Ask Dr. Spindel

Why use a Waterpik?

2012-01-28T09:18:00.001-05:00

Although a Waterpik is not as effective at removing interproximal plaque as dental floss used properly, it does seem to help cut down gingival inflammation. Most periodontists report that patients using a Waterpik device have less bleeding on probing than do other patients. Since bleeding on probing is considered one of the best measures of the presence of gingival inflammation, the Waterpik is a valuable tool for fighting periodontal disease.

It may accomplish this by causing fluid exchange in the sulcular fluids via the 'Venturi effect'. As its water pulses through interproximal spaces it may create a suction that removes crevicular fluid and any bacteria that have 'seeded' in it. This is a theory that I have heard proposed but I do not believe is a proven fact, but my experience has been that patients using the Waterpik as well brushing and flossing (or using inter proximal brushes do better when getting a periodontal exam, than those not using it.

Can Bad teeth run in the family?

2012-01-23T07:53:00.003-05:00

Patients commonly explain that 'Bad teeth run in the family". The implied message is that they themselves are not to blame for the state of their mouths. While genetics obviously plays a role in determining the likelihood of developing all sorts of health problems, so do a person's habitual patterns of behavior.

My grandmother wore two full dentures by the time she was middle age and both of my parents lost about half their teeth by the time they were senior citizens. I myself, although in my 50's, have not lost a single tooth. Why?

Although I do not know for sure, I believe the choices they made and their lack of a good dental IQ are the reasons for their extensive tooth loss. All three were chain smokers for most of their adult lives and I do not believe any of them took good care of their teeth until it was too late. Poor brushing techniques, poor diet,lack of frequent tooth cleanings, and nicotine from cigarettes probably were responsible for their tooth loss. All eventually developed adult onset diabetes which compounded their tooth problems.

Although I am far from perfect , I do not smoke, I brush regularly with an electric tooth brush, floss and get regular cleanings. These habits are most likely responsible for over coming any 'genetic predisposition' that might lead to tooth loss.

Which patients sbould be taking bisphosponates?

2012-01-19T07:22:00.004-05:00

I am sure I am not able to answer this question, but It is a valid question to ask and for medical experts to debate. Surely the decision should be made based on risk vs benefits. Taking medicines long term for preventive reasons is not without risk. Taking some medicines can place patients at higher risk for health problems than the problem they are attempting to address or prevent.

A new study published in the New England Journal of Medicineprovides useful information for both patients and their physicians. The study followed women after an initial normal bone density test to determine the likelihood of them developing osteoporosis. It found that that "osteoporosis would develop in less than 10% of older, postmenopausal women during re-screening intervals of approximately 15 years for women with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia"
I believe this finding is important since it provides some real information about a persons risk of developing Osteoporosis later in life and will help physicians decide whether they should be prescribing bisphonphonates for particular patients.

An article in the New York Times, published on January 18th, discusses the significance of the above mentioned study and provides further information and is probably worth reading. It reports that "experts also generally recommend that most people on bisphosphonates take them for just five years at a time, followed by a drug holiday of undetermined length. The idea is to reduce the risk of rare but serious side effects, including unusual thighbone fractures and loss of bone in the jaw."

How's the dental business?

2012-01-10T11:49:00.009-05:00

This is a question asked by a patient almost every day. I answer that we are doing OK, but things are a little slower than usual. Our billings for 2011 were off by 3% when compared to the previous year. I can not complain about my billings, since I am fortunate to have a mature and busy dental practice, but I am sad that it seems that some people appear to be putting off their dental check-ups and cleanings. Also it has been more common when examining a patient coming in for a hygiene appointment, to find that they haven't scheduled appointments for previously diagnosed cavities.

I am sure that some of this procrastination is due to economic worries that patients have, but any savings that they may experience by delaying cleanings or the filling of cavities, will certainly be wiped out by a single tooth being lost or needing a root canal, post and a crown.

A simple filling is less than 10% of the cost of either of the latter alternatives(rct,post and crown or extraction and implant). Also frequent cleanings do seem to lessen the odds of a patient developing active periodontal disease.

The lesson is apparent: "A stitch in time saves nine". Avoiding or fixing dental problems early will save a patient a lot of money, especially over the course of a lifetime! I am writing this post with the hope that it will encourage people to take better care of their mouths.

What should be done about bonding that has darkened over time?

2012-01-08T09:52:00.000-05:00

This can happen to bonded restorations over time. They can absorb some stain over time, but fortunately this stain often is superficial. The first thing a dentist can try is to take some sandpaper or a fine diamond bur and remove the superficial layer of composite. Often, directly under this surface lurks the ‘fresh’, original shade of composite. This 'freshening' of a composite restoration can often extend the esthetic lifetime of a bonded restoration.

A more vexing problem is stain at the margin of a bonded restoration. Although often it is superficial and can be dealt with by light sanding, sometimes the stain can extend deeper into the tooth and can not be addressed by simple sanding of the superficial layer. If the stain is deep but not associated with decay, then a small fine diamond can be used to remove it and a new layer of composite can be applied to 'spackle' the groove that the fine diamond made.

I should be noted that some stained restorations that a dentist suspects have recurrent decay, should be replaced in their entirety and not just sanded or 'spackled'.

What comes first, Bleaching or Bonding?

2012-01-08T09:41:00.000-05:00

This is a question that should be commonly asked. If fillings or cosmetic bonding is to performed on teeth that are in the 'smile zone' Then bleaching should be performed prior to any visible anterior restorations. Composite shades that are used should match the teeth after whitening is completed.

It should be noted that bonded fillings will not necessarily darken with time, but the bleached teeth they are attached to will. If this happens the teeth may need to have a bleaching touch up, in order to better match their bonded restoration(s).

Can teeth Talk?

2012-01-01T12:18:00.000-05:00

According to a recent article published in the Wall Street Journal("If Your Teeth Could Talk ...) maybe they can't, but the article points out that a number of systemic problems seem to be linked to problems in oral health. According to the Journal article "There's also growing evidence that oral health problems, particularly gum disease, can harm a patient's general health as well, raising the risk of diabetes, heart disease, stroke, pneumonia and pregnancy complications."

This idea has been posited by a large number of articles including prior Ask Dr Spindel posts.

I am glad that such a well respected and wide read News Paper is calling attention to the importance of Oral Health. This article correctly portrays the importance of dentistry to our overall health. Visits to the dentist are not just about finding tooth decay, but as the article implies, they may even help prolong our lives. Many people in the last several years have cut back on their dental visits in order to save money. Not only will delaying on fixing teeth tend to cost us more in the long run, preventive dental cleanings and treatment of periodontal disease clearly have an impact on our general health.

Great Dental New Years Resolutions?

2011-12-28T16:32:00.003-05:00

I just finished writing and posting an article on this subject on my dental website. It features ten dental resolutions that patients could make and keep for the new year. Most of us would be lucky to keep just one New Years resolution. My dental resolution is to take care of a broken molar that I have been putting off repairing.

Does Root canal hurt?

2011-12-26T10:52:00.002-05:00

With proper anesthesia root canals can be a pain free procedure. Most teeth respond to regular local anesthesia injections. For Maxillary (upper teeth) dentists usually employ a combination of buccal infiltration and a palatal injection. For Mandibular teeth(lower teeth)a mandibular or mental block is used.

Some teeth do seem to be hypersensitive at the time that root canal is started and patients still can report some sensitivity when a dentist attempts to access the pulp chamber. When this happens I sometimes use an additional intrapulpal injection in order to achieve complete anesthesia. Usually this injection does the trick for my patient and their endodontic procedure can be completed without further discomfort.

Is your office closed over the christmas holiday?

2011-12-24T11:54:00.000-05:00

Our New York dentist office traditionally has been closed between Christmas and New Years. This year is no different. Our office will be closed until January 2, 2012. My staff and I are looking forward to having some good food, geting some rest and spending time with our families. We wish all our patients have a happy and healthy holiday season and we will be back in action early next year.

Can a successfully treated root canal tooth experience occasional pain/tenderness?

2011-12-19T09:43:00.001-05:00

Sometimes root canal treated teeth, that we consider a success, do have some "low grade inlammation ". The teeth are not infected but are not entirely without tenderness.

Another possible explanation of continued symptoms it that some teeth have a small undetected crack and heavy chewing may cause some small movement of the the crack.

If symptoms are disturbing sometimes a retreatment of the root canal can cause the tooth to become less symptomatic. After all, most of our check radiographs are two dimensional and do not show the root canal system as it acutally is. Small discrepencies in the 3-D fill also may be responsible for symptoms.

Why do dentists bevel teeth when preparing them for a crown?

2011-12-15T07:44:00.000-05:00

Bevels ave been used by dentists for many years in the belief that they help achieve a more intimate fit for the crown. When I was in dental school we were taught that a bevel on a tooth that was being crowned helped insure that the margin have a smaller gap when seated. There is a definite logic to this when compared to chamfer and shoulder finish lines, but It is hard to explain in a short blog post.

Now a days, with the advent of a number of metal free types of crowns(Emax,Lava,Procera,and Zirconium) chamfer finish lines are becoming more popular since these the manufacturers of these crowns do not advocate a bevel at the finish line.

In my practice for first molar and bicuspid teeth I continue to bevel and use Pfm crowns. I find that these work well and possibly better than some of these new crowns, especially for teeth with weakened coronal tooth structure. One possible reason for their success is that the bevel shifts some of the flexural forces to a relatively uncut an intact portion of the tooth tha is below the gingiva. Most chamfer or shoulder preps seem to depend more on the integrity of the coronal tooth structure and need to have considerable intact coronal tooth to be predictably successful.

Many teeth that require full coverage restorations have weakened coronal tooth structure and many have internal cracks that should be isolated from the forces involved with chewing. In my opinion the beveled preps (pfms) or feather edge preps(full metal crowns) do the best job of isolating the weakened portion of posterior teeth from flexing forces that can be generated during a patients chewing.

Although the newer types of metal free crowns are beautiful, the verdict is out on how well and predictably they will stand up in patients mouths over the long haul.

How long after a filling is done is it safe to eat?

2011-12-11T09:24:00.002-05:00

This is a question that patients frequently ask. Dentists placing amalgam fillings often caution patients to wait 45 minutes after their filling to eat. This is advised because silver fillings tend to continue to harden after placement and the consensus is that after 45 minutes they are hard enough to withstand the forces that will be placed on them by eating.

Composite fillings are immediately ready to withstand the forces of mastication(eating) after placement- no waiting needed! That being said, most patients are numbed when having a filling and should not eat until the numbness goes away. This is especially true for patients having a mandibular block. Mandibular blocks are commonly used for achieving anesthesia prior to filling teeth in the lower jaw and they result in profound numbness in the tongue and lower lip (on one side).

My father who was a patient and a big fan of mine once returned after a dental visit and mentioned, almost apologetically, that he thought that possibly I had made a cut in his tongue during his last visit. I looked in his mouth and there was a fairly large gash in the side of his tongue. Knowing that I hadn't happened during treatment, I asked if he had anything to eat after leaving his last visit and he confessed he had a hot dog at the train station afterward.

My father's story points out the importance of not eating any food while still numb, since there is a definite possibility of a patient injuring a numb area. Hot foods may cause a burn and numb tongues and cheeks may be inadvertently bitten while they are numb and lacking normal sensation.

What should I do if my dentist has billed my dental insurance for work not done?

2011-12-04T11:35:00.002-05:00

This is a question that occasionally does come up. Some patients have come to my New York dentist office with this complaint and have asked me to check whether the work in question was actually performed.

If a patient suspects that his insurer has been billed for work that has not been performed then if possible they should first contact their dentist and ask for an explanation. If not satisfied with the explanation, then it makes sense to contact the insurance carrier and let them know that some of the work submitted for was not completed or performed. Often the insurance carrier will contact the dentist and ask for an explanation or even ask him to refund the overcharged amount.

