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Ask The Dental Doc

  • Dr. Russo answers your dental questions!

Bacterial Endocarditis

Dear Dental Doc.,
I just had a physical exam and my Doctor heard a heart murmur. He asked me if I ever had rheumatic fever. I said I did as a kid. He then told me I had to take antibiotics before any dental appointments. How come? What should I do?
Sam.

Dear Sam,
Rheumatic fever can damage body tissues by causing them to swell, but its greatest danger lies in the damage it can do to your heart. More than fifty percent of the time, rheumatic fever causes scarring of the heart’s valves. This scarring puts you at a higher risk of developing bacterial endocarditis. Bacterial endocarditis is an infection of the hearts inner lining or the heart’s valves. The inflammation can occur anywhere in the heart, but usually affects previously damaged heart valves. A normal heart has a smooth lining and valve surfaces making it difficult for bacteria to stick to it. If the heart is abnormal due to certain types of surgery or other defects, there may be rough surfaces that allow the bacteria to take hold. Once the bacteria infect the inner surface of the heart, they continue to grow producing large colonies called vegetation that may then break off and travel to the lungs, brain, kidneys and skin. The continuing infection may also seriously damage the heart valve on which the vegetations have grown.Bacterial endocarditis is a life-threatening infectious disease.

The symptoms of bacterial endocarditis depend on whether the infection is acute or sub-acute. Symptoms may include:

· Fever, chills, sweating, and night sweats.
· Chest pain
· Coughing and shortness of breath. You may even cough up blood.
· Headaches, back pain, muscle and joint pain.
· Blood in the urine.
· Nausea and vomiting.
· Blood in the whites of your eyes. Also red spots on your fingers, toes and under your fingernails.
· Irregular heartbeats.

The good news is the risk of bacterial endocarditis can be greatly reduced by:
Keeping your mouth healthy and disease free. Taking antibiotics prophylactically before any dental procedure that introduces bacteria into your bloodstream. The antibiotic of choice is Amoxicillin. The recommended dose is 2 grams one hour prior to the dental procedure. For patients who are allergic to amoxicillin, alternative antibiotics are clindamycin, azithromycin and keflex. It is also a good idea to carry a bacterial endocarditis wallet card. You can obtain one from the American Heart Association.

Better smiles for all.

John J. Russo DDS

Lower Dentures

lower denture 1 lower denture 2Dear Dr. John: I just had the last three teeth on my lower jaw pulled and a denture made. I have had an upper denture for twenty years and have had no trouble eating with it. This lower one is a different story. It moves all over the place! I’ve tried every denture adhesive on the market; nothing seems to help. Is there anything I can do to keep these teeth in place? I’m tired of eating bananas.
J. Miller-SSF

Dear Mr. Miller: Your complaint is not uncommon among people who wear full lower dentures. Upper dentures generally fit and stabilize well without the use of denture adhesives. The full lower denture tends to be a great deal more troublesome. The reasons for this lie in the anatomical differences between the upper and lower jaws.

The upper jaw, or maxilla, consists of one continuous area. It has a bony ridge that is shaped like a horseshoe, which is connected by bone called the hard palate . An upper denture fits over the ridge and hard palate creating suction. This suction is what keeps the upper denture in place.

The lower jaw or mandible, differs in several ways:
· The lower jaw is hinged and moves up and down, side to side and forward and back
· It has movable soft tissues that tend to dislodge the lower denture.
· The tongue is located between the ridge, preventing the solid surface area that creates suction in the upper denture.

These differences, account for the lack of stabilizing forces in the lower denture. Therefore the denture wearer must rely on the size of the ridge, gravity and the upper denture to stabilize a lower denture. The denture wearer must also learn to chew in an up and down motion. Often times there is very little bone height to the ridge that the denture is seated over. In these cases, the denture may slide around making it difficult to eat or talk. Denture adhesives are of little use on lower dentures and may actually make matters worse.

There is a solution to your problem, by placing two dental implants into your lower jawbone, and the corresponding attachments into your denture. These attachments hold your denture in place, acting like snaps on pants. When you place your denture in your mouth, the female portion of the attachment snaps over the male portion located on the implant. This stabilizes your denture allowing you to chew with confidence. The results are phenomenal!

The procedure is straightforward. First, the dental implants are surgically placed into your lower jawbone. After three to four months, the bone attaches to the surface of the implant securing it into your jawbone. Once this is accomplished, the male portion of attachment is screwed into the implant and the female portion is placed into your denture.

After some careful adjustments, you’ll be ready to get off bananas and onto apples!

Better smiles for all.

Arestin

Dear Dental Doc,
I finally got the nerve to see a dentist after 12 years. I only needed a few fillings, but the dentist said I had gum disease. He said it wasn’t advanced and recommended I have scaling and root planning done. He also recommended placing something called Arestin in bad areas. What do you think?

