Most patients know what an orthodontist does. Far fewer know what a prosthodontist does, or why that distinction can matter when dental problems become more complex.
In this episode of Not Just a Dentist, Dr. Rob Raimondi and Dr. Marc Sclafani explain the training, perspective, and clinical judgment behind prosthodontics. They discuss why the mouth cannot always be treated one tooth at a time and how the teeth, bite, muscles, joints, bone, facial structure, airway, and sleep can all influence the right treatment plan.
The doctors also share the story of restoring function for a 99-year-old patient, illustrating why dentistry is ultimately about much more than appearance. It can affect nutrition, communication, confidence, comfort, and quality of life.
This podcast is intended for educational purposes only and does not replace an individualized examination, diagnosis, or treatment plan from a qualified healthcare professional.
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Prosthodontics is a formally recognized dental specialty focused on diagnosis, treatment planning, rehabilitation, and the maintenance of oral function, comfort, appearance, and health.
Prosthodontists receive advanced training in areas such as:
While the word “prosthodontics” may bring artificial teeth or dentures to mind, the specialty is much broader. Its central purpose is to restore and maintain the way the mouth looks, feels, and functions.
“Cosmetic dentistry,” by comparison, describes a treatment focus rather than one of the formally recognized dental specialties. Prosthodontic training includes appearance, but it also accounts for biology, mechanics, function, comfort, and long-term stability.
A damaged tooth may look like an isolated problem. In reality, that tooth exists within a much larger system.
A comprehensive evaluation may need to consider:
This is one of the major differences discussed in the episode. Instead of looking only at the tooth causing an immediate symptom, a prosthodontic approach asks how that tooth fits into the health and stability of the entire mouth.
That perspective becomes especially important when someone has several overlapping problems, such as worn teeth, repeated fractures, missing teeth, jaw discomfort, an unstable bite, or extensive previous dental work.
A complex dental problem rarely has only one possible solution.
The doctors explain that advanced training exposes clinicians to multiple ways of approaching the same condition. When something unexpected happens during treatment, that broader foundation can also provide more ways to adapt the plan.
Just as importantly, training can help a dentist recognize when treatment should be delayed, simplified, or avoided.
A patient may arrive believing that every tooth needs to be restored, only to learn that a more conservative option is appropriate. Another patient may need orthodontic care, periodontal treatment, or evaluation by another specialist before restorative work begins.
Good treatment planning is not measured by how much dentistry is performed. It is measured by whether the care is appropriate for that particular patient.
Technical knowledge matters, but comprehensive care also requires judgment.
That judgment develops through formal education, mentorship, continuing education, repetition, and experience managing real clinical situations. It includes learning from cases that go according to plan and from those that require an adjustment.
Dr. Raimondi and Dr. Sclafani discuss the importance of seeking out mentors and continuing to learn long after dental school. The goal is not simply to master an individual procedure. It is to understand when to use it, when another approach would be better, and how each decision may affect the rest of the mouth.
One of the most interesting concepts in the episode is the difference between someone’s chronological age and the apparent age of their teeth.
A person may be 50 years old but have a mouth showing a much more advanced level of wear. Another person may be older but retain strong, stable function.
Factors that can affect this “dental age” include:
These changes do not affect appearance alone. They can influence chewing, speech, comfort, and the amount of support the teeth provide to the lower portion of the face.
When teeth become significantly worn or are lost, the distance between the upper and lower jaws can decrease. Dentists may refer to this as a loss of vertical dimension.
As that support decreases, the lower face can appear more compressed. The lips and cheeks may receive less support, and the proportions of the face may begin to change.
Skin treatments may address the surface of the face, but they do not replace structural support that has been lost within the mouth.
In appropriate cases, restoring worn or missing teeth may help rebuild that support while also improving the patient’s ability to chew and speak. The objective is not simply to create whiter or more uniform teeth. It is to restore a stable relationship between appearance and function.
The episode includes the story of a 99-year-old patient whose dentures were no longer allowing him to eat comfortably.
At that age, it might be tempting to dismiss new dental treatment as unnecessary. But the ability to chew affects the foods a person can eat. It can influence nutrition, strength, comfort, conversation, and the willingness to share meals with other people.
