Pregnancy Prenatal Care and Oral Health

Can Oral Health Have an Effect on Pregnancy?
Growing evidence suggests a link between gum disease and premature, underweight births. Pregnant women who have gum disease may be more likely to have a baby that is born too early and too small.

More research is needed to confirm how gum disease affects pregnancy outcomes. But it appears that gum disease triggers increased levels of biological fluids that induce labor. Data also suggests that when gum disease worsens during pregnancy, there's a higher risk of having a premature baby.

What Can I Do to Ensure I Have a Healthy Pregnancy?
The best advice to women considering pregnancy is to visit their dentist for a checkup and to treat any oral problems before becoming pregnant.

During your pregnancy, your teeth and gums need special attention. Regular brushing and flossing, eating a balanced diet and visiting your dentist regularly will help reduce dental problems that accompany pregnancy.

What Oral Problems Might Develop During My Pregnancy?
Studies show that many pregnant women experience pregnancy gingivitis — when dental plaque builds up on the teeth and irritates the gums. Symptoms include red, inflamed and bleeding gums.

Pregnancy gingivitis occurs more frequently during pregnancy because the increased level of hormones exaggerates the way gums react to the irritants in plaque. However, it's still plaque — not hormones — that is the major cause of gingivitis.

Keeping your teeth clean, especially near the gumline, will help dramatically reduce or even prevent gingivitis during your pregnancy. And substituting sweets with more wholesome foods such as cheese, fresh fruits or vegetables is better for your teeth.

What Can I Expect When I Visit My Dentist During My Pregnancy?
First, be sure to let your dentist know you're pregnant when you schedule your appointment. It's best to schedule your dental visit during the fourth to sixth month of your pregnancy. This is because the first three months of pregnancy are thought to be of greatest importance in your child's development. During the last trimester, stresses associated with dental visits can increase the incidence of prenatal complications.

Typically, X-rays, dental anesthetics, pain medications and antibiotics (especially tetracycline) are not prescribed during the first trimester, unless it's absolutely necessary. During the last three months of pregnancy, sitting for long periods of time in the dental chair can become uncomfortable. And there is evidence that pregnant women can be more prone to gagging. Your dentist, however, is prepared for this situation.

If you need to schedule an emergency visit, let the office know about your pregnancy before you arrive. Discuss any stresses, past miscarriages and drugs you are taking as these can all have an influence on how your dentist attends your needs. Your dentist may also want to consult with your physician before any treatment is started.

If you have any doubts or concerns, insist that your dentist and physician discuss your particular needs. If your dentist prescribes medication, do not exceed the prescribed dosage. This includes aspirin.

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Your Dentist's Education

In the United States, a dentist must complete four years of dental school. This comes after college. Dental school graduates receive either a D.D.S. or D.M.D. degree. D.D.S. stands for Doctor of Dental Surgery. D.M.D. comes from the Latin Dentariae Medicinae Doctor.

Today, students in both types of programs receive similar training. One degree is not better than the other.

After receiving a dental degree, a person must pass two board exams in order to practice dentistry. One is a national exam. The other is a state or regional exam. A dentist's license to practice is granted by the state where the practice is located.

After earning a D.D.S. or D.M.D., about 1 in 3 dentists go on for more training. Additional training beyond dental school is not required in most places for a dentist to practice.

Recently, New York and Washington state have instituted a one-year training requirement beyond dental school. Dentists can get this extra training in a general practice residency program in a hospital. Another option is an advanced education in general dentistry program. These are usually located in a dental school. These programs are typically one year long. Some include a second year. This training gives dentists more experience with different types of patients and dental procedures.

A dentist who wants to become a specialist — such as a pediatric dentist, endodontist, oral surgeon, orthodontist, prosthodontist, public health dentist or oral pathologist — must train for as many as five years after receiving a D.D.S. or D.M.D. This training occurs in an ADA accredited program, which is typically sponsored by a dental school or hospital. About 1 in 5 dentists are specialists. After completing an accredited program, a dentist is deemed board eligible. This is followed by a board exam. A specialist who passes the board exam receives the title "board certified."

Many states require dentists to keep learning throughout their careers. This is called continuing education. Dentists can take courses at a university or receive education credits by going to professional meetings. One example would be the annual meeting of the American Dental Association. Continuing education helps dentists keep up to date on the newest research and treatment options. Members of the Academy of General Dentistry who take these courses can become certified as a master in general dentistry.

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Illustrations: How a Tooth Decays

1. Healthy Tooth	2. White Spots
Enamel is the hard outer crystal-like layer. Dentin is the softer layer beneath the enamel. The pulp chamber contains nerves and blood vessels. It is considered the living part of the tooth.	Bacteria that are exposed to sugars or carbohydrates can make acid. The acid attacks the crystal-like substance in the tooth's outer surface. This process is known as demineralization. The first sign of this is a chalky white spot. At this stage, the decay process can be reversed. Using fluorides at home and in the dental office can help the tooth repair itself.
3. Enamel Decay	4. Dentin Decay
Demineralization continues. Enamel starts to break down. Once the enamel surface is broken, the tooth can no longer repair itself. The cavity has to be cleaned and restored by a dentist.	The decay reaches into the dentin, where it can spread and undermine the enamel.
5. Pulp Involvement

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Tooth Whitening

What Is It?

Tooth whitening lightens teeth and helps to remove stains and discoloration. Whitening is among the most popular cosmetic dental procedures because it can greatly improve how your teeth look. Most dentists perform tooth whitening.

Whitening is not a one-time procedure. It will need to be repeated from time to time if you want to maintain the brighter color.

What It's Used For

The outer layer of a tooth is called the enamel. The color of natural teeth is created by the reflection and scattering of light off the enamel, combined with the color of the dentin under it. Your genes affect the thickness and smoothness of the enamel. Thinner enamel allows more of the color of the dentin to show through. Having smoother or rougher enamel also affects the reflection of light and therefore the color.

Every day, a thin coating (pellicle) forms on the enamel and picks up stains. Tooth enamel also contains pores that can hold stains.

The most common reasons for teeth to get yellow or stained are:

• Using tobacco
• Drinking dark-colored liquids such as coffee, cola, tea and red wine
• Not taking good care of your teeth

Aging also makes teeth less bright as the enamel gets thinner and the dentin becomes darker.

It is also possible to have stains inside the tooth. These are called intrinsic stains. For example, intrinsic stains can be caused by exposure to too much fluoride as a child while teeth are developing. Other causes include tetracycline antibiotics. They can stain a child's teeth if taken by a mother during the second half of pregnancy or by a child who is 8 years old or younger. Teeth are still developing during these years. Trauma may also darken a tooth.

Tooth whitening is most effective on surface (extrinsic) stains.

Preparation

Other dental problems can affect the success of tooth whitening. For example, cavities need to be treated before teeth are whitened. That's because the whitening solution can pass through decayed areas and reach the inner parts of the tooth. If your gums have receded, the exposed roots of your teeth may appear yellow or discolored. Whitening products will not make them whiter.

If you have tooth decay or receding gums, whitening may make your teeth sensitive. Whitening also does not work on ceramic or porcelain crowns or veneers.

