Category Archives: Dental Procedures

Whitening/bleaching

Overview

After bleaching the teeth on the right, they are several shades lighter than the teeth on the left. Tooth bleaching can demonstrate dramatic results, whitening and brightening any smile.

After bleaching the teeth on the right, they are several shades lighter than the teeth on the left. Tooth bleaching can demonstrate dramatic results, whitening and brightening any smile.

Whitening works by applying carbamide or hydrogen peroxide solution to the tooth surface. Peroxide whitener reacts with water to form hydrogen, which produces the whitening. The degree of tooth whitening obtained is directly proportional to the strength of the whitening solution and the amount of time the solution is in contact with the tooth. Concentrations used for tooth whitening can be as low as 2-5% or as high as 22-35%. Some patients experience no side effects in whitening, while others experience tooth sensitivity and/or burns to the soft tissue.

Results depend on a number of factors:

  • The strength or percentage of the bleaching solution
  • The amount of time the bleaching agent remains active
  • The amount of time the active solution is in contact with your teeth
  • The number of repeated applications

Disadvantages of whitening include, but may not be limited to:

  • The possibility of extreme tooth sensitivity to cold and air
  • The burning of gum tissue (excess solution can spread to gum tissue and cause burns)
  • There is a limit to how white your teeth may become; many patients have unrealistic expectations and continue to seek whiter and whiter teeth, even after their teeth have been whitened as far as they will go.
  • Fillings and crowns will not whiten with your teeth; if you have a crown or fillings in the area you plan to bleach, you may need to have them replaced after you have reached your bleaching goals.

Whitening procedures

  1. For at-home whitening/bleaching, a custom tray (made for each individual patient) is the best method to deliver the bleach. The custom tray holds the whitening agent close to the tooth surface..

    For at-home whitening/bleaching, a custom tray (made for each individual patient) is the best method to deliver the bleach. The custom tray holds the whitening agent close to the tooth surface..

    Whitening strips are impregnated with various percentages of bleaching agent and can be purchased over the counter. They are placed on your teeth like a band-aid, wrapping around the edges of your teeth. Depending on the strength of the strips, these strips whiten your teeth over time. With repeated use, your teeth will whiten, and at some point, you will reach an end point where no further whitening will occur.

  2. Whitening trays are a take-home system that involves filling custom trays with various percentages of whitener and placing them over your teeth for a period of time. There are custom trays manufactured by your dentist that fit only you. There are over-the-counter trays, which do not hold bleaching solution as close to your teeth as the custom trays will. It is the close proximity of the bleaching agent to the tooth surface that whitens your teeth.
  3. In-office whitening systems are used under the supervision of your dentist. This system uses a powerfully high percentage of bleaching agent, and heat from a UV light activate and heighten the bleaching reaction. Gum tissue around your teeth is blocked with a protective “dam” because the solution can burn the soft tissue.

     

  4. Internal bleaching is whitening your tooth from the inside. If you have a tooth that has changed color following a root canal treatment that does not need a crown, this procedure may help. Once a tooth has had a root canal treatment and the color of the tooth has changed, your dentist can bleach the tooth from the inside. Once the root canal treatment has been completed and the opening to the canal has been sealed, a mixture of superoxyl and peroxide is placed on a cotton pellet and sealed inside the crown of your tooth. This method of whitening is called a “walking bleach,” and it will lose its power to whiten and have to be replaced with a fresh solution in a few days. This type of whitening can take between one and as many as six or more visits to reach the desired results. The length of time required to reach the desired results is usually dependent on how long your tooth has been dead.

Cosmetic Dentistry

Overview

A beautiful, white, healthy smile.

A beautiful, white, healthy smile.

The American Heritage Dictionary defines cosmetic as “the correction of physical defects.” Cosmetic dentistry is the correction of dental defects including a wide variety of problems, including dark fillings; broken teeth; yellow teeth, the closing of spaces; and the changing of the shape, contour, position and even the sizeof your teeth.

