Oral and Facial Surgery

While it may not be as overtly fascinating as having an extra finger or a third nipple, extra teeth or supernumerary teeth occur only in about 2% of the population within their adult set of teeth and in less than 1% of primary teeth. The condition can be referred to as polydontia or hyperdontia.

Now, before the kid in you gets too excited over the prospect of a little extra cash from the tooth fairy over an extra tooth, most of the population with hyperdontia are blissfully unaware of their extra tooth or teeth until they get an x-ray of the area. That’s because most supernumerary teeth don’t actually poke through the gums. The most common supernumerary tooth is the mesiodens (an extra tooth that forms between and just inside of the upper two front teeth). Other types include the rare fourth molar (paramolar or distomolar).

Ok, so why is an oral surgeon interested in supernumerary teeth, and why should you be as well?  Well, apart from the fact that it’s an annoying tooth code ‘99’ on your insurance predetermination form, they may require extraction even if they haven’t yet appeared through the gums. The indications for removing these teeth are plentiful, even if they remain asymptomatic in some cases.

What are the reasons a supernumerary tooth may have to be surgically removed? Occasionally there is an associated pathology with the supernumerary teeth. They may also be responsible for permanent teeth failing to erupt, erupt fully, or they may delay this process. They can also cause adjacent teeth to be displaced. Supernumerary teeth may also have to be removed when their presence causes a risk of cavities because the patient finds it difficult to maintain oral hygiene because they are inaccessible. Occasionally supernumerary teeth can affect orthodontic treatment. Also, supernumerary teeth can also compromise alveolar bone grafting or implant placement. In the cases where there is an indication for extraction, an oral surgeon can ensure the surgery is carried out skillfully and with the utmost care.

As you can see there are a number of reasons why a pesky supernumerary may have to be extracted and reasons why you want a surgeon to take the utmost care performing the extraction. We’ll even let you keep the tooth! So the next time someone asks you who in your group of friends has a third nipple, you can one-up them with cool ‘99’ and proof!

More Teeth, More Problems!

Every summer, countless teens and young adults make the pilgrimage to oral surgery offices across the land to have their wisdom teeth looked at. Usually, they’re sent by their general dentist for reasons they can’t remember, and when asked why they’ve come in, they say the almost-universal phrase “my dentist says I need them out”. But what if they’re not experiencing any problems with the teeth right now? Do they still need them out? Of course every case is different, but what every patient (and parent) should know is that pain-free doesn’t mean problem-free when it comes to wisdom teeth.

Wisdom teeth, or third molars, are the teeth in the back corners of the mouth that grow in the late teens or early twenties. Wisdom teeth may need to be removed when they cannot properly enter the mouth. They can grow sideways, erupt only half-way or even remain trapped underneath the gum and bone. These ‘impacted’ teeth can cause many problems including cavities, oral infections or even cysts or tumours that can destroy the jawbone and nearby healthy teeth. Partially-erupted teeth may allow bacteria to grow and proliferate potentially leading to gum disease that can cause swelling, stiffness and pain.

Even wisdom teeth that are symptom-free may pose an increased risk for oral infections, gum disease and cavities. Painless third molars can also push neighbouring teeth out of alignment thereby changing the bite. Many orthodontists refer their patients to an oral surgeon for third molar removal before beginning treatment to minimize the risk of gum disease and other problems that could affect the success of the orthodontic treatment.

While not all wisdom teeth need to be removed, all of them need to be managed. Oral surgeons provide sound advice based on a comprehensive examination, appropriate x-ray imaging and discussions with the patient (and family). If the decision is made to keep the wisdom teeth, patients are advised to keep the areas clean and get an annual examination to assess any changes in the teeth or gums.

My inspiration for this week’s blog is the recent uptick of patients I’ve seen who have experienced unfortunate complications associated with dental implant therapy performed abroad as part of ‘Dental Tourism’ trips. Whether it’s to evaluate implant failure, implant fracture, bone infection, or a broken jaw, more and more patients now seek me out to help remedy shoddy implant work performed abroad. While I am, of course, grateful for the opportunity to treat these patients, I am also deeply concerned about the growing trend of ‘Dental Tourism’ and the negative effect that it can have on the health and financial well-being of Canadians. Here are my answers to some frequently asked questions about ‘Dental Tourism’:

What is ‘Dental Tourism’?

Similar to ‘Medical Tourism’, ‘Dental Tourism’ is the act of traveling abroad to take advantage of relatively low-cost dental treatments available. Typically, the process involves flying to a third-world country, staying for a couple of weeks, and having dental treatment for about 30-50% of the cost of comparable treatment in Canada.

What’s wrong with taking a 2-week vacay and getting cheap dentistry? Sounds like a great deal!