Whitening can be done in the dental office or at home. For in-office whitening, your dentist probably will photograph your teeth first. This step will help him or her to monitor the progress of the treatment. Your dentist also will examine your teeth and ask you questions to find out what caused the staining.

Next, the dentist or a dental hygienist will clean your teeth. This will remove the film of bacteria, food and other substances that build up on your teeth and contribute to the staining. Once this is done, the whitening procedure begins.

For whitening at home, your dentist can make trays to hold the whitening gel that fit your teeth precisely. Home whitening gel usually needs to be applied daily for two to three weeks. Over-the-counter kits also are widely available for home use. They provide trays to hold the gel, or whitening strips that stick to your teeth. Talk to your dentist if you want to use these home products. Be sure to follow directions to avoid overuse and possible damage to your teeth and mouth.

How It's Done

There are two main types of whitening procedures. Non-vital whitening is done on a tooth that has had root-canal treatment and no longer has a live nerve. Vital whitening is performed on teeth that have live nerves.

Non-Vital Whitening

Vital whitening may not improve the appearance of a tooth that has had root-canal treatment because the stain is coming from the inside of the tooth. If this is the case, your dentist will use a different procedure that whitens the tooth from the inside. He or she will place a whitening agent inside the tooth and put a temporary filling over it. The tooth will be left this way for several days. You may need this done only once, or it can be repeated until the tooth reaches the desired shade.

Vital Whitening

The most common type of vital tooth whitening uses a gel-like whitening solution that is applied directly to the tooth surface. This product contains some form of hydrogen peroxide.

Tooth whitening can be done in the dentist's office or at home. In-office (chairside) whitening allows your dentist to use a more powerful whitening gel. A specialized light or laser activates the gel and allows bleaching to happen faster.

In-office whitening usually takes 30 to 90 minutes. You will need one to three appointments. The number will depend upon the method used, how severe your stains are and how white you want your teeth to be. Different types of stains respond differently to the treatment.

First, your dentist will apply a substance that covers and protects the gums around the teeth. Then, the whitening agent, usually hydrogen peroxide, will be placed on the teeth.

Some whitening agents are activated by a laser light, special lights or by the heat from these lights. After the whitening agent is applied, the dentist will shine the light on your teeth. If your teeth are badly discolored, your dentist may suggest that you continue the bleaching process at home for a few days or weeks.

For in-home whitening, your dentist will take impressions of your upper and lower teeth and will make custom mouthpieces to fit you. The mouthpiece needs to fit well. A close fit helps the whitening agent remain in contact with your teeth.

At home, you will fill each mouthpiece with a whitening gel your dentist provides. You will wear the mouthpiece for several hours every day. Many people achieve the amount of whitening they want within a week or two. However, you may need to wear the mouthpiece for four weeks or longer.

You also can buy whitening products over the counter. They contain a weaker whitening agent than the products you can get from your dentist. Therefore, whitening may take longer. The whitening agent is applied as a gel placed in a mouthpiece or as a strip that sticks to your teeth. Over-the-counter mouthpieces fit less securely than the kind you get from your dentist.

Whitening toothpastes are available as well. They contain abrasives that remove stains on the enamel. They do not actually change the overall color of your teeth.

Follow-Up

If you find that your gums are white or sore, follow up with your dentist.

Whitening is not a permanent solution. The stains will come back. If you smoke or consume a lot of staining foods or drinks, you may see the whiteness start to fade in as little as one month. If you avoid these sources of staining, you may not need another whitening treatment for 6 to 12 months.

Re-whitening can be done in the dentist's office or at home. If you have a custom-made mouthpiece and whitening agent at home, you can whiten your teeth as frequently as you need to. Discuss your whitening schedule with your dentist. You can talk about what whitening products would work best for you.

Risks

Whitening is unlikely to cause serious side effects, although some people's teeth may become more sensitive for a short while. You may get mild gum irritation as well. Women should not have their teeth whitened while pregnant. The effect of the whitening materials on the development of the fetus is not known. Since the procedure is cosmetic, it should be postponed until after delivery.

When To Call a Professional

If you feel your teeth would benefit from whitening, contact your dentist to discuss the procedure.

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Second Opinion: The Delta Dilemma

Second Opinion: The Delta Dilemma
Dr. Robert G. Griego, former Delta Dental board member, takes issue with the current goings-on at the insurance company.
The Delta Dilemma– Robert G. Griego, DDS Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a "Second Opinion." Perhaps some of these observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession. — Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine Delta of Washington made the decision to cut reimbursements to member dentists across the board.This has caused an uproar with Washington dentists.What has happened in Washington is nothing new though. In one form or another across the country and finally even here in Arizona, Delta has compromised the best interests of dentists for years. My experience with Delta is vast. I served on the Delta board from 2003 through 2010. I was board chair from 2006 to 2010. As a historical review, Delta was started by dentists more than 50 years ago. This first occurred in the states of California, Oregon and Washington. The goal for Delta was to be an option to the new types of dental insurance that were being developed. Delta was to be owned and managed by dentists to insure quality plans for the patients. The Arizona State Dental Association (AzDA) incorporated Delta in the mid-70s as the Arizona Dental Insurance Service. Years later because of anti-trust issues, all state dental associations except for Oregon divested themselves from Delta. This was not necessary to do as proven by Oregon who maintained their ownership and have thrived as a subsidiary of the Oregon State Dental Association. Oregon has managed the anti-trust issues very well. My involvement started in 1990 when Arizona Delta attempted to market PPO-type discounted plans as most other Delta chapters were doing. I led a movement of Arizona dentists to oppose this and we prevailed. This again occurred in 1994-95. This time it was a bitter yearlong battle but again dentists prevailed. The CEO resigned as we re-established our influence with the insurance company that we started. We honored our mission of promoting only quality insurance products. This set the stage for our incredible run of glory years for Arizona Delta. We were the envy of many dentists from other Delta chapters in the country. I stand behind this statement because at that time we were a small fledgling company. However by taking the position for quality insurance for the patients we serve and fair reimbursement for our dentists, we were able to develop our niche which was desired by patients. We became the number-one dental insurance company in the state and held that ranking for at least 12 consecutive years. Sad to say, the board and I fell prey to a takeover. Currently here in Arizona, even under the leadership of dentists, PPO-type plans are being marketed statewide for the first time in our long history of Arizona Delta! It is unbelievable to me that some long time AzDA leaders would permit this. Prior to this sad turn of events, only the premier plans were allowed to be sold under our leadership. History repeats itself and this will eventually cause the premier plans to be greatly compromised here in Arizona. I have attended numerous Delta national meetings on issues such as limitations on non-covered services to marketing steeply discounted PPOs. Usually the dentist's interests are low on Delta's list of priorities. The common denominator in each state that has slashed payments to dentists are people who sell the notion there are absolutely no other options left. Dentistry, at least here in Arizona, is in a negative freefall. Some factors are an oversupply of dentists and the full impact of two new dental schools here in Phoenix yet to be felt. Corporate dentistry has entered the Phoenix market and around 65 dental centers have opened. I do not know the quality of their services, but I understand fees are discounted which will inevitably attract certain patients. Of course, the economy remains a negative factor as well. Now Delta, the company dentists started, as the last bastion of hope and influence for dentists here in Arizona, is promoting the notion that because the economy is awful we need to bear the sacrifice to keep Delta highly profitable. Why would a board dominated by dentists allow this? I ask the question: Why is organized dentistry not in this battle? I cannot speak for Washington but here in Arizona, AzDA has remained silent toward Delta's actions. Every AzDA member should be demanding a strong position against Delta on this issue. AzDA appears to be more interested in fostering an environment of cooperation with Delta. Since when do the best interests of dentists parallel those of insurance сompanies? As the economy continues to struggle, will similar actions to Washington take place here in Arizona? Will this continue to spread to other states? In many states, the premier plan is already an insignificant part of Delta's business. Be prepared to hold your state dental associations accountable for fighting for the dentists, of course, within applicable anti-trust laws. The Delta Board of Directors must also be held accountable. Do not fall for decisions that do not protect the best interest of our patients. In my opinion, in these times, quality leaders in the dental profession are hard to find but this wonderful profession of dentistry is worth fighting for, so get involved. Author’s Bio Dr. Robert G. Griego graduated from Creighton University School of Dentistry in 1969. Dr. Griego was honored with Creighton's School of Dentistry National Alumni merit award in 2006. He has held many positions throughout his career, including president of the Arizona Dental Association and president of the Central Arizona Association. He brings 40 years of experience to his private practice in Phoenix, Arizona. Dr. Griego has been chosen AzDA's Dentist of the Year twice and is in AzDA's Hall of Fame. He has served on numerous civic organizations including The West Valley Child Crisis Center serving as Board Chair. Call Now San Francisco Dentist Request for appointment at: (415) 391 - 7751 450 Sutter street, Suite 1905 San Francisco, CA, 94108 http://malidds.com/