Sam-Burligame

Dear Sam,

In order to answer your question let me first start out by explaining what periodontal disease is. Periodontal disease, also known as gum disease, is a chronic bacterial infection of the gums, teeth, and bone that surrounds the teeth. There are millions of bacteria in our mouths. These bacteria can build up on our teeth to create a soft, sticky substance called plaque. If plaque is left undisturbed, it mixes with the minerals in saliva and calcifies, creating a harder substance called calculus or tartar.

PeriodontitisInserting the powder into the pocket
The bacteria in plaque and calculus cause the gums to become red and swollen, and generally bleed when brushed. This inflammation is called gingivitis and is the first stage of gum disease. If gingivitis is left untreated, the inflammation worsens resulting in damage to the bone and surrounding tissues holding your teeth in place. This results in periodontal pockets, which are unwanted valleys surrounding your teeth. As the disease progresses and the pockets deepen; you lose supporting bone, your teeth get loose and may eventually fall out. Fortunately, there are treatments available that effectively treat periodontal disease.

For years, the primary treatment for periodontal disease was scaling and root planning (S&RP). Your dental professional takes a scaling instrument and planes the root surfaces of your teeth below the gums, removing plaque and calculus. However, as pockets get deeper, it becomes increasingly harder to remove all of the calculus and plaque. Fortunately, we now have an adjunctive therapy called Arestin that can be placed directly into these pockets to kill the harmful bacteria.

Arestin is an antibiotic in a powder form. The active ingredient is minocyline, which is a member of the tetracycline family of antibiotics. Arestin is painlessly placed directly into periodontal pockets, where it combines with sulcular fluids adhering itself to the pocket walls. The powder is composed of microspheres that release minocyline into the pocket for approximately 21 days. This allows it to continue fighting your periodontal disease long after your S&RP appointment.

Arestin is an adjunctive therapy. When used in conjunction with scaling and root planning, it significantly reduces periodontal pockets and prevents the progression of periodontal disease.

Better smiles for all.

Cracked Tooth Syndrome

Dear Dr. John: Every time I bite into something hard a get a sharp pain in my lower left tooth. It also hurts when I drink something really cold. I saw my dentist, he took an x-ray and did some tests and said he couldn’t find anything wrong. He adjusted my bite and gave me a bill for $200! The tooth still hurts; do you have any ideas?
Candy- Redwood City

Dear Candy: First of all let me start by saying it’s impossible for me to give you a diagnosis without the benefit of examining you. Having said that, I can offer you a bit of insight on what may be the cause of your discomfort. Your symptoms are consistent with those of Cracked Tooth Syndrome.

Teeth may crack when subjected to the stress of chewing hard foods or ice, or by biting on an unexpectedly hard object. Teeth with or without restorations may exhibit this problem; but teeth restored with typical silver-alloy fillings are most susceptible.

Cracked Tooth Syndrome is exactly what it suggests, a tooth that has a crack in it. The phenomena is however not that simple. Teeth can crack in many different ways. They can start out as small craze lines in the enamel, or they can be more severe and involve the inner layers of the tooth, the dentin and the nerve. Unlike teeth with obvious fractures, teeth with Cracked Tooth Syndrome have microscopic fractures that are difficult to see and are usually not evident on x-rays. Diagnosing a tooth with CTS can be very difficult. The dentist has to carefully evaluate all of the symptoms and clinical findings before arriving at a diagnosis.

A common symptom of cracked tooth syndrome is sharp pain upon biting or chewing. The pain is generally not constant, and may only occur when you eat specific foods or bite in a certain way. The tooth may also be sensitive to cold or sweets. Because of the tremendous forces of chewing, molars are more likely to be affected by cracked tooth syndrome.

In diagnosing a crack, transillumination , microscopic evaluation, x-rays, staining techniques, tactile exam with an explorer, and a bite stick are essential. Transillumination helps the dentist to visualize the crack by the difference of the transmitted light through the tooth since the crack blocks light, causing a dark line to appear. Microscopic evaluation helps to clinically detect the extent of the crack when it is near or in the root. X-rays can show the bone breakdown around the tooth, which can help determine the size of the crack. Various stains, such as methylene blue, may also help visualize the crack. An explorer which is shaped like a sharp needle may be used to detect a crack in the surface of the tooth. Lastly, a bite stick could help reproduce the patient’s symptoms and thereby help in locating the crack.

Only after a diagnosis is made, can treatment recommendations be made. Most teeth diagnosed with CTS can be treated with a crown, however if the crack is into the nerve, a root canal may be needed. Sometimes a crack can be so severe that the only course of treatment is an extraction.

The key here is early diagnosis and treatment. A cracked tooth will not heal itself and delaying treatment will only make maters worse. Candy, since you are still having pain, I would suggest you get a second opinion from another dentist.

Better smiles for all,

John J. Russo DDS

Choosing Insurance

Dr. John I have decided to obtain dental insurance for myself and my family, how do I decide which plan is best?
Jerry, Millbrae

Without a doubt, there are a very large number of dental plans available. Many plans will only be available to groups and not individuals. Generally speaking, when researching dental plans you will find that the various products will fall into one of the following categories.

