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Ottawa Patient Dental Education

The Canadian Press
Sports, Tuesday, October 28, 2008

Sports stars using mouthguard created by Truro, N.S., dentist

-by Melanie Patten
In Halifax
The Canadian Press

TRURO, N.S. - Anil Makkar has the unusual habit of looking for photos of professional athletes with their tongues stuck out.

They could be future clients for the Nova Scotia-based dentist, who has developed unique mouth guards meant to unleash strength by relaxing the wearer's jaw - much like sticking out your tongue.

Whether they know it or not, he says, some athletes could be improving their game just by opening wide and giving their best Gene Simmons impression.

"One of the most relaxed positions of your jaw is when your jaw is basically down and forward from your skull. The act of sticking your tongue out does that for you," says Makkar, who practises in Truro, about an hour's drive northeast of Halifax.

"Some of the best athletes in the world, in crucial times, will stick out their tongue: Kobe Bryant of the Lakers always does it; Tiger Woods always does it; Tom Brady of the New England Patriots, six months ago on the cover of Sports Illustrated, had his tongue out while he was throwing the ball."

Of course there's also Michael Jordan, he says, whose posters of a flying man with an outstretched tongue still grace the walls of basketball fans five years after his NBA retirement.

Makkar, who's trained in neuromuscular dentistry, began developing the mouthguard several years ago after patients fitted with a similar piece to treat temporomandibular joint (TMJ) pain began telling him they felt stronger.

The so-called Pure Power Mouthguard, which can cost up to $2,000, doesn't make anyone stronger, says Makkar, but it "unlocks your potential."

"The jaw joint is actually the focus of power in the body because that is the most used joint in the whole body," he says.

"So what we're basically doing is trying to find the most comfortable position of that lower jaw. ... It relaxes all the muscles in the face and allows you use more of your upper and lower body strength."

The mouthguards, which are manufactured in Calgary, now grace the gums of eight PGA golfers, Dallas Cowboys receiver Terrell Owens, Shaquille O'Neal of the Phoenix Suns, Los Angeles Lakers forward Lamar Odom, and more than 200 other professional athletes.

Only certified dentists in Canada, the United States, Australia and Singapore can fit a client for the mouthpiece.

Makkar, CEO of Pure Power Athletics Inc., says no athletes have been given money to endorse the product, but there are plans for paid endorsements in the near future.

The product has already been given a major boost thanks to Manny Ramirez of the L.A. Dodgers.

A dentist suggested the former Boston Red Sox player give one of Makkar's mouthguards a try while helping a teammate who was suffering from TMJ pain.

Moments later, Ramirez smashed three balls out of the park, says Makkar, and asked to be fitted for a proper piece.

"He said, 'Doc, I'm going to sponsor this for you, I'm going to endorse this for you because it works."'

Ramirez appeared on the Oct. 13 cover of Sports Illustrated sporting the mouthguard, and can also be found on the Pure Power Athletics' website.

Seeing the product on famous athletes is something the small-town dentist is enjoying getting used to.

"The most interesting thing about this whole thing is wherever I am, people always ask, 'Where are you from?'

"And I say, 'Truro, Nova Scotia. And the next thing is, 'Where is Truro, Nova Scotia?' Because they always think some big American would have developed this."

Category: Sports and Leisure
Uniform subject(s): Sports and Leisure
Subject(s) - The Canadian Press : HEALTH; INTERNATIONAL; SPORTS
Hour of publication: 16:46E
Length: Medium, 492 words

© 2008 The Canadian Press. All rights reserved.

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Research indicates that diabetes and oral health can directly affect each other, so that means that diabetes patients may be at a greater risk of suffering from oral health issues such as gum disease and infections. Likewise, having gum disease can increase complications associated with diabetes by increasing your blood sugar levels. So how can your dentist help?

How Your Dentist Can Help

Your dentist is your oral health expert, trained to properly assess your oral health. During an oral exam, if your dentist finds signs that you are at risk for diabetes, or that your existing diabetes is not well-controlled, you'll be referred to your family doctor for follow-up treatment or testing.

