FAQs Continued....

Orthodontics
My son is 8 years old. At his last dental exam his dentist recommended that he see an orthodontist. Is 8 years old too young for braces?

The American Association of Orthodontists recommends as orthodontic examination for all children by age 7. Early evaluation provides your orthodontist the opportunity to examine your child's developing dentition and, in some cases, recommend orthodontic treatment. Subtle orthodontic problems with jaw growth and emerging teeth can be detected while some baby teeth are still present. While your child's teeth may appear to be straight, there could be a problem that only an orthodontist can detect. A check-up may reveal that your child's bite is fine. Or, the orthodontist may identify a developing problem but recommend monitoring the child's growth and development, and then, if indicated, begin treatment at the appropriate time for the child. In other cases, the orthodontist might find a problem that can benefit from early treatment. Early treatment may prevent or intercept more serious problems from developing and may make treatment at a later age shorter and less complicated. In some cases, the orthodontist will be able to achieve results that may not be possible once the face and jaws have finished growing. Early orthodontic care can be used to expand the dental arches and provide space for erupting teeth, guide the eruption of impacted teeth, or improve bite problems such as overbites and underbites. This type of orthodontic treatment is usually a first step, referred to as "Phase 1" of orthodontic care. Children are monitored in the years following Phase 1 orthodontics and most will have follow-up or "Phase 2" braces between the ages of 11 and 13 to perfect the bite and alignment of teeth. If your child is older than 7, it's certainly not too late for a check-up. Because patients differ in both physiological development and treatment needs, the orthodontist's goal is to provide each patient with the most appropriate treatment at the most appropriate time. Through an early orthodontic evaluation, you will be giving your child the best opportunity for a healthy, beautiful smile. 


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I have had my braces off for three years and am very pleased with the result. I am worried that my wisdom teeth will come in and crowd my teeth. What should I do?
In about three out of four cases where teeth nave not been removed during orthodontic treatment, there are good reasons to have the wisdom teeth removed, usually when a person reaches his or her late teen years. Your general dentist or orthodontist may recommend that your have your wisdom teeth removed if they are impacted or susceptible to infection or decay. Studies have shown that as people age, their teeth may shift. This variable pattern of gradual shifting, called maturational change usually slows down after the early 20's, but still continues to a degree throughout life for most people. Careful studies have shown, however, that wisdom teeth do not cause or contribute to the gradual crowding of lower front teeth that can develop in the late teen years and beyond. Wearing retainers as instructed after orthodontic treatment will provide the stability needed to prevent unwanted shifting of teeth. Most orthodontists examine patients after their braces are removed once or twice a year to evaluate the fit of retainers, the stability of the orthodontic result, and also the development of wisdom teeth. 


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What payment options are available for orthodontic treatment?
Most orthodontic practices offer several payment options. Treatment can be paid in full or, more commonly, the responsible party will elect to utilize a payment plan arranged with the office. In-office plans are often interest free and, therefore, a very popular payment choice. There are also outside lenders who cater to orthodontic patients. These services provide more flexibility in treatment.


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Pain When Biting
Q1: "I have a tooth that only hurts when I bite down on it with certain foods, and then the pain goes away. What do you think could be the problem?"

A1: This is one of the most common problems that dentists see in their offices. There can be several reasons why a tooth becomes sensitive to biting, and there are different tests that can be performed by your dentist to help pinpoint the problem. Every tooth has a nerve, unless it has had a root canal. This nerve gives your tooth the ability to let you know when something is wrong. You are correct to not ignore the problem. Listed below are some of the common problems associated with pain only when chewing. 
 

  • A high bite on a recently placed filling or crown: This can occur on the treated tooth or on the tooth which bites against the recently treated tooth.
  • A cracked tooth: A cracked tooth will hurt when you bite down for a short moment and most often will hurt worse when the pressure is released.
  • A loose filling: A loose filling will move when you bite down, causing pain.
  • Decay in the tooth: Often times teeth with deep decay will hurt when biting down.
  • Sinus infection: Upper back teeth will often hurt when there is a sinus infection. It is important to determine if an abscessed tooth is causing the sinus infection, or if the sinus infection is causing the tooth to hurt.
  • Clenching and grinding: Clenching and grinding will usually make several of your teeth sensitive to biting at the same time. Even if you don't think you are clenching or grinding, you may be doing it at night while you sleep.
  • An unbalanced bite: The teeth are supposed to share the load of your biting forces and they are supposed to bite together in a certain way. If the bite is not balanced, certain teeth will be over stressed and will become sensitive to biting pressure.
  • An early abscess: A tooth with an early abscess, or dead nerve, will become sensitive to biting. Eventually the pain will begin to linger and will begin to hurt even when you are not biting.