Procedures designed to help you achieve a whiter, brighter, more beautiful smile can be as simple as placing whitening strips or as complicated as full-mouth reconstruction utilizing crowns, bridges, veneers, implants; even orthodontic treatment (the realigning of your teeth with “braces”), depending on the treatment plan.

The Cosmetic Solutions

  1. Whitening/bleaching

    After bleaching the right side only: the teeth on the right are several shades lighter than the unbleached teeth on the left.

    After bleaching the right side only: the teeth on the right are several shades lighter than the unbleached teeth on the left.

    Whitening works by applying carbamide or hydrogen peroxide solution to the tooth surface. Peroxide whitener reacts with water to form hydrogen, which produces the whitening. The degree of tooth whitening obtained is directly proportional to the strength of the whitening solution and the amount of time the solution is in contact with the tooth. Concentrations used for tooth whitening can be as low as 2-5% or as high as 22-35%. Some patients experience no side effects in whitening, while others experience tooth sensitivity and/or burns to the soft tissue. See Whitening/Bleaching.

  2. White, bonded fillings

    White fillings, whether in your smile or in your back teeth, may need replacement for cosmetic or health reasons.

    1. Over time, the composite fillings in your front teeth will stain from various foods, coffee, tea, dark soda, or tobacco.
    2. The margins of your fillings may become defective over time, and the accumulation of bacterial plaque on these fillings can create recurrent decay, necessitating replacement.
  3. Direct bonding with composite (composite veneers)

    Direct bonding involves the complete coverage of the front of your teeth with tooth-colored filling material. Prior to placement of the composite material, tooth structure may or may not need to be removed, depending on each individual case. The tooth is etched and an adhesive is placed on the surface, followed by the layering of various colors of composite designed to mimic natural tooth structure. The direct bond is then contoured and polished to a high shine. Direct bonding may be able to close spaces, straighten teeth with minor misalignments, and improve color, shape, and contour. Although this procedure is usually less expensive than placing porcelain crowns or veneers, this material will stain over time and does not last as long as porcelain. This is because composite is a porous material, while porcelain is a very dense, smooth material.

  4. Porcelain veneers

    A dental laboratory model showing the right tooth is a full porcelain crown and the left tooth is a porcelain veneer.

    A dental laboratory model showing the right tooth is a full porcelain crown and the left tooth is a porcelain veneer.

    If you look at many kitchen countertops, you will notice that they are covered by a very thin layer of Formica that is glued to a wooden frame. Think of the wooden frame as your tooth and the Formica as the porcelain veneer.

    The purpose of placing veneers is to avoid excessive tooth removal. A very thin portion of your tooth is removed from the front, sides and biting edge of the tooth. Laboratory-constructed veneers are then bonded to the remaining tooth structure to replace the removed tooth structure, thus obtaining the desire cosmetic result (closing spaces, as in the example).

    Typically, veneers are used on the front upper and lower teeth, but they can be used on all teeth that show in your smile. One of the most difficult procedures is placing a single veneer or crown on a front tooth because the challenge of capturing the exact color of surrounding teeth, translucency and surface finish is difficult. If your dentist has done this to your satisfaction, he or she has an exceptional eye for detail and extremely good communication with his or her dental laboratory.

    Reasons to place porcelain veneers:

    • When there are several spaces to close or fewer large spaces, the treatment plan may indicate that more teeth need to be prepared to achieve the desired results; if too few teeth are used, the final result may leave you with oversized teeth. The general rule is that the more space there is to close, the more teeth need to be prepared. The filling of space is distributed over a greater number of teeth, creating a much nicer result.
    • The preparation is designed according to the final goal of the treatment plan, such as giving the appearance of moving the teeth forward, backward, right, or left.
    • To change the length or shape of the teeth
    • To change the color of the teeth
    • To make minor changes in the position of a tooth

    A porcelain veneer does not cover the entire tooth. Therefore, if large changes in position are needed, a full crown may be necessary to bring the tooth into the desired alignment.