The good news is that treating either gum disease or diabetes can lead to improvements in the other. For an introduction to diabetes and oral health, ask your member dentist for the ODA brochure: Your Dentist Sees More Than Just Your Teeth (left).

In addition, at your next visit, discuss with your dentist:

  • If you have been diagnosed with diabetes and the diabetes is under control.
  • If you take insulin and when your last dose of insulin was administered.
  • If there has been any other change in your medical history.
  • The names of any herbal medicines, prescription and over-the-counter drugs you are taking.

What is Diabetes?

Diabetes is a medical condition in which the body does not produce nor properly use insulin. Insulin is a hormone needed to absorb sugar, the basic fuel for cells.

If your body doesn't produce insulin, it cannot use sugars from food. Untreated diabetes can lead to heart disease, kidney disease, nerve damage and infections, and other serious complications.

There are three forms of diabetes:
type 1 - the body makes little or no insulin
type 2 - the body does not respond properly to the insulin produced
gestational - a temporary condition that occurs during pregnancy.

Symptoms of Diabetes

Some symptoms of diabetes include:

  • unusual thirst
  • frequent urination
  • extreme fatigue
  • blurred vision
  • frequent or recurring infections
  • cuts and bruises that are slow to heal
  • tingling or numbness in hands or feet

What is Gum Disease?

Gum disease is a type of bacterial infection caused by the build-up of plaque, the sticky, colourless film that forms on teeth every day. Gum disease affects both the gums and the bones supporting your teeth. It appears in two forms: gingivitis and periodontitis.

The mild form of gum disease is called gingivitis, in which the gums become sore, red, bleeding or puffy. Gingivitis can be easily reversed by a visit to the dentist, in addition to the patient working harder at brushing and flossing.

Untreated gingivitis can escalate into what's known as periodontitis. This type of gum disease can lead to the destruction of gum tissue and the bone supporting the teeth.

Oral Health Problems Associated with Diabetes
Through an oral examination, your dentist uses their training and expertise to look for certain oral health conditions that could signal a need for you to be tested for diabetes.

The most common oral health problems found in people with diabetes include:

  • gum disease (see above for different forms and their symptoms)
  • tooth decay
  • dry mouth, a condition known clinically as xerostomia
  • fungal infections
  • lesions in the mouth
  • taste impairment
  • infection and delayed healing

Am I at Risk for Diabetes?
If you're 40 or over, you may be at risk for type 2 diabetes, although many people with type 2 diabetes display no symptoms.

Other risk factors:

  • obesity, or being overweight
  • have a family member with diabetes
  • have had gestational diabetes (occurs only during pregnancy)
  • high blood pressure
  • high cholesterol

Diabetes Statistics in Ontario and Canada
Source: Canadian Diabetes Association, 2008.

Approximately 2.4 million Canadians have diabetes
That number is expected to grow to three million within the next two years
Nearly one million people with diabetes live in Ontario
Every week, more than 1,000 Ontarians learn they have diabetes
Among people with diabetes, 80 percent will die of stroke or heart disease
Ontarians with diabetes make up 7.5 percent of the population but account for:

  • 32 percent of heart attacks
  • 30 percent of strokes
  • 51 percent of new dialysis cases
  • 70 percent of limb amputations

For more information

Canadian Diabetes Association
Diabetes Ontario


Patient Fact Sheet
Periodontal Disease Gum Disease

Can Often Go Unnoticed - Until It's Too Late

You may not think periodontal disease affects you, but 75 percent of adults over 35 show signs and symptoms. Periodontal disease is the leading cause of tooth loss in adults. The reason is that it happens at an age when cavities are usually a thing of the past and the initial symptoms often go unnoticed.

Periodontal disease should be taken seriously because recent studies have also shown a possible link between periodontal disease and heart disease. The bacteria that cause periodontal disease enter the bloodstream and promote blood clots and narrowing of the arteries that cause heart attacks. Studies also show that if a woman develops severe periodontal disease during pregnancy, she is more likely to give birth to a low birth weight infant. Research now also links periodontal disease to many other health problems. The following questions and answers will inform you about this often unseen problem.


What is periodontal disease and what causes it?

