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This page has been created as a question and answer page for anyone with dental questions. Dagon H.C. Jones, DDS will check this page periodically and answer general questions about dentistry that anyone may have.

The advice and information given here are strictly for entertainment purposes only. Please understand it is impossible for any health care provider to diagnose or treat any condition via a wiki or any other online source or other media. For the most accurate information please visit your family health care provider whether dental or otherwise. That said, it is an entertaining note that questions are usually answered by dentists within the community. But legally, it's entertainment, got it?

This page is intended for questions about dental procedures, dental science, and dental materials, but not for questions about billing and insurance. Questions about billing and insurance should be addressed to your dentist's office or insurance company.

Questions about fluoride? See Water Fluoridation
Information about Xylitol can be found on the Xylitol page.

Other dentists in the community are welcome to respond to questions as well.

  1. Options for Replacing Missing Teeth
  2. Digital X-Rays
  3. Diagnodent and Shallow Decay
  4. Periodontal Disease
  5. Wisdom Teeth or 3rd Molars
  6. Sealants
  7. TMJ/TMD
  8. Root Canals
  9. Dental Emergencies
  10. Dental Filling Materials
  11. Gum Grafts
HIPAARestrictions.png Medical Professionals are limited by [WWW]HIPAA as to what information they can make public about their patients, including who their patients are. As such it is very hard for Doctors, Dentists, and Psychiatrists to respond to negative comments on the wiki. Please keep this in mind while reading any comments.

Please ask away!

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2008-04-18 08:07:17   This page has been here for a while, someone must want to know about dentistry. Am I the only one that thinks this stuff is cool? —DagonJones

2008-04-18 11:06:01   Okay, I will ask something. I need to get a bridge because I am missing tooth #4. What is the procedure like? How long does the bridge last? What can you tell me about cost? —CalamityJanie

Options for Replacing Missing Teeth

bridge.jpg implant2.jpgImplant

2008-04-24 15:25:56   Well first off you have several options for replacing a missing tooth. Usually the best option is a dental implant. After a tooth is extracted the bone in the area will slowly resorb or dissolve away because the bone no longer receives a chewing stimulus from the root of the tooth. This often does not pose a problem for maybe 25-35 years. A dental implant will maintain the density of the bone in this area because it acts like a tooth root. An implant is intended to be permanent, they have only been around for about 25 years but all research suggests that they will last for the life of the patient if properly cared for. Implants have a very high success rate (around 97% in the #4 area). A single implant is often only about 15-20% more expensive than a bridge. A bridge is used to replace a missing tooth by placing a crown on each adjacent tooth with a false tooth (called a pontic) in between the two crowns. I usually only recommend a bridge if the two adjacent teeth would benefit from crowns. It is unfortunate to have to shave down healthy teeth to make a bridge. Having said that a bridge can be an excellent way to restore a missing tooth. They feel natural but because the three teeth are now fused together you will not be able to floss normally between them and you will need to use a special tool called a floss threader to clean under the bridge. Bridges tipically last 15-20 years but can often last much longer if done well and cared for. Eventually the bone around #4 may resorb away enough that the existing bridge does not look very nice anymore and needs to be replaced. Or the bone resoprtion may (this is rare) compromise the adjacent teeth. A bridge is often billed out as the same as 3 crowns, so the price in Davis may be anywhere from $2400-3200 depending on the materials used and the dentist. A bridge takes at least 2 appointments, one to prepare the teeth for a bridge and place a temporary (This appointment can last 1.5-2.5 hrs), then you will have to return in 2-3 weeks to have the custom lab made permanent bridge cemented (0.5-1 hr appointment). An implant will likely cost about $3500-4200, once again depending on the dentist and materials used. An implant is a more involved process than a bridge and often takes 4-7 months before it is completed (this assumes the extraction site of #4 has completely healed). Ussually another doctor, typically an oral surgeon or a periodontist, will place the implant and your general dentist will restore it with a crown. The whole process takes 4-5 apppointments most of which are very short and painless. Hope this helps, I am happy to answer other questions you have. —DagonJones

2008-04-25 10:30:09   Thank you for the detailed explanation Dr. Jones... I have been undecided between an implant and a bridge... I guess I thought a bridge would be much cheaper but it seems to have its downside if it doesn't last as long. And I also agree that it would be a shame to pare down the teeth so drastically on both sides of the missing tooth. When I saw illustrations of that online, it made me kind of sad, I just can't explain it. I had a periodontal procedure about 2 months ago, and Dr. Shirazi presented me with the opportunity to just have the implant done at the same time but I chickened out, and at the time, I still thought a bridge would be better. Well, I guess I can go back. I have braces currently but he said he has barely enough space for the implant to be placed. —CalamityJanie

2008-04-25 10:46:39  You are very welcome. If you are currently wearing braces, you most likely have the opportunity to move the teeth to make more room for an implant, talk to your orthodontist and have your orthodontist and Dr. Shirazi discuss the options. Of course there are other options for the missing #4, including doing nothing (which I dont recommend because the adjacent teeth are likely to shift into the open space). Other options are limited to different types of removable appliances that you would have to take out at night. Most people dont prefer removable appliances but they are more cost effective. —DagonJones

2008-04-29 14:39:37   I've got two main questions. The first is regarding the effectiveness and the relative radiation exposure between conventional film based x-rays vs digital x-rays. The next is regarding "Diagnodent" and similar laser based tools. I just don't know much about what this can be used for, and am wondering if it might be something I'd be interested in.

Thanks for setting this page up, and thanks in advance for any feedback,

—Brett

2011-08-23 Dr. Jones. First off, thank you for all of your help yesterday. You have a new patient long-term patient now. I have been reading this page and, since I had my tooth-root extracted on my last visit, was wondering if I should consider saving up for the implant to replace the now missing root/tooth or if it is something I would be functionally fine without. I don't want a bridge in the future but seeing the information here about receding bone structure gives me a bit of pause for thought... Should I, or anyone else, be worried about this? — Wes-P

Digital X-Rays

2008-05-01 13:56:57   Great questions because I know there is a lot of “buzz” about digital x-rays (radiographs) and laser caries detection. First off lets discuss x-ray films, dental x-ray films come in 3 speeds, D, E, and F speed. F speed is the most sensitive speed and therefore requires less radiation exposure than the other two films. “Results reported in literature illustrate that switching from D to E speed produced a 30-40% reduction in exposure. Switching from E to F speed produced a 20-25% reduction in exposure, and switching from D to F-speed film produced a 60% reduction in exposure”. The above quote is from an article by the FDA located [WWW]here F speed film is newer and therefore more sensitive, there is little difference in image quality between D, E, and F speed films. Most modern dental offices that do not use digital radiographs use F speed film. I don’t know the exact reduction in radiation exposure by switching from F speed to digital radiographs but I have heard it reported that the difference between D speed and digital is a 90% reduction. So the difference between F speed and digital is probably 20-30% reduction. In my opinion (which is shared by most dentists I speak to) conventional film produces a clearer image, which makes diagnosing decay easier. However digital films are much quicker, easier to transport, and have slightly less radiation exposure to the patent.

The radiation exposure from a full mouth x-ray series (approximately 18 films) is roughly equivalent to the same exposure the average American receives during two days of daily life (exposure from solar radiation, radon gas, etc). I consider the difference in radiation exposure between F speed film and digital radiographs small enough that it is not significant.

Diagnodent and Shallow Decay

Regarding laser caries detection I will discuss the Diagnodent because it is the only device that I am familiar with and understand the technology. Similar devices exist on the market but I cannot comment on their effectiveness. A diagnodent works by shining a laser into the pits and grooves of a tooth to detects bacteria. Many oral bacteria have molecules in their cell membranes that fluoresce (give off light) when exposed to a particular wavelength of laser light. The Diagnodent measures this fluorescence and gives a number reading and an audible tone. More bacteria produce a higher pitch on the audible tone and a higher number readout. The instrument is sensitive enough to detect small levels of bacteria that do not need a filling so the number readout is important. A number of 30 or above has definitely broken through to the deeper part of the tooth and needs a filling. Numbers from 20-30 are questionable and depend on the visual presentation and the patients decay risk, therefore these are left up to clinical judgment. I have been very surprised by how deep some decay is that otherwise looked and felt normal on the surface. Heavy and dark stains in the grooves of the teeth are an indication of possible decay.

When decay is shallow and in the enamel only it is reversable. Ions from your saliva can absorb into an early lesion and remineralize the affected enamel. Fluoride and other agents can aid this remineralization process. This generally only works on the smooth surfaces of the teeth (like in between the teeth and on the sides). When decay is very shallow on the chewing surfaces of the teeth it often continues to spread despite all best efforts to keep the areas clean. This is because all the pits and grooves of the teeth harbor many bacteria and are difficult if not impossible to clean. Access to decay in the pits and grooves of the teeth is often straight forward; therefore, removal of only the decay with a very small preparation (hole) can be achieved. This is often referred to as "microdentistry". So if your dentist tells you you have cavities ask if any of them are possible to remineralize. Remineralization can be assisted by fluoride mouthrinses and xylitol chewing gum. Xylitol is a natural sweetener that inhibits bacteria from sticking to the teeth. The most important aspect of remineralization is preventing acid attack, so brush and floss daily (flossing is ussually the key) and avoid frequent sugar/charbohydrate snacks. Once decay has grown past the enamel and is into the dentin (the inner part of the tooth) a filling is necessary. If you are attepmting to remineralize some very suspicous areas of decay your dentist may want to take x-rays more frequently to make sure they dont spread too deep.

The Diagnodent is a great tool to help detect decay that is lurking deep in the pits and grooves of the teeth that would otherwise not be detected. However it is just a tool and the dentist has to understand its limitations. A Diagnodent cannot detect decay in-between the teeth and cannot be used next to an existing composite (tooth colored) filling. A Diagnodent will give a false positive if there is heavy plaque or tartar in the grooves so those grooves need to be clean. Also if a Diagnodent is used after a cleaning and the hygienist has used any colored agents (special toothpaste or plaque staining dyes) the Diagnodent may get a reading from the pigments in the dye and give a false positive. Remember that just because the Diagnodent is giving a reading, does not mean that there is decay that needs a filling.
I hope this info was helpful and I am happy to answer other questions. I would not let digital radiographs or use of a Diagnodent be a deciding factor when choosing a dentist. There is a lot of new technology in dentistry but none of it is a replacement for good clinical judgment, skill, and compassion.