  5. Porcelain crowns

    A dental laboratory model of a patient who has had their four front teeth restored with all porcelain crowns. The crowns will be returned to the dentist and bonded into the mouth.

    A dental laboratory model of a patient who has had their four front teeth restored with all porcelain crowns. The crowns will be returned to the dentist and bonded into the mouth.

    Depending on the condition of your teeth, the use of full crowns may be necessary to achieve a desirable cosmetic result. Remember, veneers do not cover the entire tooth, and if any of your teeth have had large composite fillings that extend to the “back” of your tooth, a full crown may be needed to cover the old, defective composite restorations. If your teeth are crooked and you’re not interested in having your teeth straightened through orthodontia (see Braces), the teeth can be either partially or completely realigned by the way the teeth are prepared and how the crowns are constructed. There are a number of different types of porcelain crowns that can be used to cosmetically restore a smile (see Crowns and Bridges).

  6. Braces (orthodontic treatment)

    Orthodontic treatment, or “braces,” is most often thought of as cosmetic; however, one of the primary goals of this type of treatment is the correction of proper function. Proper function of the teeth preserves the beauty of your teeth over a lifetime. Overall, cosmetic dentistry implies the correction of physical defects only; unfortunately, if appropriate function is not considered, the cosmetics may fail over time. To learn more about the advantages of orthodontics, (see Braces).

  7. Inlays and Onlays

    See article Inlays and Onlays.

Root Canal Treatment

Overview

Two teeth that have been treated with root canal treatments. Note the screw-like structure on the left: this is a dental implant.

Two teeth that have been treated with root canal treatments. Note the screw-like structure on the left: this is a dental implant.

Inside every normal, healthy tooth is a space, containing a nerve, artery, and vein, called the pulp. Inside the part of the tooth that can be seen above the gums (clinical crown) is the pulp chamber. Inside the part of the tooth below the gums (tooth roots) are the root canals (see Parts of the Tooth). When damage to the nerve, artery or vein occurs, the tooth begins to die. If the tooth becomes sensitive or painful, a root canal treatment is recommended to save the tooth.

What is a root canal treatment?

The death of a tooth can occur for a number of reasons, resulting in the need for root canal treatment. Conditions such as:

  • deep decay close to the ‘nerve chamber’ or pulp whereby bacteria involved in the decay process are now entering the pulp chamber and setting up infection.
  • fracture
  • tooth grinding (bruxism)
  • too rapid tooth movement during treatment with braces can result in the death of the tooth and require treatment of the root canal.
  • accidental trauma

When a patient receives a root canal treatment, the tooth is numbed (anesthetized) and an opening is made to allow access to the pulp chamber and root canals. The contents inside the tooth are removed, the walls on the inside of your tooth are smoothed and disinfected. The inside of your tooth is then filled and sealed to prevent bacteria from entering in the filled canals.

A root canal treatment involves removing damaged tissue inside your tooth and filling the space with a material that is very compatible with your body.

Symptoms leading to root canal treatment

The symptoms indicating the need for root canal treatment vary. Typically, when a patient reports a toothache, there are five questions that can help determine whether or not the tooth requires root canal treatment. This list of questions is a guideline in helping to determine if a root canal treatment is needed.

  1. Is any tooth sensitive to heat or cold?
  2. If yes, does the sensitivity linger for 3-5 minutes or does it subside quickly?
  3. Is the tooth pressure sensitive (does it hurt to chew or bite)?
  4. Does the tooth hurt without being disturbed? Does it hurt spontaneously?
  5. Does it wake you when sleeping?

Sometimes only sensitivity to cold occurs, but lingers for five minutes or more. Sometimes only pressure sensitivity occurs, but pain without touching the tooth, that wakes the patient up at night, and extreme heat sensitivity are strong indications that the tooth is dying.

Cold sensitivity and pressure sensitivity could mean something other than pulpal death, such as a filling that is too high or a microscopic crack in your tooth. Pain that wakes someone from a sound sleep could be from an intense episode of Clenching and Grinding. Teeth clenching and grinding (bruxism) is a potentially damaging habit that can cause intense pain that wakes the patient from a sound sleep.