How Do I Maintain Good Oral Health in My Senior Years?

How Do I Maintain Good Oral Health in My Senior Years?

Your teeth can last a lifetime with proper home care and regular dental checkups. No matter what your age, you can keep your teeth and gums healthy by brushing twice a day with a fluoride toothpaste, flossing daily and seeing your dentist regularly for professional cleanings and checkups.

What Special Oral Health Issues Should I Know About as a Senior?

Even if you brush and floss regularly, you may face certain issues in your senior years when it comes to your oral health. Wearing dentures, taking medications and general health conditions are some of the issues many seniors face. Luckily, your dentist and physician can help you meet most of these challenges quite successfully.

• Cavities and decay on the root surfaces of the teeth are more common in older adults. So it's important to brush with a fluoride toothpaste, floss daily and see your dentist regularly.
• Sensitivity can be an increasing problem as one ages. Your gums naturally recede over time, exposing areas of the tooth that are not protected by enamel. These areas are particularly prone to pain due to cold or hot foods or beverages. In severe cases cold air, as well as sensitivity to sour and sweet drinks and foods, can occur. If you experience sensitivity, try an anti-sensitivity toothpaste. If the problem persists, see your dentist, as the sensitivity may be an indication of a more serious condition, such as a cavity or a cracked or fractured tooth.
• Dry mouth is a common condition in seniors, and one that may be caused by medications or certain medical disorders. Left untreated, dry mouth can damage your teeth. Your dentist can recommend various methods to restore moisture in your mouth, as well as appropriate treatments or medications to help prevent the problems associated with dry mouth.
• Existing health conditions such as diabetes, heart disease, or cancer, can affect your oral health. Be sure to let your dentist know of any general health issues you're facing, so that he or she understands the whole situation and can help you meet your special requirements.
• Dentures can make life easier for many seniors, but they require special care. Follow your dentist's instructions carefully and see your dentist if any problems arise. An annual checkup is recommended for long-term denture wearers.
• Gum disease is a potentially serious condition that can affect people of all ages, but especially people over 40. A number of factors can increase the severity of gum disease, including:

• Bad diet
• Poor oral hygiene
• Systemic diseases, such as diabetes, heart disease and cancer.
• Environmental factors such as: stress and smoking
• Certain medications that can influence gum condition

Because the earliest stages of gum disease are reversible, it is important to spot it early on. Regular dental checkups can insure early detection and treatment of gum disease. Best of all, it is easy to prevent gum disease from developing in the first place, by practicing proper oral hygiene.

• Crowns and bridges are used to strengthen damaged teeth or replace missing ones. A crown is used to entirely cover or "cap" a damaged tooth. Besides strengthening a damaged tooth, a crown can be used to improve its appearance, shape or alignment. Bridges are commonly used to replace one or more missing teeth. They span the space where the teeth are missing. Bridges are cemented to the natural teeth or implants surrounding the empty space.

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How do I Best Care for My Teeth as an Adult?

How do I Best Care for My Teeth as an Adult?

The key to keeping a bright, healthy smile throughout adulthood is to practice proper oral hygiene. Even adults can get cavities, as well as gum disease, that can lead to serious problems. Throughout your adult life, it's important to continue to:

• Brush twice a day with a fluoride toothpaste to remove plaque-the sticky film on your teeth that's the main cause of tooth decay.
• Floss daily to remove plaque from between your teeth and under your gumline, before it can harden into tartar. Once tartar has formed, it can only be removed by a professional cleaning.
• Limit sugary or starchy foods, especially sticky snacks. The more often you snack between meals, the more chances you give the acids in plaque to attack your tooth enamel.
• Visit your dentist regularly for professional cleanings and checkups.

What Special Dental Issues Should I Be Aware of as an Adult?
Even if you brush and floss regularly, you may face certain oral health issues as an adult. Luckily, your dentist can help you meet most of these challenges quite successfully.

• Gum disease begins as gingivitis, which in this early stage is still reversible. Symptoms of gingivitis include red, swollen or tender gums that tend to bleed when you brush them. If you notice any of these symptoms, see your dentist before serious problems develop. Advanced stages of gum disease may lead to tooth loss.
  
  The health of your gums can also affect your overall health. Recent studies have shown a possible link between periodontitis (a gum disease) and other diseases, such as diabetes, heart disease and a possible link to premature births. To prevent gum disease from getting started in the first place, be sure to brush twice a day, floss daily and schedule professional cleanings every six months.
• Cavities around existing fillings (called recurrent decay) and decay on the root surfaces of the teeth become more common as we age. So it's important to brush with a fluoride toothpaste, floss daily and see your dentist regularly.
• Sensitivity can be an increasing problem as one ages. Your gums naturally recede over time, exposing areas of the tooth that are not protected by enamel. These areas are particularly prone to pain due to cold or hot foods or beverages. In severe cases cold air, as well as sensitivity to sour and sweet drinks and foods, can occur. If you experience sensitivity, try an anti-sensitivity toothpaste. If the problem persists, see your dentist, as the sensitivity may be an indication of a more serious condition, such as a cavity or a cracked or fractured tooth.
• Crowns are used to strengthen damaged teeth. A crown entirely covers or "caps" a damaged tooth. Besides strengthening a damaged tooth, a crown can be used to improve its appearance, shape or alignment. Implants and bridges are used to replace missing ones. Dental implants replace one or more teeth or are used to attach full or partial dentures. Consult with your dentist to see if implants are right for you. Bridges are commonly used to replace one or more missing teeth. They span the space where the teeth are missing. Bridges are cemented to the natural teeth or implants surrounding the empty space.