Creating better-fitting dentures did more than improve the appearance of his smile. It restored an important part of his daily life.
This is why the doctors describe prosthodontics as a form of longevity dentistry. The goal is not simply to make teeth last. It is to help the mouth continue supporting health, independence, and quality of life for as long as possible.
The conversation eventually moves from restorative dentistry into sleep and breathing.
The structure and position of the jaws can influence the space available for the tongue and airway. For some patients, jaw development, nasal breathing, sleep quality, and oral symptoms may be connected.
Teeth grinding is one example. Grinding and clenching can have multiple contributing factors, including stress, the bite, medications, sleep patterns, and breathing disturbances.
A mouthguard may protect teeth from direct wear or fracture. However, protecting the teeth does not necessarily identify why the grinding is occurring.
That distinction matters. When symptoms suggest a possible sleep or airway concern, a dentist may need to coordinate with a physician, sleep specialist, orthodontist, or another qualified provider. Testing and ongoing monitoring may be more appropriate than providing an appliance in isolation.
The doctors also discuss the potential value of identifying jaw-development and breathing concerns while a child is still growing.
When appropriate, early orthodontic or orthopedic treatment may help guide development rather than waiting until growth is complete. This does not mean every child requires expansion or intervention. It means that tooth position, jaw growth, breathing patterns, and available space should be evaluated together.
The best approach depends on the individual child and should follow a complete examination and diagnosis.
A comprehensive dental evaluation may be worthwhile when someone experiences:
None of these symptoms automatically points to one diagnosis. They indicate that the mouth may need to be evaluated as a complete system rather than as a series of unrelated teeth.
A prosthodontist is not simply a dentist who places crowns, veneers, dentures, or implants.
The specialty is grounded in understanding how the teeth, bite, muscles, joints, bone, facial structure, and long-term needs of the patient work together.
That perspective can be valuable when planning complex treatment, but it also reinforces a principle that applies to every patient:
The right dental plan should support how you eat, speak, feel, look, breathe, sleep, and live, both now and in the years ahead.
Because dentistry is never just about teeth.
Dealing with worn, missing, damaged, or repeatedly restored teeth? The team at One Manhattan Dental can evaluate how your teeth, bite, jaw, and existing dental work function together and help you understand the available options.
This article is intended for educational purposes only. It does not provide a diagnosis or replace individualized advice from your dentist, physician, or another qualified healthcare professional.
A general dentist is trained to diagnose and treat a broad range of oral health needs. A prosthodontist completes advanced specialty training focused on restoring and replacing teeth, comprehensive treatment planning, oral function, comfort, appearance, and complex restorative conditions.
A prosthodontic evaluation may be helpful for extensive tooth wear, multiple missing teeth, repeated restoration failures, complex implant treatment, full-mouth reconstruction, difficult denture cases, major bite changes, or a treatment plan involving several parts of the mouth.
Cosmetic dentistry describes treatments intended to improve appearance, but it is not listed among the formally recognized dental specialties. Prosthodontics is a recognized specialty that includes esthetics along with function, treatment planning, comfort, and long-term oral health.
Significant wear or tooth loss can reduce the structural support provided by the teeth. In some patients, this may affect the height and proportions of the lower face, along with lip and cheek support.
Grinding has several possible contributors. For some patients, sleep quality or breathing disturbances may be part of the clinical picture. A complete evaluation is needed to determine whether dental protection, sleep testing, medical care, or a combination of approaches is appropriate.
DR. ROBERT RAIMONDI: Welcome to Not Just a Dentist, the podcast where we move beyond the surface to explore the intricate connection between oral health, whole-body health, confidence, and longevity. I’m Dr. Robert Raimondi, co-founder of One Manhattan Dental in New York City.
DR. MARC SCLAFANI: And I’m Dr. Marc Sclafani, also a prosthodontist and co-founder of One Manhattan Dental.
DR. RAIMONDI: In each episode, we’ll bring more than five decades of combined experience to help you understand how great dentistry can support health, longevity, and quality of life. From full-mouth reconstruction and cosmetic dentistry to prevention, technology, and oral-systemic health, our goal is simple: to show why dentistry is never just about teeth.