Traditional fee for service Plan:
This type of dental insurance plan makes payment for the dental treatment received by the covered individual on a traditional fee-for-service basis. For some dental treatments (exams and cleanings), the payment made by the insurance company might be one hundred percent. For other types of dental services, the rate of reimbursement might be between 50%-80%. If the reimbursement from the insurance is less than 100% of the fee billed, the patient is responsible for payment and this is called a co-payment or patient portion. Traditional plans generally allow the patient to see the dentist of their choice.

Managed Care Dental Insurance Plans:
These plans are typically know as PPO’S , preferred provider organizations and DMO’s, dental maintenance organizations. All the managed care plans are developed with cost cutting in mind and as such, you may or may not receive the same coverage as one would with the traditional plan.

PPO: With cost cutting in mind, the insurance company contracts with a number of dentists to form a network of dental providers. As a part of the negotiation with the dental insurance company the dentist, in return for being included in the network and hopefully receiving an increased patient load, has agreed to discount their fees. The members of the dental plan must select from this list of network providers when choosing a dentist. If a member selects to see a dentist outside the discount network, chances are the reimbursement rate will be substantially lower or there will be no coverage at all.

DMO’S: A fixed amount per member who has chosen them to provide their dental treatment. In return, it is the dentist’s obligation is to provide any and all needed dental treatment for these individuals (as specified by the conditions of the dental plan) during this period. In this type of plan, the dentist actually makes more money if they never see the patient! For example, a typical capitation rate might be $12 per month, per patient and the plan assigns 300 members to the office. The dental office then receives a check every month for $3600, for that $3600 the dentist must provide any and all dental work required by the plan for 300 members! Often basic services are provided without co-payments and major services require a patient portion.

Of course knowing that the dentist is paid a fixed amount per plan member regardless of how much dental treatment is provided should bring some other questions to your mind. What is the reputation of the dental plan? Are there individuals you can ask about how they interpret the care they have received? Did it seem that a full range of treatment options were offered to them as a remedy for a particular dental problem or that just the quickest, cheapest fix was suggested?

I have only touched on the generalities of dental insurance and suggest you contact an expert to help you with your selection.

Sinusitis

Doc every time I get a cold or my allergies act up my upper teeth hurt. My husband says I am nuts. What can I do about this pain?

Sorry I cannot vouch for your general sanity, but I can tell you sinusitis may follow a cold and is often associated with hay fever, asthma, or any air pollution that causes inflammation. One of the most common non-dental causes of tooth pain – and sometimes-unnecessary dental treatment, is a sinus condition called acute maxillary sinusitis, and is caused by a viral or bacterial infection.

Your sinuses are hollow cavities situated behind your cheekbones (maxillary sinuses) and forehead (frontal sinuses) and around your eyes (ethmoid sinuses). Your sinuses cannot drain properly if they are inflamed, infected and swollen. The pressure created by the fluid buildup creates pressure against the surrounding nerves in your face and teeth. This creates pain in your face, teeth and may even cause headaches.

Sinuses

Proper diagnosis and treatment starts with a complete medical and dental history. Key questions are: When did the pain start? How long have you had the pain? Have you recently had a cold or suffered from allergies? Is the pain relieved when you lie down? Are your teeth sensitive to hot or cold liquids? Are the sensitive when you chew? Is the pain relieved when you use antihistamines or decongestants?

By administering a series of tests your dentist can determine if your tooth pain is caused by a dental problem or sinusitis. If it appears the tooth and gums are healthy and not causing the pain, the dentist should then refer you to your physician for further evaluation of your sinuses.

Fear Of The Dentist

Dr. John I am fifty-five years old and can count the number of times I have been to the dentist on one hand. I have not seen a dentist in 15 years. Just thinking about going to the dentist causes me anxiety and fear. I have tried to ignore my dental pain for as long as I can, now I have several teeth that hurt. I saw dental advertisement in the paper stating that with just the administration of a pill I could sleep through my treatment, this sounds really good to me. Does it work, is it safe?
Nelson – Daly City

Studies have reported that fifty percent of the American population does not seek regular dental care. Millions of Americans avoid much needed dental care due to anxiety and fear surrounding the dental experience. Visions of shots, invasive needles, and the high pitch of the dental drill keep many people out of the dental office. The key to good oral health is prevention – stopping problems before they arise. Unfortunately, people who suffer from dental anxiety often fail to visit the dentist for routine care. When they finally do go, often a small or preventable problem has turned into a problem that will require major intervention.

My first recommendation is to find an empathetic dentist! Inform the dental receptionists when you call for an appointment that you have been avoiding the dentist due to anxiety and fear, and take special notice whether or not the receptionist makes you feel more relaxed and comfortable. If you find a friendly compassionate person on the other end of the phone chances are the office caters to patients with dental fear. I suggest you set up your first appointment as a consultation only, without any procedures scheduled. This will allow you meet the office staff, and spend time with the doctor. During this first meeting with the doctor, you should be completely candid about your phobia, and inquire what methods are available to help mitigate your fears. Remember that an educated patient is a less anxious patient. Make sure your dentist explains each procedure you plan to undergo. Good dentists usually have videos, pamphlets, or books explaining the procedures they perform. A good dentist will answer all the questions you have thus lessening your anxiety.