2008-11-09 15:40:27   Great page, Dr. Jones. My question isn't about dentistry exactly, but more about low-cost dental services in Davis. Are there low-cost options for dental care in Davis, e.g. for those without coverage needing a filling? —robinlaughlin

2008-11-10 10:08:25   If you are a Yolo county resident and meet certain income requirements you can go to the Davis Community clinic "Communicare Heath centers" which is behind sutter hospital. There are 4 Communicare dental clinics in Yolo county, Davis, Woodland, West Sacramento, and Esparto. The Davis dental clinic is open Tuesday-Friday. 530-757-4667 call for more info. You will need to go into the clinic and fill out an application. They also accept Medi-Cal. If you are having an emergency you can come in at 8am or 1pm (sharp)for an emergency appointment, there is no guarantee you will be seen that day but if there is enough time you will be taken care of. I volunteer there once a month on Thursday nights so you may see me there. Communicare is a good resource but they are underfunded and have such a huge patient base that there is often a very long wait for appointments. Be prepared to provide documents to prove your residence in Yolo county and your income.—DagonJones

2009-05-17 22:20:45   My teeth have severe enamel erosion. The tips of my front teeth seem a bit translucent, and they're very sensitive. I want to find a way to remineralize, however there are two different ways that are confusing me. The first says to use toothpastes like arm and hammer enamel care with ACP. This also contains fluoride, and glycerin. I've heard that glycerin will coat the teeth, and prevent remineralization. The second method is to use all natural, fluoride, and glycerin free toothpastes. Right now I'm trying the Green Beaver brand. This has silica, and sodium bicarbonate, as well as vitamin C, which they claim helps strengthen teeth, and gums. Which of these methods is the correct way to remineralize? Does glycerin containing toothpastes really inhibit remineralization? Which would nullify the benefits of ingredients like liquid calcium, xyitol, and novamin. —bluevelocity

2009-05-18 13:16:45   I do not know if glycerin inhibits remineralization. Logically, I dont see how it could, because if it does leave a film on the teeth, it would be a water soluble permeable layer. The teeth naturally form a permeable protein layer on top of them called the "pellicle", minerals can freely move through this layer to remineralize the tooth surface. To address your question more generally, I dont think remineralization will help your problem. Remineralization refers to restoring minerals to demineralized enamel, this changes the enamel from being weak and soft to hard and durable. However, remineralization can not restore lost tooth structure or rebuild lost enamel (not to a visible extent, only a microscopic one). When acid (either dietary or from bacteria via carbohydrate metabolism) attacks tooth structure it pulls out minerals (demineralizes the tooth). Your own saliva is very good (better than any toothpaste) at providing a super saturated environment of minerals to help remineralize demineralized tooth structure. If demineralized tooth structure suffers a prolonged acid atack it will be destroyed, ussually resulting in a cavity.

You can address the sensativity by using a sensativity protection toothpaste, like sensodyne, but these often do not work all that well. You can use a professional product (only available through a dentist) called MI paste. This is the one product that may be better at remineralization than your own saliva. It prevents sensativity by blocking the microscopic tubules that are in exposed dentin. It can be applied at home and needs to be used for several weeks but generally has very good results.

Regarding the translucent incisal edges, if the enamel is very thin on those teeth you may want to consider having tooth colored composite filling material bonded on to the edges to reinfoce them. Or you can have the thin edges "sanded" off by a dentist. —DagonJones

2009-05-18 15:17:26   Floss first, and then brush; or brush first, and then floss? —TheAmazingLarry

2009-05-21 11:59:47   So, I usually wake up with a thick almost gummy white film on my teeth. Is this plaque or is it this "Permeable protein layer"? —MasonMurray

2009-05-21 19:17:43   The film on your teeth in the morning is definitely plaque, you cannot feel the pellicle, it is only a few microns thick. According to the reseach I have read and how I was taught in dental school, it does not matter what order you brush and floss. But it is VERY important that you do floss daily.

2009-05-21 19:42:25   Plaque is a bacterial biofilm. It's what you gotta take care off every day. If you don't, it'll eventually lead towards cavities and mineralize up to turn into calculus/tartar, which brushing won't remove (but your dentists sharp thingies are meant for). —EdWins

Periodontal Disease

perio1.jpghealth on left, periodontitis on right

recession.jpgRecession on left, normal on right 2009-05-22 23:15:28   The reason flossing is so important is that it removes the plaque between the teeth that brushing alone does not. This plaque can lead to cavities between the teeth or gum disease. The area between the teeth includes the area below the gumline that is between the teeth, also known as the periodontal pocket. This diagram shows a health pocket on the left and a pocket with periodontitis or periodontal disease on the right. Because the pocket area is a low oxygen (anerobic) environment, lots of nasty bacteria can breed there. Over time they produce lots of toxins, your body responds by producing inflamation (redness, swelling, bleeding etc.) Both the bacterial toxins, and your body's own response causes atachment loss, where the gum tissue atachment point migrates downwards, this creates a deeper pocket which is harder and harder to clean and can harbor more bacteria. the presence of atachment loss in the pocket area is ussually the diagnosis of periodontitis. As the gum tissue attachment point migrates downwards, the bone will follow becuase it always wants to maintain a certain distance from the gum attachment point. Periodontitis can result in rececession, which is when the gums visibly move downwards exposing the root surface. There are many other causes of recession, such as vigorous tooth brushing with a hard or medium bristle toothbrush (always use soft or extra soft, they clean just as well) some recession can come with age. Once recession has occured it can only be repaired with a gum graft. The proper treatment for gum disease is scaling and root planing (aka a deep cleaning) this is where tartar and bacteria are removed from below the gumline with specialized instruments (your gums are ussually numbed up for this). Ussually some of the gum tissue will re-attach to the root surface after the scaling and root planing, but because the bacteria can migrate back into these areas, periodontal maintenence cleanings are ussually recommended 3-4 times a year. It takes about 3 months for bacteria to build up the colonies and enviornment required to cause progression of gum disease. Even if there is no re-atachment to the root surface, if there is a reduction in the inflamation, then the severety of the disease has been reduced. —DagonJones

Regarding mouth washes, there are a wide variety of mouthwashes that are designed for different purposes. Some, like Scope, are just to freshen breath. Others, such as ACT or Fluoriguard have fluoride and help prevent cavities. Listerine helps fight gingivitis and gum disease. There is a prescription mouth rinse that kills bacteria responsible for decay and gum disease. I have never heard of mouthwash leading to thrush (or Candidiasis) but I can see the logic behind that because if the micro organism ecosystem in your mouth is disturbed it can allow Candida, a fungus, to proliferate and take over leading to thrush. However, I wouldnt worry about mouthwash causing thrush, I think that is pretty unlikely.

Wow great questions you guys, this is fun!

2009-05-23 10:15:40   Hey, out of curiosity and since you like the questions, here's a family medical oddity. My father's family is prone to never getting some of their adult teeth or getting them very late. My grandfather was x-rayed over and over during WWII by dentists because they were curious about it. I still have some teeth that never changed (premolars, and thankfully they look fine), I didn't get my second molars until I was in my mid 20s, and my wisdom teeth came in (straight and true) five years later. My father and his siblings all have some of their original teeth as well. As a side note, we're all pretty durn cavity free, other than my brother who lost all his baby teeth for adult teeth and had his molars come in at the usual times. I've always wondered how common this is. Have you run across it before or have you ever heard of it? —JabberWokky

2009-05-28 12:48:00   It is very common to have congenitally missing teeth run in families. There does not seem to be any specific pattern, like skipping generations, mother's side of the family, or anything like that. However, it is most commonly bicuspids and lateral incisors that tend to be absent. Ussually people do just fine with the baby teeth but sometimes they will fall out becuse they have shallow root structure or they can also start to resorb (melt away) which may necissitate an extraction. Regarding your second molars (aka 12 yr molars) comming in late, that sometimes happens but to the best of my knowledge it is not related to the congenitally missing teeth. —DagonJones

2009-05-28 18:49:35   Even stranger, I actually had a 3rd set tooth try to come in. I had it surgically removed because it was not properly formed, but my great-grandmother had the same thing.... Odd how it sometimes skips... er... 3 generations? —MasonMurray

2009-05-30 19:17:40   Question: My 6 year old sons "upper right lateral" baby tooth was knocked out @ Kindergarden running around—this was in October. Anyhow, we had it x-rayed and the dentist said we will have to see what happens. The "upper left lateral" tooth fell out and it's just emerging through now. I'm thinking then, his upper r. lateral would also be emerging around this time; but it's not. I felt both sides of his gums and on the right, it feels and also looks like it tooth is kind of stuck up there?? It doesn't feel the same on the left. Is there anything that can be done if the tooth is not coming down? —JRaumer

2009-05-30 22:33:07   I have a temporary crown right now and will get it replaced with a permanent one in a week and I was wondering how durable the permanent crowns are. —hankim

2009-05-31 22:04:46   JRaumer: Your son's tooth is likely to be just fine. the contralateral (other side) teeth rarely come in at exactly the same time, they are often seperated by about 6 months or so, sometimes longer sometimes less. If a primary tooth(aka baby tooth) is knocked out then there is potential for damage to the developing adult tooth, but this is very rare and unlikely. If it looks and feels like there is a tooth under there then he is probably in very good shape, often times there is a very pronounced tooth shaped swelling for several months before the adult tooth finally erupts through the gums.

hankim: A permanent crown is genarally designed to last a lifetime, however, there are many things that can cause a crown to need to be replaced. Decay, excessive wear, tooth fracture, can all necissitate replacement. The average ( and this is a very rough estimate) life of a crown is about 20 years. depending on why the tooth needed a crown in the first place plays a big role in the long term life span of a crown as well. If the tooth had very extensive decay or has a root canal then the life expectancy is less. —DagonJones

2009-06-10 18:01:11   I have a few questions about kids and teething: At what age should youngsters start going to the dentist? And, how do foods affect dental and jaw development throughout the deciduous teeth period? ——related to this last question, I've heard that eating lots of HARD foods (granola, etc) as a kid will result in straighter and stronger permanent teeth later on. Is there any truth to that? —TheAmazingLarry

2009-06-11 13:12:05   Children should see a dentist by age 1. When kids are very young we do a visual exam to check for signs of decay or other oral health problems. We also review proper brushing and flossing techniques for parents, discuss fluoride, diet, etc. from ages 1-5 I ussually recommend an exam once a year, unless the child has a high risk for decay then I recommend every six months. I have never heard of hard foods leading to straighter and stronger teeth, and I cant see how they could. This sounds like an "old wives tale" to me. The position of adult teeth can be influenced by the position of the deciduous (baby) teeth; however, the chewing forces on the baby teeth would have no effect on the development or position of the adult teeth. Tooth development can be effected by systemic factors like a very high fever or certain medications such as tetricycline (which causes gray stains on teeth), but indirect forces would not effect the cells responsible for tooth formation. Heavy chewing forces could lead to more dense bone around the baby teeth because bone is a very dynamic tissue and is responsive to physical forces. Bottom line is hard foods are not needed or recommended for proper tooth development.—DagonJones

2009-07-16 14:01:07   One of my teeth-premolar upper has slight split from one side. Is is straight down split. It doesn't bother me much except I eat too hot or too cold. My dentist was suggesting me to have a drill and fill it. I am very much cautious about my teeth and I am afraid to do the drill thinking that it will make my tooth worse coz my dentist was saying that she will make a horizontal drill and make up the split portion with fill. I am also scared that while making a horizontal drill on my teeth, she may be hurting my next teeth adjacent to it. I would like to get your opinion- Shall I go for Drill and Fill or just let it stay and avoid eating hot and cold stuff.