DR. SCLAFANI: Because this is Not Just a Dentist.
DR. RAIMONDI: We’re doing something a little different today. This is going to be a more casual conversation.
DR. SCLAFANI: Yeah. We have a more organic setup today, with a few cameras around us instead of the usual format.
DR. RAIMONDI: We may even use the camera on my phone. We’ll see what happens.
DR. SCLAFANI: We’re going back to the early days. One camera, one take.
DR. RAIMONDI: We’re going to cover a couple of different things today. Let’s start with the first question and just let the conversation go from there.
DR. RAIMONDI: I think a large percentage of patients do not realize that we’re prosthodontists or what that means. People generally understand the difference between a pediatric dentist, an oral surgeon, and a general dentist. But how do we help patients understand the difference between a specialty dentist like a prosthodontist and a formally trained restorative dentist, or terms people hear like cosmetic dentist?
DR. SCLAFANI: We like to think of prosthodontists as the architects of the mouth. You could also think of us as longevity dentists. We’re the people who help coordinate care when problems arise, who think about the mouth as a whole, and who consider how the mouth relates to the entire body.
Most patients know what an orthodontist is. They know an orthodontist straightens teeth. They may know an endodontist performs root canal treatment. Prosthodontics is probably the least recognized dental specialty. Only a small percentage of dentists are prosthodontists, so there simply aren’t that many of us compared with general dentists.
Terms such as “cosmetic dentist” or “restorative dentist” are not recognized dental specialties. A dentist can be very passionate about veneers, porcelain crowns, and cosmetic work, but cosmetic dentistry itself is not a specialty. Prosthodontics is a recognized specialty, and prosthodontists receive advanced training in restorations, crowns, bridges, implants, dentures, esthetics, the bite, and comprehensive treatment planning.
DR. RAIMONDI: In dental school, everybody receives a broad foundation. There are academic courses, laboratory courses, and clinical experience. You practice on models and plastic teeth before treating patients. Once you enter the clinic, you get exposure to many parts of dentistry: restorative care, root canals, periodontal care, oral surgery, and so on.
DR. SCLAFANI: Right. Dental school gives you a foundation in a little bit of everything. Then you decide whether you want to build on that foundation through advanced training.
In dental school, you might complete a limited number of crowns or one bridge. You are often focused on restoring one individual tooth, or perhaps two teeth next to each other. You aren’t necessarily treating the entire mouth as one coordinated system.
I had a passion for restorative dentistry from the beginning. I knew early that root canal therapy wasn’t what interested me most. I had a clinical professor, Dr. [name unclear], who was deeply involved in occlusion, meaning how the teeth come together and how the bite functions. That introduced me to the temporomandibular joints, or TMJs, and to occlusion. Those concepts are the basis of full-mouth reconstruction.
I spent a full year learning about occlusion, the muscles, the joints, and how to make patients more comfortable. That became the foundation that led me into prosthodontics.
DR. RAIMONDI: Prosthodontic training is generally an additional three-year specialty program after dental school. In my case, I completed hospital-based training and then specialized through the prosthodontic program associated with the Manhattan VA and NYU. You’re taking the foundation from dental school and concentrating intensely on complex restorative care.
DR. SCLAFANI: There is formal training and there is informal training. A restorative dentist can absolutely become very capable of managing larger cases, but it takes a tremendous amount of work. They have to pursue the right courses, find the right mentors, and continually seek out experience.
DR. RAIMONDI: The specialty program compresses a great deal of clinical experience and academic study into a structured environment. You learn to evaluate the mouth, the TMJs, the bite, and the complete system rather than seeing isolated teeth.
DR. SCLAFANI: Exactly. Even though we’re about 15 years apart in our training, there was a great deal of continuity. I completed my training at NYU. You completed your advanced program through the VA and NYU. Some of the same concepts, courses, and lecturers carried through.
The key is that we were taught from the beginning to treat the whole mouth. We don’t look only at an individual tooth. We look at the bone, the muscles, the joints, the bite, and the entire system. The mouth tells a story.
A dentist without that training may look at one chapter of the story. We are trained to look at the whole book.