Some patients may not want to contact their dentist to ask for a clarification and in that case they may choose to contact their insurance company, especially if they are sure that the procedures in question have not been performed.

What type of composite do you use for anterior bonding?

2011-11-28T12:03:00.006-05:00

As a cosmetic dentist in New York I use different types depending on the situation. Most often I use "hybrid composite". This is a category of composite that has been in usage for a long duration and has 'stood the test of time'. Hybrids have variable particle size for their 'fillers' and are usually considered the strongest type of composite when exposed to biting forces. They are less polished when compared to 'microfills'(smaller particle filler size) but most of the time the exact amount of polish is not the most important feature. Teeth are most often viewed in a 'wet' state and when viewed this way hybrids often are highly esthetic. If needed hybrid composites can be veneered with microfill composites, so that the restorations can appear shiny even when the restorations are viewed in a dry state.

A newer type of composite has been developed that is promising and has properties that mimic the best properties of hybrids and microfills. These composites,termed nanofils(Esthet-X is one example)are both resistant to flexing forces like hybrids and also can be highly polished like microfills. I have used these succesfully for anterior restorations but have not tried them for posterior restorations. Posterior fillings are under the greatest stress and I am currently using only hybrid composites for fillings in stress bearing areas on back teeth.

Currently Cosmetic Dentists must choose which of these types of composite to use in each situation. All work well when used in the correct situation and most cosmetic dentists have their own opinions on which composite to use for particular applications. There probably is not a universal composite that is best for every application.

Does a cavity cause a tooth to ache?

2011-11-22T07:06:00.004-05:00

Large carious lesions can cause a tooth to ache. Often patients report their tooth starts to hurt after eating. This is probably due to the bacteria in a carious lesion being fed by the food that a person eats. The bacteria in the process of metabolizing the food will produce acidic substances(lactic acid) and these may irritate the pulp of the affected tooth. Often these aches are transient and will come and go.

If a deep carious lesion is cleaned out carefully by a dentist and no obvious pulpal exposure occurs, the dentist can place a sedative or cement filling in the affected tooth and it may become comfortable. If the tooth is properly sealed the pulp may be allowed to recover and the tooth may become a "happy" tooth.

Of course some teeth with deep caries do require root canal since their pulps have been irreversible damaged. If after having a sedative filling has been placed in a deep lesion, the tooth continues to throb or ache,then an endodontic procedure is usually indicated. The sensitivity is coming from the tooth's pulp and removing it with a root canal will usually make the tooth comfortable.

Do you accept managed care dental plans?

2011-11-13T11:00:00.002-05:00

Although we do treat dental patients who have PPO coverage and accept their insurance as partial payment we do not participate in most plans. The sole acception is the Delta premeir plan.
We do have a very nice dentist, Dr Natalie Goldstein who shares our office. She participates in many dental insurance plans .

She has practiced with us since June and her patients seem very happy with her. She graduated from NYU several years ago and completed her General Practice Residency at Montifiore hospital in the Bronx.

If you are looking for a good dentist in New York City who does accept your managed care dental plan why not call her at 212-433-0813. At the moment she practices Tuesdays and Thursdays and accepts on line appointments through an website called Zocdoc.

What are the purpose of deep cleanings?

2011-11-06T08:35:00.005-05:00

Deep cleanings allow dentists and hygienists to remove tarter that can accumulate under gums along the roots of teeth. Another term for this procedure is "Root Planning". Often times when a hygienist performs a cleaning tarter remains below the gums. This tarter can make it more likely for a patient to have active periodontal disease. If a dentist finds that pocketing is present(pocket depths of >than 4 mm) and he suspects the presence of subgingival tarter, he may suggest one or more deep cleaning treatments.

At these visits, local anesthesia is administrated and then very sharp currettes( periodontal 'scalers" ) are used to scrape clean tooth surface below the gums. Tarter that has been present for long periods can be extremely tenacious and can be a challenge to remove. Visualization is often not possible and tarter is detected by tactile methods and the use of radiographs. Dentists use extremely sharp currettes to both detect and remove this subgingival calculus(tarter).

What is the optimal recall schedule for someone over forty?

2011-10-28T07:46:00.001-04:00

Prevention is the best medicine and in the case of frequent recall, whether it is reimbursed by dental insurance or not, it will most likely safe patients money in the long run by preventing problems and allowing dentists to discover any problems that develop at an early stage.

Although most dental insurance covers two recall visits per year,I believe that many patients, especially those over 40 , optimally should have more frequent cleanings. A three month recall is considered the standard recall schedule for patients with a history of periodontal disease. Why should someone wait for this diagnosis to choose a three month recall?

I recommend that if it is affordable, patients over forty should have three to four cleanings per year. If they would like to cut down on non reimbursed expenses, they can choose to forgo an examination on the visits not covered by their insurance.

Why do I have sensitivity to cold after a wisdom tooth extraction?

2011-10-19T07:00:00.002-04:00

Some patients report cold sensitivity after a wisdom tooth is extracted. If this occurs it usually is coming from the tooth directly anterior to the extraction sight. If the root area of that tooth is more exposed after the extraction it can feel increased cold sensitivity. Also if the tooth anterior to the extraction sight has been luxated (wiggled) during the extraction it can experience an increased sensitivity to cold. Usually this sensitivity will gradually go away.

What does it mean when someone says "I never have any cavities"?

2011-10-17T09:40:00.003-04:00

As a practicing dentist I sometimes encounter new patients, who have loved their previous dentist and are especially proud of how their teeth 'never need work'. I often hear this remark with a sense of dread; Allthogh it can mean they have great teeth, it sometimes can be a tip off that their prior dentist was not detecting some dental problems. In such a situation, It can be awkward telling them the bad news, and I am always concerned that my potential new patient will not believe me If it turns out that they do have a number of dental problems. After all they trusted and loved their old dentist and I am the 'new kid in town' and it definitely can turn out to be a case of "shoot the messenger". Often patients do not want to believe bad news and seek a second and third opinion ( often from their friends and family) before having a unwanted dental procedure.

Do you have evening hours?

2011-10-15T10:24:00.003-04:00

My office is open 9-6 P.M, Monday- Thursday. I do not have any evening hours. Our last appointment available for a patient booking is at 5 P.M.. Many years ago I tried having a late day on Wednesdays, but I found I was not comfortable seeing patients after 6 P.M., since by that time I was usually tired and I felt I wasn't able to consistently do my best job on my dental procedures.

In fact if I have a demanding dental procedure(crown preparations, endodontics), I try and have my patients book it by two pm or even earlier, since I, like most people, have the most energy and can maintain my best concentration during the first half of the day. If possible I try and schedule easier procedures towards the end of the day( fillings, crown try ins, and cleanings)

What should I do if I need a crown but can't afford one right now?

2011-10-04T07:40:00.004-04:00

In my practice I am asked this question all the time. Usually the patient asks why can't you place a large filling for now and I will do the crown later if I have a problem. This is not a particularly good option since very few patients will remove a functioning permanent filling to place an 'elective' crown. Instead they do wait until something happens to the tooth. Usually one of two things eventually happens; Either the tooth experiences recurrent decay( Large permanent fillings can be hard to execute optimally and can be more prone to voids and recurrent decay) or the tooth fractures( large fillings do not protect teeth well from fracture).

Instead of a large permanent filling I recommend a large Miracle Mix restoration. This matereial is made of a combination of glass ionomer cement and the metal fillings from amalgam(leaving out the mercuray). They are "kind" to the teeth they restore and seem to inhibit recurrent decay. Their drawbacks can be that they can be difficult to achieve good contacts and they are more brittle than compostie. They work well as an intermediate type filling and can last from 6 months to several years or more.

I use bitine rings (or analagous device) to achieve optimal contacts. I have used this restorative for 15 years or more and when I see the patient on recall appointment I mention their miracle mix filling(s) and ask if they are ready to have a crown. Eventually they go ahead and have a crown done since it is more ideal for their tooth and will help protect it from fracture.

Should a wisdom tooth ever get root canal?

2011-10-02T11:08:00.003-04:00

The answer is sometimes. If a wisdom tooth has a deep cavity and has a pulpal exposure it can be a good candidate for endodontic therapy if it has errupted in a cleanable position and is in good function. Like other posterior teeth, after having a root canal wisdom teeth should be crowned. In my practice I recommend full metal crowns for wisdom teeth(and second molars), since the chewing pressure they can experience can make porcelain breakage more likely when porcelain fused to metal is used.

If the wisdom tooth is not fully erupted or difficult for the patient to clean, then root canal is not the best option for dealing with a compromised pulp. Instead extraction is the best option. In this event, often the opposing wisdom tooth is extracted as well, since without an opposing tooth present, it may extrude over time.

What does the fall season signify to a dentist?

2011-09-29T18:47:00.004-04:00

For most small business owners,the fall season coincides with the final quarter of our business year. Unlike most business owners dentist's practices can be affected by our patients' dental insurance. Most plans are calendar year plans that start on January first and end on December 31rst. When a patient's dental insurance maximum is reached many patients seek to defer treatments to the next year if possible. For patients with non urgent dental problems this strategy can work but obviously not always. If a patient needs a root canal, or has a large carious lesion, delaying dental treatment can be a poor choice that can have cause additional problems to develop that may end up costing more in the long run.

Another group of patients can have a different set of issues. Patients can put off going to the dentist because they are busy, nothing hurts, or they are afraid of what they will find out. Far to often they have dental needs that go unaddressed, as well as dental benefits that are not utilized. Every year towards the end of December we get a flurry of phone calls asking if we have time to start a crown or do a number of fillings.

Instead of waiting until December, these patients would be better off coming in October or November for their dental work, since this would allow us time to pre-certify their dental treatment plans and let us complete the work prior to the end of their benefit period. If you haven't been to the dentist in 2011, Now is a good time to call your dentist for a check up!

Is there a more affordable alternative to Porcelain Veneers?

2011-09-26T15:18:00.009-04:00

Often times a patient who is on a budget for their cosmetic dentistry may be able to opt for bonding with composite instead of choosing porcelain veneers. The fee for bonding in my dental practice ranges from $250-$600/tooth depending on the degree of difficulty. The fee for porcelain veneers is $1850/tooth.

As a cosmetic dentist, practicing in NYC for over twenty five years, it has been my experience that bonded restorations can be a long lasting and natural looking alternative. The bonding may be more prone to developing small but is easily repaired. For it to be durable a patient does need to have excellent oral hygiene and should floss. Composite surfaces can develop porosities in a patients who has poor plaque control and the result can be that the restoration becomes stained and unattractive. In my experience, for patients with good dental hygiene the life expectancy for anterior bonded restorations is similar to that of porcelain veneers(10-15 years).

In the example shown above the patient had a class III malocclusion with crowding in his anterior maxillary segment. He didn't want to wear braces and he asked me what I could achieve without orthodontic tooth movement. I made a study model and applied wax to the model and was able to treatment plan 4 bonded restorations on his lateral and central incisors. The result was pleasing and affordable. His left lateral still is shorter than the right, but his occlusion would not allow a longer lateral. He was pleased with the result and it definately improved his appearance.

Are you accepting new dental patients?

2011-09-23T13:35:00.005-04:00

I am always surprised when someone asks me this. I guess some doctors or dentists are not? We are always happy to meet potential new patients. Usually when they call we ask if they have dental insurance in order to find out if they are allowed to go out of network. My practice only participates in Delta Premier dental insurance. We are "insurance friendly", which means that we do accept assignment of benefits from most of our patients dental insurance plans and usually we ask the patients to pay out of pocket only the portion of the bill not reimbursed by their insurance.

We ask the 'dental insurance' question because many potential new patients assume we accept(participate in) their dental insurance and might be disappointed if they visited us and found out that we do not participate in their insurance. Even though most of the callers plans do allow them to go out of network,we like to make them aware if we are not participants in their plan, prior to their booking an appointment.