As you can see, a simple symptom of pain when biting is actually a complex issue with several possible causes. You have to be a little patient as your dentist may have to go through a process of elimination in order to determine the actual cause of the problem. Giving detailed information regarding when, where, how long, and with what, will help your dentist develop a diagnosis more quickly. 
 

Q2: "I have a tooth that is very sensitive when I bite down, but not all the time. What can cause this?"


A2: Biting or pressure sensitivity can be caused by several things. I will outline some of the most common causes and their related symptoms and treatment. The important thing is not to ignore your teeth when they talk to you. Little problems will usually develop into bigger problems. 

  • Abscess: When the soft neurovascular tissue in the center of the tooth (pulp) dies, then bacteria will begin to colonize within the tooth and eventually produce puss. This puss then leaks out into the bone at the tip of the tooth and causes pain and swelling. This pain is usually fairly constant and comes on for no reason. Chewing usually makes it worse, and on upper teeth the sinus can be affected. An abscess is treated by a root canal. 
  • Clenching: Many people grind and clench their teeth and some do it subconsciously while they sleep. This can cause biting sensitivity throughout the day and typically more than one tooth is involved. It is very common to have upper and lower teeth affected on the same side. A hard acrylic bite splint, worn at night, is usually the first recommended treatment. Equilibration of the bite may also be needed. 
  • Cracked tooth: Cracks are very common in the teeth. Most often cracks occur in teeth with large fillings, or in patients that clench and grind their teeth. Some cracks do not cause pain initially, but will usually develop into larger cracks that do cause pain. Typically a cracked tooth hurts more with the release of pressure, but may also hurt when pressure is applied. The pain is usually of short duration, and sporadic in occurance. Cracks may cause the death of the pulp. Treatment usually involves a crown and quite often a root canal as well. 
  • Unbalanced bite on a recent filling or crown: When patients have dental work performed they are usually numb. Therefore it is often difficult to obtain an accurate bite on the new filling, crown, or other type of restoration. If the bite is just a little high on the new restoration, the tooth will become sensitive when biting, usually after about 5 days. Your dentist can usually perform a bite adjustment and correct the problem. 


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Periodontal Disease Questions
Q1: "What is Periodontal Disease?"

A1: Periodontal (gum) disease is the major cause of about 70 percent of adult tooth loss, affecting three out of four persons at some point in life. It is an infection caused by bacteria living in one's mouth. These bacteria, collectively called dental plaque, produce "toxins" that irritate the gum tissues, causing inflammation (redness, tenderness, swelling, bleeding, but rarely pain). As the disease progresses, destruction of the bone and supporting tissues around the teeth occur, eventually leading to tooth loss. 

 

Q2: "What are the signs and symptoms of Periodontal (gum) Disease?"

A2: There are a number of signs of gum disease, but few symptoms. One may notice bleeding of the gums during tooth brushing, red, swollen or tender gums, persistent bad breath, loose or separating teeth, a change in one's bite, pus between one's teeth and gums, and receding gums. On the other hand, you may have gum disease and not have any obvious signs. Symptoms such as pain rarely occur. Smoking "masks" the signs of gum disease as well, yet smoking is a major contributing factor to gum disease. 

 

Q3: "I've been told I have "Pyorrhea." What is that?"

A3: Pyorrhea is an old term of Periodontal Disease. 

 

Q4: "How can I find out if I have Periodontal (Gum) Disease?"

A4: By using X-rays of your teeth and bone, along with measuring the depth of the gums around your teeth, your dentist or a dental specialist (called a periodontist) can determine if you have periodontal disease. 

 

Q5: "What Causes Periodontal (gum) Disease?"

A5: Periodontal disease is a bacterial infection caused by the bacteria living in one's mouth. This bacterial film or "plaque" sticks onto the tooth surface and produces toxins that irritate the gum tissue. Over time, the plaque mineralizes onto the tooth surface to form what most people call "tarter" or "calculus." A person's genetics plays a role as well, making some people more susceptible to periodontal disease than others. Certain health factors, such as diabetes, greatly affect one's resistance to periodontal disease. Many clinical studies have also shown that use of tobacco products is detrimental to the health of the gums, and it is often times very difficult to obtain excellent periodontal treatment outcomes on those that smoke.

 

Q6: "What other factors might contribute to Periodontal Disease?"