Sometimes patients have no symptoms, but a dark spot around the tip of the root is found on an x-ray, indicating that the tooth has died.

A pulp tester may help the dentist in the diagnosis of the pulp health; however, this device only indicates if there is live tissue inside the tooth. Since the pulp tissue doesn’t die all at the same time, a pulp tester may not be as reliable as an x-ray to answer the questions above.

What creates the need for a root canal treatment?

All living tissues, including teeth, require a blood supply for healing from the damage of trauma. For example, when we get a cavity and the pulp gets irritated, our body has the ability to build up protection from the inside of the tooth, protecting the tooth from the cavity, but too often cavities grow faster than the blood supply can build up protection.

When we cut a finger, there is an enormous blood supply to the wound, allowing it to set up an inflammatory response and begin healing. The problem with teeth is that the blood supply is very small and when the tooth is “injured” badly enough, the resources needed to promote healing cannot get to the injury quickly enough and the tooth can die. A more detailed explanation of causes leading to root canal treatments follows:

  1. Deep tooth decay – Left untreated, Tooth Decay can become severe enough to irritate the pulp, or infect the inside the tooth. Both situations usually lead to death of the tooth. The bacteria involved in this infection grow and reproduce without oxygen. These bacteria produce gases that expand when heated, press on the infected nerve and create intense pain. Bacterial infection usually requires treatment with antibiotics.
  2. Trauma – There are two forms of trauma that may cause your tooth to die: acute trauma (like getting hit in the face with a baseball) or chronic trauma such as tooth grinding. Chronic tooth grinding presses the tooth into the bony socket, compressing blood vessels and choking off the blood supply. Over long periods of time, this habit may cause pulpal death.
  3. Dental treatment – Poor tooth care leading to repeated dental treatment may cause the death of the tooth. Many times, a tooth that has been repeatedly filled and eventually needs a crown, dies after the crown is prepared. Often the patient wants to know what the dentist “did to my tooth”. In reality, the tooth has been repeatedly traumatized (it is harmful for a tooth to be filled over and over) and the crown preparation, which may have been recommended years earlier, causes symptoms to become apparent.
  4. Tooth movement – If a tooth is moved too rapidly, such as with braces (orthodontic treatment), pulpal death can occur. A more important factor in pulpal death during tooth movement is the condition of the tooth prior to treatment with braces. Teeth that have sustained years of trauma from being repeatedly filled or teeth that have suffered years of clenching and grinding can die, even if they are moved slowly. Teeth can only handle a certain amount of stress or trauma before they die.

What are the risks of root canal treatment?

  1. Failure – Sometimes a root canal treatment will simply fail. This means, for some reason, the treatment performed could not completely remove the infection. When this happens, the tooth can be re-treated, usually by a specialist (see Endodontist).
    • Retreatment – This may be attempted if the initial treatment fails.
    • Root Tip Treatment (Apicoectomy) – If the initial treatment fails and the retreatment fails, minor surgery designed to expose the root tip, remove a small portion of it and place a filling into the end of the root may save the tooth from removal (extraction).
    • Extraction – If all treatment fails, removal of the tooth may be necessary.
  2. Perforation – During the opening or filing of the tooth, an instrument can accidentally perforate the tooth from the inside out. This may cause the loss of the tooth if not treated properly.
  3. Broken instruments – If an instrument accidentally breaks inside the tooth, the longevity of the tooth depends on the dentist¬タルs ability to file and fill the tooth beyond the broken tool to the tip of the root.
  4. Tooth Fracture- Once a tooth has died and a root canal treatment has been performed, the tooth is often more brittle. For this reason, a crown is usually recommended to help prevent fracture of the tooth.