What does it mean if I feel an electric shock when the dentist gives me an injection?

2011-09-14T06:59:00.003-04:00

Patients sometimes report a feeling of electricity in their jaw or lip when they are being given an injection in their lower jaw. Sometimes they report a burning or shock in their tongue. The injection most dentists use to numb the mandible is called a mandibular block. This injection is a nerve block of the mandibular nerve; a nerve that innervates the mandibular teeth. If it is pierced by the needle it will cause the patient to feel a burning sensation or a feeling of electricity in their jaw, teeth or lower lip. Anterior and adjacent to the mandibular nerve is the lingual nerve. The lingual nerve is responsible for the sensation of the tongue and if it is pierced the patient usually will report a pricking sensation or a burning on the tip of their tongue.

Although it is extremely disconcerting to patients experiencing it, this 'shock' usually causes no lasting harm and when their local anesthetic wears off their lip sensations return to normal.

If the mandibular nerve is damaged a patient can develop a lasting paresthesia of their lip on the side of the injection. Usually this paresthesia will eventually go away, but it may take 6 months to a year for lip sensations to go fully recover. Damage to the mandibular or lingual nerves is infrequent. I have been practicing for over thirty years and I have given many thousands of mandibular injections and I can count the number of paresthesias that have resulted from my injections on one hand. All eventually recovered the feeling in their tongue or lip.

Do you practice alone?

2011-09-09T14:25:00.007-04:00

Although I have a 'solo' dental practice, I share my office with several other dentists. Rents in Manhattan are pretty high and sharing a dental office makes good sense. We share the rent, cover each others practices when we are on vacation and we can confer with each other when needed. Further more our building ( 30 East 40th St.) is filled with other dentists (last time I looked at the bulletin board downstairs I counted over forty dentists!) and physicians and most are generous with sharing their varied expertise. Although it seems like a high concentration of doctors in one building, Manhattan is a big place and has room for lots of dental and medical practices.

How do you go about matching a tooth's shade?

2011-08-31T08:00:00.004-04:00

The patient shown in the picture has his two central incisors crowned. His shade was fairly easy to match but some are not. Most dentists use dental shade guides to help them choose a shade or shades for a tooth. For most posterior teeth the process that is fairly simple. When choosing a shade, I hold a shade guide adjacent to the tooth in question and look at it briefly, then I choose an alternative shade and look briefly at them next to the tooth.

When evaluating shade buttons the dentist should look at the shade for no more than a second or two at a time. If the shade guide is held against the tooth for longer it starts looking better since our eyes accommodate and we can no longer adequately judge whether the guide used is the correct for a patients tooth. In general I can choose a shade after looking at two or three alternative choices. I also let my patient view my shade button 'challenges' while I'm doing them.

For a shade to look acceptable it must not only match the hue and chroma (color) of the tooth but should be close in value( brightness). If I want to judge the value of a shade I sometimes squint while looking at it, since this essentially eliminates the color component of the shade but still allows me to perceive the black and white portion of the shade( the value).

For anterior teeth the process of picking a shade (or shades) can sometimes be extremely tricky. For tricky shades a dentist or dentist can draw out a shade map on his lab Rx that shows the different sections of the tooth surface and indicate what shades he sees in different zones of the the tooth surface. Also for tricky anterior teeth I often send photographs of the tooth or even send the patient to the laboratory for their shade selection. Sometimes after a crown try in, if I feel it is necessary my patient is sent to the laboratory either custom staining of their crown or so that the ceramicist can view how the crown looks in the mouth and have a better idea of what changes need to be made. For some single anterior teeth being made for discriminating patients or dentists, a ceramicist may even have to make remake the crown several times, before a satisfactory version is fabricated.

Where are you spending your vacation?

2011-08-22T08:01:00.003-04:00

I am currently taking a break in Woods Hole, Massachusetts in Cape Cod. I have been spending time every summer here for over over fifty years. Aside from some beautiful coastline, Woods Hole is home to the Marine Biological Laboratories, The Woods Hole Oceanographic Institute and the NOAA Fisheries. Although it is clearly a world renowned center for marine scientific research, I go there mainly for two weeks of R & R. My activities include swimming, biking, sailing, visiting with old friends, cook outs. I will return to my New York Dental office on September sixth. with my batteries recharged.

What is the thin grey line I see above (or below) my crown?

2011-08-14T09:13:00.004-04:00

Usually when I am asked this by a patient I find is they have a porcelain fused to metal crown that has been finished on the outside with a thin metal collar. This is usually done to create a finer margin for the restoration and can help insure that the crown fits optimally and the porcelain doesn't get cracked when the crown is seated.

The obvious follow up question that patients ask is why not cover the margin with porcelain in the first place? I usually choose not do this with my posterior restorations since I find that when my crown margins are covered with porcelain it can cause the crowns to fit too tightly since porcelain shrinks when it is fired and this can put pressure on thin and flexible metal that supports it at the margins. When trying in crowns with no metal collars it can sometimes cause the porcelain to 'pop' off and leave the porcelain with a chip.
If the technician chose to make the metal at the margin thicker than this wouldn't be as much of a problem, but the resulting crown would have a noticeable 'ledge' at the margin and could become a plaque trap.

I usually specify that my dental lab use a thin 'hairline metal collar' on the buccal of all my porcelain fused to metal crowns. This tiny metal margin is not usually noticeable since it has the thickness of one or two hairs and is subgingival. If a patients gums eventually recede it may become visible.

If a patient doesn't desire to have a grey line, they may consider a different type of crown (Lava, Emax, Procera, Empress) but often these crowns can be less strong or be more cement dependent than a porcelain fused to metal crown fabricated on a tooth with a bevel preparation. Although not all dentists probably will agree with me, I find that cement dependent restorations have less initial retention and tend to be more dependent on their cements to keep them attached to their teeth. If a crown is 'cement dependent' it has one more thing that may fail and often the cement is the weakest component of the restoration. It can separate either the tooth or the restoration. I have found that this can make some of these crowns more likely to become loose or come out down the road. Metal free esthetic restorations tend to have larger gaps between them and the tooth and are more likely to fail in the long run.

The pyramids were built without any cement and they have lasted for thousands of years. In my opinion, The cements used to lute pfms to teeth tend to seal up the tiny gaps between the metal and the tooth and do a better job in resisting the forces that might tend to dislodge a crown.

What is the new New York State AED Law for Dentists?

2011-08-09T13:26:00.002-04:00

The New York State legislature recently passed a law mandating that each New York Dental Facility is required to have a AED device. This law takes effect January 1,2012 and now is a good time for offices to purchase a unit. Plan ahead and don't wait until the last moment. We purchased our unit from good friend Jon Bloomberg of Core Medical Systems. He offered me a good price and he offered a good selection of units and explained the differences to me. He will give us a free in-service to our staff to help familiarize us with the unit. If anyone is interested in contacting him they can at:347-995-4461.

What is that metalic looking thing that I can see on the radiographs above the patient's maxilary incisors?

2011-08-01T06:50:00.003-04:00

This is a question I am asked every so often by one of my hygienists. Lately more often. Most of the time when I am asked this question it turns out to be that the patient in question has a nose piercing. A nose piercing usually will appear on maxillary anterior radiographs as a wire with a small ball attached.

Sometimes wires seen above teeth on periapical radiographs can be due to other causes. Seeing a metal wire in what appears to be maxilary bone can also sometimes be a tell tale sign that a patient has previously either brokent their jaw or had maxillofacial bone surgery to reposition the jaw. Surgeons can leave the wires in place after a surgery and they show up on radiographs.

What composite material do you use to cement in your porcelain veneers?

2011-07-21T20:39:00.005-04:00

I have use many different composite luting composites to bond my veneers. Currently I am using Mojo by Generic Pentron. I find it easy to use since it has a relatively low viscosity that makes it easier to seat my veneers.

In my mind a relatively low viscosity for my luting cement is important, because sometimes when using a high viscosity luting cement it can be difficult to tell when my all porcelain bonded restoration is fully seated.

Fully seating veneers is highly desirable, since it makes for a smaller amount of exposed bonding material at the margins of restorations. Exposed luting composite can over time erode and pick up unsightly stains.

Why does your office recommend 'pre-appointing' recall appointments?

2011-07-18T16:41:00.007-04:00

We recommend making your next recall appointment before you leave our office after completing your cleaning because in our experience this is the best way to insure that your next recare appointment occurs at the correct interval. All too often our patients ignore this suggestion and ask that we call to remind them when it is time.

We are happy to provide this courteously, but it tends to help delay recare appointments. When our reminder call is placed, all to often my secretary is told that a patient is too busy to schedule now or that their teeth feel fine and that she should call again in a month or so. Instead of helping a patient, the reminder call can sometimes become an aid in procrastinating scheduling a recall appointment. Also patients who wait until their recall is due may have trouble finding a time that they like.

Sometimes,after several reminder calls an appointment is made, but it is scheduled well after their due date. When a patient chooses to pre-appoint, the onus is on them to reschedule, when they receive their reminder call or post card. Hopefully, even if they need to reschedule, it will be sooner than later.

What is the little bump with a hole in it on the inside of my cheek?

2011-07-10T08:23:00.004-04:00

Usually when someone asks this question they are referring to Stensen's duct. This bump, located on the inner cheek adjacent to the maxillary first and second molars, is the opening of the duct leading from the parotid salivary gland. It can be seen bilaterally (on both cheeks) and has a little hole in it that the saliva from the parotid gland can emerge from. It is completely 'normal' and usually doesn't indicate any pathology.

Occasionally the duct can get plugged with a salivary stone or localized trauma and can become painful. When this occurs the cheek can be sometimes seen to swell when a patient is eating, since chewing stimulates salivary flow from the Parotid. If the duct does become plugged it may be necessary to visit your dentist or an Oral Surgeon. Most Oral Surgeons know how deal with a blocked Stensen's duct. It may be necessary for them to cannulate it ( they can use a small needle like cannula to re-open the duct) or sometimes prescribe an antibiotic if they suspect an infection.

What can I do if my teeth look too short?

2011-07-04T18:29:00.011-04:00

The obvious answer is to make them longer, but how to best accomplish this can get complicated. First a dentist should determine the optimal edge position of the maxillary central teeth. Usually this can be done by having a patient going through a series of lip poses; Lip at rest, lip smiling, and possibly making the sound"eeeeeee". Mock up composite can be added to the edges of the maxillary incisors in order to try out how the incisor edge would look with a slight addition. Photos can be taken of the patient in the various lip poses.

Once the optimum pleasing position of the central incisors is envisioned then the hard part takes place. usually a set of study impressions and a full set of radiographs are taken. Studying these helps a dentist to determine exactly what should be done to achieve the changes needed to the lengthen teeth. Usually most central Incisors should be about 10 mm long but how to create the additional length that is needed? Treatments needed may involve possible orthodontic treatments (including either teeth extrusion or teeth intrusion}, crown lengthening, opening the bite, porcelain veneers, crowns or simple bonding. Often a combination of these treatments may be needed.

Often, when a patient comes to my office with this or another esthetic problem it can take several visits to determine a proposal for their treatment plan. Commonly, specialists need to be consulted in order to come up with the best treatment plan.

I belong to a study club in which a group of experienced dentists get together every month or so and go over case presentations. Among our members, we have an Orthodontist, Periodontist, Oral Surgeon, a Prosthodontist and four or five general dentists. It is often surprising how many ways we can come up to restore the patient's mouths that are being presented. Most often a number of options have to be explored and the pros and cons of each need to be reviewed before we can come to a consensus for a optimal treatment plan.

When are you taking your vacation this year?

2011-07-02T06:44:00.003-04:00

Although we are pretty busy at our office in general, things do tend to slow down in during the summer months, especially August. In July and the first three weeks of August we will be maintaining our normal office schedule. We will be open Mon-Thursday 9-6 PM and will be working some Fridays if they are needed.

