Osteonecrosis of the Jaw

 

Over the past several decades, several new “anti-resorptive” drugs such as bisphosphonates have been introduced to treat osteoporosis and some types of cancer.  These medications work to decrease the turnover or remodeling activity that naturally occurs in all bones.  While they work well in preventing catastrophic injuries such as hip fractures and spine fractures, a side effect that is now well known called osteonecrosis of the jaw can occur after a surgical dental procedure.  The most common manifestation of this condition is an area of jaw bone that does not heal, but instead becomes devitalized and necrotic after a tooth removal.  This is why the condition is called osteonecrosis, which literally means dead bone.  Symptoms may include foul taste and smell, drainage, discoloration and exposure of the jaw bone, infection, and pain.

Some of the medications that have been known to cause osteonecrosis are listed below:

Bisphosphonates

  • Zolendronate (Reclast, Zometa)
  • Alendronate (Fosamax, Binosto)
  • Risedronate (Actonel, Atlevia)
  • Ibandronate (Boniva)

Rank-L inhibitor

  • Denosumab (Prolia, Xgeva)

Anti-Angiogenic medications

  • Sunitinib ( Sutent)
  • Sorafenib (Nexavar)
  • Bevacizumab (Avastin)
  • Sirolimus (Rapamune)

The risk of developing osteonecrosis while on these medications varies with route of administration (oral vs IV), dosage and length of treatment, type of medical illness (cancer or osteoporosis), local factors (pre-existing dental or periodontal infection), concurrent administration of other medications (i.e. corticosteroids are associated with increased risk of ONJ).  Most of the studies suggest a 1-2% risk of developing osteonecrosis for cancer patients and 100x lower in patients taking antiresorptive medications for osteoporosis.

If your doctor has prescribed any medications to prevent hip fractures or increase bone density, you should notify your dentist or oral surgeon prior to having any invasive dental procedure done – even if it is a simple tooth extraction.  Prevention through careful screening and strategic planning is preferred over management of the condition after osteonecrosis has already occurred.

For more information, please refer to the official position paper from the American Association of Oral & Maxillofacial Surgeons:  2014 AAOMS position paper on MRONJ

 

To your health and prosperity,

 

 

 

 

 

 


Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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Dental Implants – FAQ

 

 

A dental implant is one of the best ways to replace a missing or failing tooth. Below are some frequently asked questions regarding dental implants.

Q: Why do you recommend a dental implant to replace my tooth?
A: Dental implants are strong and can last a lifetime if taken care of properly. They will never get a cavity or require a root canal. A dental implant will prevent gum and bone loss in the jaw and prevent adjacent teeth from shifting over time.

Q: Are there any disadvantages with dental implants?
A: Dental implants can be expensive compared to other dental procedures.  Implants are surgically placed in the mouth, which can be more invasive than most dental procedures. They also require time to heal before the implant can be used as intended.

Q: Will my implant cause the metal detector to go off at the airport?
A: No. Dental implants are made from titanium. They do not trigger airport alarms or cause any issues with MRI scans.

Q: Do I have to go to sleep (IV Sedation) for my dental implant?
A: No, dental implants can be placed with just local anesthesia alone. Some patients do choose to go to sleep (IV Sedation) for their dental implant surgery, especially if they have a lot of anxiety.

Q: Why are dental implants so expensive?
A: Dental implants are classified as an implantable medical device by the FDA. They are typically made from titanium, which is costly to source and manufacture.

Q: How painful is implant surgery?
A: Most implant surgeries are less invasive and easier to recover from than a tooth extraction.
Patients typically do great with over the counter pain medications such as Ibuprofen or Tylenol for 3-4 days.

 

 

 

To your health and prosperity,

 

 

 

 

 

 

 


Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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Mucocele – A painless lip bump

 

A common procedure that I perform at my office is the surgical removal of a mucocele.  This smooth, raised, painless bump is typically found on the inner “wet” surface (mucosa) of the lower lip.  Other areas where they can appear include the upper lip mucosa, mucosa of the cheeks, or mucosa under the tongue.  The usual history involves some trauma to the area, such as accidentally biting the lip.  This injury can disrupt one of the many minor salivary glands in the lip and cause saliva to collect inside the lip instead of being ejected into the mouth.  As a result, a fluid filled bump can be felt by the patient and appears smooth and translucent upon examination of the lip.  Although mucoceles are typically painless, they can cause the lip to appear uneven and discolored.  They can also cause difficulty chewing and talking by protruding into the mouth.

