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The Dental Exam

Regular dental exams find problems before they become invasive and expensive.

Regular dental exams find problems before they become invasive and expensive.

Overview

Dental exams are recommended on an annual or bi-annual basis, depending on the preference of the patient and the dentist. While many patients want to get their teeth cleaned or bleached without having an exam, this would be considered a breach in the State Dental Board’s “Standard of Care”.

The Dental Exam

The dental exam includes the following steps:

  • A review of the medical history. All changes in the patients’ medical history and/or medications are recorded and signed by the patient.
  • Dental x-rays taken yearly or a full mouth x-ray depending on the dental health of the patient. This allows inspection of the areas between the teeth and the roots of the teeth which is used for comparison with x-rays taken in the past. Any complaint of jaw pain may indicate a Panorex X-ray be taken to view the jaw joints and surrounding area.
  • A visual inspection of the teeth.
  • A periodontal exam reviewing the attachment depths of gum tissue around each tooth (measurements should be done once a year for normal or healthy patients and every three months for patients in for periodontal maintenance treatment).
  • An oral cancer exam (see Oral Cancer).
  • Your baseline blood pressure taken once a year is now considered the standard of care.
  • Documentation of all existing conditions is usually done at the Comprehensive Exam.
  • Limited exams focus on the a limited problem (toothache, fracture, etc.) that usually brings the patient into the office as an emergency.

Only after this exam will your Dentist discuss treatments that may be required for any issues discovered during the exam; the exam also eliminates the possibility of bleaching a tooth that has a Cavity (Tooth Decay), which would cause intense sensitivity.

Oral Cancer

Overview

Oral cancer is a common health risk existing in our population; the dental and medical professions have done little to bring it to the attention of the public. The five year survival rate for oral cancer has not improved much in the past 50 years. The best method for addressing and preventing this troubling condition is early detection and treatment. Routine dental visits and regular oral cancer exams are your best protection.

The oral cancer examination

Examination for early detection of oral cancer and tissue changes should be a regular part of your dental care. At the first sign of any abnormality, the dentist must decide whether to schedule the patient for a follow up exam (to check if there have been changes to the suspected tissue), perform a biopsy or refer to an Oral Surgeon for a second opinion and/or biopsy.

The oral cancer examination may include:

  • Inspection of your hairline, the top of your ears, and over your nose; visual inspection of your scalp if your hair is thinning or if you have bald spots. These areas have had the greatest exposure to sun.
  • Palpation (as defined in the American Heritage Dictionary: to examine or explore by touching) of your lymph nodes in the neck and the area around the back of the neck
  • Inspection and palpation of your upper and lower lips
  • Inspection and palpation of your inner cheeks
  • Inspection of all the gum tissue around all of your teeth
  • Inspection of your entire tongue (the top and bottom); your dental health professional should use a piece of gauze to gently pull your tongue out for inspection of the sides (31% of all oral cancers are found on the lateral borders of the tongue). Palpation of the entire tongue (between 1985 and 1996, 30% of all oral cancers were found on the tongue)
  • Inspection of the floor of your mouth and palpation with two fingers: one inside the mouth under the tongue and one on the outside of the mouth, under the lower jaw. This allows the two fingers to press against one another to feel for any irregularities.
  • Inspection of your hard palate; palpation of your hard palate, feeling for either lumps or areas where bone may be absent
  • Inspection of your soft palate by asking you to say “ah” and watching for your soft palate to move. A mouth mirror should be used to inspect the area behind the soft palate.

Statistics on oral cancer

  1. For all stages of oral and pharyngeal cancer, the:
    • one-year survival rate is 82%
    • five-year survival rate is 59%
    • ten-year survival rate is 48%
  2. The Caucasian survival rate is 55%; the African American survival rate is 31%.
  3. Worldwide, oral cancer is the sixth most common cancer.
  4. In the oral and pharyngeal cancers are responsible for 35,000 cases and 7,600 deaths per year.
  5. About half of these cases are found in the oral cavity; cancer of the oral cavity is more common than cervical and ovarian cancer, Hodgkin’s Lymphoma, or leukemia.
  6. The average age of diagnosis is 63, with 96% of oral cancer being diagnosed after age 40 and 60% after age 65.
  7. Male-to-female ratio of oral cancer diagnosis is 2:1 with a ratio of 1:1 with advancing age.