Periodontal disease, or gum disease, is a bacterial infection of the gums, ligaments and bone that support the teeth and anchor them in the jaw. Bacteria is a normal inhabitant of the mouth and live in a thin film called plaque. If plaque is left undisturbed, it may eventually harden into a hard mineral shell known as tartar. When plaque builds on the tartar surface, it irritates and erodes healthy gum tissue, resulting in gingivitis. If left untreated, pockets begin to form between the teeth and gum tissue, and supporting bone can become badly eroded. This stage, which can result in tooth loss is called periodontitis.

What are the symptoms of periodontal disease?

Gum disease is often painless until it reaches the final stages so it often goes unnoticed. However, there are many indications of potential periodontal disease. Patients should look for gums that bleed when teeth are brushes, red and swollen gums, gums that pull away from the teeth, persistent bad breath, a metallic taste in the mouth, loose or separating teeth, pus or discharge between teeth and gums, or a change in the way teeth fit together. Patients should contact their dentist if they notice any of these symptoms.

How do I know if I have gum disease?

A general dentist or periodontist (a specialist in periodontal diseases) can easily detect periodontal disease during regular dental examinations. That's why regular checkups, ideally every six months, are crucial in catching periodontal disease while its effects can still be reversed.

During your checkup, the color and firmness of your gums will be evaluated. The dentist will test your teeth for tightness, and the way they fit together when you bite. During the examination, a small measuring instrument is painlessly inserted between the tooth and gum to measure the depth of the pockets. The dentist may also take X-rays to evaluate the bone supporting the teeth.

Are there factors that contribute to gum disease?

Smoking is one major risk factor. The chemicals found in tobacco have a harmful effect on your oral tissues, and they can deplete vitamin C and other nutrients, reducing your resistance to periodontal disease. Poor diets, typically diets high in sugars and sticky or gummy carbohydrates and low in vitamins and minerals, are also a contributing factor.

During pregnancy hormone changes can increase the blood supply to certain tissues in the body, including the gums. Many pregnant woman, as much as 60 percent, may experience red, tender or bleeding gums. Stress, diabetes, AIDS and other health conditions can also lower your resistance to gum disease.

Can periodontal disease be prevented?

Be sure to brush your teeth twice daily. To properly clean teeth, hold the brush at a 45 degree angle to the gum line and gently clean where the gums meet your teeth. Clean between your teeth at least once a day with dental floss (or other interdental cleaners, such as rubber tips and oral irrigators, as recommended by your dentist). This important step removes bacteria, plaque and food particles your tooth brush can't reach. Be sure to eat a balanced diet, which includes a variety from each of the basic food groups, to maintain optimum oral health. Visit your dentist regularly for a preventive checkup and professional cleaning to help prevent gum disease and maintain good oral health.

What if I already have periodontal disease?

See your dentist immediately. Gum disease can be treated by removing plaque and calculus pockets around the teeth and smoothing the root surfaces when it's caught in early stages. Known as scaling and root planning, and with proper home care, this will help prevent the disease from reaching further stages. Waiting until the symptoms reach a more advanced stage can result in a referral to a periodontist for treatment, and in very severe cases, surgery may be required. A good rule is not to wait until it hurts. Periodontal disease can be prevented with regular dental visits


What causes TMD?

Janet Travell, M.D. was the White House Physician under Presidents Kennedy and Johnson, who wrote the landmark textbook Myofascial Pain and Dysfunction. Dr. Travell estimated that 90 percent of pain was due to muscles. As dentists we all learned in dental school that if the bite is not balanced, pain and other symptoms can develop. Our jaw is supported by a sling of muscles that guide our teeth together in our habitual bite or Centric Occlusion (CO). Even when our jaw is ostensibly resting, our muscles position our jaw near our bite. If our bite is in harmony with our muscles, everything feels good. That is to say that as long as our muscles are at physiologic rest, neither foreshortened nor elongated, there will be no muscle pain. But if our muscles have to strain on a regular basis in the "rest" position or in CO, symptoms can develop in patients who do not accommodate well. These symptoms can take the form of headaches, facial pain, neck and shoulder pain, feelings of ear congestion, dizziness, and other symptoms not commonly considered "dental."

