“We have lots of data showing a direct correlation between inflammation in the mouth and inflammation in the body,” says Anthony Iacopino, director of the International Centre for Oral-Systemic Health, which opened at the University of Manitoba Faculty of Dentistry in Canada in 2008. Recent studies also show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes.

Such findings are fueling a push for dentists to play a greater role in patients’ overall health. Some 20 million Americans—including 6% of children and 9% of adults—saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month.

“It’s an opportunity to tell a patient, ‘You know, I’m concerned. I think you really need to see a primary care provider,’ so you are moving in the direction of better health,” says the study’s lead researcher Shiela Strauss, co-director of statistics and data management for New York University’s Colleges of Nursing and Dentistry.http://online.wsj.com/article/health_journal.html

George Kivowitz, a restorative dentist with offices in Manhattan and Newtown, Pa., says he has spotted seven cases of cancer in 32 years of practice, as well as cases of bulimia, due to the telltale erosion of enamel on the back of the upper front teeth, and methamphetamine addiction. “We call it ‘meth mouth,’ ” he says. “The outer surface of teeth just rot in a way that’s like nothing else.”

Some of the most distinctive problems come from uncontrolled diabetes, Dr. Kivowitz adds. “The gum tissue has a glistening, shiny look where it meets the teeth. It bleeds easily and pulls away from the bone—and it’s all throughout the mouth.”

An estimated six million Americans have diabetes but don’t know it—and several studies suggest that dentists could help alert them. A 2009 study from New York University found that 93% of people who have periodontal disease are at risk for diabetes, according to the criteria established by American Diabetes Association.

It’s not just that the same lifestyle habits contribute to both gum disease and high blood sugar; the two conditions exacerbate each other, experts say. Inflammation from infected gums makes it more difficult for people with diabetes to control their blood-sugar level, and high blood sugar accelerates tooth decay and gum disease, creating more inflammation.

Diabetes also complicates dental-implant surgery, because it interferes with blood vessel formation and bone growth. “When you put a dental implant in, you rely on the healing process to cement it to the jaw, so you get a higher failure rate with diabetes,” says Ed Marcus, a periodontist in Yardley, Pa., who teaches at the University of Pennsylvania and Temple University dental schools.

Dr. Marcus notes that about 50% of periodontal disease is genetic—and even young patients can have significant bone loss if they have an unusually high immune response to a small number of bacteria. Giving such patients a low dose of doxycycline daily can help modify the immune response. “It doesn’t really control the bacteria, but it helps reduce the body’s reaction,” he says.

There’s also growing evidence that the link between periodontal disease and cardiovascular problems isn’t a coincidence either. Inflammation in the gums raises C-reactive protein, thought to be a culprit in heart disease.

“They’ve found oral bacteria in the plaques that block arteries. It’s moved from a casual relationship to a risk factor,” says Mark Wolff, chairman of the Department of Cariology and Comprehensive Care at NYU College of Dentistry.

Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere, which is why people contemplating elective surgery are advised to have any needed dental work performed first.

The American Heart Association no longer recommends that people with mitral valve prolapse (in which heart values close abnormally between beats) routinely take antibiotics before dental procedures, since it’s now believed that oral bacteria enter the bloodstream all the time, from routine washing, brushing and chewing food.

But the American Heart Association, the American Medical Association and the American Orthopedic Association all urge people who have had a full joint replacement to take an antibiotic one hour before any dental visit for the rest of their lives to reduce the risk of post-surgical infections. “I have my guidelines taped to the door in my hygienists’ room,” Dr. Kivowitz says.

Dentists say they also need to stay up to date with all medications, supplements and over-the-counter drugs their patients are taking. Blood thinners can create excess bleeding in the mouth. Bisphosphonates, often prescribed for osteoporosis, can severely weaken jaw bones. Both should be stopped temporarily before oral surgery.

Antihypertensive drugs, calcium-channel blockers and some anti-inflammatory drugs can cause painful ulcerations of the gums. Many medications, from antidepressants to chemotherapy drugs, cause dry mouth, which can cause cavities to skyrocket, since saliva typically acts as a protective coating for teeth. Additional fluoride treatments can help.

Some proactive dentists have glucose monitors for another check on blood-sugar levels if they suspect diabetes. Some also take patients’ blood pressure and hold off on invasive procedures if it’s extremely high.

The Centers for Disease Control and Prevention recommends that dentists offer HIV testing, because some of the first symptoms appear in the mouth, including fungal infections and lesions. Dentists can do the HIV test with a simple mouth swab and get results in 20 minutes.

Breaking the bad news is often more difficult. “I went into oral surgery because I didn’t think I would have to deliver that kind of news to patients,” says Clifford Salm, an oral and maxillofacial surgeon in Manhattan who has found leukemia, lymphoma, AIDS and metastatic breast cancer after performing biopsies on suspicious spots. “It can be a difficult conversation,” he says, “but most patients are very grateful.”

Don’t Be Fooled by White, Shiny Teeth

A gleaming, white smile is a sign of a healthy mouth, right? Not necessarily.

“Whiteness and the health of your teeth are totally unrelated,” says Mark Wolff, an associate dean at New York University College of Dentistry.

In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease.

Even people who have no cavities can still have inflamed and infected gums. It could be that their saliva is particularly protective of their tooth enamel, while their brushing and flossing habits, needed to keep gum tissues healthy, could be lax.

“I get these patients in their mid-30s who don’t have cavities, so they haven’t been to a dentist in 10 years. But they have full-blown periodontal disease,” says George Kivowitz, a restorative dentist in Manhattan. “They are losing all the supporting structure, and I have to tell them that these gorgeous teeth will fall out of your head if we don’t turn this around.”

Using whitening products more often than recommended can erode some of the enamel and cause teeth to appear translucent. But whether that actually harms teeth is controversial. “No one has really shown that it’s damaging, but no one knows the long-term results,” says Dr. Marcus, the periodontist in Yardley, Pa.

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Tooth decay — or dental caries — is an infectious disease process that causes damage to the structure of teeth. Cavities (hollowed out spaces or holes) are the most notable consequences of dental caries. Left untreated, caries leads to pain, tooth loss — or, in rare cases, death. In this most extreme case, infection can advance to the “cavernous sinus,” an air cell behind the eye, from which it can then enter the brain. Tooth decay amounts to more than just the inconvenience of “drilling and filling”: it has the power to change a person’s diet, speech, quality of life and overall well-being. Did you know that tooth decay is one of the most common of all diseases, second only to the common cold?

Decay — A World Wide Epidemic; Painful, Costly and Preventable

Oral diseases range from cavities to cancer; they cause pain and disability for millions of Americans each year. Even more disturbing — almost all are preventable. Dental decay is a worldwide epidemic, especially among young children. The disease begins early — tooth decay affects more than one-fourth of U.S. children ages 2 to 5 and half of those ages 12 to 15. Low-income children are hardest hit: about half of those ages 6 to 19 have had decay. In addition to pain and other dysfunction, untreated cavities can cause absence from school and other social interactions, low weight and poor appearance — problems that may greatly reduce a child’s capacity to succeed in life.

Tooth decay is also a problem for U.S. adults, affecting more than ninety percent over age forty. A quarter of adults over age sixty have lost all of their teeth primarily because of decay affecting self-esteem and contributing to nutrition problems by limiting the types of foods that can be eaten.

A New Way of Looking At Dental Decay — A Dynamic Process

The mouth is an ecosystem where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of non-living enamel (the hardest substance in the human body) and an inner core of living dentin, with a consistency and composition similar to bone. Enamel is highly mineralized and crystalline in structure, composed mainly of calcium and phosphate. The teeth are bathed in saliva, a most remarkable and seldom discussed fluid. It has many important functions in keeping mouths healthy; one of the most important is its role in maintaining a “neutral” environment — a balance between acids and bases.

(Acidity is measured scientifically by the “pH” scale that runs from 1 – 14. pH 1 is extremely acidic, pH 14 extremely basic. The pH of the mouth is generally 7 – neutral.)

The oral environment is also loaded with bacteria. There are more bacteria in a single mouth than there are people who have ever lived on the earth. Certain of these bacteria have the potential to cause decay.

Here’s how it works — specific bacteria (mutans streptococci and lactobacilli) attach themselves to dental plaque, the whitish sticky film that collects on teeth in the absence of effective oral hygiene. When sugars or carbohydrates are eaten, these particular bacteria have the ability to break down the sugars to use for their own metabolism. In the process, though, they produce acid as a by-product which in turn drops the saliva pH. At about pH 5.5 the minerals in the enamel just below the surface begin to dissolve in a process known as “de-mineralization,” in which more calcium and phosphate leave the tooth surface than enter it. The effects of early de-mineralization in enamel can be seen as a white spot on the tooth.