Highest to lowest area of the incidence of oral cancer

  1. Sides of the tongue (lateral border of tongue)
  2. Lips
  3. Glands that produce saliva (salivary glands)
  4. Under the tongue (floor of mouth)
  5. Inside the cheeks and lips (buccal mucosa)
  6. The gums (gingiva)
  7. The roof of the mouth (palatal mucosa)

Risk factors associated with oral cancer

Highest risk factors: (combine any of these and chances increase by 30%)

  1. Tobacco of any kind
  2. Alcohol (ethanol beverages or mouthwash)
  3. Viruses: HPV16, HCV
  4. Age
    • More than 95% of oral cancers occur at or over age 40
    • More than 83% of oral cancers occur over the age of 55
    • Men 63 years old or older
    • Growing concern for young women in their 20’s
  5. Gender – M: F = 2:1
  6. Ethnicity – African American: Caucasian = 2:1

Secondary risk factors:

  1. Chronic inflammation, trauma (such as an ill-fitting denture or partial)
  2. Immunosuppression/solid organ transplant
  3. Nutritional deficiencies
  4. UV light

9598195

Rhodus, Dr. Nelson L. DMD, MPH (2009). Oral cancer: improving outcomes. Compendium of Continuing Education in Dentistry, 30(8), 486-499.

Rhodus, Dr. Nelson L. DMD, MPH. “Dental Management of Medically Compromised Patients.” Minneapolis, Minnesota. 5 Nov. 2010. Continuing Education, University of Minnesota.

Mouthwash/Toothpaste

 

Overview

We have come a long way in the development of toothpaste and mouthwash. Products today include the following ingredients:

  • Fluoride, which is proven to significantly reduce tooth decay
  • Hardeners to strengthen (recalcify) enamel softened by acid
  • Ingredients that help neutralize acid from foods and bacteria
  • Ingredients that interfere with acid metabolism in bacteria
  • Anti-bacterial agents

Fluoride

Fluoride is absorbed by the surface of the tooth, which includes the enamel covering the crown of your tooth and the surface of the root (cementum, see Parts of a Tooth), in the case of people with root exposure. Dental fillings called glass ionomers (see Fillings) also absorb fluoride and release it over time around the margins of the filling, helping to prevent future decay. Most over-the-counter toothpastes contain fluoride, and most dental professionals would recommend it for daily use.

Today we have a number of products with higher concentrations of fluoride intended for daily use by individuals with a high cavity rate and tooth sensitivity. When your dentist or hygienist recommends a more concentrated level of fluoride mouthwash or toothpaste, it is given as a prescription.  The prescription is used in addition to the topical application found in toothpaste and the fluoride applied by the hygienist during your dental appointment.

Fluoride in mouthwash or toothpaste is a topical form of fluoride use; systemic fluoride is incorporated into the developing tooth bud prior to its appearance in the mouth. Fluoride mouthwash and toothpastes are a topical form of fluoride, and repeated use will not harm the teeth in any way.

Tooth Hardening Biological Agents

Tooth hardening (recalcifying) mouthwash and toothpastes contain biological agents that help restore teeth that have softened from some form of acid. Acid attack (see Acid Erosion and Tooth Decay) can result from several sources:

  • The combination of bacteria, sugars, tooth structure and time
  • Acidic fruits, fruit juices, and other foods
  • The addition of lemon or lime to beverages
  • The phosphoric acid that is a primary ingredient in carbonated beverages (carbonated water, regular soda, and even diet soda). With repeated use, anything carbonated beverage will break down enamel.
  • Coffee, tea

Saliva contains natural ingredients which work to harden (recalcify) areas of your teeth softened (decalcified) by acid from bacteria or food. Problems occur when this process cannot keep up with consumption of acidic fruit, fruit juices, carbonated beverages, and/or poor oral hygiene. Regular use of the newly developed mouthwash and toothpastes can help keep your teeth stronger and healthier.

Xylitol

The addition of xylitol to toothpaste, mouthwash, and even gum has revolutionized the battle against tooth decay. Xylitol does not kill the bacteria, but it renders the bacteria 1) unable to metabolize sugars, therefore they cannot produce acid and 2) it interferes with the production of the glue-like substance that helps bacteria stick to teeth. Bacteria that are unable to stick to teeth cannot damage the tooth.