Sorry for the late reply. I doubt your adjacent teeth will be harmed by the drilling, if it is a vertical crack on the cheek side of the tooth it would be very hard to damage the adjacent teeth. For most fractures I would actually recommend a crown as opposed to just a filling. If the tooth is sensative to cold, and sensative when you bite down then the tooth almost definitely needs a crown. Fractures in teeth can spread pretty easily once established and they can lead to cusp fracture or sometimes root fracture. If there is a fracture in the root, then the tooth will need an extraction. It is very hard to say without actually examining your tooth, but I would not recommend doing nothing. If the tooth is sensative and there is visual signs of a fracture you should definitely have the tooth repaired. —— dagonjones

2009-08-27 19:21:29   My son is 14 years, 11 months. All his teeth have come in and he is currently in braces. His canines came in late (left canine just finished coming down two months ago) and space had to be created with springs to open room for them. Right now, his right maxillary second molar is primarily retained but the oral surgeon said it should have been exposed much sooner and now he should just wait as it probably won't come down after being exposed. There seems to be nothing in its path and the other three second molars came in fine. Could this be related to tooth b being extracted at 10 years old due to a cavity? Is it likely the second molar will come in after being exposed? —Genny

It would be almost impossible for the late/hindered eruption of a second molar to be related to an extraction of tooth B at age 10. The second molars do not replace any primary ("baby") teeth, therefore, it would be very difficult to damage the developing tooth bud of a second molar during an extraction of a primary tooth. By the way primary tooth B is replaced by the upper right first premolar (#5). Delayed or hindered eruption of second molars does happen sometimes, this can happen for a variety of reasons but often it is difficult to know why. Sometimes they can be moved into proper position with braces but that can sometimes be difficult. I would discuss the case with his orthodontist, ask him directly how likely it is this tooth will come into proper position. —- dagonjones

2009-09-09 11:34:57   I have a question. For all of my life, I've had a tiny black dot that appears to be a tiny hole of some sort on the top of one of my molars. It has never bothered me and I've never had a dentist say a word about it. Should I be concerned about it? —ChristyMarsden

2009-09-10 11:33:41   That tiny black dot is probably one of the pits or grooves that are very common in molars. if the pit is deep enough it can pick up quite a bit of stain. Most likely it is only staining and I would not worry about it, especially if you get regular exams. Sometimes those stains can have decay underneath them, a diagnodent (see above) is a good tool to see if there is decay there but ussually it is not necissary becuase the decay can be detected during a standard exam. —DagonJones

2009-09-10 17:57:26   I had a new crown molded a month ago, and the permanent gold one has been in for two weeks now. Would this change be enough to cause me to start biting the inside of my cheek when I eat? I started noticing this once I got the permanent crown put in, and today I started really feeling out the area where this is occurring, noticing that the "real" tooth above the freshly crowned one seems to have some deep gouges on the sides. Now this may have been there from a previous filling-I can't really tell as it may be a tooth colored filling, but it did seem like my dentist drilled on the upper tooth while the lower was being prepped for the crown. Did I imagine that, or would there be a legitimate reason for the dentist to do that, OR is the dentist looking to "guarantee" future revenue down the line when I might need a filling or another crown on my last natural molar? —CFletcher

I am going to give some quick answers and hopefully come back to put in more detail later. It is relatively common to adjust the opossing tooth during a crown preparation, this ussually does not damage the tooth but could make it feel a bit rougher, it can be polished if need be (ask your dentist next time you go in). When two teeth meet togeather there is an ideal amount of overlap that prevents the cheek from getting caught between. that can change a bit when a crown is made, it may not be the dentist or labs fault but rather simply the limitations that are present when making a crown. I have encountered this situation a few times, ussually the body adapts and the person "learns" to stop biting, if it is very serious the crown may need to be replaced. I have met many people who have a cheek biting problem with natural teeth with no crowns or fillings. -dagonjones

2009-09-13 17:40:29   Hi Dr. Jones,

On my last appt, the doctor kept calling out 3's, 4's and a few 5's. He said I had "calculus" and needed a deep cleaning. From what I have had described, the deep cleaning will open up the underside of my teeth to the outside permanently. And, because of this I will be stuck going back 3 to 4 times a year. This frightens me because it 1) opening me up to the outside world sound like it will do more hard than good and 2) since I do not have the ability to go back 3 to 4 times (or ever once a year), if I have this done and can not keep going back over and over and over I will be really, really screwed. Please tell me I am wrong? What do you recommend?
-T —ToddAndMargo
It sounds like you have periodontitis (gum disease) see the above entry :2009-05-22 23:15:28 Peridontal Disease for more info about gum disease and its treatment. Calculs is just another word for tartar, it needs to be removed because it is like a playground for bacteria. The deep cleaning will only remove bacteria and calculus from the tooth root. It will not expose any part of the tooth to the outside that was not already exposed. I think you should really commit to cleanings at least 3 times a year (even if your insurance does not cover all of them), and the deep cleaning (root planing), it can really make a big difference. The long term results of gum disease can be tooth loss, also untreated gum disease can increase your risk of cardiovascular disease, stroke, and type II diabetes. The 3's are not bad and the 4's are marginally bad, the 5's are definitely indicate the presence of gum disease, but it is not just the numbers but the severety of the inflamation present in the gums. Inflamation is indicated by redness, bleeding, and swelling of the gums—dagonjones

2009-09-13 17:56:20   Hi Dr. Jones,

I lost a lower front tooth in a car accident about 40 years ago. I have a lot of bone loss in the empty space. If I can ever afford an implant, I will need bone replacement. Can this be done with ACP (amorphous calcium phosphate) or similar? Or, am I stuck with surgery?

If surgery, where do they get the bone from? And, what effect will stealing the bone have on the site where it was stolen from?
-T —ToddAndMargo

Bone is ussually deminieralized cow bone or human bone from a tissue bank, both of which have NO risk of transmission of disease. If bone is harvested from your own body (which has the best chance of success but also the most uncomfortable) then the donor site will take a while to heal and ussually hurt but it will heal just fine in the end with almost no chance of permanent damage. The bone would ussually come from your leg or your jaw. The bone graft is considered surgery, but you will not likely need surgery to harvest bone becuase most bone grafts today use material from a tissue bank. —dagonjones

2009-12-02 10:12:08   My molar broke last night (on a Tues). A piece of it the broke off and seemed to crumble. I left a message for my dentist, but alas, her office is closed on Wednesdays. I'm flying out of town on Friday. What's a person to do? —NoelBruening

No number given. —Noel

If your dentist does not leave an emergency number just find a dentist who is available that day, Davis is full of great dentists who would be happy to help you out. Most dentists will do a temporary fix for you to last you long enough to get back to see your regular dentist.

2009-12-21 09:10:23   I have a worn out gold crown on a back molar. A couple of local dentists said they would replace it with a $450 stainless steel crown. Other say pretty much over their dead body, but would not give a reason. One says stainless is stronger and last longer, they just look bad. Since it is too far back to see, I do not care. Is there some reason to stay away from stainless and pay the $1100 for a gold crown? —ToddAndMargo

2009-12-22 10:09:24   I would strongly recommend against a stainless steel crown. Stainless steel crowns are pre made and come in a variety of sizes, none of which will provide a precise fit for your tooth. Stainless steel crowns often (almost always even in the hands of great dentists) have very rough margins. These rough margins collect plaque and tartar and often lead to decay in the long run. A custom crown is made in a laboratory and should have a very smooth margins with a precise fit that will not allow bacteria to accumulate. If cost is a big issue just keep the gold crown you have, if there is a hole worn through the top a small filling can be put there. This filling may not even be necissary if there is not decay present. Talk to your dentist and find out if the crown absolutely needs to be replaced, it may be able to be patched. A stainless steel crown will be more expensive in the long run because it will not last as long and is much more likely to lead to decay. Stainless steel is a stronger material than gold but the metal is much thinner on a stainless steel crown than a gold one. —DagonJones

2009-12-22 16:24:58   Hi! Lately I have had a lot more tooth sensitivity (cold and hot) in the back of my mouth, one molar on the right side of my mouth. I have a filling there, not too old...am wondering if this is something I need to be worried about? I brush and floss, no bleeding or pain from that anywhere...Thanks! —jsbmeb

2010-01-05 15:34:18   Your sensativity to cold could be many things, It could be a cracked tooth, infected nerve, decay, or nothing at all. Teeth are often sensative to cold, and this can change with time. Teeth with fillings are more likely to have sensativity but even perfectly healthy teeth can have transient sensativity. I would wait several weeks, your cold sensativity will likely subside with time and it may even come back in the future. If it continues to get worse or if the pain is severe and lingers for more than one minute after the cold is removed you should see a dentist. —DagonJones

Wisdom Teeth or 3rd Molars

Wisdom teeth often need to be extracted because there is simply not enough room for them in the jaw. The definition of impaction is a tooth that cannot erupt fully into the mouth. Sometimes wisdom teeth erupt fully but are in a problematic position and need to be removed. Even if the tooth is not painful or obviously problematic it may require extraction. Impacted wisdom teeth often push against the teeth in front of them and can lead to decay or resorption (biologic destruction). Wisdom teeth extraction can be done under light sedation or general anesthesia (being put to sleep) or no sedation, in all situations the areas are thoroughly numbed so there is little or no pain. Minor swelling is common and often not visibly noticable, very large swelling (like a chipmunk) is infrequent and often the result of an infection but is often easily treated with antibiotics. Pain is usually minor to moderate and often lasts for about 3-5 days and is managed well with prescription pain medication. - Dagon Jones

impaction.gif 2010-01-06 10:15:20   Hi Dr. Jones... This problem has been bothering me for years—I have a impacted wisdom tooth in my lower jaw (mesial impaction? as seen here except it is fully erupted):

I had already spent quite a lot of money a few years ago getting oral surgery to lift and straighten it, but it failed. I've been keeping it clean and so far by flossing and brushing excessively and have not had any cavities in the impacted area yet, but often times I get pain in my jaw and pressure-build up and aches...