There are many general dentists who pursue extensive continuing education and reach a very high level. But in a specialty program, you do not have to enter private practice first and learn these lessons by trial and error. You move directly from dental school into supervised advanced training.
DR. RAIMONDI: What was your first job after training?
DR. SCLAFANI: I worked in several different types of practices. I had experience in more traditional practices and also spent time in an insurance-based environment. The contrast was enormous.
DR. RAIMONDI: In a prosthodontic program, your day is divided between academic work and clinical work. You might attend coursework in the morning and then move into the clinic at the VA hospital, where you’re treating patients under the guidance of experienced prosthodontists.
They help direct your cases. You have independence, but you are not completely on your own. They review the diagnosis, help you determine how to treat the condition, check your work, and guide you through the entire process.
Every case becomes an opportunity to learn why one option may be better than another. If you begin moving in the wrong direction, somebody is there to redirect you. You build a strong foundation while treating real patients with real problems.
DR. SCLAFANI: One of our professors used to describe the difference this way: an untrained restorative dentist may have one way to solve a problem. A prosthodontist has many ways to solve it.
Then, if something unexpected happens during treatment, the person who knows only one technique may not know how to get back on track. With a broader foundation, you have alternatives.
DR. RAIMONDI: That’s the value of managing complex cases in a supervised program before entering private practice. Things do go wrong in dentistry. When you’re learning to restore an entire mouth, you encounter complications and unexpected problems in a controlled environment, with experienced people helping you solve them.
Later, when you’re treating complicated cases in the real world, you can adapt. You’ve already seen difficult situations, sometimes in environments with fewer resources, and you’ve learned how to complete or correct the treatment.
DR. SCLAFANI: Having more options doesn’t always mean doing more dentistry.
A patient may come in after being told they need ten fillings, crowns, or even surgery. You may examine them and realize that the problem can be managed much more simply. Sometimes you can adjust or polish a few areas and make the patient comfortable without putting them through extensive treatment.
DR. RAIMONDI: Exactly. Training helps you see the complete picture and sometimes solve a problem in a much simpler way.
It also teaches you when not to treat. A patient may come in believing they need a major reconstruction, but perhaps their mouth is otherwise healthy and they first need orthodontic treatment to move the teeth into a better position. Then you reevaluate the bite.
Every decision should consider the long-term effect on the mouth. It is not just about what can be done today. It’s about how the treatment may affect the longevity of the entire system.
DR. RAIMONDI: Part of advanced training is also a mindset. Even now, we’re always trying to improve. Neither of us had a direct family mentor in dentistry. A lot of people in dental school have a parent or another family member who is a dentist. We were both looking for that mentorship elsewhere.
DR. SCLAFANI: We were first-generation dentists, so formal training helped us find those mentors.
But even without a specialty program, dentists can seek out mentorship. There are excellent educational centers and continuing education programs. The mentors are out there, but you have to make the effort to find them.
DR. RAIMONDI: I would encourage any dentist who did not complete formal specialty training to seek that out. It’s never too late, and we’re always learning. We still go into other doctors’ offices and learn from them.
The goal is not to collect credentials. The goal is to take better care of patients and give people what they need and deserve.
DR. SCLAFANI: Sometimes less is more. I’m proud of the complicated cases we complete, but I’m also proud of the cases where we prevent someone from going through unnecessary treatment.
After you’ve been in practice for decades, you begin to recognize the long-term trajectory. I tell patients I’m not only concerned about what their teeth will look like in two weeks. I care about what those teeth will look and function like 20 years from now.
DR. RAIMONDI: We’ve seen enough individual problems and enough full cases that we start recognizing patterns.
DR. SCLAFANI: After seeing thousands of patients over many years, you can often identify a pattern, anticipate the problem before it fully develops, and select treatment that helps prevent it.
DR. RAIMONDI: I sometimes joke that my days involve two things: cleaning up someone else’s mistake or cleaning up one of my own.
DR. SCLAFANI: That’s honest. The important thing is that you keep learning from both.
DR. SCLAFANI: Rob, when we say we look at the whole system rather than one individual tooth, what do we really mean?