Pain Control

Novocain: Local Anesthesia in Dentistry (the “shot”)

Local anesthesia in dentistry (commonly referred to as Novocain), is used to completely remove the pain sensation of the dental procedure. Local anesthetic works by the chemical process known as dissociation. The Novocain (anesthetic) is in the form of two or more chemicals attached to one another. In healthy tissue, the pH in the tissue allows the chemicals that are hooked together to become ‘unhooked’ or to dissociate. The separation of these chemicals from one another frees up the one chemical that blocks the movement of sensation along the nerve fiber.

Dental pain can become a debilitating distraction and can come from any number of sources. The most predominate source of dental pain is tooth decay and gum disease.

Dental pain can become a debilitating distraction and can come from any number of sources. The most predominate source of dental pain is tooth decay and gum disease.

If the soft tissue in the area of the injection is infected, this means the pH in the area is different from an area of healthy soft tissue. This means the chemicals cannot dissociate enough to free up the chemical that blocks the nerve sensation. In this instance, the anesthesia won’t work as well and it takes a number of injections to get the patient “numb”. There is a limit to the amount of anesthesia that can be administered according to body weight. It is often considered a better practice to rid the patient of infection prior to treating the dental problem that requires anesthesia.

There are some complications that can occur with the administration of local anesthesia in the dental office. The most common of these are dizziness, a rapidly beating heart (tachycardia), agitation, and tremors. These problems are usually short lived and pass without further incident.

More serious complications include seizures, and bronchial spasms (allergic reactions). It can be stated that dental local anesthesia can be considered safe and that complications can be reduced if:

  • patients are routinely evaluated for risk factors (the most common being cardiovascular disease and allergies) with an adequate medical history prior to dental treatment
  • doses of local anesthetics are determined according to body weight
  • anesthetics with no or low concentrations of epinephrine are used

Analgesia: Inhalation Sedation with Nitrous Oxide or “Laughing Gas”

Nitrous oxide (N2O/O2) is a gas that is delivered through a face mask as an analgesic; it works to relieve pain and it induces a sense of calm. It has no color, smell, and doesn’t irritate the mouth, throat or lungs. Some patients experience hearing and visual effects as well. The use of N2O/O2 helps the patient relax and makes any dental procedure move along faster and easier.

Today, we know that nitrous oxide gas (N2O) can only be used for short periods of time without mixing it with at least O2 (oxygen). Nitrous oxide gas and a lack of oxygen can lead to unconsciousness and death. The “laughing gas” used now is called N2O-O2, and contains 70% oxygen to 30% nitrous oxide.

Advantages of Nitrous Oxide/Oxygen Sedation:

  • It reaches the brain within 20 seconds creates a feeling of relaxation and pain relief after about 2-3 minutes.
  • The degree to which you are sedated can be altered up or down easily.
  • Once the sedation is decreased as the procedure comes to completion, you are placed on O2 and there are no after effects. The gas leaves your body within about 3-5 minutes and there are no restrictions to driving or operating machinery.
  • With nitrous oxide, it’s easy to give incremental doses until the desired action is obtained (this is called “titration”).
  • For some procedures such as scaling and root planing, it may be possible to forego the use of local anesthesia, completely eliminating the use of the needle. This can vary widely, however and cannot be considered valid for everyone.
  • In the case of severe needle fear, N2O/O2 can be used first in order to help you relax prior to receiving the local anesthetic injection.
  • Inhalation sedation is very safe. It has very few side effects and the drugs used have no ill effects on the heart, lungs, liver, kidneys, or brain.
  • N2O/O2 has been shown to greatly reduce the problem of gagging.
  • It’s safe to use with a history of: epilepsy, liver disease, heart disease, diabetes, or cardiovascular disease.

Disadvantages of Nitrous Oxide/Oxygen Sedation:

  • Some patients simply do not reach an adequate level of sedation with safe levels of oxygen.
  • A respiratory infection, any inability to breath through your nose (such as a habitual mouth breather ), an issue with claustrophobia, would prohibit the use of N2O/O2.
  • Some patients don’t like the feeling of a loss of control experienced with the use of N2O/O2.
  • Some patients get nauseous when N2O/O2 is used
  • There is a possibility that the dental team can experience certain health problems when continuously exposed to N2O/O2 (such as spontaneous abortion).
  • Contraindications to the use of N2O/O2 are: patients with MS, emphysema, chest problems, recent eye surgery, eye pressure disorders, and during the first trimester of pregnancy.

