Dear Dr. Jahn: I have a 41-year-old student that has no sensation in the nasal area and doesn’t smell. She was born and raised in Germany and moved to the States a couple of years ago with her husband. As far as we know, she has never had any feeling or been able to smell. We suspect that her daughter, who is also my student, has, at least partially, the same issue, though she denies it.
We have been able to use her forehead area, where she does feel, as indicator of resonance. Her soprano voice, one of considerable size, is well supported and, for the most part, free but can only produce a straight tone. There is absolutely no vibrato. Can this be related to the possible nerve damage?
Dear Reader: This is a very interesting situation. The first thing you should know is that the nerves supplying the sense of smell and facial sensation are completely different from each other. The olfactory nerve, which supplies smell, does not have any other function in the body. Typically patients with no sense of smell also lack, or have an impairment of, taste. None of this should affect facial sensation, the perception of vibration in the mask area, or the vibrato.
If your student has no sensation in the nasal area, that is the trigeminal nerve, which is completely different. I would suggest consulting a neurologist to sort all of this out.
Of course, none of this has to do with her inability to produce a vibrato, unless normal sensation in the mask is required to sing this way. In this regard, I suggest an examination by an otolaryngologist and a hearing test.
—Dr. Jahn
Dear Dr. Jahn: I was recommended just yesterday to get my fifth tooth on the top right hand side extracted and to put a dental implant (a screw in my jaw with a crown on top) in its place. The dentist said the other option would be a bridge, but she thought it was not such a great option because they’d have to grind down and put crowns on the teeth in front and behind the fifth tooth and the tooth behind it is 100 percent healthy and would basically be crowned for no reason. The dentist said that I need to extract that tooth because on the X-ray she saw that I have an infection in the bone next to it.
That particular tooth was a root canal when I was 16 years old. I’m now 32, and I remember distinctly that the endodontist who did that root canal said it was really difficult to be sure if he got all the root out because it had a very curvy root at the bottom. My dentist now (who’s at the Ludwig Maximilian University dental clinic here in Munich, Germany) says that it looks like there was a crack under the crown in the tooth where then bacteria got into, and that could have created a cavity underneath the crown which could have led to the infection in the bone. I asked them if I could take antibiotics to get rid of the infection and they said no, because there is no vein that leads to the bone, or way to get the antibiotics into the area that’s affected to get rid of the infection.
So, what I’m wondering is:
1. This sounds like a bad idea to me as a singer, to drill a screw into my upper jawbone when:
a. It’s infected—and how will it heal if nothing can reach the infected site?
b. Plus, if it’s infected and not healing, how is bone supposed to grow around the screw once it’s screwed in?
c. The root of the tooth that would be extracted is so curvy—how am I to know that the screw won’t harm my other roots adjacent to it since the screw itself doesn’t curve to follow the path of the hole that the extracted tooth would leave?
d. Isn’t it possible that screwing something into my upper jawbone could also negatively affect my nerves and thereby my singing? Or my resonance?
e. Let’s say worst case scenario I get the implant and it doesn’t work for whatever reason—then what do I do? Is there even an option at that point besides having a huge gaping hole in my gum line?
2. Isn’t it just possible to do another root canal on the tooth to try and remedy the problem?
3. Do you think I should get a second opinion? And if I do, how do I know who to go to and who would understand what I’m worried about with this procedure as a singer?
4. Perhaps the bridge is really the best option, even if it requires making a perfectly healthy tooth into a crown?
Thank you a zillion for your advice. I can’t seem to find much anywhere online about dental implants that is positive news (it seems there are only negative reports about implants being a problem unto themselves and basically failing quite often), let alone related to the needs of a professional classical singer, so that also really makes me uncomfortable.
I recently read your entire book The Singer’s Guide to Complete Health and I thought it was spectacular, but I didn’t find anything about implants in it (darn!), so I was hoping that you could answer my question directly. Thank you again so much!
Dear Reader: It’s funny you should mention my book, since we are currently considering a second edition—and one prominent new addition would be on dentistry for singers.
Please realize I’m not a dentist, so I can only advise with general terms. I commend you on the validity of your questions, which are absolutely appropriate and really require a second opinion.
In general terms, it does not make sense to put a foreign body such as a titanium screw or other metal post into bone that may be infected. It would be less likely to heal and a foreign body would, in my opinion, prolong inflammation and may lead to failure of the implant. So, to me, the first issue would be to make sure that the host for the implant (i.e., your upper jawbone) is healthy enough to maintain and incorporate a metal post. If there’s persistent infection, this may require a prolonged (several weeks or even months) course of antibiotics. Your dentist’s point, which is the circulation is probably impaired, can be overcome with a prolonged course, possibly even given intravenously. Whether the infection or inflammation is there can be determined with a bone scan.
Apart from the infection issue, you are a young woman and the health and thickness of the jawbone should be absolutely adequate to support a successful implant. A small side issue, depending on how far back the implant is, is the relation of the end of the post (and your roots) to the floor of the maxillary sinus, but this would be determined prior to surgery with an X-ray. The shape of the roots would not, I think, be an issue in terms of placing the post.
If the above issues are resolved, I personally would opt for an implant. It has a much more natural feel and should not interfere with articulation or any other aspects of singing. It makes no sense to me to grind down a healthy tooth to put in a prosthesis that you would have to clean and live with for the rest of your life. The important thing is to find an endodontist who has had extensive experience with implants. Personally, I had an implant placed 20 years ago and have never had any problem with it.
—Dr. Jahn
Disclaimer: The suggestions Dr. Jahn provides in these columns are for general information only and are not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