DR. RAIMONDI: Even when somebody comes in with a small problem, we zoom out. We look at the ability to chew, the position of the teeth, the bite, the muscles, the jaw joints, the bone, the facial structure, and the airway.
Then we look at the person. What is their general health? What is their emotional relationship with dentistry? How do they want to be cared for? What is their philosophy about their own health? How is their mouth affecting their health, and how is their health affecting their mouth?
A treatment plan for someone who has a significant medical condition may be very different from the plan for someone who is otherwise healthy and may live well into their nineties or beyond. You have to consider the individual’s current condition, their goals, their likely lifespan, and what they are capable of maintaining.
DR. SCLAFANI: The benefit of advanced training is partly the number of repetitions. People talk about the 10,000-hour rule. You accumulate more experience. You learn from mistakes and successes, and ideally you remain humble about both.
That helps you treat the person in the best way possible based on your ability, their condition, their wants, their needs, and what they can reasonably manage.
DR. RAIMONDI: You learn from mistakes, but you need the right foundation. Without proper training or continuing education, a clinician can keep making the same mistake without understanding why.
The person who inspired me to become a prosthodontist, Dr. [name unclear], used to talk about judgment and experience. The basic idea was that good clinical judgment comes from experience, and experience often comes from having made imperfect judgments in the past.
DR. SCLAFANI: You don’t begin with perfect judgment. You build it. Specialty training gives you a safer, more structured place to start building it.
DR. RAIMONDI: I think of the prosthodontist as a longevity dentist. Who is better positioned to take a patient through life, keep the mouth stable and healthy, connect with the appropriate specialists, and make sure oral care complements the person’s overall health?
We track so many markers now. People monitor VO2 max, blood tests, sleep, and other indicators of health. But many people are not closely tracking what is happening with their teeth, bone, gums, and ability to eat.
You can reach your eighties or nineties and discover that you cannot eat properly because the mouth has broken down. We also see more people in their fifties and sixties with mouths that appear far older than their chronological age.
DR. SCLAFANI: You recently mentioned one of your youngest patients was around nine years old.
DR. RAIMONDI: Yes. The patient was referred by a general dentist who did not feel comfortable managing the case. When you treat a nine-year-old, you’re not thinking only about the nine-year-old sitting in front of you. You’re thinking about that person at 19, 29, 39, 49, 59, and beyond.
The decision that seems easiest at age nine may not be the best decision for that patient at age 39. Treatment for a nine-year-old is completely different from treatment for a 39-year-old. You have to connect those stages of life.
DR. SCLAFANI: One of the biggest conversations in longevity is the difference between biological age and chronological age. Someone may say, “I’m 51, but biologically I’m 39.”
We should ask the same question about the mouth: What is the age of your teeth relative to your chronological age? How do we maintain them properly? If the mouth is aging too quickly, how do we correct the problems and bring that dental age closer to the rest of the person?
DR. RAIMONDI: Everybody is trying not to age. They monitor fitness and health data, and they use skin treatments, injectables, or surgery. But people may not address what is happening to the structural foundation of the face when the teeth wear down or the bite collapses.
DR. SCLAFANI: Let’s explain vertical dimension in simple terms. Imagine measuring the distance from the bottom of the nose to the chin. If a person has no teeth or severely worn teeth, that distance can collapse.
When the space between the nose and chin decreases, the proportions of the lower face change. The face looks more compressed, and the skin and soft tissues lose support.
As architects of the mouth, we may rebuild the vertical dimension toward where it was originally. People can have fillers, Botox, or even facial surgery, but those approaches cannot fully compensate if the internal dental structure has collapsed.
DR. RAIMONDI: And it is not only cosmetic. Lost vertical dimension can affect chewing, speech, comfort, and the way the jaw functions.
By restoring the teeth appropriately, we can sometimes take years off the appearance of the face while also restoring function. That affects the person’s dental age, facial age, ability to chew, confidence, and comfort.
DR. SCLAFANI: This is not simply about placing veneers to make the front teeth whiter. If the face has collapsed, adding veneers to a few teeth does not necessarily restore the underlying structure.