Oral Sedation in Dentistry

Oral sedation dentistry involves the oral administration of sedative drugs. Dental patients with generalized anxiety, fear of needles, prior dental trauma, or generalized fear of the dentist can take oral medication and reduce their anxiety. Oral sedation requires you be driven to and from your dental appointment.

Advantages of Oral Sedation:

  • Ease of administration (you only have to take a pill)
  • Effectiveness
  • No needles involved
  • High patient acceptance
  • Amnesic effect
  • Lower cost ( as opposed to IV Sedation)
  • Allows more treatment to be completed in a shorter period of time

IV Sedation in Dentistry

IV Sedation or conscious sedation is when a drug is injected into a vein in your arm or the back of your hand. It enters the bloodstream creating a sense of deep relaxation and amnesia (memory loss). You will be conscious and able to understand and respond to the operator, however, you will not remember anything once the drug wears off. This type of sedation still requires you get local anesthetic for the dental procedure: it’s an anti-anxiety drug, not a pain medication.

Your pulse and oxygen level (pulse-ox) are measured throughout the entire procedure; this allows the operator to determine if you are getting adequate oxygen. Your blood pressure is taken before and after the procedure and you will need to be escorted home, as driving following the administration of IV sedation is prohibited.

IV sedation is extremely safe when carried out under the supervision of a specialty-trained dentist. Many patients make jokes asking: “can you put me out, Doc?” It should be noted that a license to perform sedation procedures carries with it a huge responsibility and a great deal of additional training and continuing education to maintain that privilege.

Contraindications to IV Sedation:

  • pregnancy
  • known allergy to benzodiazepines
  • alcohol intoxication
  • CNS depression
  • some instances of glaucoma.

Cautions include:

  • psychosis
  • impaired lung or kidney or liver function
  • advanced age
  • sleep apnea: many people who have sleep apnea haven’t been officially diagnosed – if you are overweight and you snore, tell your dentist
  • heart disease is generally not a contraindication
  • having been prescribed benzodiazepines for many years, your tolerance may be high; let your dentist know how long you’ve been taking them

General Anesthesia in Dentistry

General anesthesia is a controlled state of complete unconsciousness. It is necessary for the elimination of awareness, movement during dental procedures. Local anesthesia is not necessary with patients undergoing general anesthesia for dental procedures.

The most common use of general anesthesia in dentistry is for children needing extensive dental treatment, uncooperative or fearful children, children who are too young to provide a safe level of cooperation or children with special needs (such as autism).

Oral Surgery

Overview

Oral surgery can be a simple tooth removal or a lengthy operating room procedure as pictured here.

Oral surgery can be a simple tooth removal or a lengthy operating room procedure as pictured here.

The phrase “oral surgery” is an umbrella term for a range of procedures to surgically treat a variety of mouth, head and/or neck issues. These surgeries may be performed by a specialist in oral surgery (Oral Surgeon), a dentist who specializes in gum disease (Periodontist), a root canal specialist (Endodontist), a specialist in treating children (Pedodontist), or a general dentist. Each specialist is licensed to work within of his or her area of expertise, training and experience.

Throughout this article keep in mind the main message is of tooth preservation. Our teeth begin the digestion process; without teeth doing their job, we cannot properly begin the digestion of fats and carbohydrates.

Common Oral Surgery Procedures

Extractions involve the removal of teeth. These could be teeth that have fractured, decayed, or impacted teeth. In simple extractions, the teeth can usually be removed without much effort. An exception would be if the tooth had become fused to the jaw bone or “ankylosed”  (ank-ill-ohst).

These extracted teeth are used in dental schools to study dental anatomy.

These extracted teeth are used in dental schools to study dental anatomy.