Dentin and root surfaces have much less mineral than enamel and are much more vulnerable to acid dissolution de-mineralizing at a much higher pH (about 6.0 to 6.5).

Bacterial acid attacks of short duration can be “buffered” (neutralized) in about thirty minutes by adequate amounts of healthy saliva, thereby returning calcium and phosphate into the tooth sub-surface. Saliva contains a lot of calcium and phosphate “ions” (charged moving particles) that continually leave the surface enamel and are replaced from the saliva, and vice versa. This process is chemically the reverse of de-mineralization and is known as “re-mineralization.” Although the white spot may not disappear, re-mineralization is nature’s way of repairing early damage and returning the tooth surface back to status quo.

Nothing in nature is static, but instead it is dynamic and therefore changing constantly to maintain a status quo. Primarily composed of mineral, teeth continually swing between “DE-mineralization” from the bacteria on the tooth surface, and “RE-mineralization” from the effects of saliva. This interchange occurs on the microscopic level, but still very important in maintaining the normal balance.

The Caries Balance

Given similar habits, you might wonder why some people get cavities and others don’t. This dilemma can be better understood by picturing a balance between pathogenic (disease-causing) and protective (health promoting) factors. Each individual has his/her own unique balance that dynamically changes as time goes on. The trick is to identify what is out of balance and how to tip it towards health and protection.

Pathogenic factors include the large amounts of specific acid-producing Bad bacteria, the Absence of healthy salivary function, and poor Dietary habits. By contrast, protective factors include healthy Salivary function and Sealants (to seal the areas most likely to decay), the use of Antibacterial agents, topical Fluoride, and a healthy and Effective diet.

How to Assess Your Risk

Not everybody has the same level of risk for developing dental caries; this is further complicated by the fact that the risk is dynamic and changes daily, as well as over time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Modern dentistry is moving toward an approach to tooth decay management that is “evidence-based” from years of systematic, accumulated and valid scientific research. In other words, it allows individualized treatment based on current science that is customized to the patient’s actual risk that he/she presents with, rather than a “one size fits all approach.”

Risk assessment allows preventive and treatment decisions to manage those in greatest jeopardy. This approach allows for “targeted” management appropriate for individuals whether in low, medium, high or extreme risk groups. Protocols have been recently established based on the Age One Visit (for infants and toddlers) as well as for children age 6 through adulthood.

Strategies for Prevention

You can see now that prevention doesn’t simply mean brush and floss and don’t eat sugar. It is a complicated topic with many implications. In fact, your dental office may offer some additional steps to measure your caries risk (salivary and bacterial analysis) and then recommend some products that specifically manage your risk level (sealants, antibacterial agents, topical fluoride, calcium and phosphate supplements, pH neutralizers, special toothpaste and rinses, and xylitol gum). These strategies are based on tipping the balance toward health by maximizing the protective side and minimizing or eliminating the pathogenic side. Prevention must be strategic, since it affects planning on an individual and community level.

Tipping the Balance — the Right Recipe

Simply put, for dental caries (tooth decay) to occur you need the right (or rather wrong) recipe:

• Susceptible teeth (not all teeth get caries),
• Acid producing bacteria,
• Sugars or carbohydrates — the “perfect” food for the acid producing bacteria
• Prevention aims to shift the balance in favor of promoting health in three main areas:

Protecting the teeth from caries — this is best accomplished by applying fluoride topically to the crystalline structure just after the teeth erupt into the mouth. The tooth surfaces are dynamic and will allow incorporation of fluoride ions into the surface structure. Many studies show that low doses of fluoride are safe and effective against decay. Sealants are very successful and are a companion treatment to fluoride because they seal the places where decay occurs in the tiny hidden pits and fissures [Figure 1]. Clinical studies using sealants show 99% cavity-free results during six years of clinical testing on more than 1,100 teeth studied.

Identifying and reducing acid-producing bacteria — these bacteria can be identified by a simple test administered by your dentist. If these bacteria are identified, they can be modified to reduce tooth decay by the use of tooth protective products. We can further modify these harmful bacterial concentrations with the use of antibacterial mouthrinses (such as chlorhexidine) and pH neutralizing agents. It is important to note, infants are not born with the specific decay-causing bacteria but that these bacteria are actually transmitted through saliva from mothers, caregivers, or family members to young children — another reason to practice prevention.

Controlling diet — sugars and other carbohydrates can be fermented by bacteria to produce acids. It’s important to reduce refined sugars from the diet or restrict intake to mealtimes. Natural sugars (in raw fruits and vegetables) are better than the free (added) sugars found in juices, sodas, candy and the like. Total sugar intake should be less than fifty grams, about ten teaspoons, per day. Snacking between meals is dangerous because it promotes an acid environment that would take up to thirty minutes for healthy saliva to neutralize. Healthy non-sugary or non-carbohydrate snacks are therefore better, like carrots, vegetables and fresh fruits. Xylitol is an example of an “alcohol sugar” used in some chewing gums and dental products that actually reduces decay-producing bacteria, and is proving useful in decay preventing strategies. One study showed that pregnant mothers who chewed xylitol gum before giving birth reduced the transmission of these strains of bacteria to the child, thus reducing the likelihood of decay.

Today’s Treatments Can Reduce and Eliminate Tooth Decay

We understand that tooth decay, or dental caries as it is known, is a disease process, and we know the causes. As we’ll see in future articles, methods of prevention, early detection, protection and treatment have continued to improve. Dentists are using a more preventive strategy — profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life.

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Pick up most magazines or newspapers these days and you’re likely to see an ad about dental implants. And with the advent of “implant centers” in major metropolitan areas, television ads are now delivering the message that an implant center, with everything conveniently offered under one roof, is the state-of-the-art choice for dental implant treatment. Some even extol the virtues of getting your new “Teeth In A Day!” Bombarded with so many different messages about dental implants, how does the consumer make the right decisions?

While this kind of marketing distorts the limits of our current research and knowledge, this new end of the spectrum may not necessarily end in a rainbow. This important and controversial topic will be covered in two parts. A clear understanding of the increasing options available for implant treatment is a good place to start together with alternative replacements for missing teeth and their economic impact. This first part will also educate you about the problems associated with tooth loss and why implants are considered the state-of-the-art tooth replacement system.

In part two, we’ll discuss who are the most suitable and experienced dental professionals to place implants. We will discuss the why, when and where to make your implant choices including how to navigate through the implant marketing hype.

Dental Implants: The Optimal Tooth Replacement

Let’s begin by taking a look at what makes implants the most optimal tooth replacement system today. An implant connection to the bone is different than how a tooth connects to the bone but it performs the same function. Dental implants act as substitute tooth roots in a unique way.

Implants actually stabilize bone and prevent the inevitable bone loss that occurs when teeth are lost. Commercially pure titanium, of which almost all current implant surfaces are made, has the unique property of being “osteophilic” (osseo-bone, philic – loving), thus joining biochemically to bone. Osseo-integration (osseo – bone, integrate – to join or fuse with) was discovered quite by chance and has revolutionized dentistry. The fusion is almost like a pillar in concrete, allowing no movement at all. Stresses of biting forces are transmitted directly through implants to the bone — which they allow for very well. They provide virtually the same function as natural teeth roots, including stimulating the bone, thereby stabilizing it and preventing its loss.

Consequences of Tooth Loss — Believe It or Not, It’s All About Bone

The bone that encases the teeth known as “alveolar” bone, (from alveolus – sac, an extension of the jaw bone), is the special bone that surrounds and supports the teeth. It develops with the teeth as they erupt into the mouth, accompanies the teeth in life and is lost when the teeth are removed. As one famous scientist put it, “Alveolar bone is like any other bone in the body, it just lives more dangerously,” said Dr. Harry Sicher.

When teeth are lost or removed the alveolar bone, which is fragile in structure like an ice cream cone, “resorbs” or melts away. What complicates matters is the “pattern” of resorption or the melting away process. Where the bone is thinnest, it resorbs more quickly. This is particularly true for the upper front teeth where bone, gum and even the lips can appear to cave in or collapse. The dental literature indicates that 79% of the population has a smile line that will not cover these types of “defects.” This is very noticeable when smiling and many people become quite self-conscious about their appearance as a result.

It Ain’t Necessarily So!