DR. RAIMONDI: Bone loss also matters. Loss of bone can change how the teeth look, make the teeth appear longer, alter the gums, affect facial support, and change function. It all comes together as one package.
DR. SCLAFANI: Missing teeth are part of that conversation too. Choosing whether to replace a tooth with a bridge, implant, or another option can affect the mouth over time. The right decision depends on the individual situation, not simply on what is fastest or least expensive today.
DR. RAIMONDI: Restoring the mouth with implants, crowns, veneers, or other treatment, when it is truly indicated, can help improve the apparent biological age of the mouth relative to the rest of the person.
But patients need the right professionals evaluating the situation and the right end goal. Losing vertical dimension is not only an esthetic issue. It affects how you eat and may affect how you speak. If the bite has collapsed, the impact can extend into many parts of daily life.
DR. RAIMONDI: Think about the patient we’re treating together now. He’s 99 years old. He wears a complete upper denture and has only a few lower teeth remaining.
His wife brought him in because he could no longer eat properly. At 99, the concern was not primarily how the teeth looked. It was function. His denture had become so unstable that he would take it out to eat and try to chew with his gums.
They still go out to restaurants. They’re still social. But this dental problem was beginning to keep him from participating in those experiences.
DR. SCLAFANI: So by restoring the vertical dimension, the position of the teeth, and the ability to chew, we’re making him younger in a meaningful sense.
DR. RAIMONDI: Exactly. We’re supporting his ability to maintain nutrition, preserve strength, go to restaurants, talk to people, and spend time with friends and family. The mouth should be part of anybody’s longevity philosophy and longevity plan.
The first priority is removing infection and disease, but it also includes the appearance of the teeth, the function of the teeth, and the psychological role the smile plays.
DR. SCLAFANI: How many times do we see a husband come in with his wife and initially downplay how much the teeth matter?
DR. RAIMONDI: I had a patient yesterday who is missing a front tooth because of trauma. I showed him a preview of what we could do. His wife was there, and she immediately understood how significant the change would be.
He’s scheduled to begin treatment next month. Until that moment, he had been minimizing how much the appearance of his teeth affected him and how much it had changed the way he felt about himself.
DR. SCLAFANI: After treatment, patients often say, “I never realized how much my teeth, my smile, or the way my teeth functioned affected the rest of my body and the way I felt.”
They smile more. They have more energy. Their spouse may tell us they seem like a different person. We may convince ourselves that appearance does not matter, but once the problem is corrected, we realize how much emotional energy was being spent hiding it.
DR. RAIMONDI: Restoring the way somebody looked when their teeth were healthier and younger can restore more than a smile. It can change confidence, social behavior, energy, nutrition, and overall well-being.
DR. SCLAFANI: People may spend a tremendous amount of money on anti-aging treatments for the face and never address a major structural source of aging, which is the teeth and the bite.
Restoring vertical dimension does not only improve the smile. In an appropriate patient, it can make the whole face appear years younger.
You had a patient recently where you used restorations to rebuild the entire bite and restore vertical dimension. The change was not simply a set of new teeth. The patient looked younger, could eat more comfortably, and the facial tissues had better support.
DR. RAIMONDI: We can restore the lower third of the face. That can affect energy, confidence, health, and well-being.
One of the tools we sometimes use during a consultation is very simple. We may place small rolls of cotton between the teeth to slightly open the bite. The cheeks and lips receive more support, and the patient gets a brief preview of what their face may have looked like before the collapse occurred.
Of course, the actual treatment has to preserve bone and use properly designed restorations. But when it is indicated, rebuilding that support can have a broad impact on someone’s life.
DR. SCLAFANI: Rob, after all of my training and more than 30 years in practice, one of the things that still surprises me is how often a patient comes in with what appears to be a dental problem, but the larger problem is sleep.
They have grinding, cracked teeth, headaches, or jaw pain, but the issue is not only the teeth. It may involve the airway.
Let’s talk about how the airway affects sleep and why grinding is not always simply a random habit.
DR. RAIMONDI: Sleep is foundational. People use sleep trackers and look at their sleep every day because they understand how important it is.