Does My Patient Have TMD?

Malocclusion causes TMD. While nutrition and stress may be contributing factors, malocclusion is the overriding etiologic factor. How do we know if our patient's symptoms are occlusally related? First of all, it is always a good idea to check with the physician to make sure that the symptoms are not medical in origin. Next, take a proper history. Find out if the patient grinds his or her teeth, has TMJ crepitus, headaches, facial pain, dizziness or any of the other common symptoms of TMD. In your clinical exam, look for overbites, overjets, abfractions, tori, scalloped tongue, mouth breathing, anterior open bite, cross bite, wear facets, attrition, crowding, balancing interferences, incline interferences, missing teeth, and otherwise unexplainable perio problems. Continue your exam by palpating the muscles of mastication and facial expression, particularly the masseter, temporalis, lateral pterygoid, medial pterygoid, and digastrics. When a number of these signs and symptoms emerge in your examination, you may be looking at a TMD patient.

What Can Be Done?

Find the ideal occlusion. There are two major components of proper occlusion, and it is important to establish both of them ideally to relieve TMD. What can be done in everyday practice to properly diagnose and treat these legitimately suffering patients? The first component is an ideal cranio-mandibular position, where the muscles can truly relax in physiologic rest. Ultra low frequency TENS (transcutaneous electroneural stimulation) enables the properly trained clinician to find the ideal cranio-mandibular position, where tonus alone holds the jaw in rest position. Further enhancement of the correct position can be determined with electromyography, sonography, and kinesiography Then, ideal cusp-fossa relationships must be established, being careful to avoid balancing interferences and incline interferences in CO and in function.

What Are Some Practical Treatments?

Once the bite is recorded, there are a number of modalities to treat the TMD patient. If the ideal occlusion is very close to the existing CO, coronoplasty (selective grinding) can be used, guided by TENS. If the bite is significantly over closed, retruded, tilted, skewed, or otherwise tweaked, a fixed or removable orthotic (splint) can be fabricated, based upon the bite registration recorded at the ideal cranio-mandibular position. Orthotics, built as a facsimile of the ideal opposing dentition, often provide significant relief to the TMD patient. In many cases, long-term orthotic therapy is the treatment of choice. When restorations are required to provide a long-term solution, it is important to ensure that symptoms have resolved and that the bite has stabilized over time in the orthotic. Using the adjusted orthotic as a bite record for mounting casts in the laboratory, the case can then be designed using a wax up for the treatment of choice-- from a single onlay to a full mouth reconstruction, depending on the demands of the case. Orthodontics can also be used to move the teeth into the ideal craniomandibular position as established in the orthotic phase. However, it is critical to perform selective grinding after orthodontics to avoid pathologic interferences in CO and in function.

Know When to Treat and When to Refer

TMD patients can be perplexing. Oftentimes, TMD patients have complex restorative problems, upper airway obstruction, limited windows of comfort, and other complications. Until you become experienced in treating difficult cases, know when to treat and when to refer. To help you decide if a case is beyond your ability, look carefully at your diagnostic results. Is the patient a mouth breather? If so, an ENT may need to determine if the cause is enlarged tonsils and adenoids, allergies, or a deviated septum. These issues need to be resolved. Does the patient normally require multiple bite adjustments after even the smallest filling? Does the beautiful new crown never feel quite right? If so, you may be dealing with a patient who has a limited zone of comfort. Does the patient have a complex bite such as a class 3, edge to edge, or open bite in the anterior or posterior? Does the patient have complicated dentistry that is beyond your level if you need to replace it? If so, you may be over your head. In many cases such as overbite, attrition, retruded mandible, and easyto- please patients, treatment can be less complex. TMD can often be treated by placing the patient in an ideal cranio mandibular position found with the assistance of TENS. In the more complex situations mentioned above, consider a referral to a more experienced clinician.

Dr. Bernstein is a Clinical Instructor at the Las Vegas
Institute for Advanced Dental Studies. He maintains a
private practice in Piedmont, California emphasizing
complex cosmetic cases, TMD, and sedation, in an environment of outstanding personal service.


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