Superficially, ‘Dental Tourism’ sounds great – you save 50-70% on dental treatment while enjoying a two-week vacation in an exotic destination! The unfortunate reality, though, is that you pay for what you get, and, more often than not, the treatment rendered abroad fails, which carries grave physical, emotional, and financial consequences for the patient.

Why are implants placed abroad more likely to fail than implants placed in Canada?

The success rate for implants placed in North America by board-certified oral and maxillofacial surgeons remains very high – somewhere around 97-98%. There are several reasons why the success rate of implants placed on ‘Dental Tourism’ trips is significantly lower: First, the standard of care abroad is often different from what you would expect in Canada. In Ontario, for example, both the regulatory body that governs dentists and oral surgeons and Health Canada ensures that everyone who places dental implants abides by regulations that are meant to protect the public, especially those with respect to doctor training, infection control, and material selection. Oftentimes, these regulations don’t exist abroad, and practitioners are free to do whatever makes them the most money – even if it means compromising infection control standards or using implants that are (literally) made in someone’s basement.

Second, language barriers between a) the patient and the ‘Dental Tourism’ practitioner and b) the ‘Dental Tourism’ practitioner and the patient’s dentist in Canada often impede necessary communication between the parties. Miscommunication between the surgeon and restoring dentist regarding the ‘parts’ and treatment plan is a recipe for disaster, and the risk of this is increased if the practitioners do not speak the same language. Finally, dental implants placed abroad are seldom (adequately) followed up. All dental implants require periodic follow-up by dental professionals to ensure continued health. Implants placed on 2-week ‘Dental Tourism’ trips are almost never followed-up and thus fail more often because problems are only noticed when it’s too late.

What are some of the adverse consequences of ‘Dental Tourism’?

When implant treatment fails, the physical, emotional, and financial toll on the patient can be devastating, and corrective implant treatment and more expense is just the ‘tip of the iceberg’. Jaw bone infection, jaw fracture, and acquiring a communicable blood-borne disease are all possible outcomes when infection control and materials regulations are compromised. Moreover, the adverse psychological and emotional effect that treatment failure has on some patients can be profound.

You’re painting a pretty grim picture of ‘Dental Tourism’ but what can be done for me here in Ontario if I cannot afford often-expensive dental implant treatment?

Options vary on a case-by-case basis but may include payment plans, being referred to an academic institution where students or residents do the treatment at a significantly reduced cost, or having some of the reconstructive treatment done in the hospital and covered by provincial health insurance.

At the end of the day, the old adage holds true when it comes to ‘Dental Tourism’: ‘If it sounds too good to be true, it probably is!’ Do your homework, talk to people you trust, and consult with a certified specialist in Canada before making a decision that could have a devastating effect on your life and health!

Temporomandibular joint, or ‘TMJ’, disorders are often associated with a variety of classic, tell-tale symptoms; most notably, jaw pain and a clicking sound when you open or close your mouth. What many people don’t realize is that a TMJ disorder can actually affect your whole body, so you may be experiencing symptoms of a problem and don’t realize it has anything to do with your jaw joint. Here are a few of the more-surprising symptoms of temporomandibular disorders.

Neck Pain

Are you experiencing severe neck pain but don’t know why? It could be caused by TMJ dysfunction because the joint and its associated muscles play a significant role in ensuring that your head stays properly balanced atop the spinal cord. Weighing in at approximately eight pounds your head is a pretty solid load to support; if you have bad posture because your TMJ isn’t working properly, this weight can be distributed unevenly adding extra stress onto your spine and neck.

Earache and Ear Pain

The muscles of your jaw run around your ears and adjacent to your auditory tubes so it is entirely possible that TMJ pain could trigger an earache. Many people mistake this pain for an ear infection or other ear problem when in actuality the discomfort isn’t really even coming from the ear at all.

Difficulty Sleeping

The tongue is attached to your lower jaw and its position in the mouth depends on proper alignment of the lower jaw. If the jaws aren’t aligned properly the tongue may sit too far back in the mouth and possibly obstruct the airway. An advanced TMJ disorder can cause erosion of the lower jaw bone and change in its position therefore also affecting the position of the tongue. This can result in difficulty sleeping due to what feels like abnormal breathing, which could warrant a trip to the doctor only to find that a TMJ disorder is to blame.

The good news is that there are treatment options available if you are suffering from a TMJ disorder. Speak to an oral and maxillofacial surgeon about what can be done!

Believe it or not, many people fear seeing the dentist or oral surgeon to get work done. Fear drives them to think that a tooth or jaw problem will ‘just go away’ and that they will not have to deal with it if they just wait it out. Unfortunately, though, things do not usually go according to plan and the tooth or jaw problem flares up at the most inopportune time!