How Can I Help Make My Teeth Look Whiter?
Thorough cleanings by a dentist or hygienist will remove most external staining caused by food and tobacco. Using a whitening toothpaste can also help remove these surface stains between dental visits. If stains have been present for years, you may need to have your teeth professionally whitened to remove these more stubborn external stains.

Internal stains can be bleached, bonded or capped (crowned). While each of these methods is safe and effective, your dentist will recommend which treatment is appropriate for you depending on the state of your teeth and the results that you wish to achieve.

What Effect Does Diet Have On My Oral Health?
In addition to greatly affecting your overall health, proper nutrition is necessary for healthy teeth and gums. Eating a well-balanced diet gives your gum tissues and teeth the important nutrients and minerals they need to stay strong and resist infections, which can contribute to gum disease. In addition, firm, fibrous foods such as fruits and vegetables tend to help clean the teeth and tissues. Soft, sticky foods tend to remain on the grooves and between teeth, producing more plaque.

Each time you consume foods and drinks that contain sugars or starches, the bacteria in plaque produce acids that attack your teeth for 20 minutes or more. To reduce damage to your tooth enamel, limit the number or between meal snacks and drinks. And when you do snack, choose nutritious foods such as cheese, raw vegetables, plain yogurt or fruit.

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Oral Hygiene and Your Teenager

Oral Hygiene and Your Teenager

Teenagers can be tough on their teeth. They may be so busy with school, jobs, sports and social activities that they don't find time to brush. They also tend to eat a lot of junk food. Combine the two and you've got a situation ripe for tooth decay. Not surprisingly, many teenagers develop a lot of cavities. Here are a few tips to help your child get through the teen years cavity-free: Encourage your teenager to take good care of his or her teeth. This means brushing at least twice a day and flossing daily. Teenagers care a lot about how they look. Help your teen understand that bad oral hygiene can lead to stains, bad breath, missing teeth and many other dental problems. Set a good example. If you take good care of your teeth, your teenager will see that good oral hygiene is important to you. Your talks and warnings will not seem hypocritical and will carry greater weight. Have plenty of oral health-care supplies on hand. Keep soft toothbrushes, colored or flavored floss (or plastic flossers) and good-tasting toothpaste out in the bathroom. You can even keep them in the kitchen for quick use when teens are in a hurry. Don't buy junk food. Instead, keep lots of fruits and vegetables in the house for snacking.