 

 

Mucoceles can resolve spontaneously and disappear on their own, or they may continue to get larger and larger until the lip becomes quite disfigured.   They can also fluctuate in size, getting larger before decompressing and then increasing in size again.  The surgical removal of a mucocele involves numbing up the area with local anesthetic and then making an incision to scoop out the lesion and associated minor salivary gland.  The wound is then washed with saline and sutured closed with some self dissolving stitches.  The most common side effect from mucocele removal is recurrence, and in some cases further surgery is required.

 

While most mucoceles can be recognized clinically due to their characteristic look, the final definitive diagnosis can only be made after evaluation under a microscope by a pathologist.  This is an important step in ruling out any other possible disease process.  Once the suspected mucocele is removed, I always place it in a biopsy specimen jar and send it to the pathology lab for evaluation.  If the diagnosis is in fact a mucocele as expected, no further treatment is required.

 

To your health and prosperity,

  

 

 
 

 
 

 

 

 

Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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What is a Dry Socket?

Dry socket is a painful condition that can develop after a tooth extraction surgery.  This condition can be very painful and uncomfortable during the immediate healing phase and may require treatment. The medical term for dry socket is alveolar osteitis which literally means inflammation of the bone that supports the tooth. When a tooth is removed, a blood clot typically forms at the base of the hole that is left behind. This clot acts as a “band-aid” while the jaw bone regenerates. If the blood clot becomes dislodged, the bone underneath is exposed to the rest of the mouth and the area can become irritated and inflamed.
Dry socket is diagnosed from the patient’s history and is more common in the lower jaw. This condition usually develops during the first week after a tooth is extracted and is described as an aching and throbbing type of pain. Sometimes there is a foul odor and bad taste in the mouth as well. Worsening pain during the first week after surgery may be a sign of this condition, and the development of a dry socket beyond one week after surgery is highly unlikely.
To prevent disturbing the blood clot after an extraction, I recommend the following for at least one week after a tooth removal:
  • Do not use a straw
  • Do not smoke or vape
  • Do not spit forcefully
In addition, here are some additional recommendations for self care:
  • Take pain medications such as Ibuprofen or Tylenol. If pain is not controlled, call your dentist or oral surgeon.
  • Rinse with warm saltwater several times a day
  • Gently flush out the tooth socket of any food debris

Dry socket medication is derived from the oil of cloves

The incidence of dry socket is approximately 1 out of 20 patients, or about 5%. If a dry socket is suspected and pain cannot be controlled with over the counter pain medications, I typically have the patient stop by the office to place a medicated dressing into the tooth socket itself. This dressing is simply a cotton strip soaked in a compound derived from cloves. While the taste is not great, most patients find immediate relief. This temporary dressing is adequate to get patients through their dry socket and once removed several days after placement, allows the body to continue with the normal healing process. While a dry socket is painful and unpleasant, there are no long term side effects from a dry socket.

 

To your health and prosperity,

 

 

 

 

 

 

 

 

 


Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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Oral Biopsy – What to expect

 

Part of any dental exam includes a thorough intra-oral examination and x-rays.  Dentists are trained to detect anything that is unusual inside the mouth including bumps, discolorations, or any abnormalities on an x-ray.   Your dentist may refer you to an Oral Surgeon for a biopsy if there are any unusual findings inside your mouth.  The purpose of a biopsy is to obtain a definitive diagnosis by surgical removal and evaluation of tissue under a microscope by a pathologist.    Analysis of the tissue is done on a cellular level, and an official report is created.  This report is then sent to the surgeon to guide further treatment, if necessary.

At my office, I will re-check the area of concern during your initial consultation and perform my own exam and documentation.  A thorough medical and dental history is taken to guide clinical decision making.  If indicated, I will also palpate the lymph nodes under the jaw and on both sides of the neck.  We will discuss the likely cause for the growth and answer any questions that you may have.  If a biopsy is warranted, the next step is to surgically remove the entire lesion or part of the lesion depending on the size and location.      Most of the time, local anesthesia with lidocaine is sufficient to numb up the area of interest.  This technique is identical to receiving a shot at the dentist for a filling or root canal.  Once the area is numb, surgery can proceed and you should not feel any pain.   Some patients may opt to receive IV sedation for the biopsy, which is a great option especially if there is any anxiety about the surgery.

After the tissue is surgically removed, it is placed in a special medium for transport to the pathology lab.  A suture may be placed to close the surgical site, and often times I will use a self dissolving suture that will fall out about 5-7 days.  As with any surgery inside the mouth, you can expect to be sore for a few days.  It is also not uncommon to experience some mild bleeding for 24-48 hours.  The results of the biopsy typically take 10 – 14 days to return, and I typically call my patients personally to discuss the results.