The mouth can have a major relationship with sleep. The size and position of the jaws can affect the volume of the airway. Grinding during the night and pain in the morning may occur because someone cannot breathe well, because of stress, or because of a combination of factors.
When sleep is disrupted, the body has less opportunity to heal and recover. The brain’s normal waste-clearing processes are affected. Inadequate sleep has associations with cardiovascular health, immune function, cognition, mood, and how well a person functions during the day.
Dentists are often in a position to notice the signs, diagnose the dental consequences, and help direct the patient toward appropriate treatment.
DR. SCLAFANI: Sleep is a newer part of the conversation for many dentists. I’ve been practicing for more than 30 years, with formal training in TMJ treatment and splint therapy. I’ve made mouthguards throughout my career, and I have changed the way I think about diagnosing these problems.
Grinding is not always random. It may be related to the airway. The anatomy of the airway matters. The brain may be sending a survival signal that causes the lower jaw to move and the muscles to activate in an effort to open the airway.
People do not necessarily grind for no reason. Grinding may be a symptom of a larger problem.
A mouthguard alone is not always the answer. It may protect the teeth, but if the underlying cause is an airway problem, the airway still needs to be addressed.
DR. RAIMONDI: Most people assume grinding is stress. Stress may absolutely contribute, but it can also be an airway issue.
The positive development is that we can evaluate more of this now. A CBCT scan can help us assess the anatomy of the airway and the jaws. In a child, early recognition may allow appropriate orthodontic or developmental treatment while growth is still occurring.
Most people have simply been told to wear a nightguard. Very few have been asked why they are grinding.
DR. SCLAFANI: Some people think, “This is just what I do,” or, “I grind when I’m stressed.” They receive a nightguard and believe the problem is handled.
DR. RAIMONDI: The guard may protect the teeth from some of the mechanical damage, but it does not necessarily treat the source of the problem.
During an initial consultation, we may see flat wear facets, worn enamel, small cracks, or abfractions near the gumline. Those are fingerprints left by years of clenching and grinding.
Much of that activity happens during sleep, when the jaw moves backward into a more retruded position. The body may then move or clench the jaw in an attempt to breathe more effectively.
DR. SCLAFANI: This is where sleep-tracking data can be useful. People may use an Oura Ring, a smartwatch, or another device and notice repeated awakenings or poor recovery despite spending enough time in bed.
We also have to be careful with the design of a dental appliance. A poorly selected upper mouthguard can sometimes allow the lower jaw to fall farther backward and potentially worsen airway restriction. Other appliances are specifically designed to advance the lower jaw and help open the airway.
DR. RAIMONDI: When somebody comes to us and says, “I think sleep is an issue,” or their physician suggests speaking with a dentist, we begin by looking at several things.
First, are they breathing through the nose or the mouth? If nasal breathing is difficult, is there a structural problem in the nose? Is there an obstruction? Is mouth breathing simply a long-standing habit, or is it a response to an anatomical limitation?
Then we evaluate the face, the position and size of the jaws, the teeth, the bite, and the TMJs. Sleep apnea is not only a condition affecting older, overweight men. It can affect women, younger people, fit people, and children.
You cannot assume the cause based on appearance alone. There may be an anatomical issue, a nasal issue, a jaw-position issue, a bite issue, stress, or a combination of factors.
The dentist may be the first person to recognize the signs, but that does not mean the dentist should treat every part of the condition alone.
DR. SCLAFANI: I saw a patient recently who was mouth taping because she had heard it could improve sleep. She also wears a sleep tracker, but her sleep numbers remained poor.
She was confused because she was spending about nine hours in bed, taping her mouth, and still not getting restorative sleep.
We started by asking whether she could breathe comfortably through her nose. She wasn’t sure. When she paid attention to it, she realized that nasal breathing felt difficult.
There are things we can evaluate from a dental perspective, including the palate, tongue position, jaw relationship, and oral structures. But the next step is not simply to tell her to keep taping.
We’re arranging a home sleep study to determine whether sleep-disordered breathing is present. Depending on the findings, she may also need evaluation by an ENT physician or another sleep professional.