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Fillings: the Basics

Fillings: the Basics

Determining If You Need a Filling Steps to a Filling After a Filling Temporary Fillings Why Replace a Filling? Determining If You Need a Filling Your dentist may use several methods to determine if you have tooth decay, including: Observation — Some discolored spots on your teeth may indicate decay, but not all of them. Your dentist may use an explorer, a metal instrument with a sharp tip, to probe for possible decay. Healthy tooth enamel is hard and will resist pressure by the explorer. Decayed enamel is softer. The instrument will stick in it slightly. Explorers must be used with caution. Pressing too hard with an explorer can damage a healthy tooth. Cavity-detecting dye — This can be rinsed over your tooth. It will stick to decayed areas and rinse cleanly from healthy ones. X-rays — X-rays can help your dentist see decay that doesn't show on the surface. However, X-rays are often not accurate in detecting smaller cavities on occlusal (top) surfaces. Current fillings or other restorations also may block the view of decay. Laser fluorescence cavity detection aids — These small wands measure changes caused by caries (tooth decay). They are especially useful for pit and fissure areas. Decay is not the only reason you may need a filling. Other reasons include: Cracked or broken teeth Teeth that are worn from unusual use, such as: Nail-biting Tooth grinding (bruxism) Using your teeth to open things Steps to a Filling When you visit your dentist to get a filling, you may be given local anesthesia to numb the area if necessary. Next, your dentist will remove decay from the tooth, using hand instruments or a drill. Air abrasion and lasers also can be used to remove decay. A drill, which dentists call a handpiece, uses metal cones called burs to cut through the enamel and remove the decay. Burs come in many shapes and sizes. Your dentist will choose the ones that are right for the size and location of your decay. At first, your dentist will use a high speed drill (the one with the familiar whining sound) to remove the decay and unsupported enamel of the tooth. Once the drill reaches the dentin, or second layer of the tooth, the dentist may use a lower speed drill. That's because dentin is softer than enamel. Once all the decay is removed, your dentist will shape the space to prepare it for the filling. Different types of fillings require different shaping procedures to make sure they will stay in place. Your dentist may put in a base or a liner to protect the tooth's pulp (where the nerves are). The base or liner can be made of composite resin, glass ionomer, zinc oxide and eugenol, or another material. Some of these materials release fluoride to protect the tooth from further decay. If your dentist is placing a bonded filling, he or she will etch (prepare) the tooth with an acid gel before placing the filling. Etching makes tiny holes in the tooth's enamel surface. This allows the filling to bond tightly to the tooth. Bonded fillings can reduce the risk of leakage or decay under the filling. That's because the etched surface of the tooth and the filling material form a mechanical bond. Bonding is generally done with composite fillings. Certain types of fillings get hardened by a special light. With these fillings, your dentist will stop several times to shine a bright light on the resin. This cures (hardens) the material and makes it strong. Finally, after the filling is placed, your dentist will use burs to finish and polish the tooth. After a Filling Some people feel sensitivity after they receive a filling. The tooth may be sensitive to pressure, air, sweet foods or cold. Composite fillings often cause sensitivity, but other types of filling materials can, too. In most cases, the sensitivity will subside over one to two weeks. Until then, try to avoid anything that causes it. If your tooth is extremely sensitive or your sensitivity does not decrease after two weeks, contact your dentist's office. It's important to let your dentist know about any sensitivity you are feeling. The next time you need a filling, he or she may be able to use a different material and make changes to reduce sensitivity. People vary in their response to different materials. Your dentist has no way of predicting if your tooth will react to a particular material. When you talk to your dentist about the sensitivity, try to describe it as precisely as possible. This information will help decide what should be done next. Your dentist may take out the filling and put in a new one. He or she may add a base, liner or desensitizing agent on the tooth as well. If the filling was very deep, you could need a root canal treatment to solve the problem. Besides sensitivity, some people feel discomfort when they bite down. There are two types of pain, each with a different cause. The first type occurs when you bite, and worsens over time. This is caused by a filling that is too high and interferes with your bite. Once your anesthetic wears off, you would notice this right away. Contact your dentist. You will need to return to the office to have the filling reshaped. The second type of discomfort is a very sharp shock that appears only when your teeth touch. This is called galvanic shock. It is caused by two metals (one in the newly filled tooth and one in the tooth it's touching) producing an electric current in your mouth. This would happen, for example, if you had a new amalgam filling in a bottom tooth and had a gold crown in the tooth above it. Your dentist polishes the filling after it is placed, but occasionally sharp edges may remain. You can't detect this at first because of the anesthesia. If you find one, contact your dentist and arrange to have it smoothed as soon as possible to avoid injury to your tongue or mouth. Temporary Fillings You may receive a temporary filling (usually white, off-white or gray) if: Your treatment requires more than one appointment. Your dentist wants to wait a short period of time for the tooth to heal. You have a deep cavity and the pulp (containing the nerve and blood vessels) becomes exposed during treatment. You need emergency dental treatment. A temporary filling may make your tooth feel better. This is because the filling seals the tooth, protecting the pulp from bacteria and reducing sensitivity. Temporary fillings often contain eugenol, an ingredient in over-the-counter toothache remedies. Eugenol is also a component of oil of cloves, which people use for toothache pain. Temporary fillings are not meant to last. Usually, they fall out, fracture or wear out within a month or two. If you get a temporary filling, make sure you visit your dentist to get a permanent one. If you don't, your tooth could become infected or you could have other problems. Why Replace a Filling? Fillings don't last forever. They can become discolored. Composite, tooth-colored fillings pick up stains, and yellow or darken over time. When you chew, your teeth and any fillings in them are subjected to tremendous pressures. Even if no other problems develop, some fillings will wear out over time and will need to be replaced. A filling will need to be replaced earlier if it falls out, leaks or cracks. Food debris and bacteria can seep down under a filling that is cracked or leaking. Since you can't clean there, the bacteria feed on the food debris and form the acid that causes tooth decay. Decay under a filling can become extensive before you notice it or it causes you pain. This is why you should have your fillings checked regularly and get them replaced when problems are found. Fillings That Fall Out Fillings can fall out for several reasons: You bite down too hard on a tooth that has a large filling, and break the filling or the tooth. The filling material that was used cannot withstand the forces placed upon it. For example, if you have broken a large piece of your front tooth, a porcelain (tooth-colored) crown is probably a good treatment choice. In some cases, a dentist may place a composite filling instead. This may look good or acceptable. However, if the composite is too large, a strong biting motion may break the plastic material. The cavity is contaminated with saliva when the filling is placed. For composite resins, this will disrupt the bonding of the material. As a result, the bond will not stick well to the tooth and it may fall out. Cracked Fillings Both amalgam and composite fillings can crack, either soon after they are placed or after the fillings have been in place for some time. Cracks can occur soon after a filling is placed if the filling is higher than the rest of the tooth surface, and must bear most of the force of biting. Cracks also can occur over time, as the forces from chewing and biting affect the filling. Small cracks also can occur at the edges of a filling. These usually are caused by wear over time. These cracks often can be repaired. Leaking Fillings A filling is said to be leaking when the side of the filling doesn't fit tightly against the tooth. Debris and saliva can seep down between the filling and the tooth. This can lead to decay, discoloration or sensitivity. Both amalgam and composite fillings can leak. An amalgam filling sometimes leaks slightly after it is placed. You would notice this as sensitivity to cold. This sensitivity decreases for the next two to three weeks. Then it disappears altogether. Over that period, the amalgam filling naturally corrodes. The corrosion seals the edges of the filling and stops any leaks. A composite filling could be contaminated with saliva. This would weaken the bond between the filling and the tooth and allow for leaks. Other times, there may be small gaps where the tooth and filling meet. These gaps are caused by shrinkage when your dentist places the filling. Sensitivity after receiving a composite filling may disappear over time. If it doesn't, the filling may need to be replaced. Fillings also can leak as a result of wear over time. These fillings should be replaced. Worn-Out Fillings Some fillings can last for 15 years or longer. Others, however, will have to be replaced in as little as five years. Your dentist can determine if your fillings are worn enough that they need to be replaced. Clenching and Grinding If you clench or grind your teeth, you may have more problems with your fillings. The forces placed on your teeth can lead to tooth sensitivity and extra wear on your fillings. Clenching or grinding also can cause your teeth and fillings to crack or develop small craze lines. These are fine cracks you can see if you shine a light on your tooth. Keeping Your Fillings Although some fillings can last for many years, the average life of an amalgam filling is about 12 years. Composite fillings may not last this long. Your dentist will examine your fillings at your checkup visits. You may need X-rays if your dentist thinks a filling might be cracked or leaking, or to see whether decay is occurring under the filling. Make an appointment with your dentist: If a tooth is sensitive If you see a crack If part of a filling appears to be missing You should visit your dentist regularly for cleanings, brush with a fluoride toothpaste, and floss once a day. If you have many fillings or very large fillings, your dentist may prescribe a fluoride gel you can use at home. The fluoride will help strengthen the enamel of your teeth and help to prevent future cavities. Your dentist or hygienist also can apply a fluoride varnish around the edges of these teeth at your checkup visits. Replacing a Filling Before removing your old filling, your dentist will discuss treatment options with you. It is often possible to repair an old filling instead of removing it and replacing it completely. However, if the entire filling has to be replaced, the dentist may reevaluate what filling material to use. Talk with your dentist about how you would like the filling to look. Then he or she can select the material that is best for you.

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What Is Fluoride?

What Is Fluoride?

Fluoride is a natural mineral found throughout the earth's crust and widely distributed in nature. Some foods and water supplies contain fluoride.

Fluoride is often added to drinking water to help reduce tooth decay. In the 1930s, researchers found that people who grew up drinking naturally fluoridated water had up to two-thirds fewer cavities than people living in areas without fluoridated water. Studies since then have repeatedly shown that when fluoride is added to a community's water supply, tooth decay decreases. The American Dental Association, the World Health Organization and the American Medical Association, among many other organizations, have endorsed the use of fluoride in water supplies because of its effect on tooth decay.

How Does Fluoride Work?
Fluoride helps prevent cavities in two different ways:

• Fluoride concentrates in the growing bones and developing teeth of children, helping to harden the enamel on baby and adult teeth before they emerge
• Fluoride helps to harden the enamel on adult teeth that have already emerged

Fluoride works during the demineralization and remineralization processes that naturally occur in your mouth.

• After you eat, your saliva contains acids that cause demineralization a dissolving of the calcium and phosphorous under the tooth's surface
• At other times when your saliva is less acidic it does just the opposite, replenishing the calcium and phosphorous that keep your teeth hard. This process is caused remineralization. When fluoride is present during remineralization, the minerals deposited are harder than they would otherwise be, helping to strengthen your teeth and prevent dissolution during the next demineralization phase

How do I Know if I'm Getting Enough Fluoride?
If your drinking water is fluoridated, then brushing regularly with a fluoride toothpaste is considered sufficient for adults and children with healthy teeth at low risk of decay.

If your community's water is not fluoridated and does not have enough natural fluoride in it (1 part per million is considered optimal), then your dentist or pediatrician may prescribe fluoride tablets or drops for your children to take daily. Your dentist or pediatrician can tell you how much fluoride is right for your family, so be sure to ask for his or her advice.

If your water comes from a public water supply, you can find out if it's fluoridated by calling your local water district. If your water comes from a private well, you can have it analyzed by an independent environmental testing company that provides water-testing services.