 

                                              – Oral Squamous Cell Carcinoma –

 

Oral squamous cell carcinoma is the most feared result from a biopsy.  So what does oral cancer look like?  If oral cancer could be diagnosed from its appearance, there would be no need to perform a biopsy.  It can only be diagnosed through a physical biopsy and pathological  examination under a microscope.  The risk for oral cancer does increase with a history of cigarette smoking. In early stages of oral cancer, pain is typically absent.  Thankfully, the majority of biopsies do not show any cancer or precancerous activity.   Far more common are benign lesions that do not require any further treatment.  One common example is hyperkeratosis, which is essentially a callus that forms inside your mouth from rubbing up against teeth, dentures, or retainers.

It is always a good idea to obtain a definitive diagnosis by way of a biopsy as soon as possible if there are any questions or uncertainty about a growth inside your mouth.   If you discover anything new or unusual inside your mouth, please contact my office to schedule a consultation and exam- a referral from a dentist is not required.    A prompt biopsy and diagnosis will allow timely treatment if necessary, and of course, peace of mind.

 

To your health and prosperity,

 

Picture of Dr. Yang

 

 

 

 

 

 

 


Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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Non surgical treatment for clenching and TMJ pain

Clenching and grinding is a problem that many people struggle with.  This is understandable as the human bite force is incredibly strong – on average 162lbs per square inch.  There are even reports of maximal bite forces exceeding 900lbs!  Over time, clenching can lead to tooth wear, headaches, tmj pain, and enlargement of muscles involved with chewing.

 

Lifestyle modifications
One of the simplest ways to combat bruxism is to reduce stress and anxiety in your life.    You may benefit from making lifestyle changes such as:

 

  • Getting better sleep – follow good sleep hygiene habits such as avoiding screen time before bed,  taking a cold shower to encourage natural melatonin release, and avoiding fatty foods close to bedtime.
  • Watch your diet – eat healthy foods such as vegetables, fruits, whole grains.  Drink alcohol and caffeine moderately.  Avoid tobacco use.
  • Exercise – Cardiovascular exercise such as walking, jogging, cycling, or yoga can do wonders for stress.  Include lifting weights for additional health benefits.
  • Get your mind right – practice meditation and gratitude.  Becoming self aware will allow you to recognize stressful moments during your day so you can address them and become more grounded.
Night guard
Decreasing tooth to tooth contact, especially at night can prevent wear on enamel and dentin.  A night guard or occlusal guard is a device that can be worn over your teeth to achieve this goal.  While over the counter options are available, I recommend getting one professionally made by a dentist so that the night guard is customized to precisely fit your mouth and teeth.

 

 

Botox
In addition to lifestyle modifications and the use of a night guard, many patients have had success dealing with excessive clenching and bruxism with Botox injections.  Most people have heard about using Botox to reduce the appearance of facial wrinkles, but it is also used to treat medical conditions such as neck spasms, excessive sweating, chronic migraines, and bruxism.  Botox works by inhibiting the release of Acetylcholine at the neuromuscular junction – the connection between the nerve and the muscle.  This essentially prevents the muscle from contracting and relaxes the muscle as a result.

 

In the treatment of bruxism, Botox is most often injected into the masseter muscles in your cheeks.  The effects should start within a few days and reach its maximal effect in a few weeks.  There are no adverse effect to chewing, talking, or facial expressions.  However, some patients may experience some temporary bruising at the injection sites.   Botox will last for about 6-8 months before its effects on the muscle start to diminish.  Schedule your consultation today to see if botox is right for you.

 

To your health and prosperity,

  

Picture of Dr. Yang
Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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Wisdom teeth removal – FAQ

 

Many patients have questions regarding self care after wisdom teeth removal.  Below are answers to some of our most frequently asked questions.  While generally applicable in most cases, every patient and surgery is different, so please follow the postoperative instructions that are given specifically to you after your surgery.

 

Q: How long after wisdom teeth removal can I eat?
A: There are no time restrictions for eating food after wisdom teeth removal.  Once the effects of anesthesia have worn off and you are hungry, please feel free to eat!  Most patients find that starting slowly with soft foods such as smoothies, juices, and soup is the best way to start.  If you are not in pain and feel ready to advance to more solid foods, you are welcome to do so.  Spicy foods can sometimes be irritating to the gums around the surgical site, so my recommendation is to wait one week before chowing down on any blazing habanero wings.