Bone resorption always occurs naturally when teeth are lost, unless measures are taken to prevent it. We are fortunate to live in an era when this melting away process can be compensated for by grafting techniques — which can work well in experienced hands. Although bone can now be restored by grafting techniques, it’s preferable and easier to prevent its loss from occurring. Bone maintained in both sufficient volume and position will allow for proper implant positioning, which in turn will stabilize the bone and prevent further resorption. The desired end result — completely natural looking teeth.

Keys to Implant Success

In the hands of an experienced “team,” implants placed surgically in the right position not only allow for the fabrication of implant-crowns that look natural, but also function properly and are maintainable — indistinguishable from real teeth. In the wrong position or without proper forethought implants can create a nightmare for the restorative dentist and dental technician who make the crowns.

The key to implant success — can be summarized by answering two questions:

• Can an implant be placed in correct position to allow for natural aesthetics and proper tooth function?
• Is there enough bone and is it in the right place to allow tooth replacement with an implant?

Implant placement and positioning is dependant upon adequate bone volume and density, which are therefore critical to success. In experienced hands, implants are extremely successful. Documented research and clinical studies indicate success rates of over 95% — which is higher than any other tooth replacement option. Even in areas of low bone density success is quite common. Once integrated and functional, implant restorations can last a lifetime.

Success from Concept to Design

The concept and design of implants has been very well researched and tested. Implant tooth replacement systems often comprise separate and interconnecting units, which can allow the crown components to be removed and replaced if the need arises. Once an implant is placed in the bone time must be allowed for the osseo-integration (bone fusion) process to take place, usually between two to four months. One of the primary reasons for early implant failure is “loading” them with biting forces too early. Only in carefully controlled circumstances where stability of the implant(s) can be assured, is it possible to place implant crowns early, with any degree of predictable success.

The “Teeth In A Day” concept is somewhat misleading, because the crowns placed on the implants are functional, but most often temporary in nature. This is more commonly effective in the lower front jaw where the bone is denser and implants can be splinted (joined) to crowns atop the implants assuring their initial stability. It is a little less predictable in the upper jaw and for single tooth replacement, but still possible in the right hands and circumstances.

Form and Function — Consequences of Tooth Loss

We tend to think about teeth as individual units, your dentist even gives each tooth a name and number, but in fact they make up a complete system, each one adding to its neighbor to function as one. Think about how the keystone in an arch holds all the other stones or bricks in place. For purposes of description we can think about the human dentition (full complement of teeth) as being composed of the anterior (front teeth) and posterior (back) teeth. The anterior teeth (the canines and incisors) are used for cutting and tearing food, and the posterior teeth (the premolars and molars) are used for grinding and chewing.

Importantly, the posterior teeth also support the vertical height of the face. If they are lost, the face tends to lose height and close down; this is called “posterior bite collapse”. Unlike implants, teeth move; not only do changes occur to the remaining back teeth affecting their spacing and biting function, these changes also put pressure on the front teeth which tend to move or splay forward.

All of these changes have implications for normal form (aesthetics) and function (bite). They also have ramifications for other facial and jaw structures which can affect anything from the skin to muscles and jaw joints. Appearance begins to change as the height of the jaw decreases, wrinkles increase and the corners of the mouth droop. Additionally, it can become difficult to eat food because the front teeth were not designed for chewing. This is to say nothing of the social consequences of tooth loss; smiling, talking, singing, laughing and enjoying a nutritionally sound diet — all leading to both poor general and mental health.

Traditional Tooth Replacement — Not So Traditional Any More

Dental implants are a relative “new kid on the block” for replacing missing teeth, but how do they really compare to other more traditional systems?

Removable options — Past methods of removable tooth replacement have included plastic “flippers” (non-precision, simple, temporary in nature and relatively inexpensive) and precision made metal based partial dentures, which are more expensive. Both can replace individual or groups of teeth. A fundamental problem with removable prostheses (replacements) is that for stability they rest on the teeth and gums tending to cause further problems all related inevitably to their design. These include tooth decay and periodontal (gum) disease and hastening the loss of bone and teeth through pressure transmitted through the gums upon which they rest. They constitute short term options with documented studies indicating that removable partial dentures are replaced about every 5 years.

For total tooth replacement whether in the upper or lower jaw full dentures (plates) have been the only option. Since they are kept in only by pressing on the gum tissues they transmit force to the underlying bone which accelerates its loss even more quickly. They also compromise the facial structures. As they continue to collapse, full dentures must be relined (made thicker) to compensate for additional bone loss and facial sagging. They also become particularly problematic in the lower jaw where there is no palate for suction and in addition tongue forces tend to destabilize them.

Non-removable options — Fixed bridges are non-removable prostheses (tooth replacements) which are attached to the natural teeth. They act by joining other teeth together with a false tooth or teeth between them “bridging” the gap. But the biggest disadvantage; these “abutment” or adjoining teeth are cut down into small peg shapes which compromises their long term health. As well as carrying the additional load of the missing teeth they replace, they become more prone to bacterial plaque accumulation, decay, root canal problems and periodontal (gum) disease. Bridges do not have a long life span therefore they will eventually need to be replaced. Studies indicate that bridges are only 67% successful at 15 years.

Economic aspects: Comparing the Cost of Implants to Fixed Bridgework

Consider this scenario: if you lose a single tooth, the two most common methods of tooth replacement are a tooth supported bridge or an implant supported crown. The American Dental Association (ADA) reports that bridges last an average of 10 years. Clinical studies indicate that implants are over 95% successful for 20+ years.

Even with partial insurance reimbursement, the cost of a tooth supported bridge is more expensive long term. The total cost over 20-25 years or more could be significantly higher than shown above. And with an implant supported crown, the adjacent teeth are not compromised so that additional treatment is not necessary. Consider too, the concept of amortization — the process of decreasing or accounting for the cost over the period of time they are likely to last.

Implants may seem more expensive initially. But for patients who are candidates, not only are they a better treatment choice, they will last longer, possibly a lifetime, thereby making them the ideal choice and most cost effective option long term. As we shall see in part two when we guide you through the marketing hype, well planned implants most often require a team approach in assessing whether they’re right for you. Placing implants and attaching crowns to them require precision procedures and techniques.

Benefits of Dental Implant Treatment

• Enhanced quality of life
• Integrity of the facial structures is preserved
• The smile is restored as close as possible to its natural state
• Long term health of adjacent teeth is not compromised
• Replacement teeth that look, feel and function like natural teeth
• Increased stability
• Improved health due to improved nutrition and proper digestion
• Renewed self-confidence
• Improved appearance
• Improved ability to taste foods
• Increased convenience of hygiene and maintenance

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The Art of Periodontal Surgery

Periodontal surgery is a plastic (reshaping) surgical procedure designed to restore and regenerate normal form and function to lost and damaged periodontal structures which support the teeth (the gum tissue, periodontal ligament and bone). This article is an overview of what a candidate for periodontal surgery can expect and a primer for further information and discussion.

Periodontal Surgery in Perspective — What makes it work

An understanding of what periodontal surgery is designed to do, what makes it successful and what sustains the results over time is critical to successful treatment of periodontal disease. Periodontal surgery is not a cure, but rather an adjunct to making long-term treatment outcomes more favorable. Unlike surgery to take out an inflamed appendix, which removes the disease with it, the potential for the recurrence of periodontal disease still remains in susceptible individuals. The long-term goal of periodontal surgery is to increase the life expectancy of the teeth.

Over a lifetime, the treatment for periodontal disease is primarily aimed at controlling its cause, microbial dental plaque. The purpose of periodontal surgery therefore is to treat deformities and tissue loss created by the disease process. This is accomplished by eliminating “pockets” of diseased tissue; regenerating and reconstructing gum and periodontal tissue attachment to the teeth and generally to provide an environment more conducive to daily oral hygiene and professional maintenance care.

The Consequence of Periodontal Infection

The end results of periodontal disease include loss of the tight attachment of the gum and periodontal tissues to the teeth. Just as one can put a hand in a pocket, a space by the side of clothing, pockets can also form around the teeth, into which fine probing instruments can be inserted to measure the degree of vertical tissue detachment [see illustration above]. This detachment, results from chronic inflammation as described above. Breakdown ultimately causes bone and periodontal tissue destruction giving rise to different patterns and shapes of bony defects which surgical treatment aims to regenerate and repair. For the most part the detached gum tissues either recede or remain as a detached curtain around the teeth.

