COMMON SENSE DENTISTRY
Louis Malcmacher, DDS, MAGD
is usually how the big-money tooth gets started. At some
point, though, this is not only about caries. It is about dental
material choices. It is certainly about bruxism.
Bruxism affects one out of three patients and is the most
common dental disease that most dentists rarely address.
Up to 265 pounds of force can be generated onto the first
and second molars as people chew. This force is a result of
the lower jaw being a Class I lever and the power of the
masseter, temporalis, and medial pterygoid muscles working
together to close the jaw. It is easy to understand why first
molars are described as the big-money teeth. It is amazing
that they ever survive!
My message to you is this: When you begin seeing big-money teeth crack, you need to ask yourself why it is occurring
(as you should with any tooth, for that matter). Is it recurrent
caries, new caries, a dental material failure, an undermined
cusp from a previous restorative procedure, or bruxism? Most
likely, it is a combination of a few factors, some of which you
and I need to treat with a new restoration or crown.
Today we have an additional advantage in being able to
treat and prevent the first molar from becoming the big-money tooth. We can now control the patient’s bruxism by
treating the masticatory muscles with botulinum toxin
(Botox or Xeomin), which will reduce the intensity of contraction and can even “cure” bruxism. The primary muscles
being treated here are the masseter and temporalis muscles
Both patients and dentists are usually amazed at the
amount of relief achieved and how much more relaxed the
patient’s jaws feel. This, in turn, takes a lot of pressure off all
the teeth, especially the big-money teeth, which will help
save tooth structure long term.
Botox is a great tool to control bruxism and save teeth.
It is time for dental professionals to realize the destructive
effects of bruxism and how much damage it contributes to
Author’s note: Go to FacialEsthetics.org to sign up for
a free monthly e-newsletter or to access information
about live-patient Botox and dermal fillers training,
frontline TMJ/orofacial pain training, frontline bruxism
therapy, dental sleep medicine, and Medicare and
medical insurance for every dental office.
DDS, MAGD, is a
practicing general dentist
and an internationally
known lecturer and
author. Dr. Malcmacher is
the president of the
American Academy of
Facial Esthetics (AAFE)
and a consultant for
STATDDS. Contact him at
(800) 952-0521 or
Boy, was he right! That small filling eventually has to be
replaced with something a little bigger and then perhaps
something bigger—until a cusp breaks off and the tooth
requires a crown. From there, many money teeth become
sensitive and require endodontic therapy and a new crown.
Many of these teeth go on to develop root fractures or secondary caries, making them nonrestorable. Then extraction is
necessary. After that, nothing happens, or a bridge is placed
that destroys the two teeth near it, or an implant is placed.
The big-money tooth usually then involves the upper first
molar, and over time, the same scenario occurs again. How
many patients do you see whose upper and lower first molars
have opposing crowns? This happens because the lower first
molar crown damages the upper first molar as a result of the
patient’s bruxism. If the lower first molars become big-money
teeth requiring restorations, those restorations can eventually
turn into four crowns on all of the first molars and more.
Most dentists never step back to ask why this happens.
Certainly, caries plays a role in this disease cascade—that
LET’S TALK ABOUT MONEY AND TEETH, especially the big-money tooth. There
is one tooth that claims the title of the big-money tooth. It is by far the most
commonly treated tooth in the mouth, there from when we are six years old. By
now you should have guessed I am talking about the lower first molar. Nos. 19 and
30 are the most commonly treated teeth. You know how it happens. These teeth
will often have deep pits and fissures early on and will require some type of small
restoration. When I was in dental school, one restorative dentistry professor had a
saying: “Every little filling will grow up to become a crown.”
First molar before
it becomes big
First molar after
it becomes big