Antibacterial mouthwashes/toothpastes

Antibacterial products kill bacteria and create an environment where bacteria cannot reproduce and adhere to surfaces of teeth causing disease. Most of these mouthwashes are intended to treat gum disease (gingivitis and periodontal disease). Bacteria cannot be permanently eliminated; the goal is to help control and reduce the number of harmful bacteria. Swishing with mouthwash never replaces brushing and flossing. For those patients who won’t floss, a capful of antibacterial mouthwash added to the water in the waterpik reservoir, sprayed between the teeth is a good alternative.

Mouth-wetting mouthwashes/toothpastes

There are a number of medical disorders and medications that cause the mouth to produce less-than-desirable amounts of saliva. When the flow of saliva is decreased, the number of bacteria in the mouth increases. When the number of bacteria is increased, the incidence of dental disease increases as well.

A number prescription drugs – among them ones prescribed for high blood pressure, depression, anxiety, and heart disease – cause dry mouth (see Dry Mouth). Patients are often not fully informed about the problems that can occur when their mouth dries out. Saliva helps neutralize acid and supplies natural biological agents needed to harden and strengthen (recalicify) tooth enamel, so when saliva production decreases, these protections decrease as well. Decreased saliva permits bacterial numbers to increase which often leads to an increase in cavities and gum disease. Unless you have impeccable oral hygiene and have spent your early childhood in an area that supplied fluoridated water, the problem can be devastating.

Mouth-wetting mouthwashes and toothpastes help replace the reparative properties of natural saliva. They contain salivary enzymes, antibacterial properties, and agents that help neutralize substances made by bacteria that cause mouth odor.

Leukoplakia

Overview

Leukoplakia is a white thickening of the skin on the tongue, gums, floor of the mouth or inside of the cheeks due to some type of chronic (ongoing) irritation. This thickening occurs because of excessive cell growth.

Causes

  • Cigarette or cigar smoking
  • Chewing tobacco
  • Chewing the inside of the cheek
  • Ill-fitting dentures or partials
  • Broken, jagged teeth or failing fillings
  • Orthodontic wires (Braces)

Treatment

In order to treat this oral condition, your dentist must first identify and eliminate the cause. Most often, this means ending tobacco use; changing dental habits; and carrying out the recommended treatment, such as fillings, crowns, and/or replacement of ill-fitting dentures and partials.

The danger with this condition is that it is precancerous and should be monitored every three to six months following its correction. This is not to be confused with Linea Alba.

Leukoplakia is an area (vs. a line) of white, tissue that has been described as a ‘lacey-like looking area. Linea Alba is the thin white line (linea meaning “line” and alba meaning “white”) that runs along the inside of your cheek, demonstrating where your upper and lower teeth come together.

 

Lasers in Dentistry

 

Overview

Lasers have been around for a long time in medicine and more recently in dentistry. There are several types of lasers useful to dental treatment; when used correctly, lasers become an invaluable too, creating more comfort during treatment and less discomfort following treatment.

Use of lasers in dentistry:

  1. Extractions (see Oral Surgery) – the laser can be used in place of a scalpel and a handpiece. In simple extractions, using a laser around the neck of the tooth to move the ligament fibers that are firmly attached to the tooth enabling the clinician to easily remove the tooth. In more difficult extractions, the laser can remove both ligament fibers and move bone to gain better access to the tooth for removal.
  2. Crown preparations- the laser can be used to stop bleeding and move the tissue away from the finish line the clinician establishes prior to taking an impression needed for the construction of the crown.
  3. Tooth decay/fillings Lasers can remove tooth decay and as the laser is being used, it anesthetizes the tooth and allows the clinician to pick up a handpiece or a dental spoon to remove the last amount of decay comfortably.
  4. Deep decay traditionally, deep decay is usually isolated and medicated, a procedure called an indirect pulp cap.       Instead of placing a medication over the deep decay (and close to the nerve chamber: pulp), a laser can be used over the deep portion of the decay to kill any remaining bacteria.
  5. Braces (Orthodontics) Lasers can be used to safely move teeth during treatment. The laser is used over the gum tissue that covers the bone in the area of the desired tooth movement. When teeth are moved too rapidly in conventional orthodontic treatment, the roots of the teeth can become shortened, sometimes so much that the teeth can become loose. A better alternative to safely shorten treatment time is the use of a laser.
  6. Cold sores and canker sores Lasers will shorten the duration of either of these annoying situations.
  7. Biopsies- Soft tissue biopsies are more comfortably treated when taken with a laser rather that a scalpel.
  8. Root canal treatment (Endodontics) We now know that there are numerous tiny canals inside most teeth. The main canals can be seen on x-rays, but the tiny accessory canals cannot be seen until the canals are filled with sealer cement, used at the end of the cleaning of the main, visible canals.       If the tiny accessory canals are unable to be thoroughly cleaned during the root canal treatment, the treatment can fail, requiring retreatment or even extraction of the tooth.       The light emitted from lasers can be used down inside the tooth to kill bacteria in the tiny accessory canals and allows the sealer cement to fill these extra canals, improving the outcome of treatment.
  9. Gum disease (Periodontal treatment) Perhaps the most incredible use of lasers is the advances it has made in treating gum disease. Lasers effectively kill bacteria and destroy the toxins produced by these bacteria; further, they create an environment whereby the bone regrows and the ligament reattaches to the tooth root. It isn’t a cure, but a reversal of the disease process that can be monitored and controlled by appropriate visits and home care.
  10. Tightening of skin- There is a new laser being introduced in dentistry that can tighten skin on the lips, cheeks, jowls, all from inside the mouth. No cutting and non-invasive.
  11. Snoring – Lasers can be used inside the throat area to reduce the incidence and severity of snoring.
  12. Silver fillings This is the one area of dentistry that lasers cannot be used. Silver fillings are metal and the light emitted from lasers would be reflected from the metal surface, damaging the laser.

Professional use of lasers

The use of lasers in dentistry requires training and understanding of their use and limitations. Minimally invasive and kinder to the oral tissues, it’s easy to see why the body’s reaction to use of the laser is more favorable. Certification can be sought through the Academy of Laser Dentistry.

Parts of the Tooth

Tooth-Parts1Your tooth is made up of two primary structures: the crown (the part seen in the mouth), and the root (the part of the tooth that is in bone). The crown is covered with enamel, and the root is covered with cementum. The part of the tooth where the crown and the root come together is called the cemento-enamel junction.

Enamel is that part of the tooth covering the crown seen inside the mouth. Enamel is the hardest substance in your body; enamel is even harder than bone. Enamel is made up of prisms (a transparent solid with a triangular base and rectangular sides), allowing light to enter and be reflected back out, a characteristic that makes healthy teeth look pretty, creating a pleasing smile.

Enamel itself has no feeling; there are no nerves or blood vessels attached to the enamel. Any pain felt occurs through an opening in the enamel caused by wear (attrition), a crack, fracture, or decay that exposes the layer under the enamel, called the dentin.

Dentin is found under the enamel and cementum. Passages (call tubules) containing soft fibers run just under the enamel through the dentin tubules to the pulp or ‘nerve chamber’. When stimulated by bacteria (such as those found in a cavity), hot, cold or acidic foods, these fibers stimulate the nerve causing pain or sensitivity in your tooth.

The root is covered by cementum and embedded in bone; which is cushioned by a tissue called the periodontal ligament. Fibers of the ligament run from the cementum covering of the root to the bone. At the end of the root (called the apex), there is an opening where a nerve, artery and vein enter the tooth, running up the roots (root canals) and ending in a space that called the pulp chamber. The nerve brings the sense of feeling to the tooth, the artery brings oxygen rich blood to the tooth and the vein carries oxygen depleted blood away from the tooth.

 

Cracked Tooth Syndrome

Overview

This oral condition is best described as pain that occurs while either biting down or releasing a bite. The crack may or may not be visible and is rarely seen on an x-ray. If it is visible, it is usually seen as a vertical hairline crack; if it is not visible, it can usually be detected with the assistance of a “tooth sleuth”. If your tooth is cracked, it usually causes you to chew your food on the opposite side of your mouth and/or avoid certain foods on the affected side. The diagnosed condition is called Cracked Tooth Syndrome. All teeth have cracks, the majority of which experience no pain.

Symptoms

  • A sharp pain that occurs either when biting down or when the bite is released
  • The pain does not usually linger; rather, it disappears quickly when chewing stops. The pain occurs because the crack is opened when biting, and if fluids enter the open crack when you release the bite, they create pressure against the dentin on the inside of the tooth. Dentin shares a close association with the nerve inside your tooth, and when stimulated, the nerve experiences pain.
  • If you find yourself chewing food on the opposite side of your mouth and/or avoiding certain foods on the affected side
  • The tooth may also be sweet- and temperature-sensitive; this sensitivity is caused when the crack is wide enough to allow sweets and temperature to reach the dentin.