We are taking vacation from august 20th-Sept 4th. The office will be open again on Tuesday, September 5th. I personally plan on taking some needed R&R with my son in Cape Cod. Swimming, Fishing, and Sailing will hopefully be on our agenda.

Are root canals uncomfortable to have?

2011-06-25T08:36:00.003-04:00

Most of the time they are not. If the dentist achieves a good level of local anesthesia, patients undergoing an endodontic procedure experience little or no pain. Yesterday I had my first root canal treatment. My colleague, Stan Lenkowsky, started a root canal on a molar that I had cracked years ago and had become nonvital and was symptomatic. Although, I had suspected that it needed a root canal, I, like many of my own patients, procrastinated because I was worried about how uncomfortable the experience might be. This is especially ironic because I have personally performed hundreds of root canals and most patients have reported little or no discomfort during the procedure.

Stanley, an experienced endodontist in Manhattan who has a great bedside manner, made the experience a comfortable and pleasant one. He was both thorough and gentle and the slight discomfort I did experience was tolerable ( he elected not to give me a palatal injection since it can be uncomfortable and in my case he felt it would be unnecessary).

Although I had no discomfort afterwards, some patients do have some soreness after a root canal procedure and their tooth can be sensitive to biting pressure (this is the reason, often dentists relieve the occlusion of a tooth when performing a root canal). Usually Ibuprofen or Aspiring does a good job of relieving the transient discomfort that patients can have after a root canal procedure.

What is a medicated filling?

2011-06-18T14:05:00.003-04:00

Usually when a dentist says he is placing a medicated filling he means a filling that will release medication to the tooth. Most often dentists are referring to a temporary filling that has eugonol in it since it is a natural abtundant and has a sedative effect on irritated pulps. In my practice I use IRM for my 'sedative' fillings since it releases eugonol but it also is strong enough for long term use. It also seems to have antimicrobial properties and helps prevent teeth from experiencing recurrent decay prior to the placement of a permanent restoration.

Other types of 'medicated' fillings that dentists use are Glass ionomer based, since they tend to release fluoride over time. In my practice I make frequent use of a modified glass ionomer cement aptly named Miracle Mix since it is strong and seems to have properties that definitely inhibit recurrent decay adjacent to these restorations. Miracle Mix is made by taking the powder from amalgam capsules(sans mercury) and mixing it with glass ionomer powder to create a new hybrid cement restorative. The metal fillings from amalgam have copper,and silver and other metals that most likely provide additional antimicrobial protection above and beyond normal glass ionomer formulations. It has only one real drawback. Miracle Mix fillings are grey in color and can not be placed in areas where esthetics is important.

Dentrix Integration problems?

2011-06-12T18:37:00.015-04:00

My integration of Dentrix Management software with my Dexis digital Xray software is not as seamless as I expected. We have been using Dexis digital imaging for storing our radiographs for the last year and a half and most of our patients have X-ray images stored in this software. We recently installed Dentrix and were promised that the integration would be 'seamless' with Dexis. Not our experience so far.

During our second training session,Daryl Kerker, our trainer, tried gamely to show us how to register new patients. Each time she did, Dentrix would give us a disturbing prompt--to either rename a patient stored in Dexis to the new patient's name or dump their radiogaphs in a general comm folder. After a couple hours of aborted training and several calls to support, it turns out that in our case the two will not play nice together. Our best option for now was to disengage the two programs. Perhaps later, when we have registered most of our patients in Dentrix we can try again to integrate the two programs. At the moment, I am neither impressed nor happy. John Giarraputo ,my Schein Technology Specialist/Salesman, seemed unaware that this would be a problem and hasn't yet offered any satisfactory solution.

Dexis support isn't sure how I should best handle the integration in the future, but one cumbersome solution was to wait until I had manually entered all the patients in Dentrix and then manually assign new numbers to all my patients in Dexis. This sounds time consuming to me. So much for the flawless integration.

If any dentists reading this have had a similar experience and might offer any good solutions I would be happy to hear from them. At this point I am looking for solutions to these integration issues. If anyone has experienced a similar problem and has a good solution I will be happy to hear it.

How should the area under a pontic be cleaned?

2011-06-09T07:14:00.007-04:00

The area under a pontic can be cleaned by using floss. This can be accomplished easily either by using a "floss threader" or by using Oral B Superfloss. A floss threader is a plastic loop with a flexible but stiff plastic leader that can be pushed between pontic and the adjacent abutment. Floss is placed through the loop and then pulled through the proximal area. Once this is done the pontic area can be cleaned using the floss.

Often Superfloss can used to do an even better job. It is a three in one floss. The end is dipped in parafin so that it is stiffened, the middle is 'fuzzy' and thicker(almost like a soft pipe cleaner) and the end is regular floss. The parafin coated tip can be pushed through the interproximal contact and the fuzzy part can be used to clean under the pontic.

When do you prescribe an antibiotic after a root canal treatment?

2011-06-06T07:33:00.004-04:00

The use of an antibiotic in adjunct with a root canal treatment is based on the judgement of the dentist treating a patient. In my practice, most patients whose pulps were nonvital(necrotic or no longer living) are given antibiotics to take after root canal treatment. My thinking is that the contents of the root canal system are most likely contaminated with bacteria and the patient will benefit by taking an antibiotic after being treated. A small percentage of non vital cases 'flare up' after root canal instrumentation. These flare ups can involve periapical swelling and pain and a worsening of the infection. Antibiotic may help prevent the flare up,lessen any that occurs and will most likely help with the resolution of any infection already present.

For vital cases(teeth with living, non infected pulps)most times antibiotic is not prescribed. After a root canal treatment of a vital tooth there also can be some periapical tenderness and even some slight swelling, but antibiotics are not prescribed unless I suspect an infection may have developed.

Should a tooth thats broken to the gum line be fixed?

2011-06-02T07:25:00.004-04:00

This is a situation most dentists face every week. A patient comes in with a broken tooth (either with or without prior root canal treatment)and would like their tooth fixed. This poses a dilemma for dentists. Most are aware that teeth do not have enough exposed tooth available to safely hold a crown are more likely to fail than teeth that have do have sufficient 'ferrule'(sound tooth structure around the base of the tooth that can be used to anchor crowns). In my experience, it is extremely desirable for teeth to have at least 1.5 mm of ferrule in order for me to fabricate a predictably long term restoration.

What should a dentist do if a patient wants his tooth fixed and it doesn't have sufficient ferrule? First he or she must make the patient aware of this issue and its ramifications. The fact is that if a crowned tooth has insufficient ferrule, it is more likely to fail. The remaining tooth structure is much more likely to fracture and can even lead to the loss of the tooth. With this fact in mind what should a dentist do?

Ideally a patient who wants this sort of tooth restored has two good options. The first is the road least travelled. It involves having the tooth orthodontically extruded and after it stabilizes having a crown lengthening procedure. This will allow for an aesthetic result and a more predictable restoration since the resulting restored tooth will have the desired amount of ferrule.

Another option is to for go orthodontic extrusion and just perform a crown lengthening procedure ( removing bone and gum from around the tooth in order to expose more tooth structure). This can work well but can result in removing supporting bone from adjacent teeth and can cause aesthetic problems, since the resulting tooth can look too long and appear to have experienced gingival recession and 'black holes' interproximally(missing papillas).

Often patients offered either of these two options are hesitant to give approval to either and are insistent that the tooth be fixed as is. Although dentists sometimes go along with this request, it can lead to the eventual loss of the the tooth. How long such a restoration will last varies, but it is not a gamble that patients should take, if they want to keep a tooth long term.

Still another option, not yet mentioned, is that some broken teeth should be extracted and have bone grafting and an implant placed, while there still is sufficient bone available at the site. Implant restorations can be extremely predictable when placed in good candidates with the proper amount of bone support.

How do you find good dental staff members?

2011-05-24T07:36:00.003-04:00

Although I have tried a number of methods, currently Craig's List seems to be an extremely affordable and productive source. I used to place expensive classified advertisements in the New York Times, but Craig's list has a better response rate, at one tenth the cost. My office manager calls the most promising candidates. She arranges interviews and 'working interviews' for the best candidates. Usually, I am looking for 'nice' employees. I can not train someone to be nice. Skills can be trained, but personality can not!

Usually over the course of a normal work day we can gauge how well a potential candidate will fit into our office and we ask our patients whether they like the candidate. Patient input is extremely helpful when evaluating a hygienist or receptionist, since these two positions interact independently and directly with patients.

Are discount dental plans worthwhile?

2011-05-18T07:39:00.008-04:00

Dentists have overheads of 60% or more and asking them to reduce fees by 25%-50% or more can make it difficult for them to make a profit. In what probably is the best case scenario, a patient can be fortunate and find a dentist whose practice is not busy enough to keep his appointment book full and is using the discount plan to fill his empty appointment slots. In this case, the dentist is using the plan as an advertisement of his or her practice and as a way of recruiting new patients. Treating patients from the plan may not be highly profitable, but may help a dentist cover his fixed overhead.

From a patient's point of view these plans may seem like a huge bargain and are tempting to patients in search of affordable dentistry. The obvious problem is that choosing a dentist from a list of "low bidders" is probably not the best way of choosing a dentist,contractor or any type of service provider. Also, all the value of any savings will be negated, if this choice leads to dental treatments or restorations that do not work out well.

A far better method of choosing a dentist is "word of mouth" (pardon this corny pun). Getting a recommendation from a satisfied patient, or another doctor is more likely to lead to a positive dental experience than choosing from a list of discount dentists.

What should a Dentist be prepared to do while waiting for a 911 ambulance?

2011-05-13T13:01:00.002-04:00

Medical emergencies occasionally take place in dental offices and can result in a 911 call being placed. What should the dentist do while waiting for an ambulance crew to arrive? The following is a guest post by Jon Bloomberg, EMT and a respected and certified AED/CPR trainer in the New York area who will provide an answer to this question.The short answer is that New York State dentists are required to hold a current AED /CPR card to maintain a their license. The requirements may differ for other states. This implies that Dentists should be able to recognize and respond appropriately to sudden cardiac arrest, heart attack; syncope, choking, stroke and allergic reactions. Other situations may arise but these are the most frequent life-threatening situations that dentists may see in a practice.

It’s not expected that a dentist will be as proficient or knowledgeable as an EMT or ER physician. Dentists should act within the guidelines and treatments that they feel comfortable with and for which they have been trained. However, repeated group and staff training will facilitate a proper and effective response by the team.

Although New York State regulations do not require everyone in a dental office to be trained, it is a good idea for all staff members to receive training. In my experience the easiest ways to accomplish this training is to have it done in the office. Accordingly, for the past four years, I have been providing training for dentists at their convenience in their own offices. I find that when the group is cohesive (namely an office) that people learn better and are more likely to retain the learning. It is my hope that when people learn as a team that they will be better prepared to handle a medical emergency as a team.

How do I eliminate sensitivity from my posterior composites?

2011-05-11T11:24:00.003-04:00

This is a question posed by a dentist regarding her patients complaining about sensitivity after having white fillings placed.

Most often sensitivity after having a filling is due to the technique use in preparing and placing the fillings. Most of my patients are not complaining of sensitivity after having a posterior composite placed. I will attempt to explain my technique.

When preparing a filling I usually use a 330 bur with out cross cuts . This bur is rounded at the end and doesn't usually create internal cross cuts or micro cracks. When using it I use gentle hand pressure and plenty of water coolant from my hand piece. Most of the time I place vitrabond over the deepest portion of the cavity preparation. I use a 15 second all etch technique and wash off the acid solution for 10 seconds or more. I dry the cavity preparation passively by waving my high speed suction tip over the preparation. My intention is to leave the preparation 'wet'. The surface should be glistening. If I have inadvertently over dried the preparation, I will re-wet the prep using a micro brush and water.