While I like to think that I don’t have a scary face, I do acknowledge that many people legitimately fear what I do! Thankfully, being a board-certified specialist in oral and maxillofacial surgery, I can offer patients several sedation options to make them less anxious and more comfortable during dental procedures. Here are some of the dental anesthesia options available at The Davis Clinic:

Local Anesthetic

This is the classic ‘Novocaine’ injection that will numb the area around the tooth or surgical site (although we don’t actually use Novocaine anymore!). You are fully awake but will not feel discomfort during the procedure. You will be able to drive after the appointment and resume most activities.

Nitrous Oxide

This is sometimes known as ‘laughing gas’ because nitrous oxide combats feelings of stress, and gives you an overall feeling similar to the experience of consuming one-too-many alcoholic beverages! If you receive nitrous oxide, you will be able to drive after a short recovery time in the office.

Oral Sedation

There are prescription drugs that combat anxiety in the face of a dental procedure. We may provide a single prescription drug or a combination of prescription drugs that you will take at our office before your surgery and you will need someone to drive you home. In my experience, oral sedation works great for pediatric patients and mildly anxious patients undergoing procedures that last less than an hour. Very nervous patients and/or procedures that last longer than an hour often require a higher level of sedation. Read on!

IV Sedation

Intravenous, or ‘IV’, sedation puts you in a relaxed state of ‘twilight sleep’ where you are almost completely unaware of your surroundings. With this option, a Registered Nurse gently inserts an IV catheter into one of your arm veins, you are put to sleep using one or more drugs, the surgical procedure is performed and then you wake up asking when the surgery begins! After a short stint in the recovery room, you are discharged to the care of a family member or friend who will drive you home. In our office, deep IV sedation using multiple drugs is the sedation option of choice for patients looking for a comfortable experience while undergoing wisdom teeth removal or complex dental implant surgery.

General Anesthesia

Our facility is licensed and accredited just as any outpatient surgical center would be. If we advise general anesthesia, you will be completely unconscious during the procedure, and the anesthesia may be administered by a Dental or Medical Anesthetist. You will spend recovery time at our office and will need someone to drive you home.

That pretty much sums it up! Lastly, bear in mind that not every sedation option is appropriate for every patient in every setting. Talk to your surgeon about which option is right for you.

Happy sleeping everyone!

With spring (hopefully!) around the corner I’ve decided to dedicate this week’s blog to facial trauma and dental injuries. Warmer weather in Canada means more outdoor activities – street hockey, recreational softball, biking, etc. – that unfortunately can result in facial injuries that require surgery. As an experienced facial surgeon I’ve seen and treated all kinds of facial and dental injuries; ranging from a beer-league hockey player’s broken front teeth to an NHL player’s fractured jaw. Here are some answers to the most-common questions that my patients ask regarding facial trauma:

Is putting a tooth in milk after it’s knocked out a myth?

No. Milk is a readily available medium for the average person, and because time is of the essence, it is the medium of choice to store knocked-out teeth in the absence of biological media such as Hank’s solution or ViaSpan. Tooth cells need to be kept alive after injury in order help to re-establish attachment of a replanted tooth to the surrounding bone. Milk has been shown to prevent tooth cell death for a short period of time; thus maintaining cells that are vital in facilitating tooth re-attachment. More important, though, is the amount of time that elapses between tooth loss and replantation – the faster you can get to your local oral surgeon’s office, the better chance that tooth has to survive!

Should I be evaluated by an oral surgeon and/or get x-rays if I just have a cut on my face?

Absolutely. It’s always a good idea to have an oral and maxillofacial surgeon or emergency room doctor evaluate you after injury to ensure that there was no damage to the jaws, teeth, facial bones, facial nerves, saliva ducts or other areas. For cuts and bruises you might only need stitches to repair the injury; but if the injury also involves broken bones or teeth you will likely require further treatment in order to properly restore function and aesthetics.

Do you still wire people’s jaws shut to treat bone fractures?

Yes. Because we can’t put a cast on your face we sometimes have to wire the jaws together for a short period of time to immobilize and stabilize the facial bones. Other times, we can use small titanium plates and screws to fix the fracture without having to wire the jaws. Both techniques work equally well to treat facial bone fractures – just ask Kanye West who had his jaws wired together for four weeks (and wrote a great song about it)!

What are my options if my teeth were broken or knocked-out and not recovered for replantation?

Losing one or more teeth to an errant slap shot or bike accident can cause significant functional and aesthetic deficits. Thankfully several treatment options exist to replace missing or broken teeth and vary on a case-to-case basis; however dental implants have generally become the gold standard option to replace missing teeth after trauma. Thorough evaluation and diagnosis is key, though – be sure to trust your care to a provider experienced in treating facial trauma and reconstructing oral and facial defects.

Are you qualified to treat dental and facial bone injuries?

Oral and maxillofacial surgeons are the experts in face, mouth and jaw surgery, including the treatment of traumatic dental and facial injuries. As for me personally, let’s just say that my experience includes someone who’s jaw was on the wrong side of a slap shot from an NHL all star!