Diagnosis

“There may be many ways to treat a case, but there is only one correct diagnosis”

Morton Amsterdam, DDS

Periodontal disease is detected when your dentist physically and visually evaluates the gingival (gum) tissues, probes to determine whether the attachment levels to the teeth are normal or abnormal, and evaluates bone changes through dental radiographs (x-rays). Depending on these findings, along with your general health status and health history, your dentist may also refer you to a periodontist, a dentist specializing in the diagnosis and treatment of periodontal diseases.

The diagnosis of the specific type of periodontal disease that may require surgical treatment is important, because it will have a direct bearing on the techniques used and long-term outcome of treatment.

Diagnosis may also include risk assessment, to aid in determining long term outcomes, known as prognosis. Both personal and professional assessments of individual risk are available (American Academy of Periodontology www.perio.org).

Initial Preparation Sets the Stage for Surgery

Behavior Change: Consistent behavior change is the most important element in maintaining long-term periodontal health, since daily plaque removal in large part will set the stage for sustained, successful surgical treatment. For many people this involves forming new oral hygiene habits, along with cessation of smoking and other lifestyle changes.

Calculus (Tartar) Removal: Your dentist will also see that your teeth receive a thorough cleaning to remove the deposits of calcified plaque called calculus or tartar and other bacterial toxins which become ingrained into the root surfaces. This process of mechanical cleaning is generally known as scaling and root planing, using hand scaling, ultrasonic or laser instruments and will sometimes require local anesthesia.

Occlusal Bite Therapy: Generally, attention to the bite or bite disorders are treated during or after initial therapy once an inflammation free environment has been established. It is important to stabilize loose teeth prior to surgery, because this in itself encourages healing of the periodontal structures and bone.

Re-evaluation Following Initial Therapy

After three or four weeks your dentist/periodontist will evaluate the response of your periodontal tissues to the initial therapy which is being used to control the inflammation and infection induced by dental plaque. This includes oral hygiene instruction, scaling and root planing (deep cleaning) among other possible treatments. In cases where pockets are deep, 5 mm and above, the chances of successfully removing all the bacterial deposits from the root surfaces diminish, which means that they may only be removed at surgery when they can be visualized. This also applies to areas that are impossible to clean adequately because of their shapes, like “furcations,” the areas of bone loss between roots of “multi-rooted” teeth, which may only be accessed surgically.

Superficial gum tissue health in response to plaque control is critical to surgical success. If the gum tissues have not responded adequately then bacteriological testing may be indicated to ensure removal of pathogenic (disease causing) strains of bacteria by either local (applied at the site) or systemic (bodily) antibiotic treatment, or review of the diagnosis for medical conditions that may be limiting the response to initial treatment.

Surgical Therapy

Periodontal surgical treatment today encompasses a variety of sophisticated plastic surgical procedures. These include techniques to repair and regenerate soft (gingival) [Figure 1 and 2] and hard (bony) tissues and replacement of missing teeth with dental implants. Procedures are usually performed by a periodontal specialist trained in these techniques and in some cases general dentists who have taken advanced training in periodontal surgery. Most procedures are performed with local anesthesia (numbing of the gum/periodontal tissues and teeth), sometimes with the additional use of oral anti-anxiety/sedation medication or intravenous conscious sedation (twilight sleep).

The objective of surgery is generally to eliminate pockets, regenerate attachment and to create more normal periodontal form, function and esthetics. The goal is to provide an environment more conducive to oral hygiene and maintenance care so that teeth can be kept for a longer period.

Risks, Benefits and Alternatives

It is important to have a discussion with your periodontist or general dentist to educate yourself regarding the risks, benefits and alternatives before undergoing treatment:

• The specific procedure you need should be discussed so you can understand what is involved. It should include what to expect after the surgery; generally mild to moderate discomfort for a day or two, usually managed by non-steroidal anti-inflammatory and analgesic medication of the Ibuprofen or Celebrex family, antibiotics and antibacterial rinses. No vigorous activity should be undertaken for the first few days to ensure that bleeding does not occur. It is also likely that the teeth will be somewhat more sensitive to cold which will disappear over time, particularly with the application of fluoride varnishes.
• What are the benefits and likely outcomes of treatment including a determination of prognosis — what results to expect and how long they will last;
• What are the alternatives to surgical treatment; this will depend upon the type and the extent of periodontal disease you have and the procedure that is recommended.
• These issues will differ somewhat depending upon the type of periodontal surgical procedures. This process is called an informed consent, and you will probably be asked to acknowledge this process in writing.

Contra-indications

It is important for people undergoing surgery to be in general good health and not overly stressed. It is also important to give your dentist/periodontist a full medical history with all current conditions and medications you are taking, including those to which you are allergic. Situations exist medically where it is not advisable for individuals to undergo surgical treatment. These mainly fall into the following categories:

• Uncontrolled periodontal disease
• Smoking and alcohol — can not only make periodontal disease worse, but will delay healing following surgery
• Systemic (bodily) or medical conditions which are uncontrolled, e.g. diabetes, HIV (AIDS), immuno-compromised patients (in whom resistance to disease is diminished), cardiovascular (heart and blood vessel) disease, to name a few
• Medications that can affect periodontal disease or surgery, e.g. aspirin, coumadin which may cause bleeding that is difficult to stop; medications that cause gum overgrowth, e.g. calcium channel blocking drugs used to control cardiovascular disease, other medications used to control transplant rejection, and more

Current Techniques

Current techniques are based on a sound understanding of wound healing and therefore enhance and maximize the body’s healing potential. For descriptive purposes, a rather broad distinction can be drawn between periodontal surgical techniques used to treat:

• Periodontal disease that has resulted in loss of periodontal attachment with pocket formation
• Aesthetic techniques to re-contour or graft new tissue in cosmetic areas (like the upper front teeth) where there is excessive tissue, or to cover exposed roots where gum tissue has been lost
• Bone and gum tissue regeneration to develop sites for future implant placement following tooth loss or other prosthetic (false) teeth replacement
• Implant placement to replace missing teeth

Surgical techniques to treat periodontal disease have been documented as far back as 1862 when Robicsek in Hungary developed the “gingivectomy” (gingiva-gum, ectomy-removal) to treat gum overgrowth, a technique still in limited use today, in a modified form. He is also credited with early “flap procedures,” which are still the “work horse” basis of many periodontal surgical procedures today.

Flap surgery is the most conservative and versatile of procedures and consists of making an internal opening allowing a “flap” to be raised, much like opening the flap of an envelope. This allows the surgeon to work within the periodontal tissues to:

• Remove inner diseased and detached tissue lining of pockets
• Gain access to further clean and treat root surfaces
• Repair and regenerate bone, periodontal ligament tissue complex
• Close the tissues completely leaving no open wounds for rapid and comfortable healing
• Tiny suture placement to retain the gum tissues in place. Sutures either self-dissolve or are removed after a week or so. In some cases an unobtrusive dressing is applied to protect tissues while healing ensues.

Innovations in regeneration

The last two decades have seen an explosion of knowledge and new techniques to regenerate periodontal tissues. Up until the 1980’s most surgery was “resective” in nature — removing diseased tissue. From the 1960s to the 1980s soft tissue gingival (gum) grafting techniques to increase gum tissue were predictably successful. Regeneration techniques were already understood from wound healing studies and knowledge of the cell types that “coded” for new gingival, gum tissue. However techniques were less predictable when attempting to regenerate lost alveolar (tooth supporting bone) and the adjacent periodontal ligament.

Regenerating Periodontal Tissues

• • The periodontal ligament is a thin, fibrous ligament that connects the tooth root to the bony socket. Normally, teeth do not contact the bone directly; a tooth is suspended in its bony socket by the periodontal ligament which is attached to the tooth root via cementum.
  • Without new periodontal ligament formation, new attachment and bone regeneration is impossible. In the past, the difficulty had been stopping gum tissue cells growing down the freshly cleaned roots before the new periodontal ligament cells had a chance to grow and reattach to the root surface cementum. Stopping the gum tissue cells from advancing was the race that science needed to win in order to regenerate new periodontal attachment.

Guided Tissue Regeneration

• • Periodontal tissue regeneration was ingeniously solved with the advent of sub-gingival (sub-under, gingival-gum) “barrier membranes,” sort of minute subterranean band-aids. These barriers stop the growth of gum tissue cells and allows regeneration of new periodontal ligament by guiding cell growth. This technique is known as “Guided Tissue Regeneration.” Membrane technology has now advanced to the point where membranes will last exactly the appropriate amount of time needed for healing and then dissolve so that they don’t have to be removed.