I was wondering what my options are? Can it be fixed, or must it be removed? If I get it removed, will I need to remove the corresponding tooth on the jaw above it (I'm reluctant to remove one tooth, yet alone two)? Thanks in advance! —H4rry

2010-01-14 08:55:24   What you are describing is probably "pericoronitis" which simply means inflamation around the crown. It is a common problem with lower wisdom teeth. because the gum tissue sits very high around the tooth plaque, bacteria and food often get caught below the gum and lead to infection, inflamation and pain. The best solution is almost always to remove the tooth. The inflamation can be treated every time by topical antibiotic rinses or debridement (cleaning under local anesthetic) or sometimes recontouring of the gum tissue. I would not recommend these methods because the problem will ussually continue to recur.

2010-01-20 19:43:58   I have two questions. I got braces when I was ten and had them for three years. But once I got them removed I didn't use my retainer because it didn't fit properly, it would pop out. A couple of years later when I went to a different dentist, I was told that because I had braces at a young age the root of my two front teeth are short and weak. My first question is, can getting braces at an early age really do that to the root of the tooth and is the effect reversible? My second question is, because I stopped using my retainer right after the removal of my braces, I have crooked teeth again. I want to get braces again, preferably a removable aligner, but will it further damage the roots of my front teeth? And thanks in advance. —XuJeong

2010-01-25 22:49:09   During orthodontic movement the roots of teeth can become resorbed. It is more likely for this to happen when the teeth are being moved very rapidly (which was not likely the case if you were in braces for three years) , but it can occur during regular orthodontic movement. Unfortunately the effect is not reversable. It is possible to move your teeth again with braces but the chances of further resorption are present and depending on the severety of your resorption it may not be recommended. You would have to check with an orthodontist. The orthodontist would evaluate your x-rays and the severety of crowding and let you know how significant the risks are.

I emailed this question to Dr. Molitor (a local orthodontist and all around nice guy) here is what he had to say:

"These are good questions. There is no evidence that braces at an early age causes increased root resorption. As a matter of fact the opposite seems to be true. That is, orthodontic treatment on the very young rarely produces root resorption. It is true however that orthodontic treatment for younger kids often implies prolonged or multi-phase treatment which can be related to increased risk of root resorption.

For those that have already experienced root resorption, further orthodontic treatment definitely can be risky. The decision to do orthodontic treatment is always a balance of risks and benefits so it would depend on how much the teeth need to move, how much root is left on the affected teeth, and how much the "crooked teeth" bother you. "

Hope that helps.
Matt Molitor

2010-02-03 12:45:23   Any advice for somebody about to see a dentist (for a cleaning) for the first time in over 20 years? I've never had any problems (straight teeth, including wisdom teeth that came in fine and are accessible for cleaning, never had a cavity, etc), but I figure there might be some questions I should ask or something like that. Other than some back of the tooth staining from coffee and tea, I have no issues I can even think of. I should also add that I don't have any fear of dentists at all; I have just been a business owner for many years, and I didn't have dental insurance until I got married, and then didn't think about going until my wife pointed out that with our upcoming move, we'll be changing insurance, so I might as well take advantage of what we've been paying for and go now. —JabberWokky

2010-02-03 20:28:06   Very informative page. I have been considering a dentist but will need time to consider it, however, partly due to personal interactions and partly due to seeing the extremely positive reviews I think I would definitely have visit Dr. Jones. —WesOne

2010-02-03 21:24:40   JabberWokky; when you see a dentist make sure they check your periodontal (gum) health. This step is known as perodontal probing, it involves the dentist or hygienist feeling your gums and counting out a series of numbers. See the entry on this page dated 5-29-2009 for more details. If it has been a long time between cleanings there is likely a good amount of calculus (tartar) buildup on your teeth, which has likely led to inflamation or even gum disease (lets hope not). Dont feel swindled if the dentist wants you to come back for 2 or more cleanings, if there has been tartar on your teeth for more than 20 years it can be very hard to remove and sometimes it takes longer than 1 hour to get it all. If you have other questions after your first visit let me know, you can email me the x-rays and I will be happy to review them and give you my advise. —DagonJones

2010-02-09 10:52:57   What's your general feeling on sealants? I was always a very good brusher and had no cavities until late college. In high school my dentist insisted on sealing my teeth, which my mom (a former hygenist) was not very happy about because she feared they'd eventaully crack and leak, thus trapping things under the sealant. Given a sudden onset of cavities (probably 10 surfaces in 4 years) with no other changes in brushing, flossing, or visiting a dentist, is it possible the sealants were not such a hot idea? Thanks in advance. —AmLin

Sealants

2010-02-09 14:15:13   I recommend sealants based on the risk of decay for the tooth. If a person has a history of decay and the tooth has very deep pits and grooves, then a sealant is a very good idea. For kids under 10 sealants are usually recommended on the adult molars because kids commonly have a higher risk for decay (love of sweets and lack of good brushing). For a good sealant the tooth must be kept very dry during placement, if moisture gets on the tooth during the sealant process the sealant won’t bond well and it could leak. The grooves should also be very clean, it is best to clean out the grooves with a very small drill, a microblaster ( a very small sandblaster), or a spinning brush with pumice. If a sealant is placed well it will last a long time and the risk of getting decay under it is very slight. If a sealant is not bonded well then plaque can get under the seal and lead to decay. If decay is sealed in under a sealant when the sealant is placed, the decay won’t spread (if it is completely sealed) because the bacteria can not get a carbohydrate food source. Overall, sealants are a very good thing; they do much more good than harm. However, they can be a problem if they are not sealed well but this is usually rare.

2010-02-09 15:57:09   I have a cap on one of my upper molars, about two years old. Part of the cap is metal (amalgam, perhaps? not gold). Normally it doesn't bother me, but when I swim in the pool, sometimes I get an uncomfortable "metal" feeling. Any idea what could be causing that? Chlorine? Exercise? I'm clenching my teeth while swimming? Should I be worried about it? —CovertProfessor

2010-02-09 19:47:34   The metal is most likely noble white gold. Similar to the white gold in jewelry. It has a silver appearance in is commonly used in porcelain fused to metal crowns (aka caps). The sensation you are feeling is probably due to clenching your teeth while swimming, I would try to avoid that. Too much force on teeth can cause sensitivity. I would not worry too much about it, it is very common for teeth with dental work to be a little sensitive from time to time (this even happens on teeth with no dental work). I would only worry if it was painful very often (like once or twice a day) or if it started to get increasingly worse. —DagonJones

2010-02-20 15:04:50   Is it possible to induce temporary sensitivity via a ton of sugared candies? —StevenDaubert

2010-02-20 15:44:36   About four years ago I had corrective jaw surgery to fix an open bite. Now my jaw regularly locks and has to "pop" open, which sounds like a loud crack. Is this a normal complication from the surgery, or is it potentially unrelated? —MHaymond

TMJ/TMD

TMJ refers to the TemporoMandibular Joint itself and TMD refers to TemporoMandibular Disorders.

The following is a general list of recommendations for jaw pain (TMJ/TMD):

2010-02-22 11:19:59   So years ago... I got into a pretty bad car accident. Ever since, I've had this jaw popping thing happen whenever I open my mouth big to yawn or the like. It's as if the right side of my jaw unhinges itself and slides to the side ever so slightly. Never caused any pain, but lately I've been waking with an ache on that side. How do I fix that? —Aaron.Curtin

What probably happened to you Aaron is that one of these muscles or ligaments on the right side was torn and did not heal exactly the same as before. So now when you open on the right side the disc slips out of position (resulting in a pop or click). Also your jaw may be translating further on the right side resulting in your jaw moving a bit to the left. The pain you are having on the right side in the mornings is likely due to night time grinding or clenching of your teeth (aka parafunctional habits). These movements can create a lot of stress and strain on the muscles and the joint, resulting in soreness. I would guess that you have had an increase in stress in your life (stress often makes jaw discomfort worse). You could try some of the things listed above (minimize stress, minimize hard/chewy foods, thermal compresses). If your symptoms persist or get worse you should see a dentist, it would probably be best for you to have a custom bite plate made. DagonJones

2010-03-18 14:10:10   During a recent exam I was asked what my daily regimen consisted of: brushing, flossing, etc. One tool that came up that I'd never really thought about was a water pick. I don't use one, and never really thought about using one. I brush and use mouthwash at least twice a day, floss once a day, and have no problems with my gums. Is there any reason to use a water pick as part of a normal daily routine? I've always thought of them as somewhat gimmicky or for people with specific issues. —JabberWokky

2010-03-18 14:23:38   Also during the recent exam, they brought up some non-tooth oriented items. For instance, the fact that my jaw sometimes locks open when I open my mouth really wide (usually in a big yawn), and usually clicks when I open it wide. There's no pain unless it locks, and it happens so seldom that I consider it a non-issue. You've answered the question about the jaw clicking already (although they think mine is because the tendon slides over a bone causing transition). But the question I had after leaving was: how far does the practice of dentistry go beyond teeth? I've always considered it a tooth and gum field. Since they measured my jaw displacement, obviously the jaw hinge is also a common part of the field. Are there any other common non-directly-tooth related problems that one can see a dentist rather than a doctor about (or at least bring up during an exam)? —JabberWokky

2010-03-18 14:26:39   As a third, semi-rhetorical question, is there anything that people commonly do that is worse to the overall health of all parts of your body than using tobacco? —JabberWokky

2010-03-18 16:34:13   If there's only a root, is there another option other than root removal? —BruceHansen

I would have to see the situation; however, there is rarely anything (good) that can be done with just a root. A root canal could be performed on the root then it could be used for retention of a partial denture. —DagonJones

2010-03-22 11:58:29   a week ago i awoke with a sore throat. turns out it was strep and i was put on antibiotics thursday. however, the day prior (wednesday) i noticed some gum tenderness while brushing, which turned into gum bleeding and lots of tenderness/redness of the gums by thursday afternoon & friday, through to today. it would seem to be gingivitis, but i was too ill with the strep to do much about it other than continue to brush and use some listerine. my question basically is: do you think i need to get in to see a dentist asap (i'm out of dental insurance for the year due to a wisdom tooth extraction a few months ago) or, since this was likely triggered by the strep, will continued brushing etc clear it up in time? —RyanJames It is hard to say what is causing the problem, if you don't have a toothache then it is most likely gingivitis. If there is any pus coming from the area see a dentist ASAP (it could be an abscess). If it is gingivitis the best thing to do is brush well (not hard, but thorough), floss, and use listerine. Gingivitis is caused by bacteria and should get better if the area is kept clean. If it does not get better in a week I would go see your dentist. —DagonJones

2010-03-22 16:18:00   With no intent to create a debate, I will ask a very simple question: Is dental coverage included in the new health care bill? —JabberWokky

* I love your debate disclaimer. I don't think it provides for any dental coverage (I have heard of nothing). I have not followed the bill closely, I was going to wait until it was all finished to figure out what it says. My understanding is that even Canada does not have any public dental care despite their renown public health system.

