Monday, August 23, 2010

Tooth Abrasion

Treatment of dental disease is obviously what we are trained to do. However it is very exciting to be able to teach patients how to avoid needing treatment in the first place. One of the most common findings of a routine dental examination is the appearance of abrasion at the neck of teeth. Usually we see these areas from the canines (I teeth onwards) towards the molars (back teeth.)

In this photograph, you can see that the patient has abrasion at the junction of the teeth and the gum and it even involves the crown placed on the molar.

Causes of tooth abrasion:

• Aggressive tooth brushing in a scrubbing motion
• Using a toothbrush with hard bristles
• Using toothpaste, especially ‘ whitening toothpastes’ more than twice a day
• Bite issues where the forces borne by the teeth are higher than they are designed to bear and are in the direction that is unfavorable to the teeth. For example, the molars are primarily designed to withstand vertical forces so any side to side directed forces will be harmful to the tooth.
• Movement of the teeth during orthodontic treatment
• Susceptibility of the cervical area of the tooth due the bone covering it being thin
• Positioning of the tooth in the arch can higher the risk of abrasion. For instance, if a patients canines are prominently place in the arch (stick out), then they have a higher risk of abrading the enamel when they brush
Since the enamel is thinnest at this area, it doesn’t take much to see the effects of any of the above causes. Recession of the gum tissue quickly follows. Both abrasion and recession are irreversible.

Symptoms of tooth abrasion:

• Asymptomatic
• Sensitivity to cold
• Esthetic compromises to smile
Complications of tooth abrasion
• Progression of symptoms mentioned above could lead to a patient avoiding certain foods and drinks like ice cream and cold beverages
• Abrasion of enamel could be followed by entry into dentin which dictates treatment options that are more aggressive- like a crown
• In extreme cases, the nerve of the tooth maybe exposed making a root canal and a crown unavoidable.
• Loss of protective gum tissue (attached gingival- due to recession) that acts like a turtle neck around the tooth and helps keep out harmful bacteria that would cause the tooth to loosen in its socket

Photograph of an advanced abrasion that is complicated by long standing bite issues. Treatment of this case requires a thorough diagnosis and evaluation.

Prevention of Abrasion:

• Use a soft or super soft toothbrush
• Use only a small amount of toothpaste twice a day. If brushing during the day, try using Listerine or no toothpaste- instead relying on gentle circular motion of the toothbrush to remove food particles and bacteria
• Use minimal pressure while brushing
• Place the bristles of your toothbrush at an angle in the sulcus of the gum (at the junction of the tooth and gum) and gently move the brush to and fro/circularly on the spot. Try not to brush more than 2-3 teeth at a time. Do this about 10-15 times per area for the front and back of all teeth.
• Switch to a rotary brush if you cannot control the pressure with which you brush. Remember to operate it at the lowest setting possible.
• Switch to your non dominant hand while brushing. If you are right handed, try brushing with your left hand so you apply less pressure.
• Try brushing with your thumb and 2 fingers instead of grasping the brush with your hand.
• Brush slowly and deliberately.

Remember that abrasion is a condition that is preventable- not reversible. We are specially trained to detect early signs and symptoms of bite problems and damage that is caused by aggressive brushing. It is our practice mission to help you develop healthy hygiene practices and to prevent your bite from damaging your teeth.
I will have some tips to help you change your brushing habits in the next blog entry.

'til then,
Be well,
Live well,
Do well.


Passions are personal. But the result of living a life that includes, and revolves around, different passions is universal. How many times have you had a conversation with someone who just gushed about a subject or spent time with someone who seemed to be doing something that just released a special energy into the air? That enthusiasm is unmistakable and is what passion is all about. Something that gets us excited!

Well, continuing education is one of my passions. My staff knows that it’s going to be a high energy Monday when I return from a course. The good thing is that they share that passion for learning, so they are always eager to join me in bringing the best to our patients by attending courses themselves.

This June, I attended a Head and Neck Dissection course at LSU in Louisiana taught by one of dentistry’s highly regarded minds, Dr. Henry A. Gremillion (see photo to left, photo not of Dr. Gremillion). It was an excellent refresher to the anatomy of an area that I treat every day . It was a great opportunity to see once again the regions of the mouth that I administer local anesthesia to. But the bigger purpose of selecting that course was to be able to see the TMJ and all the muscles in the head and neck area that get affected when a patient’s bite is off (their teeth don’t fit their jaws properly.) The term ‘TMD’ or ‘TMJ’ is used loosely by most people when they are having muscle tension / tenderness or spasm due to this discrepancy which is caused by those muscles having to function in an adaptive capacity over a long or short period of time. In some cases, however, symptoms may be the result of actual physical deterioration of the joint.

Most learners would agree that there is a tremendous amount of energy at continuing education gatherings that propels us towards learning more so we may get better at problem solving. It is also a source of making connections with like minded practitioners. Some of my best friends and mentors in dentistry have been people that I have met at such courses. It was great seeing Vali from Michigan at LSU once again - I had taken a Dawson Academy hands-on course with him in 2007.

I can’t speak of passions and leave out food. I love to think about it, cook it, express my feelings through it, connect with my friends and family through it, learn about it and of course, eat it!

So you can only imagine how things went in New Orleans…One of the local dentists had recommended some fabulous eateries in the city and one of them was Drago’s for char broiled oysters. Once there, it was a sight to be seen. A huge grill with oysters being broiled on top, smoke billowing towards the exhaust after a liquid was generously poured over them, waiters constantly rushing to tables with trays laden with these heavenly delights and patrons not even waiting for them to cool down before tearing the accompanying french bread and dipping into the shells. My husband Tim and I were no exception. There was silence at the table until we had mopped up every single shell with the bread. And then just a single look was exchanged between us that did not need any words to describe what we had experienced. Pure delight.