I use prime and bond and apply at least three times. I assume this is enough times to allow the acetone in the formulation to chase away the water in the prep. Then I air dry and cure as recommended by the manufacturer.

At this point I apply Flow it (flowable composite)sparingly to cover most dentin surfaces. I use an endodontic explorer to disperse it in the prep and use a micro brush to remove any of the flowable that inadvertently was applied to the cavosurface. I cure this for twenty seconds. Then I use a hybrid composite that I have previously placed on my bracket table. This composite has been prepared in to little balls of varying sizes and stored under an amber dappen dish (so that it won't set prematurely). I place small amounts into the prep and adapt each addition carefully and set it with my curing light. after the preparation is filled completely I am ready to finish always using water while removing the excess composite and smoothing the filling.

Of course there are other excellent techniques for preparing, placing and finishing composites, but I thought it might be helpful for me to share my technique.

When are you going to get Ida a new computer?

2011-05-07T08:00:00.007-04:00

I am embarrassed to say that this is a question I get asked at least once per month. Ida is my office manager/receptionist and she has been using a Power Mac (circa 1996) to run our out dated office management Dental Mac software. I am not really as cheap as it sounds, since buying a new computer was not the issue. What was I waiting for???? I was waiting for the right time to invest in a new dental management system and in networking my office. This is a necessary, but fairly costly investment.

I am happy to report that we had the office wired yesterday and Ida has a brand new Dell computer! We purchased the Dentrix G4 management system and will be receiving our training shortly. This program, when used in conjunction with the Dexis digital X-ray system we installed in 2009, allows our office management system to be fully digital. If we choose, we can go paperless and use the system for maintaining all of our patients records, as well as submitting dental insurance claims electronically.

Why do cavities sometimes develop along the gum line?

2011-04-29T07:17:00.007-04:00

Although most of the cavities that dentists find in children and young adults are either pit and fissure decay(located in the occlusal surfaces of posterior teeth) or interproximal decay, located immediately below the contact area, another common place to find decay is along the gum line of teeth.

Gum line caries may be caused by a number of factors, including excessive consumption of sugary foods, sodas, bulimia, acid reflux, lemon sucking, dry mouth and general poor brushing technique. Caries usually starts with acid dissolution of tooth structure and invasion of the tooth structure by bacteria. Normally smooth surface enamel is fairly resistant to caries, especially when it is cleaned well by brushing . Sometimes even 'good brushers' can have areas that they find hard to keep clean. It is not terribly unusual to find decalcifications on the buccals of upper second and third molars, since these tooth surfaces are sometimes hard to get to with a toothbrush.

Often children both, young and adolescent, don't spend the time needed to brush their teeth systematically. Many just distribute their tooth paste around their mouths in a rather random fashion and assume that the toothpaste will 'magically' clean their teeth. This is not the case, since toothpaste doesn't actually do much cleaning. Instead the tooth brush bristles are doing most of the cleaning and they should contact all accessible tooth surfaces.

Older patients( over seventy) often present with root caries. These carious lesions tend to be located on roots of teeth that are exposed as a result of gingival recession. Cementum normally covers root surfaces, but often this thin coating get denuded over time and exposed dentin can be more at risk for decay especially, for seniors, who tend to experience the double whammy of both dry mouth and a decline in oral hygiene habits. These carious lesions can be a real challenge for dentists to restore since they can be in difficult to reach areas and restorations can experience recurrent decay afterwards.

Accordingly, to restore root caries, I almost always use high fluoride releasing restorative filling materials, such as glass ionomer formulations(Gc Miraclemix, Gerastore, RelyX) to restore these lesions, since they offer some protection from future recurrent decay.

What is the difference is between a free gingival graft and a connective tissue graft?

2011-04-23T11:18:00.005-04:00

This is a guest post written by my good friend and colleague Dr Philip Pack, an excellent periodontist practicing in New York City. I have known him for many years and often pick his brain on all matters of a periodontal nature.

Patients are really not sure what the difference is between a free gingival graft and a connective tissue graft. Patients know that both grafts are taken from the palate but are otherwise confused.

The free gingival graft is an excellent choice where the goal is to increase the amount of hard gum tissue (keratinized tissue) around a tooth. It is best used in non-esthetic areas where root coverage is not the objective. Increasing the amount of keratinized tissue will decrease the likelihood of further recession.

The connective tissue graft is the best choice where there is an esthetic problem or hot and cold sensitivity. It is the procedure of choice for covering exposed roots and obtaining a good tissue blend. A good tissue blend means that it is difficult to distinguish the graft from the adjacent tissue.

The tissue harvested from the palate for a free gingival graft is from the surface and is rectangular in shape. The connective tissue graft is also rectangular but is harvested from underneath the surface tissue. The incision for the connective tissue graft is a narrow straight line and usually heals more quickly because it is smaller.

Both procedures have been performed for many years and have stood the test of time.

Why does dentistry cost so much?

2011-04-22T11:09:00.005-04:00

While Dentists are fortunate to be involved in a helping profession, they are also small businessmen who run a private for profit business.

Getting started in dentistry is expensive and can leave young dentist's with a large debt load of hundreds of thousands of dollars in debt. Opening a dental office can also be
expensive. Dental offices are costly to build and even well established dentists can feel financial pressures.

Most patients expect their dentists to stay current with both their continuing education and maintain a modern dental office that features current dental equipment. Also, since dentistry is a service profession, successful dentists must employ a professional and friendly staff in order to deliver their dentistry and make their patients comfortable.

Salaries and benefits for well trained dental staff can be expensive since they expect compensation that is competitive with the market place and they most talented employees can easily find work with other dental or medical facilities. Salaries and employee benefits for dental offices can account for about 28 percent of operating expenses.

Most patients demand that their dentist stay current both with their continuing education and expect that their dentists use first rate materials. Similarly dental laboratories that dentists employ to achieve create beautiful and well fitted dental restorations are not inexpensive either.

It is not surprising that that a high percentage of any dental fee goes to paying operating expenses. Most dental offices have operating overheads of 60-70 percent or more. This means that dentists are left with at best 40% of every dollar they bill out. For younger dentists much of this money is used to satisfy their educational debt service.

Still, when all is said and done,most dentists do manage to maintain a good standard of living and in my opinion most are motivated by a desire to help their patients maintain a high level of dental health. I believe most work hard at their professions and earn their incomes.

What cement do you use to cement your implant crowns with?

2011-04-20T07:27:00.004-04:00

Although I sometimes use a more permanent cement, usually I use tempbond, a temporary cement that is radio-opaque. Residual excess cement can be irritating when left around an implant restoration. It can even cause an infection if left undisturbed for a number of years. Originally I started using temporary cements because I thought it would make it easier to remove an implant crown in the event that an implant abutment became loose, but even temporarily cemented implant crowns can be difficult to remove safely using GC forceps (pliers used to remove crowns). I still use it routinely because it has other advantages.

Radio-opaque temporary cement is a good choice since caries (tooth decay) is never an issue for implant restorations and excess cement can often be visualized a post-op radiograph. More importantly, it is necessary to remove all excess cement after cementing any implant crowns, and tempbond is fairly easy to remove and actually tends to be water soluble.

If an implant crown is well fitting temporary cement usually holds the crown well for many years. If a crown does come out, it can be recemented.

Why do you use so many burs?

2011-04-14T07:22:00.003-04:00

Burs are the term a dentists use for the small drill bits that fit in their drills. Dentists need to have a broad assortment of burs. Some are carbides and some are diamonds. Commonly, carbides are used for preparing fillings. They often are used only once and then thrown away. They have tiny fluted blades that are almost as sharp as razor blades. When new, they cut fast and true, with little hand pressure. After only a single use they can become dull and no longer cut efficiently.

Diamond coated burs also used for our preparations and can be purchased in several different 'grits' . I use diamond burs for my crown preparations and for shaping my bonded restorations. Diamonds are more expensive than most carbides, but can easily be sterilized and still retain most of their cutting ability.

Burs come in many different shapes and they can be used to shape teeth when a dentist is 'sculpting his preparations. Teeth come in many different shapes and sizes tand may require longer, shorter, thinner or wider burs in order for a dentist to achieve an excellent result.

While some dentists manage to provide their dentistry with only a small variety of burs, I prefer to select from a large variety, so that I can find just the right 'tool' for each situation. I believe that it helps me create predictably excellent restorations.

My crown came out. Can It be recemmented?

2011-04-06T11:13:00.006-04:00

The answer is sometimes. In my New York dental practice, if a patient comes in with a crown that has come out I carefully inspect the tooth and the inside of the crown. I look for recurrent decay on the tooth structure holding the crown. If the crown has decay around the margins of the crown it is usually a bad idea to recement the crown after removing the decay since it will not fit properly.

I also look inside the crown to see whether the cement remains inside of it or has it experienced " cement wash out". If the inside of the crown has black stain it probably indicates that the crown was "leaking" for some time prior to coming out.

If the tooth is ok and not decayed, I remove all the cement inside the crown, sandblast the internal part and use GC fitchecker to check its fit. If I like the fit I take a check radiograph and if it seems appropriate I will recement it with a permanent cement.

Sometimes recementation works well, but other times the crown can come out again. This can happen because the crown as it was fabricated doesn't have sufficient retention to stay in permanently.

What are some good dental blogs?

2011-04-02T09:04:00.005-04:00

Onlineuniversities.net has a good post giving their list of 50 Excellent Dental/Oral health blogs. The list provided is extensive and informative. I am proud to report that "Ask Dr Spindel" headed the list. Thank you for this recognition. When I first started writing this blog it had 5 visitors every day--all of them me! Last month the blog had over 6,000 unique visitors. It is my hope that the information presented will be found by people searching for answers to their dental questions and that the information presented will be helpful. Comments are welcome and questions may be forwarded to me by using the contact page on my dental office website.

What kind of crown will not ever show a grey line at the gum line?

2011-04-01T07:06:00.005-04:00

The grey line that some crowns show when a patients gums receed is usually from the metal substructure of porcelain fused to metal crowns. Although these crowns can be durable and are often a good choice in the posterior region, they are not the most esthetic for single crowns for anterior teeth.

Dentists can choose from a number of crowns that are metal free. In my New York dental practice I primarily use two types of crowns to acieve optimal esthetics in the anterior region. If strength is a priority I use Lava crowns. These crowns are good looking, have no tell tale gray metal margin and tend to be tough. They have a Zirconium core that supports the porcelain.

The best esthetics are achieved with all porcelain crowns that are bonded with composite luting cement. These can have the highest degree of translucency and are therefore the most 'life like'. They are more breakable than Lava crowns, but usually work well for anterior tooth restorations (in my experience).

Porcelain veneers can be a good option for many anterior teeth, since they leave most of the lingual tooth structure intact, but they need sufficient remaining enamel to bond to in order for them to work well. Also they are usually not as tough as the two types of crowns I mentioned. The sole exception would be a patient wtih a deep over bite. Often this type of bite puts a lot of pressure on the linguals of crowns and can cause breakage or loosening of a crown. Porcelain veneers work better for patients with these bites.

Why are my gums inflamed even though I brush and floss every day?

2011-03-26T15:44:00.004-04:00

This is a question that is commonly asked. How can my gums still be inflamed even though I spend so much time cleaning them? The answer usually is that even though many brush and floss their teeth every day many are not doing so optimally. Often people do not clean their tooth effectively at the gum line. This is probably the most important part of the tooth to get clean since plaque left near the gum is what usually causes the inflammation. Also another common mistake is to not do a systematic enough job of brushing and certain teeth are missed. Some people hope that spreading toothpaste around their teeth will get their teeth clean but that is not the case. Toothpaste does very little cleaning. It is the motion of the tooth brush that does the job and it must contact every accessible tooth surface in order to clean the teeth properly.

Similarly, many people floss incorrectly. Floss has to be wrapped around the tooth and moved up and down against it in order to properly clean the proxmal surface.

