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Sleep breathing disorders and Dentistry

So many times I will question a patient about a possible condition that they might be experiencing physically in their body. They might reply by saying that "Yes, I do have that symptom, but I'm sure it's not related to my teeth. THE KNEE BONE CONNECTED TO THE THIGH BONE Hmmmm ... Do you remember that old song from grade school? It really is true, we just never put it all together to connect the dots. The lower jaw is just a bone that is suspended from the base of the skull by a sling of muscles. Depending on how the jaw is postured which in large part is connected to how our teeth come together, this jaw position may or may not be a comfortable spot for the muscles that must support and move the lower jaw when we chew, speak, swallow, and even clench and/or grind our teeth. The muscles of the head and neck are part of a long chain of muscles that extend into our neck, shoulders, arms, down our back, and right down to our feet. If the jaw muscles are imbalanced, that imbalance can be transmitted from our head to our toes. This can lead to poor posture, body pain, and a multitude of symptoms. Did you know that the front of our upper airway (the part that passes through our neck or pharyngeal area) is the back of the oral cavity? Did you ever stop to think that the roof of our mouth is the floor of our nose? If the muscles of the neck are imbalanced or in spasm they can have an effect on the amount of resistance present in the upper airway. If a person has a narrow constricted dental arch, often the hard palate is very high. If that is the case, it can compromise the nasal airway, which in turn can increase resistance of the air passing through the nose. THE BITE AND THE AIRWAY Orthodontists are very concerned about a person's airway and how it will impact the stability of their treatment. If you breathe through your nose you will notice that your tongue is postured up against your palate. The tongue is a very powerful muscle. It exerts an outward force on the upper teeth. The cheeks and lips also house muscles which exert an opposing inward force on the teeth. The teeth will find a neutral position between these opposing forces. Someone who breathes through their mouth will have to drop their tongue down toward the floor of their mouth to allow for air to pass through. This removes the outward force on the teeth. As a result the cheeks and lips win the battle and the teeth and therefore the dental arches become constricted. This can start a cascade of events that effectively impact the upper airway which can contribute to sleep disordered breathing, most notably Obstructive Sleep Apnea. (to be discussed in a future posting) WHAT DO WE DO? Traditionally we have not realized the important connections that exist between our mouths and our bodies. As new information becomes available, we have to shift our paradigm (how we view our health and our body's functioning) to enable us to solve complex health issues. Dentists and medical doctors and other health care practitioners will have to form alliances and learn to collaborate and understand the interconnections that exist. Dentistry is coming of age. It is now important for dentists to be true "mouth doctors" and expand our scope beyond the teeth and gums. Yours for excellent health, Dr. Marty Frankel 5775 Yonge St., suite 1000 Toronto, Ontario M2M 4J1 416-770-8526

It's All About Prevention

Fortunately, most dental problems are preventable, and if we are unable to prevent a problem, if we can catch it soon enough (in an early stage) it is usually very easy to treat. One of the earliest dental problems that can occur is a condition called "Early Childhood Caries". Caries is the dental term for tooth decay or cavities. This is tooth decay that starts on the baby teeth very early in life. It can cause pain, infection, inability to eat or sleep, and very often requires extensive, which can be expensive, dental treatment. This can be prevented by introducing your child to good oral hygiene practices very early ( I flossed and brushed my kids' teeth every night until they were close to 10 years old). Start flossing as soon as the baby molar teeth (the larger back teeth) enter the mouth. This is especially important as the permanent first molars erupt around 6 years old. These teeth can become closer together as the permanent molars erupt and decay-causing bacteria can be more difficult to remove from between these teeth. Thumb sucking should be stopped by 4 years old. Sucking can place excessive forces on the teeth and have a deleterious impact on the "bite" ... the way the teeth and jaws utimately come together. This is corrected by orthodontic/orthopedic treatment. Children are very accident prone. They are learning to walk and finding their way around in the world. Proper precautions should be taken to prevent damage from these accidents. Proper car seats are very important to prevent oral/facial trauma. Accident proof your home with proper locks on closet doors, gates etc. Don't leave your child unattended in walkers, jumpers, bath seats, the play pen. It only takes a second for something serious to occur. Wear properly fitted helmets for bike riding, roller blading, scooters, skateboarding. If your child has an accident that involves a tooth, broken or not, it is very important to see your dentist right away. Only approximately 1/3 of the tooth is visible above the gum. Even though a tooth might look fine after an accident, there could be damage to the nerve inside the tooth, to the jaw bone, and other related structures. The best time to take your baby to the dentist for their first dental visit is sometime between 6 and 12 months. This visit is very important for many reasons. This is a well-baby visit. It helps the child get accustomed to being in a dental chair in what is usually a very non-threatening appointment, and allows the dentist the chance to learn the child's medical and birth history, to assess the current health status of your child's mouth, and to educate the parent and provide guidance on how to care for and maintain their child's teeth. Regular dental visits can help with the maintenance of good oral health, allows for early detection of tooth decay and gum problems. This is the best way to start your child on a path to good oral health habits, and life long excellent oral health. To summarize, here are the steps to healthy teeth for life ... 1) HEALTHY PREGNANCY 2) HEALTHY NUTRITION - EXCELLENT DIET 3) GOOD ORAL HYGIENE PRACTICES 4) APPROPRIATE USE OF FLUORIDE 5) REGULAR DENTAL VISITS I hope you have found this information to be of value and that you will take action to ensure the very best for you and your children. Yours for excellent health, Dr. Marty Frankel, 5775 Yonge St., Suite 1000, Toronto, Ontario Canada, 416-770-8526,