2010-03-24 12:56:16   Can eating too much citrus be bad for the teeth? Grapefruit was on sale at Safeway for the past week, and I’ve been eating 1–3 a day… last night while brushing my teeth felt a bit more sensitive than usual. —EBT

Yes, citrus can be damaging to teeth. Citrus fruits are very high in citric acid, that is what gives them the sour or tart flavor. The acid can dissolve the minerals in tooth structure. This can make teeth more sensitive but most often people don't notice any discomfort but the erosion can be seen on the teeth. Lemons are the most acidic and people who suck on lemons often have severe acid erosion on their front teeth. I love oranges and eat a ton of them when they are in season, it is usually not a problem. The best thing to do is avoid keeping the fruit in contact with the teeth for prolonged periods of time, enjoy in moderation. Eating a bunch of grapefruit for a week is not likely to have long term significant consequences, most likely the acid has removed a thin protective layer of calcium that covers any exposed root surfaces. This will often make these rooth surfaces sensitive. Try using a sensitivity protection toothpaste for a few weeks and the sensitivity will likely go away. —DagonJones

2010-04-19 20:19:13   What is the cost to replace a crown on a molar? —shilee91

2010-04-19 21:48:24   A typical crown in Davis costs $800-1000 (regardless of the tooth it is on). If you have insurance, most insurance companies will pay for 50% of the cost. Let me know if you have more specific questions. —DagonJones

2010-04-19 21:56:20   Besides brushing at least twice a day and using flouride and Listerine, what's the best way to get rid of stains around the gum line and between teeth in the time between dentist visits? I read somewhere to brush with baking soda, but then I also read that that's really bad for the tooth enamel. —MonicaWilliams

There are not many home products that remove stains well because it does require a fairly abrasive compound to do so, try using baking soda with dental floss to get the areas between the teeth, use an up and down motion while pressing against each tooth. For areas at the gumline use a brush with baking soda. Baking soda is best used once a week because it is fairly abrasive, I would not consider it bad for enamel but using it daily could cause excessive abrasion. —DagonJones

2010-04-29 01:48:12   I must confess... I'm afraid to go to the dentist. My parents took me up until I moved out, I went once since then, and I have been avoiding dentists altogether for like 3 years now. Bad, I know. I am having tooth pain now so I know I need to make an appointment soon, but I have a question that may or may not help me feel better about going. I am cavity-prone, I get cavities all the time. Why is it that whenever a dentist sees a cavity they have to stab that sharp hook thingy into it and cause me immense pain? If you can see the cavity there already, is it really necessary to jab it? I am cringing just thinking about it now. I know I will have cavities next time I see a dentist so I think this is why I hate it so much. —JenniferCook

This is actually a very good question. Caries (cavities) are diagnosed primarily by feel, not sight. Dark areas in the pits and grooves of the teeth may be heavily stained and not carious. An instrument called and explorer (that little hook thingy) is used to feel these areas to find out if they are soft or hard. If the tooth structure is soft, then it is decayed. This should not hurt but sometimes people have very sensitive teeth or deep areas of decay and it can be painful (I do this daily and only get a painful response about 1-2% of the time). Some areas of decay can be deep within the grooves and below the level of the explorer and wont be detected by feel. To find decay in these areas a [WWW]diagnodent can be used to detect decay. When you see a dentist, ask them to use a diagnodent (call the office to see if they have one) or be gentle and only feel the area if they have to, sometimes the decay is so obvious by sight that feeling it with the explorer is not necessary. No one will be offended and no one will think you are a wimp, we see people every day who are nervous, anxious, and afraid. Don't be hard on yourself about not going to the dentist in the last few years, many other people are in the same situation you are. Your dental team is there to help get you back on track with proper oral care, not scold you for what you did wrong. —DagonJones

2010-06-06 16:30:05   I have several root canal treated teeth, yet everytime my dentist close the canal with the plastic pin. I get a swelling under the tooth. One molar he already extracted because he said it was unsavable. Can a systemic disease be causing the swellings I am experiencing after he close my root canal treated tooth. Thank you

I have never heard of a systemic disease causing recurrent infections in root canal treated teeth, however a compromised immune system can make them more likely to occur. Root canals are not always successful, sometimes they become reinfected and need re treatment or sometimes extraction. I am not sure what you are talking about when you say close the canal with a plastic pin, perhaps you are referring to the "gutta percha" which is a rubber based material used to seal the canals, can you tell me a bit more? —DagonJones

Root Canals

endo1.jpgInfected Pulp

endo2.jpgCleansing and Shaping endo3.jpgSealing with Gutta Percha This is an excellent opportunity to talk about root canals. A root canal (or Endodontic [endo = inside, dontic = tooth] treatment) is performed when the pulp chamber inside a tooth becomes infected. The pulp chamber is the hollow area inside a tooth that houses the nerve and blood vessels. The nerve and blood vessels enter the tooth through a very small hole at the base of the root (see image at the very top of this page). The most common reason for infection of the pulp is bacterial contamination due to decay, a cavity gets deep enough that it penetrates the pulp. Once the pulp is infected, the immune system cannot bring enough blood flow through the small portal at the base of the tooth to supply an adequate immune response to heal the infection. The tooth must either be extracted or the all the nerve and vascular tissue must be removed from the pulp space. Removal of the tissue within the pulp space, sterilization, and subsequent sealing of the canal space is what a root canal consists of.
A root canal begins by removing all decay and providing a clear access hole to the pulp chamber and canals. The canals are then cleaned and shaped using small files. Cleansing refers to removal of all bacteria, nerve and vascular tissue. Shaping refers to widening the canals to remove potentially infected tooth structure and allow adequate room for the filling material. During the cleansing and shaping process the canals are rinsed and sanitized using a diluted bleach solution (all of this is done with a rubber dam to prevent the bleach solution from entering the mouth). Once the cleansing and shaping of the canal is completed the canal is dried and filled with a thermoplastic (softens when heated) material called gutta percha. The material is heated to soften it and it is condensed into the canals so that is fills in all the space, sealing cement is also used to further assure all spaces are filled and sealed. The root canal is now finished and a permanent restoration is needed to fill in the space created by the decay and access cavity. Root canal treated teeth often require a crown to help prevent fracture. Root canal treated teeth have a much higher risk for fracture because they have often lost a considerable amount of tooth structure due to decay and the access cavity.
A root canal can become re-infected for a variety of reasons. If the canal space is not cleaned out thoroughly or if it is not adequately sealed a re-infection is more likely. However re-infections can occur even when the root canal is done ideally. Recurrent decay (a new cavity under the final restoration) can get into the sealed canal space and cause a re-infection.

2010-07-05 19:53:23   Do any dentists in Yolo County or nearby counties use rectangular collimation? The recommendation to use it has been in place since 1989 because it reduces x-ray exposure to 1/4 of what it is with round collimation—and it makes a sharper image by reducing scatter radiation. Do dentists fear the small increase in reshoots more than they fear over-radiating their patients by a factor of four? While it is wonderful that most dentists now use ultra-fast F speed film or digital receptors to help reduce radiation exposure, ADA and others say to use both the fast receptor and the rectangular collimator. Why is this taking so long? Thank you. —BarbaraKing A collimator is the “cone” or cylinder that attaches to an x-ray unit. A collimator directs the x-ray beam. Using a rectangular collimator can reduce the amount of scatter radiation but it also increases the amount of “cone cuts” or operator errors that require retakes. Round collimators are used in most dental offices to reduce the need to retake films. I am not aware of any offices that use rectangular collimation in Davis or Yolo county. I think the reason most offices have not switched is because retakes can be a significant burden, and given the very low radiation exposure of current dental films the need to further reduce exposure is not viewed as a critical issue. —DagonJones

2010-07-12 10:37:43   This is a question I was asked recently and I thought I would post it here. A patient wanted to know if brushing after every meal (about 5 times a day) can cause harm to the enamel of the teeth.

Yes, brushing after every meal can harm your teeth but it is not likely to cause too much damage. When you eat acidic or foods high in carbohydrates an acidic environment is created in your mouth. This acidic environment temporarily softens the enamel of your teeth (the enamel will re absorb minerals and harden in about an hour). If you brush immediately after a meal you can remove some of the softened enamel. I recommend brushing 2-3 times a day and generally before meals or at least 60 minutes after a meal are best. Brushing more than 2-3 times a day does very little to remove additional plaque and does not have much effect on your risk of developing cavities.

2010-07-20 16:43:03   Hi! Thank you for your page. I am an international student at UCDavis and one of the worst things for a foreigner is to learn how to deal with health related issues. Things are done differently in every country, so I guess that helping us to understand dentist procedures could be a nice addition to your page. If interested, I have two questions right away. First, is it common that your main dentist does not pull teeth? In my country that is one of the most basic things but here, I was referred to another dentist who took a whole new set of Xrays and photos and even had his hygienist explain to me how to brush my teeth (which had already been done at my main dentist's office). Of course that was charged and with that visit (plus my main dentist one) I maxed out my insurance. I do not know if that is poor coordination btw the offices or standard practice. Ah, and the second one did not even pull my tooth so I am flying to my country to have the extraction done. Second, if I wanted to change my main dentist, would the new dentist accept the x rays that I already have taken? I don't feel comfortable with Xrays exposition when unnecessary. And how do I know if the new dentist would perform extractions? Thanks! —CarlaGomez

In California it is rather common for general dentists to refer all extractions to an oral surgeon. However, many general dentists (myself included) have a lot of experience with extractions and do perform them in their office. It is just a personal decision by the dentist. You have a legal right to get a copy of your x-rays (your dentist may charge a duplication fee), your new dentist will likely accept the films you bring in as long as the quality is good enough to perform a thorough diagnosis. If you want to know if your new dentist performs extractions just ask the receptionist when you call to schedule an appointment. Good luck! —DagonJones

2010-07-28 11:52:27   When a tooth is extracted, has it become standard practice to pack the empty socket with graft material, whether or not implantology is contemplated?