In our office, we cater to patients with dental fear, and utilize both Inhalation Sedation, as well as oral sedation. Both can be effective and relatively safe, when administered by a properly trained dentist.

I am confident that if you select the right dentist you will be well on your way to anxiety free dental visits. As you get to know and trust your dentist, hygienist and other members of the practice, you will find your fears begin to diminish. In time, regular dental care will become a normal part of your life.

Root Planing

Dear Dr. John,
I am forty two years old and only have a few fillings and no crowns. I was transferred to California from Washington State by my employer, my new dentist informed me I have gum disease and will need root planing cleaning. When I asked her how much the cleaning would cost she told me $1050. I know the cost of living in California is high but that’s ridiculous, what is the going rate, will I lose my teeth if I don’t get it done?

Shawn- Redwood City

Shawn you are not alone with your malady, it is estimated that 90% of the world adult population has some form of gum disease. Periodontal diseases, including gingivitis and peridontitis, are serious oral infections that, left untreated can lead to premature tooth loss.

Periodontal disease is a chronic infection involving the gums and the underlying bone around the roots of your teeth. The mildest form of gum disease is called gingivitis. Swollen and reddened gums that bleed easily when you brush are prime symptoms of gingivitis. Gingivitis is caused by the accumulation of bacteria in dental plaque. Plaque is a sticky film that collects around your teeth. The recommended treatment for gingivitis is a professional cleaning, along with a good home oral hygiene regimen. With proper brushing and flossing, it is possible to be disease free in as little as a week!

Left untreated gingivitis can progress to periodontitis. Plaque left undisturbed, calcifies creating “tarter” or calculus, which can form below or above the gums. Calculus is irritating to the gums and causes swelling and inflammation. More importantly, bacteria will continue to collect on the calculus releasing toxins, these toxins eventually breakdown the supporting tissues around your teeth, including the bone holding your roots in place. As you lose supporting bone, your teeth loosen, and if not treated will eventually require extraction.

Healthy gumsGingivitis

The main cause of periodontal disease is bacteria found in dental plaque. However, there are additional risk factors that you should be aware of.

  1. Smoking
  2. Pregnancy and Puberty
  3. Stress
  4. Clenching and grinding your teeth
  5. Poor nutrition
  6. Medications
  7. Diabetes
  8. Immune diseases
Anyone exhibiting any of these risk factors should take additional steps to protect their teeth and gums. I recommend professional cleanings 3-4 times a year. You raised the question of costs; root planing is not a routine polishing that one might have done every six months in conjunction with their check-up. Full mouth root planning is an extremely labor intensive procedure and generally is preformed in two appointments, with each appointment being approximately two hours in length. I don’t think the $1050 fee you were quoted was not out of the normal fee range for four hours of a dental professional’s time.
Better smiles for all.

John J. Russo DDS

Fillings

Dear Dr. John,
I have a PPO dental plan and just got assigned to a new dental office. My new dentist did an exam and showed me my silver fillings with his in-mouth camera. My silver fillings are black and cracked he wants to replace them with white fillings, but says my insurance company will only pay for amalgam, so I will have to pay the difference out of my pocket if I want the white fillings. Help what material should I opt for? Which lasts longer?

Thanks Jan,
Daly City

Jan, in view of the fact that I don’t have the benefit of examining you; I can only offer general information regarding fillings. Most fillings older than 10 years are likely amalgams {a mixture of Silver, Mercury, Tin and Copper}. This material is mixed together and is tightly packed into the cavity preparation; the dentist then carves it to fit your tooth. This material and procedure dates back to the early 1800’s. There is no question amalgam has served us well, the material is relatively inexpensive and the procedure itself is not particularly technique sensitive or time consuming.

However I am of the opinion that the new composite filling materials health risks associated with mercury.

As stated above amalgam as a filling material served us well but was not without drawbacks. A list of possible problems with amalgam; it expands and contracts, and often acts like a wedge and cracks a tooth, and amalgam darkens with age. Another potential problem occurs during the procedure when amalgam is pressed into the cavity preparation, there tends to be a gap between the tooth structure and the amalgam filling material. This gap allows bacteria to enter between the filling and the tooth structure, which then starts the decay process and if not caught in time a root canal procedure.

While it is true, the new composite filling material is more expensive, takes substantially more chair time, and is technique sensitive; in my opinion the finished restoration is both cosmetically and functionally superior, my advice spend the extra money.

It is important to note an absence of pain doesn’t necessarily mean there isn’t an underlying problem.Taking care of a cracked filling or a filling that has an open margin before it causes you pain will save you time and money in the long run.

Jan hope this information helps you make an informed decision.

Better smiles for all,

Dr. John J. Russo

Veneers

Dear Dental Doc,

I am 32 years old, and I got veneers on my six front teeth, $8400. I was so excited, I was going to get straight white teeth without braces, but when the procedure was done I was disappointed with the look of my new smile. I returned to the dentist and she convinced me to try them for 90 days. After a few months one veneer fell off and two others cracked. I was told my veneers were going to be permanent, but is there anything out there that is more permanent?