When most people think of ‘Botox’ the first thing that comes to mind relates to its cosmetic application to treat forehead wrinkles and ‘crow’s feet’. What many people don’t know about Botox is that it can also be used quite predictably to manage TMJ-related pain and muscle dysfunction. Indeed, over the past few years I have had a lot of success using Botox to treat patients with TMJ problems, large jaw muscles and/or facial pain. Like any treatment, it cannot be used for everyone; but I can attest that it is quite effective in helping to manage many different TMJ-related problems. If you are considering getting Botox to manage TMJ pain, or are a dentist or physician considering administering it to your TMD patients, here are some things to keep in mind:

First, more-conservative treatment options should be explored before considering Botox. Despite being a surgeon, I always try to render conservative, non-surgical treatment before considering injections or invasive surgery. The core value of our profession, primum non nocere or ‘first, do not harm’, guides me here: I would never risk harming a patient with injections or surgery who could otherwise be treated less-aggressively. Non-surgical therapy for TMJ typically involves making a special night guard that fits on the teeth, prescribing medication therapy, adjusting the bite or making a referral for jaw physiotherapy. If done right, these therapies work great to alleviate pain in the majority of patients. I only consider Botox to treat the small percentage patients who have tried these treatments yet still have pain, including those patients who cannot tolerate a night guard.

A caveat to above principle is when Botox is used as a first-line therapy to treat big, over-worked, over-built, unaesthetic jaw muscles. Your jaw muscles are like any other muscle in your body – they grow bigger with use and over-use; however, unlike a desirable ‘6-pack’ or ‘buns of steel’, excessive jaw muscle growth is not aesthetic and can be quite uncomfortable. In these cases, Botox can be used quite predictably to reduce muscle bulk and produce a flatter, more-natural jaw line. Bear in mind, though, that if the cause of the muscle growth is not addressed, the muscles will continue to grow despite repeated injections. Also know that may take multiple injections over the course of a year to produce the desired aesthetic result.

Finally, be sure of your diagnosis before getting (or giving) Botox. Certain types of muscle pain will not respond to Botox as predictably as others. Botox works really well to treat muscles that hurt and have been over-worked as opposed to muscles that hurt and have not been over-worked. If your muscles hurt and have not been over-worked you may want to speak to your doctor or surgeon about treatment options that do not involve the administration of Botox.

As you can see, Botox can be used for more than just smoothing wrinkles and making people look younger. Indeed it has many applications related to the management of TMJ-related facial pain and excessive jaw muscle use and growth. That being said, it is not a universal cure. Professional evaluation and diagnosis is the key to solving most TMJ- and facial pain-related conditions. Talk to a specialist about if Botox is the right treatment for you.

Patients with several missing or broken-down teeth regularly ask me about how dental implants can be used to reconstruct their dentition. They have often heard the term ‘All-on-4’ before but do not fully understand what it is or how it works. The purpose of this blog is shed some light on ‘All-on-4’ and provide some basic information about how this revolutionary technique works to better people’s lives.

To fully grasp what ‘All-on-4’ is you should first understand what a dental implant is. A dental implant is a small metal screw that is inserted into your jawbone in order to replace a missing tooth. Surgery is required to insert the implant. Once the implant bonds to your bone, a cap is attached to give you a new aesthetic and functional prosthetic tooth.

What is ‘All-on-4’?

The key concept behind ‘All-on-4’ is that you do not need a dental implant for each one of your missing teeth. All you need is four strategically-placed implants to attach a custom-made, highly-aesthetic, non-removable denture. That’s the beauty of the ‘All-on-4’ technique.

Why is ‘All-on-4’ sometimes called ‘Teeth-In-A-Day’?

‘All-on-4’ is also known as ‘Teeth-In-A-Day’ because you walk into the office with teeth at the beginning of the day and leave after surgery with a brand new set of teeth same-day!

‘All-on-4’ sounds too good to be true. What’s the catch?

There is no catch for most people. Multiple studies over many years have shown that fixed prostheses supported by four dental implants are a long-lasting and beneficial alternative to the conventional dentures that your grandparents used.

Is everyone a candidate for ‘All-on-4’?

No, unfortunately not. If you are a heavy smoker or diabetic, have taken certain medications or have certain jaw conditions, you might not be the best candidate for ‘All-on-4’. Fear not, though – there are other prosthetic options for full-arch reconstruction with dental implants that can work very well in higher-risk individuals.

So, is ‘All-on-4’ a ‘Panacea’ for patients with multiple missing teeth?

‘All-on-4’ is not a ‘Panacea’ for patients with multiple missing teeth but it is a great treatment option for many people. Talk to your oral and maxillofacial surgeon about whether ‘All-on-4’ is the right fit for you!