If the tooth to be extracted is severely decayed, it is considered weak and brittle and may require the gum tissue to be moved out of the way and a small portion of bone removed to ease tooth removal. Often, these teeth fracture and a portion remains attached in the bony socket. The broken piece should be retrieved and only left behind if it carries a greater risk vs. benefit; an example would be accidental pushing of the root tip from an upper molar into the sinus cavity. Any tooth part that enters the sinus should be removed. The patient should always be informed when needing to leave a fractured root tip in place.

Impactions are usually “wisdom teeth” that are completely covered by bone (full boney impaction), partially covered by bone (partial boney impaction), or covered only by soft tissue (soft tissue impaction). Oral surgeons are highly trained in the area of third molar (wisdom teeth) extractions, as it is one of the most common procedures they perform.

Implant placement for the replacement of missing teeth. (See Dental Implants)

Biopsy of suspicious oral lesions and diagnosis of Oral Cancer.

Bone grafting is the transplanting of bone tissue in areas where bone is not wide enough or thick enough; this bone grafting or addition would then permit completion of other dental procedures (such as implant placement).

Denture Preparation

  • Alveolpoplasty (al-vee’-lo-plas-tee)-  An alveoloplasty involves shaping of the jaw bone following tooth removal to prepare for the placement of dentures or partials. The gum tissue is laid back and the bone exposed for smoothing and shaping, removing any irregularities or undercuts. This allows a more comfortable fit to the dentures following healing.
  •  Vestibuloplasty (ves-tib’-u-low-plas-tee)- A vestibuloplasty involves increasing the “attached tissue”. If you pull your lower lip out, you can see where the pink tissue is loose and where it is attached firmly to bone. If the loose tissue is loose up onto the area where the denture sits, the denture will become unseated whenever the muscles in the face are used i.e. eating and talking.

A final stage to braces as a correction of a jaw problem called Protrusion or Retrusion of the upper and lower jaws. An orthodontist moves the teeth into a position that readies the patient for the jaw surgery; an oral surgeon performs the surgery only after all growth is complete.

Facial fractures due to accidents or physical trauma may require surgical intervention; these types of injuries usually require an oral surgeon as a member of a medical team.

Congenital defects such as cleft lip and cleft palate generally require a team approach which can consist of an oral surgeon and a team of medical professionals, including a plastic surgeon.

Gum Disease Treatment (periodontal pocket elimination) is a type of surgery performed by specialists (see Periodontist) to treat gum disease. This surgery is done when non-surgical procedures, such as scaling and root planning, have failed to provide the desired reduction in the pocket depths around the teeth. Periodontal treatment, whether surgical or non-surgical, is intended to make the cuff of gum tissue around the neck of the tooth shallow enough for the patient to keep it clean.

Soft tissue grafting is done to cover areas that have lost their gum tissue covering. The “donor site” is usually the roof of the mouth. A small piece of gum tissue is removed from the roof of the mouth and transferred to the area that lacks coverage.

Root Tip Treatment (Apicoectomy) is the surgery most performed when conventional root canal treatment has failed to bring about the desired results, a procedure called an apicoectomy is recommended. The word comes from apico (at the tip of the root) and ectomy (removal), or the removal of the tip of the root. Apicoectomies are typically performed by an Endodontist.

This procedure involves laying the gum tissue back and making a small window in the bone adjacent to the tip of the root in question. A portion of the root tip is removed by beveling the root tip and placing a filling material to close the opening at the root tip. The gum tissue is replaced and stitched closed.

Extraction of “baby teeth” in preparation for braces (see Braces (Orthodontics), is a common procedure performed by a children’s dentist (Pedodontist).

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.

Dental Implants

Overview

Implants in dentistry involve the surgical placement of the implant into bone and the implant becoming firmly fused or integrated with bone. Dental implants are used for the replacement of lost teeth, the securing of full dentures, as an anchor for orthodontic treatment (see Braces), or for the restoring of facial deformities, due to cancer, accidents or burns.