What is a tooth sleuth?

A tooth sleuth is a plastic tool that can isolate and help locate a crack because it isolates the cracked cusp on the biting surface of the tooth. By systematically placing the sleuth on each cusp and asking you to bite down, a dentist can determine if your tooth has a crack. The area where the crack is located can be determined with the aid of a tooth sleuth.

What causes the tooth to become cracked?

  • Bad habits such as chewing on ice, pens, pencils, jaw breakers, etc.
  • The chronic grinding of your teeth
  • A blow to the mouth
  • The weakening of your tooth due to overly large fillings
  • The brittleness of your tooth following a root canal treatment. The pain you experience may be coming from the periodontal ligament because the tooth itself is dead. If the crack extends to the area of the periodontal ligament, your dentist may recommend a crown immediately.
  • Misaligned teeth receiving more stress than is acceptable during chewing

Treatment of cracked tooth syndrome.

  • The treatment of a cracked tooth depends on the size of the crack and the ability of the dentist to eliminate the problem causing the crack
  • Minor cracks may be treated with desensitizers, but without eliminating the cause, the crack will probably recur and worsen
  • Typically, the placement of a crown will keep the crack from opening and will alleviate the pain
  • There is no way of knowing if the crack extends below the bone level; only time will tell once the crown is placed. If the problem persists over time following crown placement, you may be experiencing a complete vertical fracture and your tooth may not be salvageable.

The most important thing to remember is that most dental expense is caused by putting dental visits off. Visit your dental professionals regularly to catch problems early and keep expense down.

Crowns

Overview

A crown, as the name implies, does not sit on top of the tooth; it covers three-quarters, seven-eighths or the entire tooth. Crowns that cover three-quarters or seven-eighths of the tooth are made out of metal or porcelain, and are used when a portion of the tooth is still healthy and does not need to be covered. This article focuses on full-coverage crowns. There are a number of different materials used to construct full-coverage crowns.

Your tooth is prepared for a crown by reducing the size of the tooth, usually under local anesthesia. A small cord is then packed under your gum around the preparation to allow the crown margin to be seen (the “finish line” where the crown stops and the tooth continues: where the crown and tooth come together). The instructions for constructing the crown are made by the dentist and sent by written prescription to a laboratory by one of two methods:

  1. By far the most common method today involves an impression of your prepared tooth. The dentist uses a syringe to place a putty-like material around your tooth; the material then hardens around the tooth, creating an impression of the shape of the tooth preparation.
  2. Technology now provides dentists with the ability to scan the prepared tooth into a computer. The image is sent electronically to the laboratory for construction of the crown.
  3. Today’s technology also allows the crown to be scanned and milled from a block of material in the dental office and placed on the tooth the same day.

Why do you need a crown?

A crown is usually needed:

  • When a portion of your tooth fractures off
  • When a fracture line (a crack) runs deep into the tooth structure, causing pain when you chew (see Cracked Tooth Syndrome)
  • When a filling is too wide or when more than 50% of the biting surface is covered with a filling
  • When a root canal treatment has been performed, it is widely accepted that a tooth that has gone through root canal treatment is more brittle (because it is dead). To prevent fracture, a crown is recommended.
  • When you or your dentist want to improve the positioning of a tooth, without moving the tooth/teeth orthodontically. (see Braces)
  • When a tooth is needed to anchor a bridge (see Bridges)
  • When a tooth has tipped over time and a partial denture needs to be placed; a tooth can be prepared for a crown to upright it,, improving the placement of the removable partial
  • When a tooth has no opposing tooth to stop it and, if an upper tooth, has dropped down too far, or, if a lower tooth, has drifted up too far, a crown can be placed to bring the tooth back into the proper position
  • When a tooth has a large, old filling with defective margins (the area where the tooth and the filling come together), there is a high probability that bacteria has created decay under the filling and the filling is simply too large to be replaced, a crown is indicated to protect the life of the tooth

What are the different types of crowns?