Television shows such as “Extreme Makeover” The Swan, and Doctor 90210, have created a large demand for cosmetic dentistry. The doctors and the dentist on these shows are an elite group of highly trained professionals that are able to create what was once considered impossible.

A highly trained and accomplished cosmetic dentist is capable of incorporating a whole host of dental procedures in conjunction with artistic perception to produce that perfect smile. Unfortunately, not all dentists that try their hand at large-scale cosmetic cases possess the advanced training and, or the artistic perception required to create the “perfect smile”.

Porcelain veneers are considered to be permanent restorations, with esthetics and strength similar to that of natural teeth. Properly placed veneers should last between 7 to 15 years.

You stated your veneers were done to straighten your teeth. To assure the best result, this procedure requires a suitably trained cosmetic dentist in close concert with a cosmetic dental laboratory. Together they will create your new smile in the form of a wax model. Another method used by cosmetic dentists is to temporarily create your new smile directly over your teeth with tooth colored filling material. With this method the patient has the advantage of immediately seeing their new smile in their mouth. Both of the above procedures allow the patient to see what the new smile will look like before the dentist starts reducing the natural teeth. If any changes are to be made, it is relatively easy at this point in the procedure.

Your dentist may have used the “prep and pray” technique. Utilizing this technique, the dentist prepares the teeth and then allows the lab technician to create the veneers without a clear plan on what the final smile should look like. This is risky and lends itself to a myriad of surprises!

A properly trained cosmetic dentist will carefully plan for the final result. There should never be surprises when veneers are placed. When veneers are properly prepared, the temporaries should feel very close in shape and size to the final veneers. If necessary, the temporaries can be altered. The laboratory is notified of the changes, and the changes are then incorporated into the permanent veneers.

It sounds like your dentist lacked the proper training and or aesthetic vision needed to accomplish the desired result. Properly done, a veneer case should look good, feel great, and last a number of years.

Better smiles for all,

Dr. John

Unhappy With My Teeth

HELP MY SMILE!

Dear Dr. John,
I am unhappy with the way my teeth look! They’re stained, crooked, short, and they have gaps between them. What are my options?

Catherine-Belmont

Patients unhappy with the appearance of their smile have several options. These options include, teeth whitening, bonding, porcelain veneers and all ceramic crowns and bridges. The least expensive and most popular cosmetic procedure is teeth whitening. Teeth whitening can be very effective in brightening stained teeth. There are essentially two techniques for whitening teeth. The first technique requires two office appointments. Impressions of your teeth are taken during your first appointment; these are used to fabricate custom trays that will hold the whitening gel in contact with your teeth. On your second appointment you return to pick up your custom trays and the whitening gel. Once dispensed, the patient applies the whitening gel at home as prescribed by the dentist. The second technique is performed in little over an hour in the office with BriteSmiles’ patented teeth whitening procedure . This procedure utilizes a light activated gel, which erases years of staining in just over an hour’s time. With the BriteSmile procedure it is not unusual to see patients whiten their teeth by as much as ten shades, the results can be amazing!

Although teeth whitening will brighten your smile, the procedure does not address cosmetic issues such as gaps, crooked teeth, and tooth length. Direct bonding is the placement of tooth colored material directly on the front surfaces of the teeth to cover stains and modify the shapes and spaces of mal-positioned teeth. Bonding is a relatively inexpensive procedure that usually requires one visit. The shortcoming of bonding is it stains easily and is not very durable.

Provided you are a good candidate, the best way to improve a smile is with the placement of porcelain veneers. Porcelain veneers are thin shells of porcelain that are bonded to the front surfaces of teeth. Veneers can permanently eliminate stains on the front surfaces of teeth and can be used to change the positions of misaligned teeth to create that perfect smile. Although porcelain veneers require the removal of some tooth structure, it is considerably less than what is required for the placement of ceramic crowns. The advantages of veneers include strength, durability and long lasting esthetics.

Just a note of caution here, not all dentists have the same training in relation to cosmetic dentistry. Cosmetic dentistry is not a legally recognized specialty, which makes you somewhat vulnerable as a consumer. Any licensed dentist may advertise as a cosmetic dentist. It is incumbent upon you to make sure the dentist you select has extensive training in COSMETIC dentistry.

Better smiles for all,

John J. Russo D.D.S.

Do I Need Night Guard

Dear Dr. John: My dentist says I am a bruxer and need a night guard? Can you explain what a night guard is, how they are made and how much they costs?
Catherine-Palo Alto

Bruxism is the dental term for tooth grinding. This condition wears teeth prematurely and may cause facial pain and or jaw joint pain. People who grind and clench, called bruxers, they unintentionally bite down too hard at inappropriate times, such as in their sleep. People usually aren’t diagnosed with bruxism until it is too late; many people don’t realize they have the habit, and your dentist isn’t aware until the premature wear presents itself. Bruxism is fairly common, it is estimated one in three people suffer from bruxism.