I have made two videos for About.com that may be helpful for people seeking help with improving their oral home care. One video is tittled "How to floss properly" and demonstrates how to use floss effectively. The other tittled "How to brush teeth" demonstrates a suggested method for brushing teeth using a manual tooth brush.

Is dentistry an easy profession?

2011-03-25T23:09:00.010-04:00

Although often dentists are often portrayed in the cinema as happy buffoons, dentistry is a challenging profession. Performing dentistry on a daily basis requires discipline, concentration and it helps if a dentist develops a skill in managing people.

Every day , dentists are presented with patients suffering from a variety of dental problems, many of whom have fears or anxieties that need addressing as well.

It is not a coincidence that the dental profession pioneered the use of Nitrous Oxide and Ether anaesthesia as well as the use of local anesthetics. Management of fearful patients has always been a big part of the job.

Dentists use a variety of techniques to lessen the apprehension of their patients, including painless injection technique, music, and often make use of conversation to aid in making their patients more comfortable.

Aside from dealing with nervous patients, dentists must be able to perform exacting procedures on teeth that involve a high degree of hand eye coordination and the ability to sculpt dental restorations that will be not only durable but look and function like the natural tooth structures that they replace.

Most dentists function under time constraints since most work with multiple scheduled appointments for patients who do not like to be kept waiting. Keeping an eye on the clock is certainly part of their job. To complicate matters on many days some of their patients present with dental emergencies and we often must find a way to shoe horn their treatment into an already crowded schedule.

As a practicing dentist for over thirty years I have found dentistry to be a rewarding and ever challenging profession. At the end of most days I am tired but can look back on what I have accomplished and leave my office with the feeling that I have been engaged in a worthwhile endeavor. Nothing accomplished easily is challenging or ultimately interesting and any profession that is mastered in a year or two is most likely ultimately boring.

My bite feels wrong after a filling. What can be done?

2011-03-19T08:32:00.003-04:00

This one is almost too obvious. When a filling is placed often dentists ask their patients if the bite feels right. Since most patients are numb they can have difficulty judging whether the bite is correct. When their anesthesia wears off it easy for them to judge if their teeth are meeting properly.

A high bite can cause a patient significant pain and should not be ignored. Aside from causing a 'tooth ache' it can even lead to a fracture of the tooth since it is bearing the bulk of the pressure exerted from a patient's jaw muscles.

If the bite is off after a filling is placed, the dentist should be called and a short appointment made so that he can adjust the bite. This usually involves the dentist having the patient bite on articulating paper so that the 'high' spots on the new filling can me marked. These are adjusted using with the dental drill. This process can be repeated until the patients bite is correct. The whole process usually takes several minutes and requires no anesthesia.

Is tooth bleaching only temporary?

2011-03-13T09:22:00.004-04:00

This is a frequently asked question by people contemplating whitening their teeth. I usually answer, not really. Teeth that have been 'bleached' using hydrogen peroxide or carbamide peroxide formulations do tend to turn more yellow over time, but often the results can last for years.

Most patients interested in maintaining a 'bright' smile do perform bleaching touch ups using custom trays or over the counter formulations such as Crest Whitestrips. Usually only a few treatments are needed to renew a smile's brightness. It should be noted that diet and oral habits such as smoking or chewing tobacco can shorten the span of time needed between touch ups.

For patients contemplating chair side whitening with any light assisted system , we strongly recommend that custom whitening trays are also fabricated for later use. They will be useful for touch ups or in achieving more whitening afterwards (if needed).

What are the symptoms of pericoronitis?

2011-03-05T11:49:00.003-05:00

Pericoronitis is an infection involving a partially impacted lower wisdom tooth. Usually there is a small flap of gingiva that partially covers this tooth and the area becomes infected. Patients with a pericoronitis experience soreness in the gums behind their mandibular second molar. Other symptoms can vary, but can include trismus (pain on opening), restricted opening, pain when swallowing and also localized swelling of the cheek on the affected side. Patients may or may not run a fever. Treatment of this condition is indicated and usually involves a visit to the dentist and course of the appropriate antibiotic. Rinsing with warm saline solution is also often recommended.

Once the infection diminishes and the symptoms subside a decision should be made on whether the tooth involved should come out. If the tooth frequently get re-infected than an extraction is usually indicated.

Does medicare cover dentistry?

2011-03-04T10:21:00.002-05:00

No it does not cover dental care in a private denal office setting. Medicare is designed to provide primary medical coverage for those 65 or over. It is not intended to cover dental procedures. AARP does offer dental coverage though Delta Dental. If you are member you are eligable to apply. For more information go to their website at: http://www.deltadentalins.com/aarp/?sourcecode=6NT

Why do dentists vary so much in their treatment plans and fees?

2011-02-25T09:39:00.005-05:00

Although dentistry can be treated like a commodity just like any other, it is an art and not a science. Dentists often discover techniques and treatments that "work well in their hands" and tend to recommend them to their patients. Many dentists do things differently and invariably some offer better results than others. Often in dentistry as in life, it not what you do that’s important, it’s how you do it! For example, an excellent filling can be better for a patient than a poorly fitted crown.

Fees are of intense interest to many people shopping for a dentist and often patients seem to be shopping for affordable dentistry. This is all well and good, but usually it is wise when seeking ‘bids’ to stay away from the low bidder (unless you’re our government?) Of course high fees do not guarantee good work, but as one of my wise dental assistants once pointed out "You can’t get to heaven without dying”. Similarly where dentistry is concerned, good work often takes time and usually has a fee that properly reimburses the dentist for it.

This last part is some advice for those patients with PPO dental insurance. If you are happy with your dentist and have achieved good results over the years, but are unhappy that he doesn't participate with your dental insurance plan, you might be wise to stay with him or her. It can be difficult to judge the quality of a dentist's work solely based on an interview or relying on online dental reviews. Of course there are many fine dentists participating with dental insurance plans, but switching dentists when you are happy may not be the wisest choice. This is especially true if you really can afford his services, but are hoping to save a little money by switching to a participating office.

Crown instead of core in composite after root canal?

2011-02-23T07:20:00.006-05:00

This is a question that I was just asked by questioner on allexperts.com. I thought it was a good one, so I am posting a longer version of the answer here as well. It is a question that many patients have after a root canal. Why can't I have a filling instead of a crown? I usually have a separate answer for anterior and posterior teeth.

For anterior teeth, after an endodontic procedure I often recommend just filling the endodonic access hole. These teeth often experience a considerable lateral force component and preparing them extensively for a crown can weaken their ability to withstand these forces. If of course, they are missing too much tooth structure I will crown them, but otherwise I will often fill them. If they need too due to darkening of the tooth, I will often recommend a porcelain veneer. This restoration requires less tooth preparation than a full crown.

For posterior teeth (Molars and premolars) I almost always recommend a protective crown or onlay restoration. Not only do these teeth experience a greater percentage of vertical vs horizontal force loading, but they also are under greater stress due to their position in the jaw. The further posterior a tooth is in the dental arch, the greater the occlusal force it experiences. In my opinion they will more likely fracture than anterior teeth without cuspal protection. Both crowns and onlays can offer far better protection than a simple bonded filling or core will.

Why is dental floss probably the best investment you could ever make?

2011-02-18T08:32:00.009-05:00

Ok, maybe this is a little overstated, since purchasing Google stock at the IPO might yield a better rate of return, but floss purchased and used properly at an early age will yield high dividends in the future. If a twelve year old starts using floss correctly on a daily basis, there is a good chance he or she will never develop proximal caries. Assuming that he or she sticks to a recommended twice yearly cleaning and check up, periodontal disease is not likely to become a problem.

Over the course of a lifetime, not having to repair, extract and replace teeth may save enough money to buy a very expensive car or two (depending on how much dental work they would have required). In this economic climate, saving money is a hot topic, and I am making a pitch for us all to save money by taking better care of our teeth.

If you are like most people you probably haven't always been a perfect flosser and probably haven't always had your teeth cleaned on schedule, but it is never too late to do better. Why not make a belated New Years Resolution? Why not resolve to floss every day and of course please schedule a recall appointment when my secretary calls to remind you!

Can a tooth still have feeling after a root canal is completed?

2011-02-15T11:10:00.001-05:00

Root canal procedures remove the pulp from a tooth. Even when some tissue is left behind it is not living tissue. Endodontically treated teeth do not have the ability to feel cold sensitivity unless vital pulp tissue remains in an untreated root and this rarely is the case.

If your endodontically treated tooth seems to be sensitive to cold, the most likely cause is an adjacent tooth. A visit to the dentist where he performs an ice challenge will usually demonstrate which tooth is experiencing sensitivity.

That being said, teeth with endodontics still can feel pain due to the presence the periodontal ligament. If the tooth displays either periapical inflammation or infection it can be sensitive to pressure, chewing or percussion. Failing root canals can present as 'toothaches' as well. Cracks in endodontically treated teeth similarly can cause pain in the surrounding periodontal ligaments.

Can a denture look natural?

2011-02-10T07:13:00.004-05:00

Full dentures can provide a patient with a natural cosmetic result, although sometimes it requires a team effort with a dental laboratory to achieve the optimum result. The technician setting up the denture doesn't have a patient's lips in front of him when he is creating his denture set up. Often denture teeth are placed too far out off the alveolar ridge so that when the denture is worn the teeth appear too prominent. If necessary the dentist may have to ask the technician to grind the backs of the teeth in order to allow them to be set up closer to the patient's alveolar ridge.

It is up to the dentist to try a denture in while the teeth are set in wax in order to verify that the setup is pleasing and that the teeth are correctly positioned. Also teeth should be arranged with some variations in orientation and position and should not be over aligned since this can provide an artificial look. Natural teeth have some variations in their alignment and this must be evident in a denture set up in order for it to look natural. It doesn't take much variation to be esthetic, but there should be some.

This concept is true for all cosmetic restorations,porcelain veneers included. Too much symmetry can lead to a static and unflattering presentation that can create a look that might be incorrectly termed "the denture look" where every tooth is exactly and ideally placed so that the overall result is too perfect and looks artificial.

Can a dentist alter the crowns or bridges that a dental laboratory provides?

2011-02-08T07:32:00.003-05:00

Absolutely. Often dental restorations provided by a dental laboratory require minor modifications in order to fit or look right. When inserting a crown or bridge I do a number of checks, prior to insertion. I check the contact points, the internal fit, the occlusion(bite), and may do minor alterations of the shape to improve a crown or bridges esthetics. Often the modified crown or bridge need not go back to the lab, but is then polished "chair side" and inserted either temporarily or permanently.

These minor modification can make the difference between a potential failure and a succesful dental restoration and I feel a dentist should routinely check laboratory restorations for fit,function and esthetics prior to permanent insertion. As beautiful as crowns and bridges can look on their models, they must fit and look good in the mouth as well.

How do you make root form implant temporaries?

2011-02-01T13:37:00.002-05:00

There are a number of ways. The photo above was made by taking a fixture level open tray impression and having the laboratory fabricate a temporary bridge with root contours.

Usually when I am temporizing a single implant in the "esthetic zone"(From premolar-premolar) I use a prefab Ion crown that I attach to an implant part specially designed for a screw retained temporary. I customize the root portion using free hand composite material. It works nicely, but takes some chair time to fabricate properly.

What advice do you have for people with amalgam fillings, many of whom have had them for years? Should they get them replaced? If so, with what?

2011-01-28T07:13:00.000-05:00

Although I don’t place many amalgam fillings in my patients mouths, I agree with the American Dental Association’s position that “dental amalgam is a safe and effective treatment option for the general population” It is my belief that amalgams pose no real health risk to my patients since they only release minute quantities of mercury. When they need to be replaced I tend to use either composite restorations for small to medium sized fillings or recommend crowns for teeth missing a larger percentage of tooth structure.

What do you think are the biggest misconceptions about dental health?