Growth Factors — Magic Molecules

• • Most recently, basic science has further demystified wound healing with an understanding of growth factors. The process of inflammation, the body’s response to injury and infection causes the attraction of particular cells and liberation of their components, so-called growth factors — “magic molecules” which initiate and promote wound healing. The ability to isolate these substances, determine their roles and then to be able to manufacture them has allowed periodontal and other surgical specialists to use growth factors to regenerate tissues, making results more predictable and healing uneventful.

Summary

Today’s highly sophisticated and meticulous surgical techniques allow the periodontal surgeon to regenerate and reconstruct lost and missing tissues. Modern procedures are kinder to the patients; are carried out with local anesthesia (numbing the area/s) in combination with either oral (anti-anxiety) sedation or intravenous conscious sedation (twilight sleep). There are minimal post surgical issues, minimal discomfort and little bleeding, either during or after surgery. Periodontal surgery includes elements of art, experience and a great deal of scientific knowledge of techniques and wound healing to prolong the life of your teeth with greater predictability than ever before.

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Oral sedation allows you to relax both your mind and body, and focus on feeling peaceful rather than anxious

By Dr. Michael D. Silverman

Anxiety Just Melts Away

When you are afraid, your threshold for pain is much lower, you become hypersensitive to every sensation, prick, and noise. Fear and anxiety trigger the release of certain chemicals like adrenalin which put your “fight or flight” instincts on high alert. You anticipate that something is going to hurt and so you tense your muscles, even if it is subconsciously. In this heightened state of anxiety you experience more pain during and even after treatment. However this response can virtually be eliminated with oral sedation dentistry!

The whole purpose of oral sedation is to make you as comfortable and relaxed as possible. It allows you to let your guard down, relax both your mind and body, and focus on feeling peaceful rather than anxious. Your apprehension and hypersensitivity to pain melt away, yet you remain awake and in control.

Sometimes referred to as “comfortable” or “relaxation” dentistry, these terms are used to describe the feelings most people perceive during their dental visits, which are produced by oral sedation.

Safety and Effectiveness

Oral Sedation dentistry allows you the confidence and peace of mind to experience dental procedures in a whole new way. Hours seem to pass like mere minutes so that necessary dental treatment can be performed comfortably. When you are relaxed you allow your dentist to be able to work more efficiently by focusing on the work at hand, with the confidence that you are comfortable.

A variety of oral sedative and anxiolytic medications have been developed especially for these purposes. They have been subjected to rigorous research and testing and have a long safety record after decades of use. In addition several have “amnesic” properties, meaning that you remember little to nothing after treatment.

The safety of sedation medications is measured by pharmacists and health professionals on a scale called the “therapeutic index.” The larger the number is on the scale, the safer the drug. Oral sedatives and anxiolytics used in dentistry have the highest numbers possible on the therapeutic index, making them the least likely to cause an adverse reaction.

How to Ensure Safety — What to Let Your Dentist Know

It is critical to provide your dentist with a complete health history including:

• Medical conditions for which you are being treated
• Any and all medications prescribed by a doctor
• Over-the-counter medications, remedies and vitamins (including aspirin)
• Alternative or herbal supplements: Many people seek relief from depression and anxiety symptoms with natural remedies like St. John’s Wort and Kava Kava. These may have a mild interaction with oral sedatives, so it’s critical that you tell your dentist if you are taking them. The medications and dosages for your oral sedation treatment can be adjusted to compensate for any interactions.
• Certain foods: Even something as seemingly insignificant as drinking grapefruit juice can have an effect on sedation. The enzymes in grapefruit interfere with the systems that metabolize (break down) certain oral sedation medications in your body, so you should not consume grapefruit 72 hours prior to or immediately after a sedation procedure.
• Also be sure to tell your doctor about factors like smoking and alcohol consumption, since these can influence the effectiveness of sedation medications.

Administer the Medication Yourself

Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. In fact, once you’re comfortable with oral sedatives, it may even be easier to have local anesthesia (numbing shots in the mouth) to further facilitate the ease of dental procedures. Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. Medications are given orally (by mouth). They are either placed and dissolved under the tongue, or they can just be swallowed whole.

Many dentists prefer the sublingual (under the tongue) route which works even more quickly. Taken this way they are absorbed into the bloodstream more rapidly. Both methods are safe and effective and work in a matter of minutes. You can even try the medication the night before to see how it affects you and also ensure a good night’s sleep.

Planning for Your Appointment

Once you and your dentist decide to use oral sedation for your next appointment, you will need to make some preparations:

• Your health history can affect your before-and-aftercare plans, especially for diabetics and smokers, so make sure your dentist knows about any medical conditions that you may have.
• You may be instructed to take oral sedation medication the night before your appointment to make sure you get a good night’s sleep.
• You should not eat or drink anything six hours prior to your appointment unless directed by your dentist.
• Be prepared to take time off from work following your appointment. For short appointments, only half a day may be necessary. If a longer appointment is planned, make arrangements to take the remainder of the day off.
• You will need a companion to drive you to and from your appointment; you should not drive or operate heavy machinery until the medication has worn off; this will vary depending upon what drug has been prescribed — follow the directions exactly.
• Be sure to stay hydrated and drink lots of fluids following your appointment.

Which Medication is Right for You?

While your dentist will decide which medications are appropriate for your treatment, being familiar with the different drugs available can be helpful for you. Knowledge about oral sedation is not only powerful — it is empowering.

There are several commonly prescribed medications, including, but not limited to Valium®, Halcion®, Sonata®, Ativan®, Vistaril® and Versed®. With the exception of Vistaril® and Sonata® they all belong to a class of medications called benzodiazepines. Benzodiazepines are prescribed for the treatment of anxiety, insomnia, agitation, seizures, and muscle spasms. Taken in small doses, they are highly effective at relieving the above mentioned conditions.

Each medication has a different duration of action (how long it affects you) and different half-life (how long it remains in your body). Dosages can vary greatly depending on whether swallowed whole or placed under the tongue in addition to the treatment protocols for which the sedation is being used. The drugs take effect anywhere from 20 minutes to an hour. Some varieties of the medication have “amnesic” properties, meaning that you remember little or nothing of your time in the dental chair after the procedure is completed.

Other Forms of Sedation Dentistry

• Inhalation Conscious Sedation is also known as “Nitrous Oxide/Oxygen Sedation.” Nitrous oxide, commonly and inappropriately called laughing gas, has been used by dentists for nearly 100 years. It is an excellent analgesic (pain reliever), but a less effective anxiolytic (anti-anxiety) medication. It is administered through a nasal hood, which is similar to a small cup placed over your nose. Nitrous oxide is extremely safe because it is mixed directly with oxygen to provide you with a feeling of euphoria or light-headedness. All bodily functions remain essentially normal. You may experience a tingling sensation from the use of nitrous oxide. However, its effects wear off almost immediately so there is no “hangover effect.”

In combination with an oral sedative, nitrous oxide allows your dentist to fine-tune the exact amount of sedation needed to provide you with the best possible experience.

• Intravenous (IV) Conscious Sedation also known as “Deep Conscious Sedation” is used by some dentists, and surgical specialists like oral surgeons and periodontists who must undertake specialized training and certification in IV use. With this type of sedation, medications are administered directly into the blood stream intravenously (intra-within, venous-vein). The main advantage of this method is that it works immediately and the level of sedation can be adjusted quickly and easily. There is a higher degree of risk associated with IV sedation since normal bodily functions especially heart rate, blood pressure and breathing can be altered necessitating specialized monitoring equipment. The drugs used for IV Sedation are more potent when given this way than when taken orally and amnesia may be more profound.

Finding the Right Dentist

Like any informed consumer, you will want to make sure that your dentist is qualified to provide sedation dentistry. It is a good idea to request information on your dentist’s training, credentials, and the techniques that may be used prior to an appointment.

You Are Not Alone

Talk to your dentist about your fears and concerns so that together you can decide on the best treatment for you. It’s important to remember that dentistry has come a long way. Years of research have been dedicated to studying and finding methods to alleviate pain and anxiety. There are safe and time-tested options available to ensure that you have a positive and painless experience. Step out from under the shadow of fear and into the calm of sedation dentistry. You are not alone and you don’t have to be afraid anymore.

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By Dr. Joel H. Berg

When parents or caregivers mistakenly say, “They are only baby teeth, they are going to fall out anyway” they have the wrong impression. The Age One Dental Visit sets the tone for lifelong dental health. The fact is, primary teeth serve as the guides for the permanent teeth and are critically important to the health and function of their adult successors. What’s more, primary teeth are the child’s teeth for most of childhood — children don’t usually begin losing them until about age six, and the last primary teeth aren’t lost until around age twelve. It’s just as important to care for them as for the permanent teeth that come later.