Caring for your child's teeth - A few more TIPS

To continue from last week I would like to speak briefly about Fluoride. This has been a controversial topic for as long as I can remember. I am a supporter of Fluoride, but just the right amount. Do you know that there are places in the world where fluoride occurs naturally in the water in quantities as high as 80 parts per million (ppm)? Someone who is pro-fluoride would actually remove 79 ppm from that drinking water to bring it in line with the optimal level. Years ago it was determined that the optimum level of fluoride should be slightly less than 1 ppm. This provides a very good level of protection to the tooth ( the tooth becomes more resistant to tooth decay). We find, that as the level of fluoride increases a condition called Fluorosis becomes more common place. Signs of Dental Fluorosis include white or brown discolouration of the dental enamel and unattractive texture to the tooth surface. If you live in an area where fluoride is added to the water system it would be good to find out what the level of Fluoride is in your water. Also be careful to limit the amount of fluoride your child receives from other sources such as toothpaste and foods that may be made with water added that might contain fluoride. Tooth decay and gum disease are caused by bacteria in the mouth. This bacteria can be transmitted in such ways as play, kissing your child, sharing cups, spoons, etc. It is important for parents to have excellent oral hygiene practices to help minimize the risk of transmitting this bacteria to their children. Another common cause of tooth decay is the act of putting your baby to bed with a bottle containing juice or milk. If your child needs a bottle once they are in bed try your best to train them to take water. Other drinks can be excellent sources of sugar which bathe the teeth all night and can lead to severe dental decay. Next week I will share a few more important points on the care of your child's teeth. Until then I wish you all well. To your excellent health, Dr. Marty Frankel 5775 Yonge Street, suite 1000 416-770-8526

Some Thoughts on Baby Teeth (The Primary Dentition)

In my last blog post I talked about children and Obstructive Sleep Apnea. This got me thinking about "baby teeth" and their importance. I thought this would be valuable for expectant parents or parents of young children. The primary teeth are needed for chewing - so that children can progress from a liquid diet to a full spectrum of foods, for speech - many sounds that we make such as "t", "s", "d" "f" "l" and others rely on teeth and tooth position, for appearance, and for the proper development and eruption of the permanent teeth. The primary teeth start to develop during the first 3 months of pregnancy. As such it is very important for the pregnant mother to keep all her doctor visits, eat enough calcium in her diet, avoid non-prescription medications, not smoke, and avoid alcohol. The first baby teeth erupt at about 6 to 7 months. They are normally the 2 lower incisors. By 12 months there are usually 8 to 12 teeth present and by 2 to 3 years the full complement of 20 teeth should be present. One of the uncomfortable things that children experience as the teeth erupt through the gum is teething pain. This is the feeling of the teeth "cutting" through the gums. This can be accompanied by mild fever, a rash around the mouth, and ear infections. A cool teething ring can be very soothing. It is also very important to start cleaning the teeth as soon as they appear in the mouth. You can use a gentle toothbrush made for infants, or initially even a gentle cloth or cotton guaze can be used. If your child drinks from a bottle it is important not to let them sleep with the bottle, especially if it contains juice or milk, two sources of sugar. In the next few postings I will continue with this line of thought. With proper care most dental problems are preventable. This can help achieve the goal of "healthy teeth for life". Yours for excellent health, Dr. Marty Frankel, 5775 Yonge St., Suite 1000, Toronto, Ontario, 416-770-8526,,