I believe the root cause of buxism can be attributed to stress, and certain personality types. Specific emotions such as anger, pain and frustration can also trigger bruxing.

Once diagnosed, your dentist may prescribe a plastic mouth appliance, called a night guard. It is worn to absorb the force of biting and clenching, and prevents tooth on tooth contact. This appliance can prevent future damage to the teeth and the jaw joint, and may help in changing the patient’s destructive behavior.

A night guard is a hard or soft plastic horseshoe appliance that fits snugly over the biting surfaces of the teeth.

Most custom night guards are fabricated in the dental laboratory from a mold of your teeth. After the dentist receives the night guard from the laboratory, he will adjust it to make sure it is comfortable and the occlusion is correct. A properly fitted night guard should feel comfortable, although initially it may feel snug.

The cost of a custom fitted night guard from your dentist will range from $250- $1000. The specific cost of a night guard depends on how its made and the purpose for which it will be used.

Better smiles for all.

Dr. John J. Russo

Sensitive Teeth

Dear Dr. John,

Every time I drink or eat something cold, my teeth hurt. My teeth even hurt when I breathe in cold air! Can you tell me why my teeth are so sensitive and what I can do about them?

Joe-Menlo Park

Tooth sensitivity is a common complaint among dental patients. In order to understand why your teeth are sensitive you must first understand a bit of tooth anatomy. A tooth is composed of three layers. The outer layer above the gums is called the enamel. The middle layer above the gums is called the dentin and structure below the gums (root) is called the cementum. The inner layer of the tooth is called the pulp.

Most often tooth sensitivity is due to a wearing away of enamel, or receding gums. Receding gums is the most common cause of sensitive teeth in adults. Once gums recede they expose the tooth’s root. In as much as roots are not covered by enamel, thousands of tiny channels or tubules are exposed. These channels lead to the tooth’s pulp or nerve center. When the open tubules come in contact with an external stimulus, such as heat, cold or pressure you feel tooth pain.

Penetration in the enamel can be caused by various factors; such as a bad bite, grinding or clenching your teeth, brushing with a stiff bristled toothbrush, and use of abrasive toothpaste. A bad bite can create tremendous forces. These forces cause the enamel to flex, over a period of time this continual flexing causes the enamel to fracture. This fracture exposes the dentin, and causes hypersensitivity to external stimuli such as heat, cold and pressure. Grinding or clenching your teeth can create excessive wear or micro-fractures in the enamel, exposing dentin. Most if not all patients would be well served with the use of a high quality soft bristled toothbrush, changed on a regular basis; and a non-abrasive toothpaste.

In conclusion, your dentist needs to evaluate the cause of your sensitivity by taking x-rays and performing complete and thorough clinical examination. Only after the cause of your pain is determined, can treatment recommendations be made.

Better smile for all,

Dr John Russo

Dentures

Dear doc.

I have been wearing full dentures for the past thirty years, for the past five years I have had trouble with my lower denture staying put. I have had three new sets made and was just informed that my problem wasn’t the denture but in fact my jawbone was dissolving? My dentist is sending me to a specialist, what should I expect?
Thanks Richard.

It is important for patients have realistic expectations when replacing natural teeth with dentures. Traditional dentures are only a marginal substitute for your natural dentition, and as you have experienced, the lower denture is generally the more troublesome of the two. There are several inherent problems with lower dentures:

The lower denture has much less surface area to rest upon. The upper denture for example utilizes the entire roof of your mouth to help stabilize the denture.

The lower denture comes in contact with more movable mouth surfaces than an upper denture. These movable surfaces tend to dislodge the lower denture.

Loss of the jawbone ridge, allows the lower denture to come into closer contact with tissue extension , which cause destabilizing forces.

In as much as you stated you have worn dentures for thirty years I suspect that you have loss both height and mass in your jawbone ridge. Your lower denture rests on top and on each side of the ridge and relies on it to support your denture. Without a good ridge, the denture can move side-to-side and front to back, making it difficult to chew and speak.

When you got your first denture 30 years ago, you likely had an adequate jawbone ridge. Over the years, the pressure placed on your ridge has caused the underlying bone to re-absorb or “dissolve”. This re-absorption can progress to the point where there is very little ridge left, and thus little or no stabilization. At this point your denture just “floats” on your lower jaw causing you pain when you chew.

Your specialist may suggest that you have dental implants placed. Placing implants into the jawbone and fabricating a denture to connect with the Implant fasteners will greatly stabilize a lower denture. However, if your ridge is inadequate to accommodate implants, you will need to build up your ridge . To this end, the specialist may suggest a bone graft, or surgery to lower the gum tissue.

There is a relatively new procedure developed by a Russian orthopedic surgeon. With the use of small metal plates and screws, the jawbone is surgically cut creating micro-fractures, this results in simultaneous expansion of the soft tissue and bone volume. After a period of time the plates and screws are removed and the dental implants placed. A lower denture is then fabricated that facilitates connection to the implants. The results are a greatly stabilized lower denture. Although early in its application to dentistry, this procedure looks very promising.

Better smiles for all.