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X-Rays

X-Rays What Are X-Rays? X-rays are a form of energy that travels in waves. X-rays can enter solid objects, where they either are absorbed or continue to pass through. X-rays tend to be absorbed by denser objects but pass easily through less dense objects. Teeth and bone are very dense, so they absorb X-rays. X-rays pass more easily through gums and cheeks. That's why cheeks and gums appear dark and without detail on a dental X-ray, but teeth show up much lighter. Restorations such as crowns and fillings, which are even denser than bone, will show up as solid, bright white areas. Dental decay and caries (cavities) will appear on an X-ray as a darker patch. What You See on an X-Ray • Call Now San Francisco Dentist Request for appointment at: (415) 391 - 7751 450 Sutter street, Suite 1905 San Francisco, CA, 94108 http://malidds.com/ ©2001-2007 Aetna All rights reserved. 12/12/2006

What are the Stages of Gum Disease?

 

What are the Stages of Gum Disease?

What is Gum Disease?
Gum disease is an inflammation of the gums that can progress to affect the bone that surrounds and supports your teeth. It is caused by the bacteria in plaque, a sticky, colorless film that constantly forms on your teeth. If not removed through daily brushing and flossing, plaque can build up and the bacteria infect not only your gums and teeth, but eventually the gum tissue and bone that support the teeth. This can cause them to become loose, fall out or have to be removed by a dentist.

There are three stages of gum disease:

• Gingivitis: this is the earliest stage of gum disease, an inflammation of the gums caused by plaque buildup at the gumline. If daily brushing and flossing do not remove the plaque, it produces toxins (poisons) that can irritate the gum tissue, causing gingivitis. You may notice some bleeding during brushing and flossing. At this early stage in gum disease, damage can be reversed, since the bone and connective tissue that hold the teeth in place are not yet affected.
• Periodontitis: at this stage, the supporting bone and fibers that hold your teeth in place are irreversibly damaged. Your gums may begin to form a pocket below the gumline, which traps food and plaque. Proper dental treatment and improved home care can usually help prevent further damage.
• Advanced Periodontitis: in this final stage of gum disease, the fibers and bone supporting your teeth are destroyed, which can cause your teeth to shift or loosen. This can affect your bite and, if aggressive treatment can't save them, teeth may need to be removed.

How do I Know if I Have Gum Disease?

Gum disease can occur at any age, but it is most common among adults. If detected in its early stages, gum disease can be reversed so see your dentist if you notice any of the following symptoms:

• Gums that are red, puffy or swollen, or tender
• Gums that bleed during brushing or flossing
• Teeth that look longer because your gums have receded
• Gums that have separated, or pulled away, from your teeth, creating a pocket
• Changes in the way your teeth fit together when you bite
• Pus coming from between your teeth and gums
• Constant bad breath or a bad taste in your mouth

How is Gum Disease Treated?

• The early stages of gum disease can often be reversed with proper brushing and flossing. Good oral health will help keep plaque from building up.
• A professional cleaning by your dentist or hygienist is the only way to remove plaque that has built up and hardened into tartar. Your dentist or hygienist will clean or "scale" your teeth to remove the tartar above and below the gumline. If your condition is more severe, a root planing procedure may be performed. Root planing helps to smooth irregularities on the roots of the teeth making it more difficult for plaque to deposit there.

By scheduling regular checkups, early stage gum disease can be treated before it leads to a much more serious condition. If your condition is more advanced, treatment in the dental office will be required.

	Healthy Gums - healthy gums are firm and don't bleed. They fit snugly around the teeth.
	Gingivitis - gums are mildly inflamed, may appear red or swollen and may bleed during brushing.
	Periodontitis - gums begin to separate and recede from the teeth. This allows plaque to move toward the roots, supporting fibers and bone.
	Advanced Periodontitis - supporting fibers and bone are destroyed. Teeth become loose and may need to be removed.
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What is Plaque?

What is Plaque?

Plaque is a sticky, colorless film of bacteria and sugars that constantly forms on our teeth. It is the main cause of cavities and gum disease, and can harden into tartar if not removed daily.

How Do I Know if I Have Plaque?
Everyone develops plaque because bacteria are constantly forming in our mouths. These bacteria use ingredients found in our diet and saliva to grow. Plaque causes cavities when the acids from plaque attack teeth after eating. With repeated acid attacks, the tooth enamel can break down and a cavity may form. Plaque that is not removed can also irritate the gums around your teeth, leading to gingivitis (red, swollen, bleeding gums), periodontal disease and tooth loss.

How Can I Prevent Plaque Buildup?
It's easy to prevent plaque buildup with proper care. Make sure to:

• Brush thoroughly at least twice a day to remove plaque from all surfaces of your teeth
• Floss daily to remove plaque from between your teeth and under your gumline, where your toothbrush may not reach
• Limit sugary or starchy foods, especially sticky snacks
• Schedule regular dental visits for professional cleanings and dental examinations

	During scaling, plaque and tartar are removed from the crown and root of the tooth.
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All About Cavities