When it comes to sleep apnea, how can we help our children

One of the most important things we can do as medical/dental professionals is to help prevent problems from occurring in the first place. When it comes to Sleep Apnea, as we were discussing this in our last post, with adults, the best we can do is manage it, but with children we can actually cure it. If you think about it, the mouth is one of 2 openings to the upper airway. One is the nose, and the other is the mouth. The healthiest way to breathe is through the nose. The cilia (little hairs in your nose) filter the air to remove allergens, bacteria etc., the nose also humidifies the air. When a person breathes through their nose, the tongue normally postures up against the hard palate and the lips close together and seal the oral cavity. The final position of the teeth in the dental arches is a neutral one found between the outward pressure exerted by the tongue and the inward pressure of the muscles of the lips and cheeks. Early in life for many children, the nose may block due to allergies to the environment, milk, and other foods and items. This forces the person to breathe through their mouth. In order to do that, the tongue must drop down towards the floor of the mouth. Now, the inward force from the muscles of the lips and cheeks cause the dental arch to become constricted. This can lead to the palatal vault rising upward and in turn cause an increase of nasal resistance. Parents should pay attention to the breathing patterns of their children. Do they snore? Do they breathe through their mouth, or through their nose? Do they have food allergies. If these are found, have the family doctor refer you to a pediatric ENT (ear-nose-throat) to eliminate the problem. In future postings I will elaborate on this issue. If you have any questions or comments, you can always reach me at, 416-770-8526, or on Facebook at Dr. Marty Frankel - Smiles by Design.

Sleep Apnea - Let's wake up and do something about it!

I just returned from an in depth course about sleep apnea and the dental management of it. Sleep has become a huge area of interest in medicine over the last few years ... and rightly so. Poor quality sleep and apnea affect so many different areas of our health that it should really be of interest to everyone. I will briefly mention a few things about sleep apnea. Apnea occurs in our sleep and it refers to an episode where we stop breathing for 10 seconds or more. When a person has an overnight sleep study this is one of the parameters that is measured. During the study the number of times a person stops breathing is totalled along with some other breathing issues. A calculation is then done to determine how many times a person has breathing issues per hour. This is know as the AHI and the degree of severity is scored as follows. AHI less than 5 is normal. From 5 to 15 is mild, 15 to 30 is moderate, and above 30 is severe. I have a patient who stopped breathing more than 80 times per hour. Consider that 80 X 10 is 800 seconds per hour that he was not breathing fully. That is more than 10 minutes per hour! This places a huge strain on the heart which must work harder to ensure that the person gets enough oxygen to their system. This could be an explanation for why some people have heart attacks in their sleep. Poor oxygen uptake can impact the endocrine system ... our production of hormones of particular interest is stress hormones and insulin which is related to diabetes, our moods ... people who don't sleep well can be very grumpy and short-tempered which in turn impacts their outlook on life and their relationships (of interest to psychiatry) to name a few. Over-tiredness can make it very dangerous to operate machinery such as automobiles (can lead to more motor vehicle accidents), airplanes - I wouldn't want a tired pilot, transport trucks, trains etc. ... The toll that improper sleep takes on society is enormous. How is it that dentistry has become involved in this area? If you think about it, the mouth is an opening to the upper airway. It can play a major role in creating airway resistance. It is also below the nose and the anatomy of the mouth has a direct impact on the nasal passages. It can have a dramatic impact on nasal resistance, snoring, and sleep apnea. It should come as no surprise that dentistry plays an important role in the treatment of Obstructive Sleep Apnea (OSA). The standard medical solution for OSA is CPAP (continuous positive air pressure) which is the gold standard for apnea treatment. Many people do not find it comfortable however, and it is good to know that there is an alternative in the form of Oral Appliances which are very effective for the treatment of mild to moderate sleep apnea, and can be useful in combination with CPAP for more severe forms. I hope you found this interesting and of value. I believe that it would be important for every adult and some children to have sleep studies to evaluate their sleep quality. I'll be back soon with more information from the world of dentistry ... Dr. Marty Frankel, 5775 Yonge Street, Suite 1000 Toronto, Ontario M2M 4J1 416-770-8526

Does forward head posture cause a bad bite? In this episode of LVI TV, Dr. Bill Dickerson explains the link between head and neck posture, and the way our teeth come together. He also touches on how this can lead to symptoms of Temperomandibular Disorders (TMD). This further highlights what I mentioned in my last blog post. Dr. Marty Frankel, 416-770-8526,, 5775 Yonge Street, Suite 1000, Toronto M2M 4J1