I tried hard to recreate that recipe back in NJ and this is surprisingly close enough to mimic the taste.

- Light a charcoal fire.
- Ensure that the fire is red hot and your grill is positioned fairly close to the fire. (6-8 inches)
- If you have them, add some hickory chips that you have presaoked.
- Place thoroughly washed unopened clams or oysters on the grill (I used fresh
oysters and clams from a fish market). They will open up in a few minutes. Be patient.
- Once they have opened up, pour salted melted butter very generously over the clams or oyster shells. The fire will engulf them quickly. Then add grated Parmesan cheese (powder form) and let them cook for a couple more minutes. I’ve also dunked the clams in a bowl with the mixture and that worked just fine also. The mix (and resulting flames) seem to cause any unopened clams to get in line with the others.
- If Clams,have a big serving bowl ready with about 1-2 sticks of melted butter and some Parmesan mixed in it. Keep taking off the clams and place in serving dish straight from the grill. Mix all together. You will notice a very smoky flavor in the butter.

Serve with French baguettes or Italian bread that you warmed on the grill.

Excellent with cold beer or your favorite beverage.

Bon Apetit!

Be well,
Live well,
Do well.

Inaugural Post

My name is Sunita Merriman and it is my privilege to welcome you to the inaugural entry to my blog.

The title of this blog is Dental Chronicles. I am dentist by profession and am one of the blessed people that understand what Confucius meant when he said,
“Look for an occupation that you like, and you will not labor for a single day in your life.” To me dentistry is not just about ‘fixing teeth’ but about the health and well being of my patients. I strongly believe that my goal of helping my patients keep their teeth looking and feeling great for the rest of their life is realistic and within the reach of the average person in America. Smile makeovers are not just for celebrities and the rich. They can be had by anyone who feels that they would improve their self esteem, social engagement, job opportunities and sense of esthetics. A well trained dentist can actually make a significant improvement in a patients smile by not necessarily doing a total ‘reconstruction’ of their teeth but by performing a minimal amount of dentistry that makes a subtle but pleasing changes to the overall effect of their smile.

Being a good dentist to me also means to be able to detect conditions that would become a more complex problem later on. Something that gets diagnosed early on would mean that my patients would avoid needing to undergo more procedures, spend more money and have a compromised or even hopeless result later on when the issue has compounded. That is not what I want for my patients.

I practice Complete Dentistry which simply put means that I take into consideration my patient’s entire masticatory system when examining them and determining their treatment needs. This allows me to be able to prescribe the minimum amount of dental procedures they will need over their life time and is truly the most conservative way to practice dentistry. It is only when the Temporomandibular joints, the muscles that attach the upper and lower jaws to the adjoining structures and the teeth work together as a harmonious system that there is good oral health. It is no surprise to me when I see patients with TMJ symptoms and worn teeth in my practice on a daily basis. It is not normal and the pain, suffering and irreversible destruction of teeth could have been avoided if diagnosed early on.

If I could have a dime for every time I’ve had a patient say, “Dr. Merriman, it’s not you. Don’t take it personally, but I hate coming to the dentist.” I would be donating a good amount of money to my favorite charity.

Here at my practice, we do take it personally! Dentistry is not just about teeth. It is about our patients feeling comfortable in our skills and knowledge and trusting our intentions to help them. This takes time and patience and an atmosphere and environment that are designed to allow our patients to be heard while they express their fears and concerns. We want our patients to be our partners in their care and to be excited about the fact that they have decided to invest in their health and well being. That is a powerful feeling...

Everyone is different and will take a unique approach to their care. The beauty of helping individuals reach their goals with a customized approach based on their need is what makes our job exciting and fulfilling!

The practice of dentistry is dynamic. There is much to learn and keep up with at a pretty fast pace. In this ever changing world of dental materials and technologies, some basic values remain constant. Integrity, honesty, compassion, quality, learning, sharing and most of all humility are on the top of my list.
No one ever gets anywhere by themselves. I am the poster child of this reality.

I would like to conclude this entry by making special mention of some of my mentors and champions:

-My mother Shan Merriman who told me to always dream Big and In Color and made me believe that I could achieve all those dreams.
-My family that likes me even when I don’t find myself amusing.
-Biji and Aunt Phyll who inspired me with their generosity of spirit and unconditional love
-Dr. Frank Spear who early on in the development of my practice validated a lot of what I ’ knew’ inherently as my path by having a 3 day lecture around it which made me feel that I could practice successfully with excellence and passion.
-Dr. Peter Dawson who taught me about Complete Dentistry but more importantly exemplifies what it means to be uncommonly gracious and giving, brilliant yet approachable, strong and unyielding in the face of challenges and most of all, passionate about mentoring others so we can all raise the bar beyond ‘usual and customary’
-My friends who inspire me to be worthy of their love and support.
-My team at work who inspire me to work hard to earn their commitment and respect.
-My patients who inspire me to improve daily so I may earn their trust.
-My daughters Nina and Simrin who give me purpose.
-My husband Tim who lovingly colors in the big dreams!

I look forward to having you with me on this journey of sharing information about dentistry, your well being , and optimal health and life lessons that I learn every day about living with passion!

Martha’s Vineyard July 2010

'til next time,
Be well,
Live well,
Do well.