Dental Implants used for the replacement of teeth:

An actual laboratory constructed bridge on a lab model of an actual patient’s mouth

An actual laboratory constructed bridge on a lab model of an actual patient’s mouth

Dental implants involve three parts to the full replacement of the lost tooth. First is the implant itself; this is a surgical procedure that places the implant in bone. The goal is to get the titanium coated device to integrate or bond to the bone; integration takes time, approximately 3-6 months.

Once the implant is fully integrated in bone, the second step is to place the abutment. The abutment is seen above the gumline and it supports the crown. The abutment is usually screwed into the implant and the third and final step is the cementation of the Crown. The crown is not removable by the patient, but cemented much the same way it is cemented to an actual tooth. Implants can also support a Bridge or a Denture in the same manner.

Dental Implants used for the stabilization of dentures:

Sometimes over the course of a lifetime, teeth are prematurely lost and once teeth are lost, the jaw bone shrinks or resorbs. Gum disease (Periodontal Disease) also attacks bone causing tooth loss; the loss of the teeth causes the loss of bone and may make it difficult to hold dentures in place.


The placement of dental implants can help stabilize the denture and hold it more firmly in place. There are two ways the denture can be placed over the implant/implants: the denture can be screwed into the implant, making removal only possible by a dental professional or it can snap into place and be removable by the patient.

It should be noted that if there is not enough bone available to place the implant, further surgical procedures may be necessary before placing the dental implant. It may be necessary to do a bone graft and in the upper arch it may be necessary to lift the maxillary sinus called a ‘sinus lift’ .

Dental Implants used for orthodontic treatment:

Orthodontic treatment (see Braces) involves placing forces on certain teeth by anchoring appliances on other teeth, usually molars. In cases where there are no molars available (or other strong anchor teeth to use as anchors), dental implants can be placed to use as anchors. The dental implants are small and don’t fully fuse or integrate with bone and are easy to remove at the end of orthodontic treatment.

Dental Implants for the restoration of facial deformities:

When facial deformities occur due to disease or accidents, dental implants can be placed in facial bones to replace the lost facial structures. These procedures usually involve a team approach of the Prosthodontist (see Dental Specialties), ENT (ear, nose and throat) medical professionals, plastic surgeons, and others, depending on the situation.

Issues to consider for long-term success of dental implants:

There are a number of issues to consider when planning the placement of dental implants. Some of these include, but may not be limited to, the success or failure of dental implant placement:

  1. Heavy smokers, diabetic patients with uncontrolled blood sugar, and poor oral hygiene may preclude the long term success of dental implants. These patients are at a higher risk for Gum Disease (Periodontal Disease) which can cause implants to fail.
  2. Patients on biphosphonates (bone building drugs) may be at risk for long-term success of dental implants. The planning should consider both the type of drugs and the length of time the drug has been used.
  3. Placement of dental implants and the forces that will be required of the implant. The placement of the implant must properly distribute forces to prevent fracture of the crown, bridge or denture it supports, as well as the implant parts (the implant, abutment or screw). Inappropriate forces can cause bone loss around the implant, so bone density also plays a role in long-term success.
  4. Thickness of bone: both the vertical thickness (the height) and the horizontal thickness (the width) is a consideration to the placement of dental implants.

Risks involved in the placement of dental implants:

  1. infection following surgery
  2. excessive bleeding during surgery
  3. damage to nearby nerves, the sinus, blood vessels
  4. death of the flap of tissue that is opened to gain access to bone
  5. fracture of the implant, abutment or abutment screw
  6. failure of the implant to bond (integrate) with bone
  7. unacceptable esthetics due to gum or bone shrinkage around the restored implant due to a poor surgical outcome or poor oral hygiene

Implants have a high success rate when planning and home care before and after placement are optimal. The replacement of teeth with dental implants restores the ability to properly emulsify food and undoubtedly aids in better nutrition. Without a full dentition, a softer, less nutritious diet is consumed and quite possibly contributes to many of the diseases we see in our practices every day. Further, a healthy smile leads to higher self esteem and an overall higher feeling of well being.

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.

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.