Braces

Dear Doc.
I am a 35-year-old female, my front teeth are crooked, but I don’t want to wear braces. I want to avoid tin man grin. Are there any other options and how much to do they cost?

Dear Betty,

There are currently three options available to straighten your smile.

1. Instant orthodontics
2. Traditional orthodontics
3. Invisalign

If you’re primary concern is limited to your front teeth, then instant orthodontics maybe for you. Today, with the advancement in adhesive technology, we can achieve incredible bond strength of porcelain to tooth structure. As a result of this technology we are capable of doing more with porcelain crowns and veneers than ever before. One such application is the correction of mild to moderate crowding of the anterior teeth or what we call Instant Orthodontics. The instant orthodontic procedure may be done in as few as two appointments. Most often four to eight teeth are prepared for porcelain veneers. Impressions are taken and sent to the dental laboratory. When cemented the newly fabricated veneers will be straight. This procedure works best with mild to moderate crowding. Cost for six veneers can run $5000 to $9000. Additionally if substantial reduction is required, teeth may become sensitive and require root canals.

Traditional orthodontics utilizing porcelain brackets is an improvement over the tin grin look, however you’ll still have a wire running through the brackets. Brushing and flossing are still a big problem and you still will have that adolescent look. The average treatment time for adult orthodontics is approximately 24-36 month’s. The cost of traditional adult orthodontics will range $5000 to $7000.

Invisalign is the invisible way to straighten your teeth without brackets and wires. The Invisalign system utilizes a series of clear removable aligners to straighten your teeth. Invisalign utilizes 3-D computer technology to create the aligners. The Invisalign computer scans your models. The information is digitized creating a final model of your mouth with straight teeth. A series of clear aligners are then fabricated to achieve the required movement. Each aligner is designed to place controlled pressure on the teeth to be moved. You wear each set of aligners for about two weeks, removing them only to eat, drink, brush and floss. Treatment progresses at a faster rate than with traditional orthodontics. The average treatment time is 9-15 months. You can expect to pay between five to seven thousand dollars for the Invisalign system.

Betty both the traditional and Invisalign systems will allow your dentist to correct major bite and occlusion problems whereas instant orthodontics for the most part is cosmetic and limited to the few teeth involved.

Better smiles for all.

Teeth Whitening

Dear Dr. John,

Last weekend I purchased a teeth-whitening kit at my local drugstore. I followed the directions and everything was ok for the first two days. On the third day I woke-up in excruciating pain. It seemed that every tooth in my mouth and gums hurt. I thought bleaching was safe—?
George.

Dear George,
Your complaints are not uncommon with over the counter teeth whitening systems. Generally speaking home bleaching is a safe procedure if done properly. There are two generally accepted methods used to bleach teeth.

1. In office whitening
2. Home treatments

The most popular in office whitening system is the BriteSmile Professional Teeth Whitening System. The BriteSmile system utilizes a patented blue light, which activates a gentle hydrogen-peroxide gel that is applied to your teeth. The peroxide bleaches the stains in your tooth enamel, safely and effectively whitening your teeth. This procedure usually takes just a little over an hour. I have used this system in my office for several years and often see patients’ teeth ten shades whiter after the BriteSmile procedure!

Home treatments consist of:
1. Brush-on whitening
2. Strips you stick on your teeth
3. Trays with bleaching gels.

Brush-on whitening is a great concept, however it is not very effective as a primary teeth whitening system. However, it can be effective as a touch-up system.

Whitening strips are simple to use, however they do not bleach your teeth uniformly. The strips are flat and are unable to form to the contours of your teeth’s anatomy. This usually results in uneven whitening.

Trays with bleaching gels are still the best way to bleach your teeth at home. Just a note of caution here, not all tray/gel systems are created equal. Some over-the-counter trays do not conform to your teeth and do not hold the gel in the proper position. Many over-the -counter whitening gels are not thick enough to stay in place and leak out of the tray, and onto the gums. Many over-the -counter gels typically contain less effective active ingredients or a lower concentration of active ingredients.

Some people experience temporary tooth sensitivity during treatment. Others have reported discomfort in the gums or in loose fillings. Gum irritation usually disappears within one to three days after beginning the procedure and upon the discontinuation or completion of treatment.

George, it sounds like your trays may have leaked bleaching agent onto your gums, causing gum irritation. The pain you experienced in your teeth may be due to cracked or missing fillings, or you may have gum recession that has exposed a portion of your roots. The bleaching solution tends to penetrate these areas, causing the nerves in teeth to become irritated resulting in generalized tooth pain.

The preferred method for the home bleaching is only available from you dentist. Your dentist will do a complete exam noting any areas that might be potential problems, before dispensing the system. Custom molds will then be taken of your teeth, and custom trays fabricated. These custom trays allow for uniform distribution of whitening agent, and cause less gum irritation. All in all a better result!

Better smiles for all.