 

All-porcelain crowns

* Zirconium crowns:

  • A zirconium core with porcelain over the top (strong) or a full zirconium crown (stronger and recommended for patients who grind their teeth; milled from a computer image)
  • Tooth-colored crowns designed to restore any of your teeth
  • Usually more expensive because they are more costly to manufacture than porcelain fused to metal crowns

* Pressed porcelain crowns:

 

  • Designed to be used in the “aesthetic zone” or the smile-line.
  • Although very beautiful, do not possess the strength of zirconium crowns.
  • Most closely resemble the enamel layer of natural teeth; their translucency and color capabilities are aesthetically outstanding.
  • Usually more expensive because they are more costly to manufacture than non-porcelain crowns

Composite with fiber-reinforcement crowns

  • Tooth-colored composite resin with fibers added to strengthen the resin
  • Do not possess the strength of zirconium or porcelain crowns
  • Not usually the most popular crowns to use to restore a tooth
  • Metal-free, making them very translucent and aesthetically pleasing

Milled Porcelain Crowns

  • An all porcelain premolar and molar crown.

    An all porcelain premolar and molar crown.

    The prepared tooth is scanned into a computer.

  • The crown is designed and a block of porcelain is placed in a milling machine and the crown design is milled in the dental office.
  • Within minutes the crown can be bonded onto the prepared tooth.
  • This is the only crown that eliminates having to place temporary crown while the lab constructs and returns the finished product.

Porcelain fused to metal crowns (PFM)

* Porcelain fused to high noble or precious metal and covered in porcelain:

  • A porcelain fused to metal crown with high gold content in the metal. Note: the metal is lighter in color.

    A porcelain fused to metal crown with high gold content in the metal. Note: the metal is lighter in color.

    A metal substructure with a higher concentration of gold

  • Designed especially for individuals who have a nickel or other metal allergy but want a tooth-colored, less expensive crown
  • May become more expensive depending on the market value of gold

* Porcelain fused to noble or semi-precious metal and covered in porcelain:

  • A metal substructure with a lower concentration of gold
  • May cause an allergic reaction in individuals allergic to some metals
  • Visually look no different than a high noble PFM crown

* Porcelain fused to non-precious or base metal and covered with porcelain:

  • Have a substructure made of non-precious metal, which contains no gold
  • Visually look no different, to the untrained eye, than crowns made with precious or semi-precious metal

* Captek crowns

  • These crowns contain gold in the substructure that is very yellow, giving the porcelain a much warmer tone
  • Most dentists and dental technicians feel the porcelain has a warmer color to it when there is a greater percentage of gold in the metal substructure.

All-metal crowns

 * Full gold crowns (FGC):

A Full Gold Crown

A Full Gold Crown

  • As the name implies, fully cover the tooth and are all gold in color
  • Kinder to the teeth they oppose because metal is softer than porcelain and it creates less wear; more appropriate for patients who grind their teeth because metal is softer against natural teeth.
  • More appropriate for patients with metal allergies because they have a higher concentration of gold and fewer base metals.

* Full semi-precious crowns:

  • Contain less gold and range in color from silvery to gold
  • Not as aesthetically pleasing as an all-porcelain crown, a PFM crown, or an FGC
  • Sometimes more cost-effective

* Full non-precious crowns:

  • Silvery in color
  • Made of base metal (no gold)

* Stainless steel crowns:

  • Not custom-made by a dental laboratory to fit your prepared tooth, but instead are a stock crown placed in one visit to your dentist.
  • Used as a short-term solution to your dental problems and are meant to be replaced at some point by a laboratory-constructed or office milled crown.

Inlays and Onlays

Overview

Note: the second to the last tooth is a full crown as it covers the entire tooth. The last tooth is restored with an onlay.  An onlay is a more conservative treatment as less tooth structure is removed.

Note: the second to the last tooth is a full crown as it covers the entire tooth. The last tooth is restored with an onlay. An onlay is a more conservative treatment as less tooth structure is removed.

An Inlay is a method to replace lost tooth structure; an inlay is constructed in a laboratory and bonded into the tooth.

An Inlay is a method to replace lost tooth structure; an inlay is constructed in a laboratory and bonded into the tooth.

An inlay is a laboratory-constructed restoration that is placed between the cusp tips of your tooth and typically restores the area between your teeth as well. An onlay covers anywhere from one cusp tip to the entire biting surface, but not the entire tongue and cheek side of your tooth like a crown does. To the untrained eye, these restorations look like large white (composite) fillings; in reality, they are prepared much the same as a crown and sent to a dental laboratory for construction.