2011-01-27T07:02:00.000-05:00

Most people like to believe that if there mouth doesn’t bother them, it must be OK. Many wait until something is hurting or they recognize a symptom that should be addressed. This is not the best way to maintain dental health. The best strategy is to maintain a regular schedule of recare appointments with your dentist. Although most dentists recommend twice yearly visits, this schedule could also be annual or quarterly depending on a patient’s need and budget. If you can’t afford to go twice a year, than an annual visit is better than going when something hurts. Having your mouth cleaned and examined, removes tarter and plaque from your teeth and tends to improve the health of your mouth and gums. Also small problems addressed early are less likely to lead to big ones later.

What teeth, mouth, gum, and other dental symptoms or warning signs should never be ignored?

2011-01-26T06:50:00.000-05:00

Of course most of us go to the dentist when we have a tooth ache, but many of us wait until the symptoms are severe. Often it’s best to visit your dentist at the first sign of trouble. Swelling, Intermittent pain, sudden increase in sensitivities to cold or hot or bleeding gums are all symptoms that should not be ignored.
Swelling of the gums can be an indication of an infection and should never be ignored. Often the sooner an infection is discovered and treated, the better the outcome. Intermittent pain on chewing can be an indication of cracked tooth syndrome and cracks in teeth should be addressed before they are allowed to propagate and cause worse problems for a patient. A sudden increase in sensitivity to cold or hot liquids should not be ignored since this can be a evidence of an underlying tooth problem that may need to be treated. Bleeding gums also can be a cause for concern since they often signify that a gingivitis or periodontal inflammation or infection is present.

We’ve all heard that it’s important to brush and floss. What other important things should you do every day to take care of your oral health?

2011-01-25T06:59:00.002-05:00

Smoking and alcohol can be extremely detrimental to a person’s oral health. Both habits put a person at much higher risk for developing cancer of the mouth or throat. In addition, I have found that my patients who smoke have a much higher incidence of periodontal disease and periodontal bone loss than those who do not.

Diet is another factor that plays a role in oral health. Carbonated soda consumption or an acidic diet can lead to the breakdown and erosion of teeth and make caries more likely. Frequent consumption of sugary foods or a high carbohydrate diet also can have this effect.

Of course we should be able to enjoy all sorts of foods and beverages, but when considering their potential for producing harmful effects, what matters most is the amount of time these foods remain in the mouth. If you consume them once or twice a day they are much less likely to cause a problem than if they are consumed throughout the day.

What's the connection between oral and dental health and conditions such as heart disease and diabetes?

2011-01-23T16:40:00.009-05:00

This question was submitted by Everydayhealth.com as part of an interview they requested of me. I thought they asked some excellent questions, so I have decided to post one question and answer each day for the next 5 days. Here is my first answer: There is plenty of evidence that having your teeth cleaned and a mouth free of periodontal disease is good for you’re over all general health. This is not an entirely new idea. In 1933 Charles Mayo, one of the founders of the Mayo Clinic, was quoted as saying “The presence dental health is important. Dentistry is a distinctive health service and can extend human life ten years.”

Many studies(Slade et al is one), show a correlation between periodontal disease and cardiac disease. Also there is at least one study indicating that treatment of periodontal disease improves endothelial (vascular) function. In addition evidence indicates that periodontal disease may cause a worsening of a diabetic’s glycemic control. The exact mechanism is still being debated and studied, but the scientific literature makes a strong case for the connection of vascular disease, diabetes control and periodontal disease.

Can chipped bonding be repaired?

2011-01-19T06:56:00.005-05:00

Using bonded composite can be a durable way to restore a tooth, however if the bonding is placed near the incisal edge of a tooth it can chip or crack. This chipping can mar the esthetics of a restoration and at that point a dentist has the option of replacing the entire restoration or just repairing the chipped portion.

When the pre-existing filling is in good shape, but is marred by the missing portion, a repair often is the most affordable and easy solution. Although additions to pre-existing composites may not have the same bond strength as an initial placement, they can provide a durable solution when properly performed.

As is true for all bonding procedures, cleanliness and good moisture control a extremely important to the long term success of composite restoration. Also care should be taken by a dentist to check for anterior excursions that the patient may make. The repair should not be unduly stressed during the mouths lateral and protrusive excursions. Often the reason the initial composite chipped was due to a stress placed on it during these excursions. If the subsequent repair is to be successful often a slight bite adjustment is recommended.

What are the alternatives to apicoectomy surgery?

2011-01-16T10:09:00.003-05:00

Apicoectomies are performed on teeth that have had a prior root canal procedure that has failed. This procedure is a 'reverse' root canal in which the tooth's apex is cleaned, shaped and sealed through a surgically made window near the end of the root. Although apical surgery is a viable way of addressing a failed root canal, patients do have two other treatment options.

If the tooth is amenable, than a conventional endodontic retreatment probably has a greater chance of success. This is a good option if the tooth has not been restored with a post and core or if an endodontist feels that a post maybe safely removed in order to retreat the root canal conventionally.

Another option that has become increasingly popular is to skip an apical procedure and instead extract the tooth in question and place an implant instead. Proponents of this treatment usually maintain that it is better to place an implant while there is sufficient bone at the site. (Usually performing apical surgery involves removing some additional bone at the apex in order for the surgeon to have better access to the end of the root.)Further more they often point out that apical surgeries have a lower rate of success than implants do.

Personally I believe that each case should be considered on an individual basis with a patient's individual circumstance carefully evaluated, before a decision is made on which course of treatment is best.

Is it normal to have pain and swelling after a dental implant?

2011-01-05T06:58:00.003-05:00

Although it is not unusual for patient to have minimal symptoms after implant placement, sometimes they do experience pain and some swelling afterwards. It doesn't necessarily mean that the implant placement will not be successful. Often implant surgeons have to make a vertical flap incision while placing an implant and also can perform bone grafting at the time of placement. These two procedures can cause some swelling of the face afterwards and patients can experience post treatment discomfort. Some patients can also experience bruising of the face due to tissue manipulation of the cheek during surgery.

If you are having any unexpected symptoms after implant surgery it is a good idea to call you dentist and discuss your symptoms since it is possible for bone grafts or implants to develop infections after their placement. It is advisable to inform your dentist of any unanticipated symptoms,especially if they do not resolve after a week post surgery.

How do you correct crowding using Invisalign?

2010-12-29T11:05:00.002-05:00

Invisalign can be an excellent way to correct minor anterior crowding. Without extracting teeth there are two methods dentists use to create the space needed. We can either push teeth out to create a greater circumference to an arch form or we can 'slenderize' some of the teeth. If a patients teeth are already in the right place (in relationship to their lips) than slenderization is the technique I most commonly employ. This involves using interproximal diamond coated strips to slightly abrade the proximal surfaces of teeth as needed. The amounts removed usually are from .2-.5mm per surface and when done properly, 'stripping' of the proximal enamel surfaces does no real harm.

When are you closing the office for the holidays?

2010-12-23T04:20:00.004-05:00

December 23rd is the last day our office is open. My staff and I are taking the week off for vacation and spending some time with our families. We wish all our patients happy holidays and will return back to work on January 3rd. Hopefully when we see you next year all will be well.

Anterior night guard vs. maxillary guard?

2010-12-17T07:56:00.008-05:00

(Photo shows an NTI Appliance)

Question: I've been wearing the latter for 30+ years but the new dentist Kaiser referred me to for a new guard to a dentist who recommended an anterior guard. He switched from giving patients maxillary guards to anterior ones after attending a seminar from a Frank Spears,DDS, who seems from his website to be an adjunct prof. at U of Wash. and spends a lot of his time giving lectures and selling DVDs.

I've come across articles saying that if you have any joint damage you shouldn't use the anterior appliance, but I only know 30 yr. old xrays showed that I had spurring in one joint and I have a history of pain that has improved in the last 10 years or so to a degree that I'm usually asymptomatic. The new dentist says I'm ok since I have no jaw clicking.

I also read that there's a chance of "eruption" of back teeth in certain circumstances, although the dentist says there's no problem if one only wear it while sleeping. An internet source says there's danger if you wear it more than 8 hours (I sleep 9 hours).

The orthodontist who made my old max. night guard said I should stick with the maxillary type and that anterior ones put too much pressure on the TMJ.

When I told the new dentist what the old one said, he replied that the old one is living in the past century.

Are anterior plates the preferred type now? It seems there is a lot more downside for anterior ones, especially since no one has suggested doing tests to ascertain if I have joint disease in the jaw.

Answer:I just attended a Spear seminar and he did advocate using the anterior bite ramp appliance for patients without any 'joint derangement'. He reported that the literature indicated that it might be more effective in discouraging bruxing. The type that he likes is actually full arch night guard with an anterior bite ramp included. As to posterior eruption, You are unlikely to experience permanent posterior eruption as long as you do not wear it all the time. Certainly 8 or 9 hrs per day won't cause this. You may notice some alteration in your bite in the morning when you wake up, but after 20 minutes or so, your bite will return to normal.

Since the type that Dr Spear recommends covers the entire arch,. it can't possibly allow eruption. Ask you dentist about this.

In my opinion, you can have either type and its OK. I still use the older style night guard and it works. Sometimes patients do report that they are still bruxing with it, but at least it seems to offer some protection to their teeth. Choose which ever style you feel comfortable having and be done with it. Sometimes dentists are caught up in fads, just like anyone. I do believe that either choice is acceptable.

What are the symptoms of a failing root canal?

2010-12-11T17:25:00.004-05:00

Root canals fail due to the presence of an infection. Although some infected teeth that have had root canal are not symptomatic, many people with a failing root canals may experience localized swelling and/or pain. The pain may be manifested either as a general ache or could be experienced when chewing. Sometimes it is possible to palpate a small tender area located adjacent to the end of the root that has a slight localized swelling.

Some failing root canals can develop a fistula to help allow the periapical infection to drain. Fistulas can look like red spots or can look like red spots with, a white area in the center. when gently massaged a fistula may or may not demonstrate a small amount of purulent drainage.

If you think you may have a failing root canal, the best thing to do is to visit a dentist and have him examine you. He will perform any tests needed to clinically diagnose your condition.

Waiting to see if an infection subsides on its own is not usually a good idea, since untreated infections can spread and make succesful treatment more difficult. Visiting your dentist is clearly the best course of action, since diagnosing the cause of the infection will allow the most appropriate treatment before a patients condition is allowed to worsen.

Do you offer Invisalign?

2010-12-06T07:07:00.002-05:00

Yes, we do offer Invisalign. I enjoy using Invisalign to enhance my patients smiles. Often I recommend using Invisalign as the best option,when performing a smile consultation. Many patients coming for a smile consultation have perfectly nice teeth but may have a problem with anterior crowding,spaces, or anterior flaring. If I feel that Invisalign can handle their problem I believe it is preferable to a commonly recommended alternative-6-10 porcelain veneers. Although porcelain veneers can look great, the procedure involved with fabricating them usually involves prepping the teeth and the life expectancy of well done porcelain veneers is about 10-20 years.

Can a problem with a back tooth refer pain to a front tooth?

2010-12-02T07:33:00.002-05:00

In my experience this does not usually happen.Often patients who haven't been to a dentist for a while may have multiple problems, but I try to deal with the problem that is bothering them the most. Occasionally patients with a problem on a top back tooth report that the pain is coming from the bottom teeth on the same side, but not from the anterior teeth. Accordingly when a patient presents with pain in the segment, I usually try to focus on the anterior teeth in the quadrant that a patient reports their pain.

Can Bruxism be affected by medications.

2010-11-27T08:18:00.009-05:00

While most dentists treat bruxism using night guards,and stress management techniques, a number of studies have shown that medications can affect bruxism. One study of bruxers has indicated that clonidine may be an effective medicine to lesson bruxism. It may work by prolonging stage 2 sleep and suppressing REM sleep.