Dr. John J. Russo

X-Rays

Dear doc.
Last week I went to see a new dentist. I basically just wanted a cleaning but they were advertising a special that included and exam and cleaning. When I got to the office I was informed I would be required to have x-rays taken in order to get my cleaning and exam. When I refused they told me that American Dental Association mandated it. I felt I was being scammed for an extra $75 so I left. Isn’t that a lot for x-rays? What’s the story; does the ADA require the dentist to take x=rays in order to have a cleaning and exam?
Thanks
Phil

Phil the American Dental Association does get involved in the development of the “parameters of dental care”. However it does not have any legal jurisdiction in the actual practice of dentistry. There is no requirement that a dentist be a member of the ADA, membership is purely voluntary. The practice of dentistry is regulated by the state under the auspices of the Dental Board Of California. The actual laws are found in the dental practice act.

The way in which your dentist operates his practice is largely at his or her discretion. The dental practice act does not dictate how actual procedures are to be preformed. The general rule is, a procedure must be preformed within the “standards of care”. If the standard of care in your area requires x-rays be taken for a specific procedure and your dentist ignores the standard, he or she could be held legally at fault, should a problem arise.

A common problem that might arise if a dentist didn’t take x-rays is failure to diagnose a serious problem that could only be diagnosed with the aid x-rays. Many times patients assume since they are not experiencing any symptoms, that they are in fact, free of oral disease. This in fact may not be the case! Many times decay, abscesses and bone loss are asymptomatic. On a more serious note, I have seen patients in my practice that were symptom free, yet with the aid of dental x-rays, and a thorough oral exam, cancer was detected.

The seventy-five dollar charge for full-mouth x-rays is well within the norm for area.

You did not mention whether or not the ad stated that x-rays would be required at an extra charge, if not I feel the ad is misleading. Medically speaking I don’t feel your new dentist was scamming you. It is in the patients’ best interest to have x-rays taken, to facilitate a complete and thorough exam.

Better Smiles for all,

John J. Russo DDS

Partial Dentures

Dear Dr. John,
I currently have a removable partial denture. I hate the way it looks! Every time I smile, you can see the ugly wire clasps. At the time I had it done, it was all I could afford. Since I’m older, and have the finances, what options do I now have?
Dave.

Dave, as always I can only speak in generalities, as I have not examined you.

Partial dentures are used to replace missing teeth in two different scenarios. The first scenario is when you have a missing tooth or teeth in-between two other teeth. This is called a tooth borne partial. The second scenario is where missing teeth only have intact teeth on one side.

Tooth borne {1} Tissue borne {2}
Tooth borne partial denture Tissue borne partial denture

Fixed bridge Dental implant with artificial tooth

In the first scenario you have two options in replacing the missing teeth. The first is a permanent fixed bridge. A fixed bridge can be placed if the adjacent teeth are strong enough to withstand the additional stresses that will be placed on them. The second option for tooth borne is the dental implant. With today’s advances in implantlogy, dental implants are now a viable cost effective alternative to fixed bridges. Implants are placed in the area of the missing teeth. The advantages of implants over a fixed bridge are that your natural teeth are left intact.

If your partial denture is tissue borne then dental implants are your only viable option.

Partial dentures generally utilize one of two types of mechanical retention to hold the appliance in place. Most partial dentures utilize wire clasps that wrap around the tooth, however there are partial dentures that use precision attachments. Precision attachments are similar to garment snaps. Precision attachments eliminate the metal clasps you find esthetically unacceptable. Given that the anchor teeth to be crowned are strong this is a good option where implants cannot be used.

Dave my advice, given that you are a viable candidate and finances allow, is to opt for dental implants.

Better smiles for all.
Dr. John Russo
Director of Russo Dental Care

Bad Breath

Dear Dr. Russo,

I just saw my MD for a physical. Everything was fine, but he noticed I had bad breath and asked me to see my dentist. He said I could have gum disease and if so, it could cause many health problems. Can you tell me what diseases it can cause and what I can do to prevent this from happening?
Thanks,
Jill

Jill I suspect your doctor may have noticed inflamed and infected gums, in addition to your halitosis. Most people will have bad breath from time to time; this condition in and of itself is not the prime indicator for severe gum disease. Given that you do in fact have severe periodontal disease I agree with your doctor. Oral bacterium not only affects the health of your mouth, but also can cause various medical problems elsewhere in your body. Patients with advanced gum disease release significantly higher levels of bacterial components such as endotoxins into the bloodstream. Once released into the bloodstream these toxins travel to other areas of the body.

Oral bacteria has been linked to cardiac disease, stroke, diabetes stomach ulcers and pneumonia. Another heart condition caused by oral bacteria is bacterial endocarditis. Patients who have a heart valve defect or mitral valve prolapse are at risk. Oral bacteria enter your bloodstream and congregate on your heart valves causing further valve damage. This condition can be life threatening, so make certain your dentist is aware of any heart problems so he can determine if you need to take antibiotics prior to your treatment.

Prevention is always easier than the cure. My recommendation is semi-annual checkups, and dental cleanings three times a year. Home care should include daily brushing, flossing and tongue scraping. This will keep the bacteria at acceptable levels. The benefits are healthier teeth, fresher breath and a periodontal disease free mouth.

Better smiles for all,

Dr. John J. Russo



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