Why do I need an inlay or onlay?

A molar tooth with an Onlay that is constructed in a dental laboratory.

A molar tooth with an Onlay that is constructed in a dental laboratory.

When a tooth needs to be restored, but the area needing the restoration is too large for a filling and a crown would be considered excessive, an inlay or an onlay may be the restoration of choice. There are “rules” that dictate when a lab constructed restoration (such as an inlay, onlay or crowns) is indicated versus a filling. Large fillings do not support the long term health of teeth as well as a laboratory constructed restoration.

Advantages of inlays/onlays:

  1. They conserve tooth structure, as crowns require more tooth removal.
  2. They are a better restoration than a large filling because they are laboratory constructed and bonded into place.
  3. They are more attractive than a large silver (amalgam) filling.
  4. They are thought to strengthen your tooth once bonded into place.

Disadvantages:

  1. They are more time-consuming to prepare and insert.
  2. They are more expensive than a filling and about as expensive as a crown.
  3. There are many more margins exposed, allowing more potential contact with bacterial plaque, so are best placed in patients with superior oral hygiene.
  4. They are not the restoration of choice if you grind your teeth, unless made with gold.

What are the different types of inlays and onlays?

Porcelain inlays and onlays:

  • Very aesthetically pleasing restorations constructed by a lab or milled in the office and bonded into your tooth.
  • Probably the most popular; pressed porcelain is somewhat brittle until bonded to your tooth, when it takes on superior strength. Porcelain will wear your opposing teeth more than gold.

shutterstock_166386377Fiber-reinforced composite inlays and onlays:

  • Very aesthetically pleasing restorations constructed by the lab and bonded into your tooth preparation
  • Virtually disappear when bonded into the tooth
  • More kind to the opposing teeth, creating less wear, but not as strong as gold or porcelain.

Gold inlays and onlays:

  • Constructed by the lab and cemented (vs. bonded) into your tooth preparation made by your dentist
  • More kind to the opposing teeth than porcelain, creating less wear
  • Best utilized on people who grind their teeth (see Clenching and Grinding your Teeth: Bruxism); they are metal, which makes them very strong and metal is more kind to the teeth they chew against.

Gum Disease (Periodontal Disease)

 

Overview

9598195Gum disease or periodontal disease is a bacterial infection that affects over 80% of patients to varying degrees. Not only is gum disease the number one causes of tooth loss in adults, we now know it plays a key role in a number of medical conditions. Although there is no cure, killing and controlling bacteria is the key to better health.

What is Gum Disease (Periodontal Disease)?

shutterstock_240812176
Gum disease or periodontal disease is an infection of the tooth parts that support and surround the tooth (see Parts of the Tooth): gum, ligament (or periodontal ligament), and bone. The activity and waste products of infectious bacteria cause the gums to become red, swollen and bleed easily (inflammation: pain, heat, swelling, redness and loss of function). The stage of the disease is determined by measuring the cuff of skin around the tooth in six places. In later stages the disease can also be seen on x-rays. Early detection and treatment along with proper home care can control the disease and help the patient keep their teeth for a life-time.

The disease can begin as early as four and five years of age and is evident when the patient has red gums around and between the teeth. By the teenage years, the gums are red and now swollen with heavy bleeding when touched. This stage of the disease is called gingivitis and is the only stage of the disease that is reversible.

As the disease progresses, the bacteria will attack the area of the tooth where the skin is attached to the tooth (periodontal ligament), causing it to loosen or unattach from the tooth creating a ‘pocket’. When the dentist or hygienist measures the gums and finds such condition, they are no longer considered healthy (0-3mm in depth is considered healthy). This stage of the disease is not reversible.

Without intervention, the disease will progress into deeper areas around the teeth where aggressive bacteria can thrive and create the environment where the patients’ own body will destroy the bone around the tooth, eventually causing tooth loss.

Early detection and treatment is the needed to control periodontal disease. Typical treatment may include a non-surgical approach of scaling and root planing, placement of medication into the pockets, and a plan for maintenance based on the severity of the disease.

In more advanced cases, periodontal surgery may be necessary to eliminate the pockets around teeth (decrease the pocket depth to 0-3mm), and possibly graft bone. All periodontal treatment is designed to reduce pocket depths, allowing the patient to control the growth of bacteria at home between dental visits.