I ask this because this is what was told me by an oral surgeon. He stated that the bone should be restored for the benefit of those teeth adjacent to the extraction site. My insurance company does not cover this part of the procedure; however, if the application of bone graft material is now considered standard, then I should challenge their denial of coverage.

What is your opinion?

- - Herb

It really depends upon the situation. Placing bone grafting material into a socket (aka socket preservation) is a very good idea if there has been destruction of bone due to gum disease (periodontal defect) or infection from the tooth that was extracted. However, socket preservation is not always needed, there are many situations where bone grafting is not going to do much at all. Socket preservation primarily helps maintain the buccal to lingual width (that is cheak to tongue distance) of the bone ridge. Preserving this width does not do much to help maintain the integrity of the neighboring teeth but it is good to preserve natural looking gum tissue in visible areas of the mouth, especially when a replacement tooth (implant or bridge) is planned in the future. So to answer your question more directly, I do not feel like socket preservation is the standard of care in all situations, but for some situations it is a very good idea. If there is extensive bone loss very close to the adjacent teeth due to periodontal disease or infection, then socket preservation will be a benefit for those teeth. Let me know if you have more questions—DagonJones

2010-08-05 16:14:57   hi dr. jones, my dentist told me (based off of diagnodent) that my wisdom tooth has a cavity on it (a number around 38). she wants to extract it. would it be possible for a regular filling to go on my wisdom tooth instead of an extraction? could that be done? —lifeatapoint

2010-08-05 16:17:45   hi dr jones, another question: is it normal for a white filling right next to a silver filling (on the same tooth) and will that new white filling lead the silver filling in that tooth to expand and/or crack the tooth? —lifeatapoint

Yes, a filling can be done on a wisdom tooth instead of an extraction. You may need to have a silver amalgam filling on that tooth because the tooth must be kept dry in order to use a white filling and that is sometimes very difficult on a wisdom tooth. There may be other reasons your dentist is recommending an extraction (such as risk for gum infections around the tooth) so you should ask her about it. To answer your other question; it is fine to have a composite (white) filling right next to an amalgam (silver filling) on the same tooth. The two fillings right next to each other will not put the tooth at any additional risk for fracture. —DagonJones

2010-09-27 10:37:46   Hello Dr. Jones, What is your procedure for silver filling removal? Do you follow the guidelines listed by the IAOMT for safe removal? —lifeatapoint

2010-11-03 19:00:48   Dr Jones—I'm curious. Having read your Xylitol info, what is your opinion of [WWW]Zellies and its alleged positive effect on dental health? —PeterBoulay

Zellies look like a good product. They are very comparable to Epic mints and gums, they both have the same amount of xylitol per mint and gum. The shape and size of the gum and mints are almost identical they are probably manufactured by the same company and just branded differently. All the claims they make on their website about the dental health benefits of xylitol are accurate and supported by current research articles. —DagonJones

2011-01-24 08:27:29   Nicely done page. On root canals, you might mention that in addition to abscesses, cracked teeth can also require them. Most older folks like myself have had more root canals from cracks than infections.

I'd also appreciate some mention of emergency dental treatment. I assumed that if you were in pain and required treatment, a dentist would find a way to accommodate you. Having been in that situation with one of the most highly regarded dentists in Davis, I've found that it is not necessarily the case. Friends have had the same experience with other highly regarded dentists. Perhaps you could offer guidelines for appropriate dental emergencies and accepted medical ethics that would require that a dentist provide emergency treatment. —JimStewart

You are right Jim, sometimes fractures can go into the nerve and cause the need for a root canal. In my experience I have found that when fractures are that deep, the tooth is often not restorable because the fracture goes too far down the root. So you were lucky to be able to save your tooth with a root canal. Regarding emergencies, I am sorry to hear that you had experiences where you were in pain and your dentist was not available. Most dental emergencies can be managed with pain medication and/or antibiotics for a few days before treatment is needed, so often during a weekend or after hours all that is needed is to phone in a prescription. If there is trauma or other significant issues that require immediate attention Dr. Johnson and I will see patients in the office during off hours. Most dentists I know have an answering service or a cellphone that they use to let patients get in touch with them after hours. If we go out of town for the weekend we make sure that there is another dentist who has agreed to take any emergency calls for us while we are unavailable. The practices I just mentioned are pretty standard for the dental profession. Unfortunately not all dentists are as diligent about keeping their phone with them or being as available as they should, and sometimes patients think they need to be seen immediately when the issue is not necessarily as urgent as they might think. Hope that addresses the issues you were interested in. I can come back later and add some detailed information about what types of emergencies require immediate treatment and which ones can wait a few days. —DagonJones

Dental Emergencies

Fractured tooth: Most fractured teeth are on back teeth that have old amalgam (silver) fillings. Most fractures result in a cusp and/or part of the filling falling out. Sometimes there is sensitivity to cold and heat or no symptoms at all. In these situations it is not necessary to see a dentist immediately. The exposed tooth structure will need a filling or crown but will not be further damaged by being exposed for a few days, after several months the area may start to decay due to plaque accumulation.
Sometimes part of the tooth that broke is still attached to the gum tissue. Part of the tooth wiggles and wobbles (and is often rather painful) but wont come out. These situations often require treatment within 0-48 hours because the fractured portion must be removed under local anesthetic (it is just too painful otherwise).
If there is intense pain that is present all the time on a fracture tooth then urgent attention is required. If there is bleeding from the inside of the tooth that means the nerve is exposed and the tooth will need a root canal or extraction.

Tooth knocked out or loose: in these situations urgent care is needed. If a tooth is visibly loose and there is bleeding from the gums around the tooth the tooth will need to be repositioned and stabilized by a dentist ASAP. If a tooth is knocked out completely, gently rinse off any debris from the tooth in water and take care not to touch the root. Store the tooth in milk or in the mouth of the patient (but try not to swallow it) and contact a dentist ASAP. In some situations the tooth can be re implanted but the success rate is low. If the tooth that was knocked out is a baby tooth then re implantation is not recommended but urgent care is often needed to address other teeth that may be loose or damage to the surrounding soft tissues.

Toothache: Most toothaches do not require urgent care. Most dental pain increases slowly and can be managed with prescription pain medication and/or antibiotics until regular office hours. Antibiotics are only needed if there is swelling (size of a marble or bigger swelling). Sometimes dental pain comes on strong and fast, if the pain is very severe then urgent care may be needed.

Please post on this page if you think of a common dental emergency that is not described above.

2011-01-31 12:26:00   I've had a crown for several years, and in the last few months I get random pain now and then, usually lasting from 10 minutes to an hour or two. Due to general sensitivity (especially to cold) I use Sensodyne toothpaste. Talked with my dentist about it, and she said it looks like I stress-grind, and the grinding pressure on top of the crown is what gives me the pain. She said the fact that I don't feel the pain everyday but rather every few weeks is an indication of that. Anything, other than a mouthguard (or yoga/massages for stress :P), that I can do? —EdWins

There are many things that can cause biting sensitivity, and one of them is frequent clenching or grinding. A membrane of ligaments surrounds the area between the root and the bone. These ligaments can become irritated from too much force and can cause sensitivity in the tooth. Sensodyne is not likely to make a difference for this type of sensitivity, that only really works for sensitivity to cold/heat. A nightguard usually works best, you should also have your dentist check the bite on the crown (she probably did this when you mentioned it), if the bite is a little high an adjustment might reduce the discomfort. What you are describing is very common, even on teeth with no previous dental work. The good news is that the discomfort is often minor and temporary. —DagonJones

2011-02-01 12:45:48   Last year during an overzealous routine clean, about half of one of my top molars broke off horizontally. My dentist reconstructed the tooth, but six months later it broke off again. Now he says I must have a root canal and crown, because he says he has no idea if the root is damaged; there is quite a bit of the tooth left, and it is not discoloured or sensitive. Being terrified of dental work (traumatized as a child), I really don't want to go the root canal way. As this seems to be a purely preventative measure, is there another option apart from extraction. The dentin is exposed, but I'm wondering whether the remaining part of the tooth could be sealed or capped in some way to protect it from decay or infection. I'd appreciate a second opinion. —MaryKeast

post.jpgA root canal is sometimes needed (even when there is no damage to the nerve) in order to place a post and core to support a crown

I won't call what I am telling you a true second opinion because I have no way of knowing the details of the situation without doing an exam. Having said that, sometimes a root canal is needed to place posts into the root so that the posts can help retain a buildup that is needed to help support a crown. However, that does not sound like the situation in your case. You may have the option of doing another filling (which will likely break off again as the first one did), or a crown. It sounds like a crown is going to be WAY better than another filling. You could have a crown without a root canal first. Lets say you get the crown and no root canal, and a few months or years later it becomes apparent the tooth did need a root canal. A root canal can be be performed by drilling a hole through the chewing surface of the crown. As long as the crown is gold or porcelain fused to metal (and not a full porcelain crown) then it is very unlikely the crown will need to be replaced to do the root canal. It is always preferable to do a root canal before a crown because the alternative damages the crown, but it is rarely necessary. —DagonJones

2011-03-07 19:41:04   Hi, I had leukemia treatment 13 years ago which has resulted (amongst other things) in my having a permanent dry mouth condition. I've had a multitude of cavities because of this, and during a recent half year of extreme stress, I developed significant periodontal disease. I had non-surgical treatment for it, and my dentist told me last month that I no longer have any gum pockets and very little plaque(hooray!). Since the three-month long periodontal disease treatment (ouch!), I have been maintaining my teeth with a 35-40 minute session every night, in which I floss, brush with inter-dental brushes, and use a high-quality electric toothbrush for 16-20 minutes. My question is, am I brushing too much? I am under the impression that I do not have any enamel left (is that possible?), but I am very worried about keeping my own teeth (I'm only 33). Is my tooth routine too extreme? —AmberWilkin

2011-04-15 13:35:30   I don't live in Davis so hope it's. OK to post (although moving very there is tempting!) My question is - I had a root canal in 7 from a car accident but for some reason there was an unresolved fracture. Later my tooth broke at fracture and needed a post and crown - another dentist did that work and I left the temp on for quite a while with no problems. Finally got the perm crown and now experiencing excess saliva, which is doubly odd because I had dry mouth before due to medications. It's been about a month. Is this just an adjustment period or should I be concerned? The new crown fits a little differently (better) than the temp but they did make it thicker on the back (I think because my original tooth was thin). Thanks for your mouth. At first I was glad my mouth wasn't dry but it's gone way too extreme. —EmmaInteresting

It is certainly ok to post here if you don't live in Davis (even if you had to live in Davis to post there is no way to confirm that so I don't really care.) I have never heard of a crown causing excess saliva. I don't see how it would be possible unless you were playing with the crown a lot with your tongue. The excess movement might stimulate some more saliva flow but I doubt it would be noticeable. If you stopped using certain medications around the same time, you might be perceiving your now normal saliva flow as excess considering the change. Excess saliva flow will not cause any problems for your teeth or gums, in fact it will help prevent cavities (saliva naturally fights decay). —DagonJones

2011-06-03 13:37:15   Hey Dr. Jones, you are taking my wisdom teeth out in a couple weeks, but I figured I would post my questions here so everybody could benefit from the answers (plus I'll hopefully be too doped up on the day to remember anything, let alone have a coherent conversation).