Mouth taping is a popular topic, and nasal breathing can be beneficial when the airway is open and the person can breathe normally through the nose. But if somebody truly has an airway obstruction or sleep-disordered breathing, forcing the mouth closed without understanding the problem can be the wrong approach.
DR. RAIMONDI: You had foundational TMJ training before completing prosthodontics. When someone has a TMJ issue, how can an appropriately designed appliance help?
DR. SCLAFANI: First, not every patient who needs a nightguard has a sleep disorder. Many patients have occlusal or muscular issues without sleep apnea.
The TMJ is influenced by several systems at once: the muscles, the airway, the bite, stress, posture, and the position of the jaws. Some clinicians treat each problem in isolation, but we try to look at the complete picture.
When someone clenches and grinds, the muscles often become symptomatic first. The masseter muscles in the cheeks and the temporalis muscles at the temples may become overworked and painful. Patients develop muscle spasms, facial pain, headaches, or discomfort that can extend into the neck.
Then the teeth begin to show damage. We see cracks, worn enamel, failing restorations, and changes in the bite. As the teeth wear down, vertical dimension can be lost, which may increase the strain on the system. It becomes a chain reaction.
In the appropriate patient, an appliance can slightly increase vertical dimension, redistribute force, reduce stress on the muscles, and reduce load on the joints. If the person does not have an airway problem, that may provide significant relief.
DR. SCLAFANI: I recommend that patients monitor sleep when possible. We do not want to place an appliance that protects the teeth but worsens sleep-disordered breathing.
For patients who do not have a sleep issue, we can make excellent conventional appliances to protect the teeth and support the muscles and joints.
For patients who may have an airway issue, we coordinate with physicians and sleep specialists. We review sleep-study data and CBCT imaging, evaluate the airway, and determine the appropriate collaborative approach.
Sometimes treatment involves an appliance. Sometimes it involves CPAP. Sometimes it involves changes in sleep hygiene, nasal treatment, medical care, or a combination of approaches.
DR. RAIMONDI: CPAP remains one of the most effective ways to deliver positive airway pressure when it is indicated. Another option for selected patients is a mandibular advancement appliance.
That is not simply an upper and lower mouthguard. The two components are connected in a way that prevents the lower jaw from falling backward and holds it forward to help open the airway.
The patient should complete the appropriate sleep study, use the appliance, and then be tested again while wearing it. We need objective information showing that the treatment is actually working.
DR. SCLAFANI: When we address cracked teeth, headaches, grinding, and clenching in the proper way, we can improve more than a dental symptom. We may support better breathing and sleep, help people function better during the day, improve how present they are with their families, and prevent additional breakdown of the teeth and supporting structures.
It all comes together.
DR. RAIMONDI: My practical advice is to use some type of sleep tracker if you’re concerned about grinding, clenching, or poor sleep. It could be a ring, a watch, or another validated device. It is not a diagnosis, but it can help identify patterns and give you useful information to bring to your doctors.
DR. SCLAFANI: You recently had a patient with one of the less expensive versions of a sleep ring, right?
DR. RAIMONDI: Yes. It was around $60 and had a similar-looking platform. The biggest issue was that the charge did not always last through the night.
DR. SCLAFANI: That’s the tradeoff.
DR. RAIMONDI: My score was an 85 last night, a 90 the night before, and a 94 before that.
DR. SCLAFANI: Now you’re showing off.
DR. RAIMONDI: The point is that the data can make you pay attention. Maybe you had a glass of wine, ate too late, were dehydrated, or had another change in your routine. You can begin to see what affects your sleep.
DR. SCLAFANI: Think about sleep issues as more than grinding. If you’re grinding, chipping your front teeth, waking with headaches, or having jaw problems, do not ignore it.
Talk with your medical doctor. Talk with a dentist who has the appropriate training. There may be more to the problem than simply protecting the teeth.
DR. RAIMONDI: Great. Please keep sending us the topics you want us to discuss. Let us know what is working and what isn’t.
Connect with us, whether you’re a dentist, a patient, or simply interested in these subjects. We want to help you understand the message and be a partner in your health.
DR. SCLAFANI: Not just your dentist, but a partner in helping you understand how these issues fit together.
DR. RAIMONDI: We’ll see you next time.