Treatment: Scaling and root planning

Scaling and root planing is generally considered the initial, non-surgical procedure of choice in the treatment of periodontal disease. This procedure may involve just a few teeth or all the teeth and is designed to remove and kill bacteria, but also smooth the root surface making it more difficult for bacteria to stick to the root surface. This is followed by professional visits to determine if further treatment is necessary. The goal of treatment is to reduce the deep pockets, making it easier to remove and control the growth of bacteria.

No discussion regarding treatment of periodontal disease would be complete without the discussion of Lasers in Dentistry. Today’s dental lasers are revolutionizing the treatment of periodontal disease as lasers can not only effectively destroy bacteria, they can create an environment that causes the body to re-grow bone around the tooth.

Treatment Goals:

Remove tarter (calculus: hardened deposits of bacteria)

Calculus, or “tartar,” as most people call it, is attached to the side of the tooth, either above or below the gum line. It is attached to the tooth like a barnacle on the side of a boat. The calculus itself will not harm you; it is the bacteria covering the calculus and being held up against the gum tissue is harmful. Calculus aids in the progression of the disease as the bacteria continues to infect the gums and the ligament and eventually creating an environment whereby your own body destroys bone.

Kill the bacteria in the base of the pocket

After: Once the plaque and tarter have been removed, the soft tissue will appear inflamed. However, the tissue can now heal because the disease causing agents have been removed.

After: Once the plaque and tarter have been removed, the soft tissue will appear inflamed. However, the tissue can now heal because the disease causing agents have been removed.

The ultrasonic scaler is a tool that vibrates at a high frequency and sprays water and/or medication. The most damaging bacteria in this disease are called anaerobic bacteria (they grow without oxygen) and they are found in the deepest part of the pocket. The scaler reaches deep into the pocket and the vibrating frequency damages the bacteria, killing it.

Although ultrasonic scalers destroy bacteria, they are not as affective as the dental laser. Dental lasers are revolutionizing the treatment of periodontal disease. Lasers not only destroy bacteria, they create an environment that helps the pocket heal and the body to re-grow bone around the tooth.

Smooth the root surface

The root of the tooth is covered by cementum. Cementum receives its blood supply (all tissue needs a blood supply) from the ligament that surrounds the root and cushions the tooth in the bone. As the disease progresses, the gum tissue recedes and the surface of the root starts to become exposed.

Once the root is no longer covered, the surface of the root dies, (becomes necrotic). Once this takes place, the root surface becomes rough and irregular. This rough surface allows the bacteria to stick to the tooth easier and encourages the progression of the disease. Planing the root surface makes it more difficult for the bacteria to stick to the tooth. Therefore, smoothing the root helps the tissue heal.

Placement of medications

Some studies show that the placement of antibiotics or other medicines in the pockets will help control bacterial growth and therefore help control the disease.

Aid in home care

If pockets are too deep, the patient will have a more difficult time removing plaque. There may or may not be areas that don’t heal. These areas may require you to use other home care aids to clean these deep pockets. These include, but may not be limited to, the proxy brush, swab tips, a waterpik, or the rubber tip stimulator.

Patient education

If you have been treated for gum disease, you will probably be instructed to return every three months for a professional cleaning. You will also need to do your part by thoroughly cleaning your teeth every day with a toothbrush, dental floss, and other tools because the disease is never cured, only controlled. Although you may think you are doing a great job with your home care, most people need to be monitored and have their technique altered from time to time to be shown where they are doing a good job and where they need improvement.

Periodontal Surgery/Lasers

The conventional method for the reduction of deep pockets by is surgery. In severe cases, following healing, the teeth appear longer in the areas where more bone has been lost in the disease process. There’s a phrase that says “he looks a little long in the tooth”. This is because in order to surgically eliminate deep pockets, the gum tissue has to be reduced as part of the surgical procedure.

Dental Lasers eliminate this problem because laser treatment works deep in the pocket to kill bacteria and creating an environment for bone growth and reattachment of gum tissue. This means that following treatment with lasers, the destruction from bacteria can be reversed without leaving the teeth looking long and unattractive. However, commitment to homecare, and continuous monitoring and maintenance appointments are necessary to ensure control of the bacteria to prevent recurrence of the pockets.