Shoulder Replacement and Teeth Grinding

Reach Out

Imagine living with arm and shoulder pain day and night, relying on narcotics to take the edge off. On top of the pain, your arm and shoulder are nearly useless—you can’t reach up and out to flip on a light switch, start your car or turn on a faucet. If you’re right handed and the problem is in your right shoulder, you switch many tasks to your left hand. The culprit: a badly torn rotator cuff coupled with degenerative arthritis.

“They may have difficulty getting a good night’s rest because they have significant pain. People have difficulty driving, difficulty putting a seatbelt on because their arm is weak and painful,” says Dr. Ernesto Luciano-Perez of Virginia Orthopaedic and Spine Specialists in Portsmouth. “People have difficulty even dressing themselves. If you’re in your kitchen cooking and you want to get something you have on your top shelf ... you have to reconfigure your whole kitchen, your whole life so you can function with your shoulder the way it is.”

Some doctors even call it a ‘gimp’ arm. Although the nerves are fine, the lack of a functioning rotator cuff means the arm is essentially paralyzed. “We use the term ‘false paralysis’ because it looks like the arm is paralyzed,” says Dr. Jack L. Siegel of the Jordan-Young Institute for Orthopedic Surgery and Sports Medicine in Virginia Beach. “The patient tries to raise his hand in front of him and all he can do his shrug his shoulders. The arm cannot come up. People say ‘I don’t want to live this way the rest of my life.’”

For those who suffer only from degenerative arthritis, a shoulder replacement can help. But your shoulder needs a functioning rotator cuff to do its job. If the rotator cuff is too damaged to repair, a conventional shoulder replacement is probably doomed to fail, surgeons say. Some patients have had multiple surgeries with no relief.

Until about eight years ago, there were no options in the United States for such patients. But since 2003, a surgery pioneered 25 years ago in France—reverse shoulder replacement—has become available in the United States and is offered in Hampton Roads. Siegel was part of the select group of orthopedic surgeons who began using the technique and training other surgeons. In a normal shoulder, the upper arm bone ends in a ball that fits into a socket formed by the shoulder blade. In a reverse shoulder replacement, the prosthetic shoulder’s socket is instead on the upper arm and the ball is on the shoulder. The reversal slightly changes the shoulder’s pivot point. That allows the patient’s functioning deltoid muscles, after physical therapy, to take over the job of the non-functioning rotator cuff, says Dr Martin Coleman of the Orthopaedic and Spine Center in Newport News.

Up to half of people over 75 have some form of rotator cuff tear, Luciano-Perez says. But reverse shoulder replacement surgery isn’t for everyone. A candidate for surgery must be in constant pain, very unhappy with the shoulder’s function and have tried conservative treatments such as injections and physical therapy without success, Siegel says. “The number one reason to do this operation is pain,” he says.

In most cases, the patient also should be over 70 with the exception being those suffering from severe rheumatoid arthritis. The patient should not be in a wheelchair or on crutches because the pressure on the shoulder to use the wheelchair or crutches could loosen the prosthetic shoulder. Siegel has operated on patients as old as 90 with good results, he says. Surgeons are proceeding cautiously, partly because there are no long-term studies in the United States on how long the device lasts. But results from Europe are encouraging, Siegel says. And the design is still being improved.

Still, for a select group of patients the procedure is life changing. Patient sleep better, see improved arm function and experience little to no pain, Siegel says. Playing basketball probably isn’t an option but patients can resume basic tasks—brushing hair, opening doors, driving and turning on lights, Luciano- Perez says.

Patients often achieve two or three times the range of motion they had before reverse shoulder replacement surgery. For range of arm motion upward, 165 to 180 degrees is normal. Prior to surgery, many patients can’t lift their affected arm beyond 40 to 60 degrees, Siegel says. After surgery and physical therapy, patients may achieve 120 degrees. Some patients continue to see improvement 18 months after surgery, he says. “They’re ecstatic,” Coleman says. Many patients say they feel better the day after the surgery—even though they’re still recuperating. “The surgery is peanuts compared to the pain they had before,” he says. “In the old days, patients were told they had to just live with it. We’ve been doing the surgery for about five years now, and we’re seeing amazing results.” Although this option is available for those in dire need, don’t ignore shoulder pain—there are often easier fixes if problems are caught earlier. If you’re having shoulder pain, tell your family physician or orthopedic doctor so you can get a torn rotator cuff repaired before it gets worse—even torn so badly there’s essentially no rotator cuff left.