An Ounce of Prevention

What really is prevention anyway? Prevention in the truest sense of the word means stopping an anticipated problem before it even starts. The importance of primary teeth and preparing for a lifetime of good oral health are the main reasons why parents should bring their children to see a dentist or pediatric dentist (children’s specialist), preferably before their first birthday. It’s more than just a casual visit: even a one-year old needs a comprehensive examination and even some preventive applications. Parents will benefit from the guidance of “Family Oral Health Education” including: risk assessment for decay; training (hands on) in teeth cleaning; nutritional counseling and use of cups for drinking; fluoride recommendations based on individual needs and important follow-up appointments for monitoring based on the level of risk determined by your dentist.

A baby’s first visit to the dentist sets the stage for lifelong oral health.

The Age One Visit may also reveal underlying conditions that may indicate future problems, and determine how often follow-up visits might be needed. Children with low risk for oral or dental disease might only be seen annually or semi-annually until the primary (baby) teeth are all fully erupted in the mouth and in occlusion (biting function). Children assessed at high risk might be seen as often as every two to three months.

Diagnosing and Treating Tooth Decay

One of the prime purposes for an Age One Visit is to examine the child for a number of forms of tooth decay that can affect babies and small children. For many years, health and childcare professionals have recognized a specific pattern of such decay, known as Baby Bottle Tooth Decay (BBTD). BBTD was believed to be primarily associated with the use of a sleep-time bottle that contains a liquid with natural or added sugars such as formula, juice or Kool-Aid. It generally occurs between the ages of twelve to eighteen months.

In recent years, similar cases of early and severe tooth decay have been found in children who do not fit the classic BBTD pattern of bottle use. The term Early Childhood Caries (ECC) is now being used to reflect a broader concept of the problem of tooth decay in infants and young children. ECC includes cavities associated with many causative factors, mostly sugars. These include continuous use of a “Sippy-cup,” at-will breast-feeding throughout the night, use of a sweetened pacifier or the regular use of sugar-based oral medicine to treat chronic illness.

For many years, health and childcare professionals have recognized a specific pattern of decay, known as Baby Bottle Tooth Decay (BBTD).

ECC develops rapidly — the progression from the hard, outer enamel layer of the tooth into the softer, inner dentin can occur in six months or less. It first affects the upper front baby teeth, which usually erupt at around eight months of age, followed by the primary molars (back teeth), which begin to erupt at about twelve months of age. At its most severe stage, ECC may then affect the lower front teeth.

The extent and severity of ECC can vary depending on culture, the child’s genetic makeup and socio-economic factors. On the other hand, ECC is really much like any other type of tooth decay, dependent on the presence of three conditions: specific bacteria in dental plaque on the teeth, unprotected teeth and the right mix of carbohydrates from food and drinks, such as natural or refined sugars.

“Here We Go Round and Round” — Breaking the Cycle of Decay

These conditions form a cycle of events, even in babies, that slowly unravel oral health: decay causing bacteria interact with the carbohydrates (sugars) to produce acid; the acid in continual contact with the teeth slowly demineralizes (dissolves) the tooth enamel; as demineralization continues, cavities form.

Because all three of these conditions must be present for a cavity to form, there are at least three opportunities for intervention: (1) eliminate or reduce the bacteria through oral hygiene; (2) reduce the presence and frequency of carbohydrates by dietary changes; and/or (3) make the tooth more resistant through the use of fluoride.

Until a child is about seven years old, an adult needs to brush the child’s teeth for them.

Age One Visits provide insight into these three opportunities for both the child and parents. For example, Age One Visits can help parents or caregivers learn the proper techniques for cleaning their children’s teeth. Until a child is about seven years old, an adult needs to brush the child’s teeth for them. Parents can allow the child to brush his or her own teeth, but at least once a day, preferably at bedtime, an adult should carefully and thoroughly brush the child’s teeth.

The child’s dentist can demonstrate the proper way to clean a child’s teeth, a procedure that usually takes less than two minutes with a very small child’s toothbrush or by simply wiping the teeth off with a wet cloth.

Dental professionals can also provide important information on the types of food and their frequency that promote a child’s oral health. At first glance, many foods like cereals, granola bars, and similar snacks may seem healthy and good for a child to have throughout the day. They aren’t — and neither are foods like raisins or fruit juices, even though they contain natural sugars and are full of vitamins and minerals. Carbohydrates in cereals, crackers, and granola bars will stick to the teeth where bacteria can easily interact with them over extended periods of time. And, regardless of whether the food contains processed or naturally-occurring sugars, bacteria metabolize both and form acid. Parents are advised to avoid giving their children sugary foods, especially in high frequency, that have any form of sugar listed as the first or second ingredient.

It’s not just baby drool; frequent snacking also inhibits one of the mouth’s most important cavity-fighters — saliva. Saliva neutralizes acid and supplies calcium and fluoride to protect and even reverse early decay. But it takes time — about two hours to neutralize the effects of acid. So, a snack every hour — which promotes the continual presence of acid in the mouth — won’t give saliva the opportunity to work effectively.

Breast Feeding, Baby Bottles and Other Practices

• Generally, breast-feeding is highly recommended for babies and doesn’t necessarily inhibit good oral health in young children. Breast milk by itself does not promote tooth decay any more than other forms of fermentable carbohydrates. On the other hand, once a child begins to consume foods or liquids in addition to breast milk, the combination of breast milk and other sugar-rich foods may potentially put the child at risk of developing ECC. Babies should be removed from the breast when they are finished feeding and children should not be allowed to nurse at will throughout the night.

• Baby bottles are frequently used by parents or caregivers to modify the child’s behavior by giving it during sleep time to stop fussing or crying. Other methods of improper bottle-feeding include propping the bottle or round-the-clock feeding. All these practices promote the constant production of acid in the mouth, so the use of baby bottles should be limited to meal-times.
• Pacifiers dipped throughout the day in a variety of different sweeteners, including jam, corn syrup or sugar, results in frequent exposure of the teeth to fermentable carbohydrates and promote higher acid levels in the mouth.

• Children with chronic illnesses or special health care needs may also be at increased risk of ECC if their medication contains sugar. Also, certain medications such as antihistamines may cause decreased saliva production causing mouth dryness and diminishing the protective effects of saliva. Daily oral hygiene care for these children is critically important.

• Every time bacteria are exposed to sugars, either refined or “natural,” they produce acid — so the more frequently a child eats sugar, the more frequently the teeth are exposed to acid. Frequent sugar exposures equals frequent acid exposures. Parents can therefore reduce the chances of their child developing cavities by limiting the frequency and amount of sugar their child consumes and not snacking on sugary products especially between meals.

Opportunity for Promoting the Entire Family’s Health

• A child’s oral health is closely related to the family’s overall dental health and hygiene practices. The Age One Visit can educate parents or caregivers on the importance of their own good oral hygiene.

• Children are not born with high levels of cavity-causing bacteria in their mouths. They acquire the bacteria from their caregiver, usually their mother, through close contact. These bacteria are transmitted through kissing, sharing eating utensils like a spoon or a glass, sharing food, or cleaning off a pacifier by mouth. The period when a child is most susceptible to acquiring the decay-causing bacteria is quite short, beginning as early as six months of age and continuing through approximately thirty-one months.

• There is mounting evidence that a child’s oral health is closely tied to his or her mother’s. This is why it is important that caregivers of young children promote their own oral health through regular dental visits and proper hygiene habits. The Age One Visit is a good reminder — and a learning opportunity — for proper hygiene and care.

• Diagnosis, prevention, education and treatment — the Age One Visit can cover a lot of ground for your baby’s first visit to the dentist. Most importantly, the immediate diagnosis and treatment of emerging dental problems, as well as the long-term attention to good oral hygiene, can help build a foundation of good dental health for your child — and your entire family — that will last a lifetime.

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The notion of adding materials to teeth in order to change the way they look is nothing new to dentistry. Traditionally, teeth are prepared in some way or fashion in order to place and retain a restorative material — typically a filling, porcelain veneer or crown. Not only is tooth reduction generally necessary to restore lost or damaged natural enamel as a result of the ravages of tooth decay or trauma, but it is also necessary to create room to place an aesthetic and functional “restoration.”