Other studies have shown that SSRI's(antidepressents) can cause an increase in bruxism and suggested that either lessoning the dose of the SSRI or prescribing Buspirone may help.

Most dentists do not prescribe the above mentioned medicines and if you are taking an antidepressant or would like to find out about clonidine, it would be a good idea to ask your physician. If they are unaware of the use of these medicines and their effects on bruxism you can refer them to this post and the links it provides to peer review articles.

Do Whitening Toothpastes Work?

2010-11-21T08:58:00.005-05:00

Yes and no. They do work by removing external stains on teeth, but they do not seem to actually 'bleach' the teeth the way peroxide based treatments work. Even the tooth paste formulas that include peroxide may not work well, since peroxide when mixed with toothpaste is not stable and degrades rapidly over time.

The best way to whiten your teeth still involves applying a gel with either hydrogen peroxide or carbamide peroxide on the teeth. There are a number of commercial preparations available over the counter or you can use a technique offered by your dentist. Most dentists offer either chairside whitening(in an hour or so) or can make custom trays that when worn with carbamide peroxide inside will gently whiten teeth over time.

What are the advantages of Digital Radiography?

2010-11-20T07:51:00.004-05:00

Well, our office has been using the digital radiography since September of 2009 and I thought this topic might be good one for a blog post.

For sure, not having to develop film saves a lot of time every day and my patients almost universally approve of my upgrade to digital radiography. They like being able to easily view images of their teeth and are happy when they hear that the images are achieved with much lower radiation settings. This is the most obvious advantage of digital radiography; Patients receive a much lower dose of radiation than they would from the use of traditional X ray films. I find I can produce usable images with a third of the radiation that I used to produce film images.

Another feature of digital radiography is their ability to easily produce enlarged images of the teeth. In the last year I have found that found that showing enlarged images of their teeth to patients makes it much easier for them to understand my treatment recommendations and the digital enhancement features of my software program(Dexis) I use can help with the visualization of problems.

I also appreciate of the ease of emailing these images to specialists. I am able to get almost "instant second opinions" for my patients. Almost every day I send a radiograph to either my endodontist, periodontist or oral surgeon, in order to get their input for one of my patients. This is a great service since not only do my patients not have to pay an additional fee for the consultation, but prior to this I would have mailed their film to the specialist and I would have waited several days for the feedback.

Although I must confess that I sometimes miss the "richness" old fashioned film produced images, there is no going back for me. The advantages of digitally produced dental images far out way any disadvantages and I am fully commit ed to this new digital age!

Have you taken any good continuing education courses lately?

2010-11-14T15:21:00.003-05:00

I've just come back from the Scottsdale Center for Dentistry. I attended a three day course by Frank Spear named "Treating the Worn Dentition". The information was well organized and helpful not only in better understanding some of the different causes of tooth wear , but also Dr. Spear presented different strategies he uses to treat successfully repair and restore different kinds of wear. I give his course a "Thumbs up". His presentation was interesting and well organized. Scottsdale is beautiful and I enjoyed visiting there as well!

What is a "UCLA" temporary crown?

2010-11-09T07:30:00.003-05:00

"UCLA" crowns are a term for implant crowns that screwed directly into an implant without any intermediate abutment. They can fabricated as temporary or permanent implant crowns. In my practice, when I am restoring an implant in the "esthetic zone"(Premolar- Pemolar) I utilize these as interim restorations in order to help develop a gingival contour around the crown. When the gingiva is mature, I will then take a fixture level impression and have a custom abutment and a permenent crown fabricated.

Can crowns be as cosmetic as porcelain veneers are?

2010-11-06T10:45:00.002-04:00

What makes porcelain veneers appear natural is that they can be made to appear transluscent and look like real teeth. Bonded porcelain crowns can also be made to look this way. In the photo above the left central is covered with a natural looking bonded porcelain crown. It is hard to tell its not real!

Is Halloween bad for teeth?

2010-10-31T13:12:00.005-04:00

Seeing as tonight is Halloween, this is a topical question. No Halloween is not bad for teeth but gorging with candy is! Holidays in general are a time for enjoying sweets, but Halloween is certainly the candy manufacturers favorite holiday.

Now don't get me wrong, I enjoy candy now and then, but eating too much is bad for teeth. Every time candy is eaten it lingers in the mouth for twenty minutes or so. Sugar is a preferred diet for the bacteria in our teeth's plaque and feeding them sugar throughout the day is a bad idea!

Probably the best strategy to follow around Halloween is to not allow your kids to keep their bags of candy nor keep candy left out around the kitchen, but instead parents should keep it in their possession and dole it out a little at a time. The basic idea is to not let your kids snack all day long on their candy for weeks after Halloween since that could definitely lead to cavities.

Can a Cavity Fix itself?

2010-10-23T16:40:00.002-04:00

No it can't, but some carious lessions do seem to peter out and arrest. The problem is that it is difficult for a dentist to be sure about whether this has happened without cleaning out the lesion.

Sometimes a long standing lesion has layers of blackened and dryed out decayed matter, but at the deapest part of the lesion there still seems to be some activity. This part of the lesion is wetter and a lighter chocolate color, that often seems to be associated with "active decay". Only by cleaning out the entire lesion and treating it can a dentist be sure that the lesion if arrested.

Can extensive dental treatment put a patient at risk for developing other health problems?

2010-10-19T07:45:00.002-04:00

It is not unusual for patients undergoing long dental appointments to comment that they feel slightly under the weather afterwards and sometimes the next day as well. This feeling of malaise passes after 48 hours,but doesn't seem to have lasting effects.

A new study,published in Annals of Internal Medicine(October 19, 2010 vol. 153 no. 8 499-506)may suggest otherwise. It suggests that extensive dental treatment may place some patients at a slightly greater risk for vascular events. The study found that "The rate of vascular events significantly increased in the first 4 weeks after invasive dental treatment (incidence ratio, 1.50 [95% CI, 1.09 to 2.06]) and gradually returned to the baseline rate within 6 months".

Although this finding is alarming, it clearly doesn't mean that patients should avoid dental treatment. The studies authors conclude that "the absolute risks are minimal, and the long-term benefits on vascular health will probably outweigh the short-lived adverse effects."

Clearly this finding needs to be further studied to help minimize any potential risks to patients undergoing extensive dental treatments.

Should a dentist offer medical advice?

2010-10-12T07:30:00.004-04:00

Although a dentist is licensed primarily to treat diseases and disorders of the oral cavity, He or she is in position to observe his patients in other aspects as well. Dentists are not licensed to treat medical conditions unrelated to the mouth but they do have a responsibility to observe their patients holistically. A dentist routinely sees his patients every year, and consequently spends a good deal of time with them.

In the course of these visits the dentist will invariably have conversations with patients and often medical problems unrelated to dentistry are brought up. Although dentists are not necessarily well versed in every phase of medicine, as concerned health care providers they can encourage patients to seek appropriate medical treatment for a condition.

This is especially true when treating the elderly, since they often have an increased need for dental treatments and often have a long standing relationship with their dentist. Often a dentist can play a role by encouraging them to seek appropriate treatment for medical problems that they are experiencing.

How do you do an indirect pulp cap?

2010-10-08T07:23:00.000-04:00

I have been performing my version of an indirect pulp cap for over twenty years. I have had good results and most of the time they work(probably better than 85%). Indirect pulp caps involve leaving some affected dentin over the pulp and medicating it with something that may inactivate any residual bacteria remaining in the layer of 'affected dentin' without killing the pulp. I usually use Dycal as my initial layer over this affected dentin and then place another less water soluble material over it such as Vitrabond, IRM or Miracle Mix. All of these second layers also seem to inhibit decay and the growth of caries forming bacteria. The dycal seems to dessicate the small amount of decay(or affected dentin) remaining, and may then allow secondary dentin to slowly form.

I do remove 95% of the decayed matter in the tooth and will remove very soft dentin material if it is in 'bulk'. I Use very small spoon excavators with tublicid red and very gentle hand pressure to remove the softened dentin near the pulp. I utilize a strong light to illuminate the tooth. so that I can avoid accidentally exposing the pulp. Often when well illuminated the dentin near the pulp is partially translucent and the pink from the pulp can be visible prior to removing the thin layer of dentin covering it.

I consider an indirect pulp cap a success if the tooth remains asymptomatic over time, but do periodically check periapical radiographs for signs that the tooth has become non vital such as a periapical radioluscency.

Why do you take an X-ray after filling a tooth?

2010-10-05T07:18:00.003-04:00

I do commonly take one bitewing xray after filling a tooth in which the proximal(side next to the adjacent tooth) surface is restored. This will show me some relevant information. It helps me visualize the proximity of the filling to the pulp and to see if the tooth is filled without any voids,gaps or overhangs. It also allows me to check the proximal contour(How the filling contacts the adjacent tooth).

Sometimes teeth that are filled are in need of a crown and the X-ray is used to send the insurance company, since it shows how much filling is in the tooth. Often that is one of the criteria an insurance company uses when deciding to allow or disallow a treatment plan for a crown.

Many dentists do not take this sort of check film,but choose to wait until the patient has his or her next check up films taken. This is certainly OK, but I usually choose to check at the visit I place a filling if I am placing a filling.

What does a dentist do with crowns or bridges that he removes from a mouth?

2010-10-01T07:32:00.004-04:00

When a crown or a bridge is removed, many patients ask if it has any value? I guess they are hopeful that they can apply some of the value to the new restoration that will be needed.

The answer is not much. Most crowns that I remove I place in the trash. There is a market for scrap metal, but the value of a scrap crown is usually not high. I haven't checked recently(the price of gold is sky high!), but the dental scrap dealers generally don't reimburse us much for old crowns.

Scrap gold is worth more than semi-precious or non precious metal scrap. The last time I sold my scrap gold t, I had collected a batch for over five years and I received less than three hundred dollars.

Unfortunately, unless a dentist has a large amount of gold, dental scrap dealers tend to make low offers for it(they like to make a profit on their purchases). When scrap is present in large quantities it can be sent to a refiner and it can be worth more, but the refiner is paid a fee for his work.

How do dentists attract new patients?

2010-09-25T17:16:00.008-04:00

There are a number of ways that dentists attract new patients. Probably the best way of attracting them is developing 'good word of mouth'. Fifty years ago, this more or less meant that if a dentist treated his patients fairly and competently, they would refer friends and family. This generally was the way things worked. Maybe a dentist would have a small sign outside his offices advertising his professional services as well.

Some enterprising dentists advertised their services in local papers, yellow pages or sponsored local events or children's sports teams. Now things are changing. Potential new patients not only desire a dentist who has performed competently for a friend or family member, but often would like to read about him or her on the Internet!

Probably the first thing many people do, when considering a new dentist, is to Google his name and see what turns up! Many would like to find an attractive website and primarily positive online reviews for the dentist by his patients. This is "2010 style word of mouth"!

This part is addressed primarily to my dental colleagues. I think it is important that dentists, both young and old give some thought to this new form of marketing, sometimes called "Reputation Management". Clearly what a patient finds out online about a dentist will either help or hurt his chances getting new patients! Practices that are successful in maintaining a good online presence will tend to prosper, even in difficult economic climates.

Can popcorn cause an abscess?

2010-09-19T15:50:00.005-04:00

Although popcorn can be a delicious snack it can cause tooth problems. Aside from the fact that uncooked kernnels found in bags of popcorn can worsen cracks in teeth, the indigestible brown husks can become wedged in between the gums and teeth. This can be especially prevalent around partially impacted lower wisdom teeth. It is not all that unusual to discover a patients pericoronitis to be caused by a popcorn husk that had become wedged under the flap of skin that covered the wisdom tooth.

The husk has to be fished out in order for this sort of infection to resolve. It acts a little like a 'splinter'. Although small it can cause a localized infection and a great deal of pain. Once the husk is out,the patient is usually placed on antibiotics and instructed to rinse frequently with warm saline solution, unitl the infection resolves.