All About Cavities What's in Your Mouth? How Your Teeth Decay Types and Stages of Decay Preventing Cavities What's in Your Mouth? To understand what happens when your teeth decay, it's helpful to know what's in your mouth naturally. Here are a few of the elements: Saliva — Your mouth and teeth are constantly bathed in saliva. We never give much thought to our spit, but this fluid is remarkable for what it does to help protect our oral health. Saliva keeps teeth and other parts of your mouth moist and washes away bits of food. Saliva contains minerals that strengthen teeth. It includes buffering agents. They reduce the levels of acid that can decay teeth. Saliva also protects against some viruses and bacteria. Plaque — Plaque appears as a soft, gooey substance that sticks to the teeth a bit like jam sticks to a spoon. It is, in fact, colonies of bacteria, protozoa, mycoplasmas, yeasts and viruses clumping together in a gel-like organic material. Also in the mix are bacteria byproducts, white blood cells, food debris and body tissue. Plaque grows when bacteria attach to the tooth and begin multiplying. Plaque starts forming immediately after a tooth is cleaned; it takes about an hour for plaque to build up to measurable levels. As time goes on, different types of microorganisms appear, and the plaque thickens. Calculus — If left alone long enough, plaque absorbs minerals from saliva. These minerals form crystals and harden the plaque into calculus. Then new plaque forms on top of existing calculus. This new layer can also become hard. Bacteria — We have many types of bacteria in our mouths. Some bacteria are good; they help control destructive bacteria. When it comes to decay, Streptococcus mutans and Lactobacilli are the bacteria that cause the most damage to teeth. How Your Teeth Decay The bacteria in your mouth need food to live and multiply. When you eat sugary foods and other carbohydrates, the bacteria use them as food, too. The bacteria then produce acids that can dissolve tooth enamel (outer layer of the tooth). It's not just candy and ice cream we're talking about. All carbohydrate foods eventually break down into simple sugars. These include glucose and fructose. Some of this process begins in the mouth. Foods that break down into simple sugars in the mouth are called fermentable carbohydrates. These include the obvious sugary foods, such as cookies, cakes, soft drinks and candy. But they also include pretzels, crackers, bananas, potato chips and breakfast cereals. Bacteria in your mouth turn the sugars in these foods into acids. These acids begin to dissolve the mineral crystals in teeth. The more times you eat each day, the more times your teeth are exposed to an acid attack. This attack can lead to tooth decay, also known as dental caries. First, the acid begins to dissolve calcium and phosphate crystals inside a tooth. A white spot may appear on the enamel in this weakened area. But the loss of minerals develops beneath the surface of the enamel. The surface may still be smooth. At this stage, the tooth can be repaired with the help of fluoride, proteins and minerals (calcium and phosphate) in the saliva. The saliva also helps reduce the acid levels from bacteria that attack the tooth. Once the decay breaks through the enamel to cause a cavity, the damage is permanent. A dentist must clean out the decay and fill the cavity. Left untreated, the decay will get worse. It can destroy a tooth all the way through the enamel, through the inside dentin layer and down to the pulp or nerve of the tooth. That's why it is important to treat caries at a very early stage, when the process can be reversed. Types and Stages of Decay Young children can get a type of decay called baby bottle tooth decay or early childhood caries. It destroys enamel quickly. This type of decay is common in children who are put to sleep with a bottle of milk or juice. The bottle exposes the teeth constantly to carbohydrates through the night. Bacteria can grow rapidly and produce acid that decays teeth. Decay can become worse if the parent does not clean the child's teeth. It can eat through enamel and leave a large cavity in a matter of months. In older adults, the exposed roots of teeth can develop cavities. This is called root caries. Older adults are more likely to have receding gums caused by years of hard brushing or periodontal disease. They also are more likely to have dry mouth (xerostomia). The decrease in saliva results in less protection of the teeth. This increases the risk of decay. Many common medicines can cause dry mouth. Be sure to ask the doctor or pharmacist if any of your medicines cause dry mouth. Decay can form beneath fillings or other tooth repairs, such as crowns. Sometimes bacteria and bits of food can slip between the tooth and a poorly placed filling or crown. This also can happen if the filling cracks or pulls away from the tooth, leaving a gap. Preventing Cavities Do you or your family members get cavities often? Dental research has found out that certain factors can affect your risk of tooth decay. These factors include The current number of decayed or filled teeth Your fluoride exposure Family history of decay How well you take care of your teeth The amount of saliva and the balance of minerals, enzymes and buffering agents it contains How often and what types of foods you eat (especially carbohydrates) Ask your dentist about the best ways to reduce your risks and limit dental decay. To prevent your teeth from decaying, you can do two things: Strengthen your teeth's defenses with fluoride, sealants and agents that contain calcium and phosphate ions. Reduce the number of bacteria in your mouth. Fluoride penetrates into teeth. It strengthens them by replacing minerals that acid has destroyed. The benefits of fluoride to teeth were first discovered in the 1930s. Dentists started to notice that people who drank water that naturally contained fluoride had less tooth decay. In 1945, communities started to add fluoride to water supplies. Adding fluoride to water systems has been the most successful cavity prevention method to date. In the early 1960s, fluoride also began to be added to toothpaste. This also had a major impact on cavity prevention. Now almost all toothpastes contain fluoride. Everyone should brush with a fluoride toothpaste every day. Dental offices sometimes recommend higher levels of fluoride in toothpastes, gels and mouth rinses for both children and adults. More recently, agents containing calcium and phosphate have been developed. MI Paste and MI Paste Plus both contain Recaldent (the calcium-phosphate ingredient). Your dentist can apply them to your teeth. Recaldent also also can be found in chewing gum (some Trident products) and toothpaste. These agents help prevent and reverse early decay that has not yet led to a cavity. Sealants are protective coatings placed over the tops of the back teeth — molars and premolars. They block bacteria and acids from sticking in the tiny grooves on the chewing surfaces of these teeth. Sealants can be placed in adults and children. Children can have sealants on their baby molars, and also on the permanent molars once they come in. Dentists can put sealants on molars with signs of early decay, as long as the decay hasn't broken through the enamel. You can never get rid of all the bacteria in your mouth. But you can take steps to control bacteria: Brush twice a day. Floss daily. Reduce the number of times each day that you consume fermentable carbohydrates. Some prescription mouthwashes (those that contain chlorhexidine) reduce bacteria in your mouth. This can help prevent decay. Chewing sugarless gums, especially those with xylitol, can help reduce bacteria levels and increase the flow of saliva. Most importantly, visit your dentist regularly. Then the dentist can find any decay early, when it can be treated and reversed. ©2002-2009 Aetna All rights reserved. 3/22/2009

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High-end Implant and Ceramic Work Equals Natural Results