The purpose of this article is to introduce and provide a clear understanding of an alternative cosmetic treatment option, the “no-prep” or “prepless veneer,” whereby no drilling is required to enhance a smile. It also endeavors to bring clarity and understanding to the numerous areas of confusion regarding this treatment modality. Most importantly, it examines the case selection process; when prepless dentistry will work and when it won’t. As with almost all dental and medical procedures, there are risks, benefits and alternatives. It is with the help of a dental professional experienced in these advanced techniques, together with your own goals and understanding, that you can make decisions that are right for you.

No-Drilling: Reality Or Ridiculous?

“Prepless veneers” is a concept that elicits various reactions and opinions among dentists, ranging from absolute disbelief that they can facilitate effective restorations, to appreciation for these conservative and advanced works of art! This range of opinion about a novel approach to cosmetic dentistry is vast and with good reason. The concept of “additive only” restorations intuitively causes the experienced clinician reason for concern as visions of bulky, over-contoured teeth quickly come to mind. Unfortunately, some prepless techniques and products circulated heavily in the media have shown thick, bulky looking restorations, causing skepticism among some dentists and consumers alike.

And yet, despite these concerns, an undeniable trend is emerging among many esteemed cosmetic dentists to incorporate not only minimal prep, but also “no-prep” restorations into their compendium of viable treatment options and alternatives. In recent years, new developments in techniques and materials have resulted in a fresh look at the aesthetic possibilities for the no-prep veneer option. Cases done by talented dentists and lab technicians have produced results which would meet the highest standards in cosmetic dentistry [Figures 1 and 2]. Part of the advanced level of training for prepless veneers includes the important aspect of proper case selection. Not every situation lends itself to a no-prep approach, but when it does, the results can be not only beautiful, but also stable and reversible!

Paradigms and Beliefs — A Shift

The promotion and endorsement of “prepless” veneers is predicated on the following paradigms and beliefs:

• It is not necessary to prepare a tooth to create a border (known in dental terms as a “margin”). Highly skilled dental technicians can design a custom-fit veneer that feathers into the tooth just short of the gumline.
• Aside from the other obvious benefits of prepless veneers, they are not placed under the gum tissue. This eliminates the risk of the restorations having a negative impact on the periodontal (gum tissue) health.
• In many cases it is possible to use an additive-only approach to create aesthetically pleasing and natural-looking restorations without reducing the underlying tooth structure.
• Consumers who are looking for a way to enhance their smiles are more likely to seek out and accept a no-prep approach with a highly-skilled dentist in situations in which they don’t need aggressive enamel removal.

Potential Cases for No-Prep Veneers

• There are a significant number of patients who have relatively small teeth for a variety of reasons:, e.g. external causes such as acid erosion; genetic factors resulting in naturally small teeth and in spacing between the teeth; discrepancies between jaw size and teeth size — to name a few. These instances all provide potential candidates for “prep-less” restorations [Figures 3 and 4].
• Orthodontic cases that involved the extraction of teeth to solve a crowding problem typically result in narrow arch forms with the teeth that sometimes tilt inwards.
• Short, worn teeth — creating a smile with more visible tooth length can sometimes “turn back the clock” for someone who has worn their teeth down by grinding.
• Narrow smiles — Many times, the teeth in the sides of the smile are positioned inward and do not show from a frontal view.
• Teeth that need to be more visually present, e.g. when big lips may overpower them, or the teeth are too small in relation to the overall smile.
• Teeth that are genetically misshapen; “Peg laterals” is a fairly common condition in which one or both of the teeth directly next to the two upper front teeth are very small and peg-shaped.

When No-Prep Veneers Won’t Work

While no-prep veneers can make many positive changes, there are some situations that no-prep veneers can’t correct. In cases that involve improper tooth position, large discrepancies in root position, poor bite relations or a poor facial profile, some form of orthodontic treatment will be required to mechanically move the teeth. If orthodontic treatment is declined, some amount of tooth preparation may be required to create the illusion of proper alignment. When veneers are used to “camouflage” improper tooth positions, it must be with an understanding of the degree of limitations and risks.

Not every smile can be enhanced with prepless veneers. Teeth that are already relatively large or positioned forward in the smile do not typically lend themselves to adding another layer of thickness. In these situations, careful decision-making in partnership with your dentist will be necessary to explore other options that might involve tooth preparation or orthodontics.

There is no substitute for an expert dentist’s talent and expertise in the various cosmetic techniques. These skills — combined with a clear understanding of an individual’s goals and determination of the clinical needs obtained by a thorough diagnostic evaluation — are critical to ensuring a successful and beautiful smile.

Test-Drive Your Smile: Another Benefit of Prepless Veneers

Committing to porcelain veneers can take a great deal of faith on the part of a patient because once the teeth are permanently reduced, there is no reversing the decision to have veneers designed. With no-prep veneers, the process is reversible (though removing them is not an easy task and best accomplished using a laser) and practically risk-free.

If a patient qualifies for prepless veneers, a highly-skilled dentist can artistically design hand-sculpted prototypes in order to allow both a preview and “test-drive” of a new smile. In this prototype phase, changes can easily be made to the tooth-colored materials and to capture them as a blueprint for the laboratory technician who fabricates the final veneers.

While this same approach can also be used for traditional veneers, the difference with no-prep veneers lies in the fact that the prototypes can be easily removed and the patient’s original smile is unaltered.

A Preview of Coming Attractions

After a discussion about the goals and anticipated outcomes of the smile enhancement, detailed diagnostic records are gathered prior to beginning any dental restorations.

A comprehensive smile analysis is completed in order to compile information about the function and health of all the dental structures including the surrounding lips and facial features. Sometimes, a simple “mock up” can be made as a rough sketch in an effort to determine the feasibility of a prepless approach. The prototypes allow evaluation of the results in temporary materials before even making the final veneers. This is where an understanding of natural tooth shapes and contours allows an experienced cosmetic dentist to create the changes necessary for creating a natural looking smile.

The prototype stage allows individuals the exciting prospect of being involved in their smile design process. They can interact with their dentists providing feedback on shapes, sizes, and even colors of the new teeth. The prototypes can be test driven for several weeks while they are duplicated in the final porcelain veneers.

Once the laboratory technician has fabricated the custom porcelain restorations, the prototypes are removed and the final veneers are bonded directly to the enamel on the front surface of the teeth. The porcelain is then carefully contoured and polished to exactly mimic the natural teeth.

Questions to ask your dentist

• Am I a candidate for prepless or drill-free veneers?
• Can you create prototype veneers for me to test drive what my new smile will look like?
• How much will the prepless or drill-free veneers cost?

Conclusion

Though additive-only techniques cannot be used in every case, prepless veneers should be considered for their benefits in cases where they may apply in whole or in part. A prepless approach requires specific skills and training together with a keen sensitivity to natural tooth contours. Those who want to explore this as an option should consult with a dentist whose credentials and experience demonstrate an understanding of this technique-sensitive option.

More and more, dentistry, like medicine, is finding ways to be as conservative as possible while providing the best possible results. No-prep or prepless veneers are one way to improve and enhance smiles without the downside of drilling away healthy tooth enamel.

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By Dr. V. Kim Kutsch and Dr. Douglas A. Young

Modern dentistry is moving towards an approach to tooth decay management that is evidence-based — meaning it is based on years of systematic, accumulated, and valid scientific research. In other words, using current science, your dental treatment is tailored to your actual risk rather than a “one size fits all” approach. The previous method of “drilling and filling” to treat decay does not change the conditions that lead to the disease in the first place, so that the risk for further infection still remains. What follows below are facts you should know to change the conditions that lead to decay!

A New Look At Dental Decay — A Dynamic Infectious Disease Process

To help you understand, think of the mouth as an ecosystem, where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of enamel, a highly mineralized and crystalline structure composed mainly of calcium and phosphate. The teeth are bathed in remarkable fluid— saliva. While it has many functions, one of the most important is its role in maintaining a neutral pH environment or balance between the acids and bases found in your mouth. Acidity is measured scientifically by the pH scale, which ranges from 1 – 14. A pH value of 1 is extremely acidic while a pH value of 14 is extremely basic. The pH of the mouth is generally 7 – neutral.

The oral environment is loaded with bacteria with some of them having the potential to cause decay. Specific acidogenic (acid producing) bacteria attach themselves to dental plaque, the whitish sticky biofilm that collects and forms on the teeth. When you eat sugars or carbohydrates, these acidogenic bacteria break down the sugars and produce acid as a by-product, which in turn drops the salivary pH. At about pH 5.5, the minerals just below the enamel surfaces of the teeth begin to dissolve in a process known as de-mineralization. During this process, more calcium and phosphate leave the surface of the teeth than enter it — the first step in the decay process leading toward cavity formation. And because a tooth’s roots are made of dentin, which is softer than enamel, they are more susceptible to decay. For example, the roots of an exposed tooth will de-mineralize quickly and easily with even weak acids at pH 6.0 – 6.7, which is much closer to neutral.

