The Money Tooth

You have four teeth that will probably cost you more money than any other teeth in your mouth. These expensive teeth are your first permanent teeth- your six year molars. These teeth are known to your dentist as first molars.

For most people the typical life story of a lower first molar goes something like this: the tooth erupts into the mouth of a six-year-old who does not have immaculate dental hygiene habits and may have less than excellent dietary habits as well.The battle to maintain healthy tooth enamel begins. The average molar has deep grooves in the biting surface. These grooves are microscopic and too small for anyone to clean. As a result, decay usually gains a foothold in these grooves. If the person has regular checkups, the dentist diagnoses the decay in the small grooves and places a correspondingly small restoration. If a person has no checkups, then the decay will eventually reach the nerve of the tooth, causing pain. The solutions at this point are root canal treatment and crown, or removal of the tooth. 

Now back to the person who gets regular checkups. The small restoration lasts until the tooth’s owner becomes a teenager. The teen years can be very hard on teeth due to sodas, energy drinks, unhealthy snacking and poor oral hygiene. At this point decay will probably appear on the side of the tooth which is touching an adjacent tooth. The smallish initial filling must now be enlarged to include the areas of decay on the sides of these teeth. If the teenaged tooth owner embraces better habits along the way, years may pass before this filling needs replacement. Eventually it does need to be replaced and the filling becomes just a bit larger. More time passes. Perhaps a cusp breaks. (the cusp is the “points” on a molar). Now the tooth needs a crown….and if the tooth is painful or has developed extensive decay, the tooth may need a root canal as well.  These treatments work out well for a number of years, perhaps even for the rest of the person’s life.  However, if the oral environment is unfavorable, the tooth may develop recurrent decay, structural fractures or become undermined by periodontal disease.  Any of these problems can lead to tooth loss.

Chapter two in the story of the first molars involves the upper first molars. They tend to follow along just a step or two behind the lower first molars. Once the lowers are crowned, the cusps of the uppers may begin to break. When the cusps break on the upper first molars then they will need crowns of their own.  Upper molars are the teeth most frequently lost to periodontal disease.

According to one dental school professor: “Every little filling will grow up to be a crown.”

“UNLESS……..” (quoting from The Lorax now)

Unless steps are taken to outsmart and outmaneuver the forces that make your first molars “money teeth.”

The disease cascade that turns first molars into “money teeth” has three components: decay, excessive stress and gum disease.

Decay typically sets the first ambush for these teeth. The best defensive strategy against decay includes excellent dental hygiene habits. Excellent dental hygiene begins when you bring the baby home. Start getting the child familiar with your fingers around their lips and gums.  At the first sign of a tooth introduce a tooth brush in the mouth. Don’t leave the important job of brushing teeth to your two-year-old or even to your six year old.  Teach them by brushing their teeth for them. Make wise food and drink choices for yourself and your children. Water is the only wise drink choice for nonmeal times. Do your best to have regular dental checkups and ask for sealants to be placed.

Sealants provide a shield against the decay causing bacteria that crawl into the microscopic grooves in teeth. Once the bacteria are ensconced in the grooves bad things begin to happen. First, the bacteria need to deficate so they poop all over the tooth. This poop is acid and interacts with the tooth enamel and weakens it. The bacteria then crawl into the weakened enamel and take the battle into the dentin of the tooth. So, the quicker sealants can get placed, the better. If the grooves are sealed before there is detectable damage, the bacteria that get trapped under the sealant starve to death and the bacteria left outside the sealant cannot get in. Sealants sometimes need to be replaced due to de-bonding or chipping. One of the things dentists do at checkups is evaluate the condition of sealants.

The second item in the disease cascade is excessive stress. Teeth are meant to touch each other for only brief periods during the day – the time that we spend swallowing and chewing. Actual chewing forces are directed at the teeth for only about nine minutes per day. During chewing these forces range from 5 – 44 pounds per square inch (psi). Eating a raw carrot, for example, requires 28 psi. So, if we touch our teeth together only for swallowing and chewing, we should have no dental disease that results from excessive stress. 

However, up to 80 % of people suffer from some degree of excessive stress on the teeth. This excessive stress is often called “bruxism.” Bruxism is defined as the unconscious gnashing, grinding, or clenching of the teeth. It is the most common dental disease and is rarely addressed. 265 lbs of force can be generated on the first and second molars as a result of bruxism. As a result of constantly exercising the chewing muscles, patients who brux develop a greater maximum bite force than nonbruxers. For bruxers, the preasure placed on teeth may exceed 500 psi.

Perhaps your dentist has asked if you are aware of grinding your teeth. You probably said something like “I used to, but I don’t do that anymore” or “No, I don’t do that.”  A few will recognize that they brux because they have sore muscles and or sore teeth in the morning.  A dentist can usually spot a bruxer immediately and can show you why they asked about it. Flat teeth, short teeth, pitted teeth, gumline erosion, chipped edges on front teeth and teeth that are sensitive are all signs of bruxism. So, if your dentist asks if you grind your teeth.  Say, “yes”, or “I am not aware that I grind but, do you think I grind?”

While the causes of bruxism are not completely understood, several contributing factors are recognized. Teeth that are not aligned properly and do not come together in a balanced and organized way are one factor. Psychological stress, some medications, and certain physical conditions can contribute to bruxism. 

Bruxism is addressed less often because it is less well understood by patients and their dentists. It is harder to explain than cavities and gum disease and patients are less inclined to manage it because it often does not cause pain. However, bruxism is a huge contributor to the “money teeth” condition.  If excessive stress on teeth is not managed, chips and fractures occur that can necessitate crowns, root canals and even removals.  So, if your dentist expresses concern about stresses in your mouth, do not be dismissive. Listen and follow advice on this matter because doing so can save you thousands of dollars.

The first line of defence against bruxing is typically an occlusal guard. This is a protective covering over either your upper or lower arch that is carefully adjusted to faciliate smooth interaction of your upper and lower teeth. Often when an occlusal guard is advised the patient declines because “my insurance does not pay for it.”  What seems difficult to explain and or comprehend is that an occlusal guard, even without insurance benefit, is much less expensive than the results of not wearing an occlusal guard. Other interventions can include equilibration, stress management, evaluation of medications that you may be taking, botulinum toxin or orthodontics.

The third item in the disease cascade is periodontal disease. The best defences against periodontal disease are immaculate oral hygiene and avoidance of tobacco. Unless you plan to see your dental hygienist daily, you are the most important defender of your periodontal health. At your regularly scheduled hygiene visits, ask your hygienest to critique your oral hygiene skills and take their advice to heart.  There are genetic factors in the perio world as well, but as yet we cannot alter them, so concentrate on the factors that can be controlled.

Nobody wants to have “money teeth.”  Wherever you are in life, implement the defences against “money teeth” that are available to you.  Consult your dentist and hygienist regarding your particular vulnerabilities and what to do about them. You can make a difference with the help of your oral health professionals.