High-end Implant and Ceramic Work Equals Natural Results	August 2011
Artistic skill and ceramic work come together in this case.
The patient, a 75-year-old male, presented with non-restorable lower four anterior teeth. His partial was non-functional and his remaining maxillary teeth were few, leading him to wear a maxillary prosthetic appliance. After analyzing the X-ray and coordinating with the clinical findings, it was determined that the mandibular anterior teeth were non-restorable. Panorex X-ray also revealed that he did have, on a two-dimensional basis, adequate bone support from the apices of the non-restorable teeth to the inferior border of his mandible in the anterior component for implants. It was also noted he had moderate atrophy of the mandibular left and right posterior ridges. The CT scan1,2 of his mandible (Fig. 1) revealed that he had adequate bone thickness and bone density³ apical to the infected mandibular anterior teeth for four implants. Fig. 1: The CT scan verifies the bone density and thickness. Fig. 2: Stereo lithography and bone reduction guide. Fig. 3: The implants were surgically placed. Fig. 4: The temporary abutment verification index placed in the mouth ensures fit in the doctor's office. Fig. 5: A verification index was used to verify implant placement. Fig. 6: Light curing wax was applied over the lower UCLA abutments for design of the lower teeth. The treatment outline 4 was as follows: It was decided to use an interactive CT scan utilizing SimPlant (Materialise Dental) protocol to fabricate stereo lithography stents. One of these stents had a bone reduction guide for bone reduction in the mandibular anterior area (Fig. 2). The patient was prepped with standard operating procedures on an outpatient basis. We then proceeded to extract the mandibular non-restorable anterior teeth and at that time a bone reduction guide was placed over the osseous structures. It was determined that we would perform bone contouring in the mandibular anteriors to reduce the sharp ridges that remained after the extraction. The horizontal reduction of bone resulted in a wide buccal-lingual dimension so that circumferentially, implants would be completely encased in bone. Bone density using Hounsfield units was evaluated via SimPlant and showed that he had adequate bone density,5 which consisted of D1 and D2 bone for 15mmX5mm BioHorizon implants in the mandibular anterior area. After this, the bone reduction guide was used to reduce the bone height in the mandibular anterior and eliminate the sharp ridge. Four BioHorizon implants, 5mm in diameter and 15mm in length, were strategically placed in the mandibular anterior area (Fig. 3) and temporary abutments for verification index were placed (Fig. 4). After the implants were placed using the stereo lithography guides, the ridges in the posterior quadrants bilaterally (they had a knife ridge) were reduced in order to eliminate the disparity of ridge height. It was beneficial to level the bone throughout the mandibular arch by removing the very thin knife ridges in the posteriors. With the surgical reduction coping and the stereo lithography guide, the trimming of the bone of the posterior region resulted in an even osseous structure throughout the mandibular arch. The surgical protocol and implant placement resulted in excellent healing.6 Fig. 7: Primopattern LC paste was used to wax the framework. Fig. 8: The framework design was contoured. Fig. 9: The wax-up with UCLA abutments were spruced and ready for investing. Fig. 10: The framework was invested using GC Fujivest. Fig. 11: After casting, the restorations were placed on the model to ensure proper fit and design. Fig. 12: The porcelain's custom shade was checked on the model. Fig. 13: The author's multi-porcelain layering technique was utilized using GC Initial MC porcelain for life-like crowns. Fig. 14: After first firing, the porcelain had this appearance. Fig. 15: Porcelain build-up was checked for shade match. Fig. 16: Completed build-up appearance before firing Fig. 17: Side view, immediate placement Fig. 18: Gum color check, opposite side Approximately four or five months after the surgery, the mandibular anterior implants were exposed and healing caps were placed. The patient has good oral hygiene and was extremely compliant. After the implants were uncovered, standard operating protocol was instituted for impression taking using an open-tray technique. Verification jigs were fabricated and it was ascertained that he had a passive fit (Fig. 5). The protocol established was to place the patient in fixed restorations with four well-placed, well-integrated, long implants with UCLA abutments for design study, in good quality bone with the protocol of a fixed appliance (Fig. 6). The abutments were compared to the upper denture study model for proper design of the mandibular reconstruction. Maxillary reconstruction will also be planned after completion of the mandibular arch. After grinding the abutments for size check, light-curing wax was placed on top, burned out and cast, then baked at 1,550 degrees Fahrenheit (Figs. 7 & 8). Resulting frame design was completed and exhibited (Fig. 9) – ready for investing, with GC Fujivest the next completed step (Fig. 10). After casting, the restorations were placed on the model to ensure proper fit and design (Fig. 11) and the technician performed a custom shade check (Fig. 12). Using a porcelain multi-layering technique, GC Initial MC porcelain was applied by the technician for natural, life-like crowns (Fig. 13). The porcelain had this appearance after first firing (Fig. 14) and the build-up was then checked for shade match (Fig. 15). Before firing, the completed build-up had this appearance (Fig. 16). In a side view, after immediate placement, note the detailed design of the teeth (Fig. 17). The mesial of #27 was created to protrude slightly and the distal of #26 is purposely in slightly for a natural appearance. Likewise, the mesial of #26 is moved outward and the distal of #25 inward. For an exact match, (Fig. 18) the gum color was created using GC MC Gum Shade and the LSK Chairside Shade Guide system as a matching standard in order to reproduce excellent ceramic color for patient tissue. Close observation will reveal a medium pink base color, with a clear application on top and a slightly frosty layer to finalize the effect. Regarding the shape of the gums, the technician's goal was to create a healthy appearing gingival area by following a natural convex and concave flow to the tissue. Saliva underneath the gum tissue was mimicked for a life-like gum appearance, with a whitish horizontal line in the gingival third and translucency and opal, white and clear combination in the incisal third. In the incisal edge, an orange brown color was very lightly applied to mimic exposed dentin, but not severely. Interproximally, an appropriate amount of ochre stain further mimics the age of the patient's teeth. These modifications were applied based on the author's impression of the patient's existing dentition and his applied integration in order to create a vivid, life-like appearance. Understanding occlusion concepts, he knows that the mandibular needed to be built accordingly, taking into consideration the curve of Spee. Fig. 19: Front view (final) In the final full frontal view (Fig. 19), the concept of natural teeth is fully displayed. This restoration is an ideal example of a life-like case, with all the artistic skill and ceramic work coming together at the same time. These results were only possible due to perfect preparation and teamwork, all working in harmony. The proper tools – GC Initial pink porcelain for stump color and a shade guide that precisely mimics real color – contributed to the outcome, as well. These beautifully segmented teeth, flawlessly transitioned, offer a perfect solution to this patient's smile. The various prosthetic protocols were carried out for try-ins and establishing a proper plane of occlusion and the fixed bridge was screw retained. Excellent exit of the screw holes in the prosthesis was achieved, through planning, clinician-lab communication and also with stereo lithography stents that would allow the trajectory to be at the center of the cingulum of the implants. The case was extremely successful and the patient was pleased. Oral hygiene instructions were given to the patient. It is noted that on one of the photographs, he has a maxillary temporary denture only on several teeth. Phase II of this treatment will be to remove the remaining maxillary teeth and establish the same protocol of implant placement on the maxillary arch. The patient is in treatment for the maxillary arch and the part two would be to show the completed case with the maxillary reconstruction. References Sarment DP, Al-Shammari K, Kazor CE. (2003 Jun). Stereolithographic surgical templates for place ment of dental implants in complex cases. Int J Periodontics Restorative Dent. 23(3):287-95. Lal K, White GS, Morea DN, Wright RF (2006 Jan-Feb) Use of stereolithographic templates for sur gical and prosthodontic implant planning and placement. Part I. The concept. J Prosthodont. 15(1):51-8. Rebaudi A, Trisi P, Cella R, Cecchini G. (2010 Jan-Feb). Preoperative evaluation of bone quality and bone density using a novel CT/microCT-based hard-normal-soft classification system. Int J Oral Maxil lofac Implants. 25(1):75-85. Tischler M. 2010 Sep-Oct. Treatment planning implant dentistry: an overview for the general dentist. Gen Dent. 58(5):368-745. Turkyilmaz, I, Turkyilmaz, TF, Tumer, C. (2007 April). Bone density assessments of oral implant sites using computerized tomography. Journal of Oral Rehabilitation. 34(4):267-272. Abbo B, Razzoog. ME. 2007 Jul. Restoring the partially edentulous patient in the aesthetic zone: computer-guided implant surgery. Dent Today. 26(7):136, 138-40.
Author Bios
Joseph L. Caruso, DDS, MS, is licensed to practice dentistry in the states of Illinois and California and holds a specialty license in prosthodontics. His extensive training and experience include comprehensive and complex implant treatments along with full-mouth reconstruction emphasizing high aesthetic porcelain veneers and crowns. Dr. Caruso was awarded the Leonardo da Vinci Award for Excellence in Dentistry for 2005. He received his doctorate degree from Northwestern University's School of Dentistry and his master's degree in oral biology from Loyola University. He is active in continuing dental education and often lectures nationally and internationally on the latest diagnostic CT scans for implant and aesthetic techniques. He also participates in the testing and evaluation of advanced technological equipment and materials as they relate to modern clinical dentistry. He has been elected and is a fellow to both the American and International College of Dentists. Luke S. Kahng, CDT, is the owner of LSK121 Oral Prosthetics, a dental laboratory in Naperville, Illinois. In addition to being a board member for several dental publications, he has published more than 60 articles with major dental journals. He also lectures internationally, offering hands-on seminars to dental technicians and clinicians alike.The first edition of his highly successful Chairside Shade Selection Guide was launched in 2009, with international sales worldwide. Changes were incorporated into the second edition of the Chairside Shade Guide, launched in November 2010, with updating to include three components: posterior, anterior and rehabilitation design, specific for in-office custom shade matching techniques.He is the author of three hardcover books, including Anatomy from Nature, The Esthetic Guide Book and Smile Selection + CS³ Clinical Cases. Visit www.lsk121.com for more information.

Call Now San Francisco Dentist
Request for appointment at: (415) 391 - 7751
450 Sutter street, Suite 1905
San Francisco, CA, 94108
http://malidds.com/