Why Me? How To Assess Your Risk

Given similar habits, you might wonder why some people get cavities and others don’t. Dr. John Featherstone, an imminent researcher studying the effects of all these different factors, introduced the concept of the Caries Balance in 2002, in which he demonstrated that both the disease, dental caries, and dental health are a delicate balance between pathologic (disease causing) and protective (health promoting) factors. This dilemma can be further explained by understanding that individuals have their own unique balance, similar to a playground’s seesaw that is constantly changing. The challenges are to identify what is out of balance and how to tip it towards health and protection.

It’s Sort Of Like…

A great analogy is likening caries risk assessment to how a physician assesses risk for cardiovascular (“cardio” – heart; “vascular” – blood vessel) disease. The physician reviews your health history, takes your blood pressure, monitors your heart, and provides a treatment plan that may include prescription medications to reduce or manage risk. If your blood pressure is high, it doesn’t indicate that you have had a heart attack or stroke or that you definitely will one day. However, it does mean that you are at higher risk for having a heart attack or stroke and that it would be wise for you to take preventive actions! Some of these include: changing your life-style in terms of diet, exercise, and perhaps medication for lowering your risk.

This same process is precisely what we are doing in dentistry today with the CAMBRA approach. We are providing individualized dental care so that we can minimize your caries risk. In fact, modern dentistry can now evaluate risk factors for dental caries disease and use them to make preventive recommendations with the goal of lowering the risk of tooth decay. And as a result, create more predictable, longer-lasting results for any cosmetic or restorative dental procedures.

New Tools Of The Trade

As we’ve already said, not everyone has the same risk level for developing dental caries. This is further complicated by the fact that risk is dynamic and changes daily, as well as over longer periods of time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Simply put, there are factors that tip the balance. Some of these include: Disease Indicators and Risk Factors that lead to imbalance, which underscores the risk of disease. Protective Factors shift the balance toward health. These entities are measurable and quantifiable; but importantly, they are modifiable thus leading to predictable preventive and treatment outcomes.

From Research to Practice

By profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life, today’s dental professionals are using a more proactive approach. We’ve summarized these points in the illustrations of the caries balance and imbalance to show you how to identify your own risks. Not only do these illustrations show you what is out of balance, but they also show you what is required to correct it. Mastering the skills necessary to determine risk accurately is greatly aided when your dental professional uses a caries risk assessment form to ask you specific, scientifically validated questions to help pinpoint imbalances. And once an imbalance is identified, corrective action should be taken.

Your dentist may use two types of forms to help assess and manage your risks. One is for children between the ages of 0 – 5 and the other is for everyone (including adults) over the age of 6. The simple form we’ve included shows how easy it is to access and record your Disease Indicators and Risk Factors.

Disease Indicators

Psychologists tell us that the best predictor of future behavior is past behavior. That’s sort of how Disease Indicators work; they are clear signs of what could happen based on what has happened. Identifying them includes the use of modern dentistry’s most sophisticated tools for early diagnosis of decay. This topic will be discussed at length in the next article in this series, “Minimally Invasive Dentistry.”

Here are a few highlights:

Visible cavitations: Decay that is visible in teeth ranging from very early (microscopic) detection using, for example, innovative laser technology, to cavities that are visible to the naked eye.

Radiographic lesions: Early decay that is visible by using today’s highly sensitive yet low dosage x-rays (pictures).

White spot lesions: The first sign of decay in the contacting surfaces of the tooth’s enamel that is often reversible with fluorides.

Cavity within the last 3 years: Any previous cavities add to your risk of further disease.

Risk Factors

A Risk Factor is a variable associated with an increased chance of disease or infection. Risk factors may be linked with a disease, but they do not necessarily cause the disease. For example, it is inaccurate to say, “being young causes tooth decay” just because young people are at a higher risk due to the fact that young enamel is less resistant to decay.

Visible plaque: Dental bacterial plaque, now known as biofilm, is the whitish film that collects on teeth in the absence of effective oral hygiene. When it is clearly visible, it means there is a very high quantity of it. And if the pH of the mouth is low (acidic), the biofilm are especially prone to contain decay producing (acidogenic) bacteria.

Inadequate saliva flow: As we stated earlier, your saliva is critical for protecting your teeth against decay. If you have poor salivary flow (dry mouth), or if its ability to neutralize acid is diminished, protection against decay is seriously compromised. This is considered an extreme caries risk.

Medications that cause dry mouth: Many medications can cause hypo-salivation (“hypo” – below or under; “salivation” – saliva production) leading to dry mouth, which significantly increases the risk of decay. This is also considered an extreme caries risk.

Frequent snacking: Eating sugars, refined carbohydrates, and acidic foods actually promote acid producing “BAD” bacteria, as discussed earlier. Eating a healthy diet will help, but so will reducing how often and how long you expose your teeth to them.

Appliances: Retainers, orthodontic appliances, and bite or night guards all tend to restrict saliva flow over the teeth causing stagnation and promotion of dental bacterial plaque.

Deep pits and fissures: The shapes of teeth vary from person to person thanks to your genetic make-up — another thing you can blame or give credit to your parents for! In other words, your genetics control how deep the tiny grooves (fissures) and pits are on your tooth surfaces. And the deeper they are, the more likely they are to harbor bacteria you just can’t reach or remove with a toothbrush.

Acidic beverages or foods: Not only do acidic beverages and foods increase your risk of tooth decay by promoting the growth of aciduric (acid loving) bacteria, but they also can also directly cause erosion of the whole enamel tooth surface in addition to the areas that usually decay.

Other: Conditions like bulimia and anorexia (psychological conditions in which individuals induce vomiting), and GERD (Gastro-Esophageal Reflux Disease) can create highly acidic conditions in the mouth causing severe erosive damage to teeth.

Testing

Why wait for disease to start with early white spots or cavities when today it is possible to test for the acid-producing bacteria by taking a sample of the biofilm and testing it for acid producing bacteria? For example, if an acid producing biofilm is detected early, you can avoid passing these germs to others as parents and caregivers do unintentionally to infants. Or why not try to eradicate these bacteria by changing the conditions (pH balance) of the mouth? Testing meters can now give estimates of acid producing bacteria in 15 seconds. A reading from 0 – 1500 correlates with low risk and a reading of 1501-9999 correlates with higher risk. This simple and inexpensive test can also be repeated after treatment and is a great motivational tool for both patient and dental professional alike as everyone likes to know if change is working!

Diagnosis and Prognosis

A diagnosis can now be made based on your individual risk from the facts collected on your caries risk assessment form. This is important for three basic reasons: firstly, it is based on identifiable evidence; secondly, the risk can be modified based on recommendations and actions; and thirdly, repeating the procedure can objectively measure change to reduce your risk and improve your health. This affects your prognosis or the ability to predict the probable course and positive outcome from taking action.

Prescribe

In addition to the traditional things you’ve always been told to do like brush, floss, pay attention to your diet, and see your dentist regularly, treatment and preventive strategies are now based on your individual risk rather than treating everybody with the same approach.

If your risk is high, your dental professional may prescribe a program to reduce it. Some of the newer and more specific agents include:

• Rinses containing a safe dilution of sodium hypochlorite solution that can kill bacteria and raise pH (lower acidity) in those individuals found to have high acid producing bacteria levels. Other products are available that are designed to balance an acidic mouth and keep the pH neutral and encourage more normal bacteria.
• Rinses containing chlorhexidine, an antibacterial agent that has been used for eons to reduce bacteria, to disrupt their influence, and to lower the counts of those causing disease.
• Fluoride containing rinses to strengthen enamel surfaces making them more resistant to decay while encouraging re-mineralization.
• Xylitol, a natural sugar alcohol used for years as a sweetener and alternative to sucrose (table sugar), is known to disrupt the ability of acid-producing bacteria to thrive and attach to teeth. Xylitol is available in a rinse, spray, chewing gum, as well a breath-mint.

Once your risk has been modified and reduced, the level of prevention and treatment can be matched to it. For example, you can move from a treatment strategy to more of a preventive one.

Partnership

Finally, it’s about partnership. Your relationship with your dental office team is based on both a scientific approach as well as caring health professionals who have your best interest at heart. Working together, they will ensure that dental decay is a disease of your past so that you can enjoy a lifetime of good oral and dental health.

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