I've already made a list of soft foods to eat after the surgery (pudding, mashed potatoes, applesauce, plain yogurt, soups, cream of wheat, refried beans, etc. if anybody needs ideas) and I've heard the typical advice about not using a straw, not eating anything hotter than lukewarm, that kind of thing - but I was wondering about some gray areas:

Peanut butter: too sticky?
Pureed Indian food: too spicy? (also, if I get my "supremely spicy" flavor hummus is that bad?)
I also heard that drinking pineapple juice and biting down on black tea bags will speed the healing process. Old wives' tales?

Thanks and see you soon! —MeggoWaffle

Peanut butter is just fine. Indian food might be a bit spicy and therefore irritate the extraction sites but if it does not hurt while you are eating it then you should be fine (just make sure you eat only bland foods if you are still numb). Pretty much any food that is comfortable to eat is ok. Black tea bags contain tannin which constricts the blood vessels and reduces bleeding but will not speed up healing. Pineapple juice does not seem to do anything special, I found several references to it reducing swelling or helping healing on a Google search, but nothing from reputable sources. I searched for research papers on this subject and found nothing so it is most likely an old wives tale. In regards to the anesthesia, you will be rather sleepy and out of it for several hours afterwards so it does help to have a "babysitter". We will not be using general anesthesia or IV sedation so your sedation level will be rather light and easier to come down from. —DagonJones
Update on Pineapple Juice: It has the chemical Bromelain in it, which supposedly reduces swelling. There is a German study from 1989 that found that it reduced swelling a small amount following third molar extraction, but not enough to be statistically significant. So I still don't think it will do any good.
On a side note Grapefruit Juice can increase the effect of many medications because it inhibits an enzyme called Cytochrome P450 (CYP450). This enzyme is responsible for breaking down many medications in the blood stream. So if you have less of the enzyme, the effect of the medication is increased. This is generally undesirable and can cause dangerous difficulties with breathing if taken while using sedatives or anesthesia so it should be avoided when taking any medication.

2011-10-02 20:18:04   My 14 y/o daughter has a 12 yr molar that the dentist says x-rays show adult tooth coming in crooked has only eaten away one root. Dentist planned to sedate and remove the tooth which I would have to pay a co-pay for. I told her I'd pay her if she could remove it. She did. I am worried now if she left any root in, have we created a worse problem? Or will her body just reabsorb it as the adult tooth pushes up. Thank you for considering my question. —DebbiJohns

Good question, however, I am a little confused. The 12 year molar (aka 2nd molar) is an adult tooth that erupts into the gums behind the first molar without replacing a baby tooth. I am assuming that she had a baby tooth removed to make way for the adult tooth. It sounds like the adult tooth did not resorb (eat away) all of the roots of the baby tooth, and therefore the baby tooth would not fall out on its own. If the baby tooth was extracted and a portion of root was left behind, most of the time the remaining root will be resorbed or remain in the bone without any problem. In rare situations the root can become infected and require further treatment. Check the area every few days, if the area is very red and swollen and your daughter reports increasing pain, that would be a sign of infection and she needs to go back to the dentist soon. Even without any infection the area should be monitored every 6 months to make sure the adult tooth is erupting normally. Please let me know if you have any other questions (or if I was wrong in my assumption). —DagonJones

2011-12-08 17:54:44   Hi Dagon I was asking a friend of mine a dental question and I was referred here: I had a filling fall out a while back and it is now really starting to hurt me, how much do you think it would cost to get repaired? I didn't realize it had fallen out until now it is located in the top right middle side of my mouth. Thanks —KellenRuel

Tom brings up a good point. Most dentists will replace a filling at no charge if it was done within a year or two, of course this depends on the circumstances of the situation and the individual policy of the dentist. If the filling just needs to be replaced it could cost anywhere from $150-$250 depending on the size of the filling and the type of material used. The fact that you are having pain is a concern because this indicates there is likely decay on the tooth and it may have entered the nerve. If that is the case the tooth will likely need a root canal and a crown (see the above description about root canals "[WWW]here"). If the tooth needs a root canal and crown there is considerable more work involved and the fees could be $1300-$2000 depending on the tooth. If you have dental insurance, your insurance will cover a portion of the fees. If the tooth is hurting all by itself (it throbs or aches when you are not touching it or eating) then that is a sign it will likely need a root canal. If it is just sensitive when you drink cold liquids and the pain goes away immediately after the cold is gone then that is a normal reaction for a tooth that has lost a filling and you most likely don't need a root canal. It sounds like the filling fell out and it felt fine for a while but now it is hurting, this is most likely a situation where decay is present and it has spread to the nerve and you will probably need a root canal or extraction of the tooth. I would advise you to see a dentist soon because you could develop an abscess in this area which is often very painful and a significant infection which will need attention. I hope this helps and I wish you good luck. —DagonJones

2012-01-04 05:42:59   Hi Dr. Jones, I was a regular seeing my dentist twice a year but getting 4 cleanings per year. At my March visit the Hygenist was very aggrssive and scrapped hard and hit my teeth with the polisher and pressed with Her weight against fronts and back of teeth. I was in a state of shock and asked what she did and she said it was just the polish that I was seeing. Lumping as I was rinsing. My tongue on the back of the 4 bottom front teeth felt strange like they were too clean. After that food started sticking too my teeth and food did not taste right. Choking on food as I tried to eat. Now all my teeth are yellowing some translucent, you can see verticle cracks and the sensitivity is constant. I had no sensitivity until this cleaning. I had amalgram fillings from a young teenager and they Are all raised and blackened. Saw dentist in June and begged him to fix 1 molar with a crown as it was raised so high and exposed on the whole tooth. He said he wanted to wait. I went back the following month and he said my teeth are to thin and they all would need to be capped. The 8 bicuspids that never had any fillings are all worn away. I told my spouse about this as I went regular to dentist and to have this happen All at once and not over a period of time seems odd. I note he fired the Hygenist I had for all those years. When we went for the consult he said we will cap them when I deem it necessary. I felt it was necessary then. Nevertheless, he let me suffer and I went to another dentist that said all my fillings were cracked and he worked on upper left and bottom right and now my bite is off having headaches difficulty eating and speaking. My face is distorted, mouth difficult to open, air hurts all the teeth I have hard calculus forming 2 days after a cleaning, gums are receding and I am in agony. Face nose and cheek pain. Lips constantly cracking and mouth ulcers inside on gums. What type of dentist do I need? Who can determine if I have bone loss. Glands under jaw inflamed. Face sinking and redness in nose and cheek and chin area. I stopped using soma care toothbrush for oral b ultra soft. Was always a great flosser but from her scraping the floss gets stuck in every tooth and breaks off. Brushing is painful and food is getting stuck up above my teeth in my cheeks. Using biotine for dry mouth. Lips are enlarged and while all my face is shrinking they are protruding from my teeth shifting forward. Also top molars are shifting out to cheeks and bottom are going inward not the u shape they were. I have vision problems and headaches that I believe Are a result of this. If you need more information please do not hesitate to ask. I tried to have mercury Poisioning test done but not enough lipos in my blood.

I need to start by saying that unfortunately I don’t think I can be much help for you. You describe a lot of symptoms here that I consider to be out of the scope of my practice as a dentist. You list headaches, vision problems, pain in nose and cheeks, and changes to your facial structure. These are all symptoms that I do not feel comfortable diagnosing or treating.
Regarding the sensitivity you are feeling on your teeth, it sounds like you have had a history of periodontal disease as this often requires cleanings 3-4 times a year. Periodontal disease can result in recession that exposes the sensitive roots of the teeth. Sensitivity protection toothpastes (like Sensodyne) can sometimes help or a dentist dispensed product called “MI paste” can be applied to your root surfaces by you at home and that often helps with sensitivity. It is common for sensitivity on root surfaces to increase right after a cleaning because tartar is removed from the surface of the roots. This tartar should be removed because it contains lots of bacteria that can make periodontitis worse, but it also covers the sensitive surfaces of the roots and removing it can increase sensitivity.
Regarding the vertical fracture lines in your teeth; under the right lighting you can often see dozens of small cracks in the enamel of teeth, these are called “craze lines”. They are confined only to the enamel, cause no pain, and are very common. No treatment is recommended for craze lines
You also mentioned your bite is off after some recent dental work. This could be a result of some of the fillings being too high, they may need to be adjusted. I would suggest having the dentist who placed them check for high spots. Often when multiple fillings are done it may be impossible to get the exact same bite as before, this is not always a problem as many people will adjust to a slightly different bite within a few weeks.
Regarding the shredding of floss between your teeth, this is often caused by very tight contacts between teeth or very rough fillings. Aggressive scaling of your teeth by a hygienist would not be able to tighten the contacts, and often would result in smoother surfaces of the fillings unless a filling broke or chipped during the cleaning. I do not think the flossing difficulties are a result of the cleaning you described. I would recommend a high quality floss like Glide. High quality flosses slide easily between tight teeth and tend to shred less.
You also mention food sticking to your teeth, food not tasting right, choking on food while eating. I am sorry to say that I do not know what could be causing these symptoms. I cannot think of any reason why they would be caused by a very aggressive cleaning. I am very sorry to hear you are in so much discomfort and I understand you are very concerned about all the changes you described. I would strongly suggest that you start by seeing your physician to discuss the headaches, facial pain/redness, and vision problems. These could be symptoms related to a systemic heath problem. If you have any other questions please feel free to ask and I will answer to the best of my ability. —DagonJones

2012-01-04 11:30:59 Dr Dagon: Can you please provide your opinion on using amalgam for fillings? What are the alternatives to amalgam and do they last as long?
—BrianPaddock