“Sometimes when a doctor asks a patient, ‘How long have you been having problems?’ the response is ‘About 10 years,’” Luciano-Perez says. “Especially with rotator cuff tears, now we have the ability to get very good outcomes with minimally invasive surgery. These patients have excellent opportunities to do well. Don’t ignore the symptoms. Reach out for help early on.”


The Daily Grind

If you’ve been blaming your frequent headaches on caffeine withdrawal, eye strain or your boss, chew on this: the cause could be a bad bite.

If you wake up with a headache many mornings, you may be clenching and grinding your teeth while you sleep. The clenching and grinding could be caused by a bite that’s out of balance or you could just have an ingrained grinding habit. Either way, you’ll end up with headaches and damaged teeth. Bite problems are the most overlooked dental issue, say dentists Dr. F. Charles Stange of F. Charles Stange and Associates in Chesapeake and Dr. Lisa Marie Samaha of Port Warwick Dental Arts in Newport News.

“People think it’s normal to have two or three headaches a week because that’s what they’ve been used to for years,” Stange says. “I’ll have patients wake up in the morning with a headache and they’ll go get a cup of coffee. Caffeine fixes it, but it’s not the cause. Some will have headaches every day. Most of the time they’re on migraine medication. Clenching and grinding is probably the most damaging thing people do to their teeth, Stange says. “It destroys the supporting structure of the teeth,” he says. “The teeth eventually will become looser. Teeth will crack. Fillings will crack. You will get decay under the fillings. It will break the seal under crowns.” A bad bite also can cause pain and spasms in the neck and shoulders, Samaha says.

Samaha strongly believes that a bad bite must be balanced and brought into its ideal, natural position. “The problem is usually present because teeth do not meet in harmony with your lower jaw at the proper position,” she says. In her practice, Samaha uses painless electrical stimulation, called TENsing, to help retrain the jaw muscles for the optimal bite position. Meantime, the patient wears a custom-fitted bite guard at night to prevent clenching and grinding until the bite is in balance. The next step is to gently polish specific areas of enamel to remove interferences in the way the teeth come together, allowing the teeth to be able to mesh easily, Samaha says.

Stange also polishes and smoothes the teeth of his patients who clench and grind to help change behavior. When people grind and clench their teeth, they like to play with certain spots,” he says. Smoothing away the prominent spots removes the temptation, he says. Relaxation techniques and muscle relaxers also help.

Stange believes the main issue is not the bite, but rather the unconscious mind. People who clench and grind may do it during the day, but they do it more strongly at night, he says. “It’s not controlled by your conscious mind,” he says. “I think it is ingrained in a patient from birth. When they’re stressed, worried about something, figuring out a problem—that’s what they do. The part of the brain that is fired up when people are solving problems is right next to the part of the brain that fires the muscles when you move your jaw.”

A custom-fitted bite guard, at a cost of $400 to $700, re-trains patients not to clench and grind. “It’s not the same feeling with a bite guard in the mouth,” he says.

You can save money with a one-sizefits- all bite guard, but it won’t do you any good in the drawer with your toothpaste. “You need to have it custom made to prevent any movement of the teeth and also to make it more comfortable,” Stange says. “If it’s comfortable, you’ll use it. If it’s not comfortable, you won’t use it.”

With a dentist-directed solution and proper treatment, the headaches and other pain are gone within weeks, Stange and Samaha say. “It’s totally fixable,” Stange says. “I have a 95 percent success rate. Because it’s that simple.” Afterward, your new bite will feel different, Samaha says. “Most patients will say, ‘I never knew my teeth could fit together like this,’” she says. “You will gradually accept your new chewing position, and it will feel very acceptable, even wonderful.”

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