A6: Although bacterial "plaque" and tarter are the main causes of gum disease, genetics plays a role as well, making some people more susceptible to the disease. Other contributing factors include: cigarette smoking, smokeless tobacco, systemic health concerns such as Diabetes, and stress. It is important to note that these factors are not causative, just contributive. 

 

Q7: "How is Periodontal Disease Treated?"

A7: Following thorough examination to diagnose the disease, treatment will depend on a number of factors, including disease severity, systemic health issues, and patient age. Initial therapy usually involves "deep cleaning" under the gum line to remove plaque and tarter deposits off of the roots of the teeth. Sometimes more advanced treatment, in terms of periodontal surgery, can be necessary as well. The main goal of periodontal therapy is to thoroughly "decontaminate" the tooth surface under the gum line. It is important to understand that since gum disease is a "chronic" disease, it is never completely cured, but rather controlled over time. Thus, ongoing care is needed and once the disease is initally brought under control, frequent "periodontal maintenance cleanings" are necessary for most patients. 

 

Q8: "Can Periodontal Disease contribute to other health problems?"

A8: It used to be the thought that periodontal (gum) disease only led to possible tooth loss. However, a great deal of research has clearly shown that uncontrolled gum disease can contribute to other general health concerns including: Cardiovascular (heart) disease and stroke, diabetes, bacterial pneumonia, Rheumatoid Arthritis and preterm, low-birth weight infants. Other connections to general health are under investigation as well, since periodontal disease is a major source of inflammation within the body. Therefore, controlling gum disease is important, not only to save one's teeth, but also for one's overall health.

 

Q9: "Can Periodontal Disease be prevented?"

A9: Most cases of Periodontal Disease are the result of neglect on the part of the patient. Thorough brushing and flossing on a daily basis, along with regular dental care (which should include routine periodontal examination for all adults), will help prevent very common human diseases. However, since genetics also plays a role in some forms of periodontal disease, some patients are much more susceptible to gum disease than the average person. In these cases, the disease may begin at a much earlier age and progress much more rapidly than normal. 

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Permanent Teeth That Never Develop
Q: "My daughter is missing one of her permanent teeth in the front of her mouth. What causes this, and what can be done after the baby tooth comes out?"

Congenitally missing teeth are surprisingly common, and these missing permanent teeth can be in different areas of the mouth. Extra teeth, or supernumerary teeth, can occur as well. The cause is most often genetic, and the same missing teeth can usually be found in other close family members. The condition may also skip generations. Sometimes the baby teeth can be retained longer since there is not a permanent tooth to push it out. I have seen several patients in their fifties that still had their baby teeth in the back, but this is less common in the front teeth. Other times, the roots of the baby teeth can not hold up to the strength the adult muscle forces when chewing, and they are lost. Several things can be considered when this problem occurs. 

1. Spaces should not usually be left open since this may cause tooth shifting and atrophy (shrinkage) of the bone where the tooth was supposed to be. This bone shrinkage would make it harder to place an implant in the future. 

2. Spaces can sometimes be closed with braces (orthodontics) if the other teeth are big enough to fill the width of the jaw. 

3. The space for the permanent tooth can be created and preserved with braces. This allows the placement of an implant which then takes the place of the permanent tooth that was supposed to be there. This is usually the best option if there is just too much space to close with braces. Long term success is excellent with implants, and the implant would prevent the atrophy of the bone just like a normal tooth would. 

4. If the permanent tooth space is preserved or created, a fixed bridge can be made using the adjacent teeth for anchorage. Since healthy teeth have to be altered to make a fixed bridge, it is becoming more common to do implants than bridges. 

Some of these options may only be performed on fully grown individuals. While we are waiting for growth to occur, there are several ways of temporarily placing a fake tooth in the missing space to help keep your daughter smiling. 

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Porcelain Veneers and the "Hollywood Smile"

Thanks to the television show "Extreme Makeovers," many people have become aware of the dramatic changes that can be achieved through cosmetic dentistry. Porcelain veneers, or laminates, are one of the common procedures used on the makeover recipients. Porcelain veneers are a thin shell of porcelain, similar to a fake fingernail, that is bonded to the surface of a tooth. They can be used to lengthen the teeth, make the teeth look straighter, widen the teeth, or to cover dark discoloration on the teeth. Most often, some preparation of the tooth, though minimal, is required. Therefore, the procedure is not usually reversible. Porcelain veneers cannot be used on a tooth that has had a lot of previous loss of tooth structure from decay or fracture. In those cases, crowns are a better alternative. 