 

Q: How long after wisdom teeth removal can I drink?
A: Drinking liquids such as water, juice, coffee is fine as soon as you are awake enough from anesthesia.  I am often also asked if alcohol is safe to drink after surgery.  The answer is generally yes, in moderation.  However, you must not drink alcohol if you are taking any narcotic pain medication that was prescribed for pain such as hydrocodone or oxycodone.

 

Q: How long after wisdom teeth removal can I smoke?
A: Smoking can cause a delay in healing of the extraction sites.  It may also increase the risk of dry socket, which is a painful condition that sometimes develops after wisdom teeth surgery.  The answer to this question is simple – hold off as long as you possibly can to smoke after surgery.  The longer you abstain from smoking, the larger the benefit for healing and your general health.

 

Q: How long after wisdom teeth removal can I work out?
A: It depends on the level of activity – Taking walks can resume immediately and this may actually help decrease facial swelling.  In most cases, weight lifting, running, or other aerobic exercises are safe to do once your pain is controlled without taking any narcotic pain medication.  Contact sports such as football, boxing, or water polo may resume after you are completely recovered from your surgery.

 

Q: How long after wisdom teeth removal can I use a straw?
A:  The reason why the use of straws are discouraged after wisdom teeth surgery is because any suction in the mouth can cause dislodgment of the blood clots in your tooth sockets.  This may cause bleeding and increase your risk of a dry socket.  If your recovery is typical, the use of straws may resume after one week.

 

To your health and prosperity,

 

Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

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What exactly is a tooth infection/abscess?

A dental abscess forms when your body’s immune system reacts to bacteria that finds its way inside of a tooth.  This can happen if the integrity of the tooth is compromised by cavities, fractures, or periodontal disease.  An abscess can develop even if you are unaware of any of these conditions, as only a microscopic amount of bacteria inside the tooth can cause serious symptoms.  The most common signs that you have dental abscess include:

 

  • Pain – typically in the area of the infected tooth
  • Facial
  • and intraoral swelling
  • Warmth and redness of skin overlying the abscess
  • Fevers and chills
  • Inability to open the mouth very wide
  • Difficulty swallowing food and liquids

 

 

Development of a dental abscess is considered a dental emergency because they can be very painful and in rare cases cause life threatening complications. During the six years I spent in Dallas in oral surgery residency, I witnessed several patients become permanently disabled… from a tooth abscess! Thankfully, most dental abscesses can be quickly addressed by your dentist or oral surgeon to prevent life threatening consequences.  Furthermore, the risk of serious complications from a dental infection depends upon your health status.  Pre existing conditions such as hypertension, diabetes, immune disorders, and certain medications such as steroid use may increase the risk of the infection spreading more rapidly.

 

Diagnosis
Most dental abscesses are diagnosed using clinical evaluation as well as x-rays.  Depending on the severity of the abscess, more extensive imaging may be required such as a CT scan.  If you have labs drawn, the white blood cell count is typically elevated, indicating an active immune response.

 

Treatment
A tooth abscess can be treated by removing the source of the infection.  This can be done in two ways.

 

#1 – Root canal. Cleaning the inside of the tooth with a root canal in order to remove all bacteria from the inside of the tooth.  Once a root canal is successfully finished, you should have a sterile tooth once again and your body’s immune system will no longer mount an immune response.  Your dentist can perform this procedure or she may refer you to an endodontist, a dentist specializing in root canal therapy.

 

#2 – Surgical removal of the infected tooth.  Remember, the bacteria inside the tooth causes the abscess.  If the entire tooth is removed, the source of the infection is gone and the body can heal properly.  Depending on the size of the abscess, you may also require an incision and drainage.  This procedure simply relieves the pressure that has built up and allows all the pus that has collected to drain out. Patients often find immediate relief afterwards.  This procedure can usually be done in the dental office under local anesthesia or IV sedation.  If the infection is very severe, the OR setting at a hospital is more appropriate.

 

 

I have treated many dental abscesses in my practice by removing the infected tooth with or without incision and drainage and the vast majority of patients do very well with this treatment.  After surgery, you can expect significant reduction in pain and pressure.  The swelling slowly decreases over the next few days and should completely resolve within 1-2 weeks.  Antibiotics are also an important part of treatment, the most common being Amoxicillin or Clindamycin.

 

If you suspect that you are developing a dental abscess, the best thing to do is to schedule an emergency visit with your dentist.  If you are experiencing rapidly worsening fevers, chills, nausea, difficulty opening your mouth, difficulty breathing, or swallowing, present to the nearest emergency room immediately.  Dental abscesses can be scary but if they are properly treated early, most severe consequences can be avoided.

 

To your health and prosperity,

 


Daniel Yang DDS, MD
Yorba Linda Oral & Maxillofacial Surgery

 

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