Muscles in Dentistry

Most people including many dentists do not realize the important role that muscles play in Dentistry. The movements of our jaw in chewing, speaking, yawning, eating, swallowing are all controlled by muscles. The muscles must work in harmony with the teeth and the joints of the jaw. When this harmony does not exist it can lead to a variety of problems such as bite problems, muscle pain, and jaw joint problems to name a few. A number of years ago, a study was performed to investigate the effect of an imbalanced bite on the alignment of the spine of rats. Pre-study x-rays were taken of the rat's spine. A small filling was bonded to the biting surface of one of the rodent's molars. This created an imbalance in the bite of the animal. A few weeks later another x-ray was taken and the result was that the spine developed very obvious curvature. At this point the small filling was removed and another x-ray taken a few weeks later revealed that the spine had returned to its normal pre-study shape. What does this mean to we humans. The planes of the body such as the line of our shoulder heights, or the line drawn through our hips or our knees seek to be level to the world. If an unbalancing stimulus is introduced, such as the filling in the rat, our bodies will compensate for the irritation by shifting the balance of our weight and the muscle alignment can and will change. Imagine a pebble in your shoe while you try to walk a few city blocks. As this pebble becomes more and more irritating, we will try to shift our posture to avoid the irritating feeling of the pebble. This can lead to muscle pain in our legs, excess pressure on the hip on the opposite side to the pebble, perhaps a sore back, and eventually the neck and even the jaw muscles. This same cascade of events can occur in the opposite direction when the bite is imbalanced and the muscles of the head and neck become strained as a result. This consideration of the effect of muscles in dentistry is one of the aspects that the approach to dental treatment called "physiologic neuromuscular dentistry" takes into account. If you suffer from chronic headaches, jaw pain, limited jaw opening, neck pain, and many other symptoms, then this may be an approach to dental care that can help. Over the next few postings, I will discuss some of the applications of this approach and how it may be of help to many people. Dr. Marty Frankel, 416-770-8526,

What happens if you don't remove all the plaque and have regular examinations

Yesterday I received a phone call from a patient saying that she bit into something soft and her upper left "eye tooth" broke off at the gum-line. There was no pain, but she was embarrassed to smile and was worried about what would have to be done to give her a tooth so that she could smile and function in a social setting. Why did this happen? She had gotten busy and neglected to appear for a hygiene visit for about 4 years. During that time (a stressful time for her) she developed extensive tooth decay on about 6 teeth. A few of these will need to have root canal treatment because the decay has eaten it's way into the nerves of those teeth. The tooth that I looked at today may not need the root canal treatment. ... but the decay was so extensive, it had eaten into the tooth like a beaver chews into a tree, that the tooth could no longer support itself and it fractured. It was very tricky to restore, and it challenged me and forced me to be creative, but after about 1 1/2 hours I was finished repairing the tooth. This was a temporary repair and the options for final treatment are rather complex. This patient will need extraction and implant replacement of the tooth, extraction and a bridge, or root canal treatment followed by gum surgery and a crown. Had she been more consistent with her dental hygiene appointments I would have been able to catch the decay sooner and avoid this unfortunate situation. It seems from my experience that if we go longer than 2 years between x-rays that it is possible for tooth decay that may have been too small to be detected at first, to grow into a full blown area of tooth decay on the tooth. It's good to have x-rays taken at least every 2 years to catch decay before root canal treatment is needed. Dr. Marty Frankel 416-770-8526

Dental Tips

Greetings from Toronto. Today I am resuming my blog posts. I will be posting to this space approximately once a week and will be talking about topics of dental interest. I will also submit information that is currently available from other sources on dentistry and related topics. Today I would like to talk about a few things related to cleaning teeth. I had a patient who came into the office last week for a hygiene visit. It had been a little over a year since she had last had her teeth cleaned. Although she has excellent homecare, she brushes and flosses regularly, she was surprised to find that she had a lot of build up of bacteria and debris under the gum line. She didn't realize how important her office visits were. Cleaning of teeth is a job that is best shared. There are things that we can do in the dental office and things that people must do at home. Plaque, which is basically bacteria, builds up around the teeth. It is soft and can be removed at home with a tooth brush and floss. It only takes 24 hours to build up on the tooth surface. If it's not removed at home daily, it can grow down around the tooth and get under the gum where it can destroy the bone that supports the tooth roots, and it can also enter the blood stream where it can cause or contribute to health problems such as heart issues, stroke, diabetes, respiratory issues, and the list goes on. Over time that bacteria along with mineral deposits on the teeth, (know as calculus or tartar) can adhere to the tooth. These deposits are hard, and must be removed professionally. Different people will build up deposits at different rates. This is what we do at the office, we remove the hard deposits, and help to set up an appropriate interval for maintenance visits. Look out for more "Dental Tips" as we move forward over the next while. Sincerely, Dr. Marty Frankel 5775 Yonge Street, Suite 1000 Toronto, Ontario, M4M 2J1 416-770-8526