Dental Filling Materials

[WWW]Here is a link to the Dental materials fact sheet that is required to be provided to all patients by the Dental board of CA. This is a very nice pamphlet that details the strengths, weaknesses, and toxicity concerns of available dental materials.
I consider amalgam to be a safe, good restorative material. There are situations when amalgam is the best material. Each material has its own strengths and weaknesses. Amalgam is not a pretty color, but it works well in a moist environment and does not require enamel to bond to the way that composite (white fillings) do so it can be used when composite should not be used. It is less technique sensitive than other materials so it usually lasts longer when used in difficult areas to access (like behind the last molars, or on people with very limited opening). It is very durable to compression forces when it is at least 1.5mm thick, so it is a very good material for medium to large fillings. It typically lasts longer (but not necessarily) than composites because it is less technique sensitive, conditions have to be just right to get a long lasting composite filling. Amalgam is not the best material for very small fillings because it requires a certain thickness to be strong.
The most common alternative to Amalgam is Composite. Composite is a resin (basically a plastic) reinforced with particles of silica. Composite bonds very reliably to Enamel (the hard outer layer of teeth) but less reliably to dentin (the softer inner part of a tooth). For this reason it is not appropriate for cavities that are deep between the teeth because there is often a lack of sufficient enamel on the deepest part of the tooth and moisture control is difficult. Provided moisture can be controlled a composite can be used in a situation like this but it will have a higher chance or recurrent decay than a comparable amalgam filling. Compisite is very strong even when it is very thin, for this reason it is better than amalgam for shallow, conservative fillings.
Another family of tooth colored filling materials are Glass Ionomers and Resin modified Glass ionomers. This family of restorative materials bond to the tooth via a chemical reaction. They absorb and release fluoride over time so they are very good at resisting recurrent decay. They are rather weak to compressive forces and therefore are not appropriate for the chewing surfaces of adult molars. They work well in a moist environment so they a good alternative when moisture control is difficult. Glass ionomers work best for cavities near the gumline. If someone has a deep cavity that involves a chewing surface in a back molar and does not want an amalgam filling, using only a glass ionomer would not be appropriate because it will not withstand the compressive forces over time. So sometimes Glass ionomer and composites can be layered to provide a good long lasting alternative to Amalgams. This technique (sometimes called a “sandwich” technique) contains multiple steps. Due to this fact it is rather technique sensitive and time consuming, so there are more potential for problems like voids between the filling layers.
Other restorative materials include laboratory made gold and porcelain restorations (crowns, inlays and onlays). These restorations have to be made in a lab from an impression of the prepared tooth. Due to this fact they often require 2 visits (but may not if the dentist has an in house computer aided milling machine). Due to the additional expense and time involved these restorations are more expensive than a direct placed filling material. Laboratory made restorations work best when there is extensive destruction to a tooth or fracture of the tooth is a concern. Direct filling materials (amalgam and composites) can leave a tooth susceptible to fracture, especially when the filling is very large. Most gold and porcelain restorations are designed to cover the cusps of the tooth and therefore help prevent future fractures. I was taught and personally think gold is the best restorative material for medium to large restorations. The margins (the area where the restoration meets the tooth) of gold restorations are often smoother than porcelain therefore resulting in less plaque accumulation. There is a lot of information and detail I can go into about each material but this provides a pretty good overview. If anyone has further questions please follow the link to the dental materials fact sheet or feel free to ask. —DagonJones

Gum Grafts

mgj.jpgThe junction between hard gums and thin mucosa

davis wiki gingiva.jpgRecession on two central incisors There are two major reasons a patient is referred to a periodontist for an evaluation for gum grafting. First and most important is to stop recession and bone loss around teeth to prevent the loss of that tooth (or teeth). Second and less frequent is for repair of esthetic defects. Many times, after treating a tooth with a gum graft to restore health and prevent further recession, the tooth also looks better esthetically because the exposed root has at least been partially covered with the gum graft and has less recession.

What happens when a patient is referred for an evaluation of gum recession? I will address that issue and any factors that may contribute to the gum recession including the lack of sufficient hard gum tissue around the tooth. The are two basic types of oral tissues in the mouth: keratinized non-movable hard tissue around the teeth for protection during chewing and mucosa which is more thin and delicate but movable. These tissues have very different functions which is evidenced by their macroscopic and microscopic anatomy. If there is not enough hard keratinized gum tissue around the tooth then there can be progressive loss of gum tissue and bone.   Genetics is probably the biggest factor contributing to recession. People with fair delicate skin generally have fair delicate gum tissue that is more susceptible to gum recession because their gum tissue is traumatized and torn easier during chewing or tooth brushing. Some people also have genetically strong frenums, which is the attachment from the lip. This can predispose them to recession. Another common factor is using or having used in the past a tooth brush with medium or stiff bristles. Years ago dentists used to tell patients to use stiff tooth brushes because they clean better. This is true, but we found that it comes at the cost of causing recession more often. Most dentists now recommend soft or extra-soft tooth brushes. Soft tooth brushes might not clean quite as well, but they are safer for the gums. Likewise, if a patient is using a very abrasive toothpaste (especially ones that advertise their tooth-whitening ability), then beware of their being very abrasive and wearing away the gum tissue. Fortunately the American Dental Association tests toothpastes for effectiveness and safety. If a toothpaste has the ADA Seal of Approval, then it is effective and also safe to use with regard to abrasiveness. A fourth factor contributing to gum recession is the tooth being out of alignment even a slight amount and being traumatized and loosened because of the way the teeth hit.  In that case having their general dentist make the patient a night guard can help significantly. Another factor can be orthodontic movement of teeth. Fortunately, the orthodontists in our area are very proactive in sending patients for an evaluation before or during orthodontic treatment if they suspect a problem. Severe cases of recession usually have more than one of these factors going on simultaneously.

So why should you worry? One reason is that besides loosing gum tissue you are also loosing the bone that supports the teeth. I emphasize bone loss because where you can see the root of a tooth not only gum tissue has been lost, but also the bone that was also covering the root. The tooth is normally embedded in bone and the gum tissue covers the bone. There is an old saying in periodontics that is corny, but summarizes the problem: “The (gum) tissue is the issue, but the bone sets the tone.” Another problem is that roots are very soft, unlike enamel, and are more prone to cavities if exposed to the oral environment. When tooth roots get cavities, the decay can destroy teeth rapidly. If there is bone loss between the teeth (chronic adult periodontitis) in addition to bone loss from recession on the outside surfaces of the teeth, then the situation is more complicated.

What can or should be done? The generally accepted treatment for progressive recession of gum tissue (along with the bone loss that accompanies recession) due to the lack of sufficient hard gum tissue is the addition of hard gum tissue by a gum graft.  I emphasize the word progressive because not all recession needs to be treated with grafting. If someone has been using a stiff tooth brush and has lost some keratinized gum tissue around their teeth but still has enough keratinized tissue remaining to resist further recession, then the treatment of choice may be to simply switch the patient to a softer tooth brush and monitor for further recession. This will  many times prevent further recession and bone loss.  If there is not adequate hard gum tissue to prevent further recession then a gum graft should be considered. The gum graft (a general term which includes “free gingival grafts”, “connective tissue grafts”, and “pedicle grafts”) has more than 50 years of clinical research and there have been many thousands of research publications over the years in refereed scientific journals as to its effectiveness.  The gum tissue that is grafted can come from the roof of the mouth or from a tissue bank. The autogenous tissue (from the roof of your mouth) is firmer and harder than the allogenic tissue (from tissue banks). But using the tissue from tissue banks eliminates a second sore area. The area on the roof of the mouth usually feels like a pizza burn for a week or two, but will totally fill with new tissue in within a few months.

What are the side effects and contraindications? The main side effect is soreness on the roof of the mouth. Patients should kick back for a day or two and sip cold liquids over the surgery areas. I usually give long acting local anesthesia so people can go home and place cold liquids (such as ice water) on the surgery area while still numb. Cooling the surgery area during and after treatment will reduce any bleeding, swelling or post op soreness and help things heal faster. Some people notice a temporary sensitivity to cold that goes away within a few weeks to months. Applying desensitizing agents at post op visits helps greatly. A major contraindication is if patient does not want it.  Uncontrolled high blood pressure or uncontrolled diabetes are also contraindications to gum grafting. Unrealistic expectations is also a contraindication. The larger the amount of recession and the more the bone loss, the less root can be covered for esthetics. Plus, everybody heals differently. I can do the same exact procedure on two different patients and have two different results. One patient may get significant root coverage and the other minimal. Although getting root coverage is not totally predictable, getting adequate hard tissue for health and to prevent further recession is very predictable. Clear communication between the doctor and the patient is very important before starting gum grafting. It is important that the patient understands the risks, benefits and alternatives to various treatments and then makes an informed decision as to their course of treatment and accepts responsibility for their decision. —DavidJolkovsky

leo.jpgDark spot indicating bone loss and infection fistula.jpgA Fistula, an area where pus is draining from an infection 2012-01-09 01:25:05   I am a college student on a very tight budget and have a question. I had a tooth that had decay extra deep and when the dentist drilled it out he said he might have left a microscopic hole in my tooth which would lead the a nerve. He put a special sealent on it to hope and save it. He told me if it was sensitive to hot or cold I would have to get a route canal. The only problem is I can't afford one. It hasn't became sensitive to hot or cold yet but I am wondering if it does, will not getting a route canal cause any other harm to my body besides pain? —kamogurl1213

What you are describing is a rather common situation when decay is very deep. The deepest part of decay can penetrate a very small section of the pulp chamber (nerve canal space), if this happens bacteria can enter the pulp chamber and lead to an infection that requires a [WWW]root canal. This situation can also happen when the decay is very close to the pulp chamber but there is not a visible penetration into the pulp chamber. It is unpredictable to determine whether or not the tooth will need a root canal. In my opinion, your dentist did the right thing by placing a seal over the exposed area and asking you to look out for symptoms. If the tooth needs a root canal it may take months or years before you notice symptoms. You will most likely notice a throbbing pain that occurs for no reason or pain to cold that lingers for several minutes after the cold stimulus is gone. It is possible for an an infection to occur in the root (requiring a root canal) but you will have no symptoms at all. This situation can be detected by taking screening x rays of the root, a dark circle will show up on the x ray around the tip of the root indicating there is an infection present.
To answer your question, if an infection develops and you do not get a root canal the infection can become severe. These infections can be (but are not often) life threatening. Usually the pain is so severe that people have to go to the dentist for either an extraction or a root canal. Pronounced facial swelling can occur due to the infection. Sometimes the infection is not very severe and if the pus can drain (usually through a small hole or "fistula" in your gums that looks like a pimple) then it may not be painful. In any situation it is best to get the root canal or extraction, if an infection is present your body is constantly fighting off the infection and bacterial toxins are created. All of this is not good for your overall health. As the infection continues bone around the tooth will be lost (this can be regenerated later). In your situation I would wait and watch for any symptoms, if the hole to the pulp chamber is small there is a very good chance the tooth will be just fine and you may not need a root canal. —DagonJones

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