Unlike the "Extreme Makeover" cases, porcelain veneers are not the preferred choice for many aesthetic concerns. For instance, if teeth are not straight, then orthodontics (braces) is usually the preferred choice because orthodontics does not require irreversibly changing the existing tooth structure. Additionally, veneers may not be the best choice for someone who has a problem with clenching or grinding their teeth, as this will cause premature failure of the veneer. Most importantly, if there is inadequate support on the back teeth to withhold the pressures of chewing, then the front teeth may become overly stressed. In this case too, porcelain veneers would be a poor choice. 

There are many choices in dentistry today, but is important for the patient to make informed choices. Unfortunately, it is not always as simple as it looks on television. Careful planning is as important in remodeling a mouth as it is in remodeling a house. The rewards of a beautiful smile are worth the extra time and patience. 

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Preferred Provider Dentists
Q: "My dentist is not included on a "preferred provider" list given to me by my insurance company and because of this, I have to pay higher CO-pays. Why do some dentists choose not to be a preferred provider, and should I consider switching providers?"

A: This question can be very complicated to answer because one dentist's reasons for not becoming a "preferred provider" can be different from that of another dentist. First of all, the designation of "preferred provider" should not be interpreted as a description of the clinical skills of the dentist. The benefit (to a dentist) of being a "preferred provider" is having your name on a "list," which in turn brings in new patients to the dental office. In return, the dentist usually agrees to offer a discount, in their fees, to the patients enrolled in that particular dental plan. These dentists feel that they can provide an acceptable standard of care while, at the same time, discounting their fees. Essentially, they consider that the new patient flow (resulting from being a "preferred provider") outweighs the discount in their fees.

Conversely, if a dentist feels that their usual fees are fairly set in accordance to what they need to be, in order to provide a certain standard of care, they are not likely to enroll in the plan. Instead, they choose to rely on referrals from other satisfied patients to build their practice.

It would not be accurate to say that "preferred providers" always offer a lower standard of care or vice versa. It depends on the dentist, the office, and many other considerations.

This is where you come in as the patient and consumer of services. If your current dentist has always taken time answering your questions, insured your comfort, maintained a well qualified staff, state of the art facilities, and has generally made you happy, then maybe the difference in co-pay that you pay is worth it. Excellent doctor-patient relationships are very valuable, and the cost of losing that type of relationship may be higher than what the savings, to you, was worth.

If you choose to explore the "preferred provider" option, it would be best to discuss this with your current dentist to determine your ability to return if you are unsatisfied with the new provider. When trying the new "preferred provider," you will already have your experiences with your current provider for comparison. If you find that your dental cleanings take half the time, and other important things are sacrificed, then you have to make a decision on what you value most; your savings or your care. Always remember that the best decisions in health care are made between doctors and patients. The way a third party reimburses for care should always be a secondary consideration. 

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Radiation Exposure
Q: "It seems that all of the dental X-rays could be harmful. Should I be worried?"

A: As you probably know, dental X-rays involve a very low dose of radiation. This tiny dose of radiation is nothing for you to worry about, but your dentist takes special precautions to eliminate any safety risks. That's why your dentist covers you with a lead apron. The benefits of any dental procedure should outweigh the risks. By providing early detection and prevention of dental disease and pathologic diseases, dental X-rays provide far more benefits then the minimal risk from the small dosage of radiation. Our office now uses digital X-rays which have reduced radiation exposure by 80-90% over regular dental film. We view our X-rays on the computer instead of on a view box. Since this technology is available now, it should be utilized. It may take dentists a while to completely convert because of the rather high cost of the technology. 

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Replacing Existing Crowns
Q: "Why does my permanent crown on my tooth need to be replaced? I thought it was good forever."

A: A crown on a tooth is still placed over the natural tooth. There is always an interface between where the edges of the crown end and the tooth begins. This interface is still susceptible to all of the diseases that affect a natural tooth, especially exposure to acids like those found in soda pop and plaque. Decay may begin beneath the edge of a crown at the gum line. This sometimes can only be treated by removing the "permanent crown" and replacing it with a new one after the decay is removed. 

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Restoring Baby Teeth
Q: "Why should I pay to fix my child's baby teeth. They are going to fall out anyway?"

A: If cavities in baby teeth are not treated they will cause pain or infection. If this goes on too long the permanent teeth may become harmed. If the baby tooth becomes badly decayed or has to be pulled, teeth will shift and there will be space lost for the permanent teeth to come in. This will result in expensive orthodontic problems that will need to be treated later. With the modern dentistry of today, cavities can be treated when they are very small, often without local anesthetic. 

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