Dental Health in Early Childhood

By age two, most of the twenty primary teeth are in place, and the child should have been to the dentist at least once for an examination. Fluoride treatments will help to harden teeth against the ravages of children s diet and improper oral hygiene. Until about age seven, you should allow your child to brush correctly.

A Conversation With a Parent

I recall one parent, whose child had multiple cavities at every visit, telling me, “Dr. Bonnick. I do everything right with this child. I brush her teeth every night myself. She does not eat candies. My husband and I have decided not to buy snacks. I just don t know what to do?

She continued, “Well, Dr. Bonnick, it must be genetic. My whole family has soft teeth. It runs in the family. This dental thing is getting expensive, and I have three children. They all come here.”

I asked her, “When do you brush their teeth in the morning?”

She replied, “Dr. Bonnick, we are in a mad rush to get them to school. We are always running late; the kids hold us up. Do you have kids? Doesn’t everyone make their kids brush their teeth when they get up? Could their breath smell bad? We don t have time to brush after breakfast because we are rushing to get to school.”

I then asked, “When they get to school, do they brush?”

She replied, “They can’t brush in school. The teachers won’t allow them to brush in school. Aren’t they supposed to brush when they first get up?”

My response was that they should brush after eating to remove leftover food so the bacteria can starve. The rule is after any meal, snack, or drink (except water), all of us should brush our teeth.

This parent required her kids to brush twice a day — once when waking up and once before going to bed. By not brushing after meals, they wear plaque on their teeth for the rest of the day until bedtime. This is a prime scenario for cavities and gum disease to develop.

The parent mentioned that her school would not let their kids brush their teeth after lunch. She asked, “Would you give me a note for the teacher?”

“Absolutely, “ I replied. “If you have the children brush when they wake up, have them brush again after breakfast, and if they brush after lunch, they’ll be on their way to better oral health.” 

How Bacteria Grows On Your Child’s Teeth

It is incredible how many well-intentioned parents and teachers will tell the children to brush their teeth two times per day. The proper way to care for teeth and preserve them from the destruction of cavities is to brush within twenty minutes after each meal, drink, or snack.

As a dental student, I remember researching my senior project at the University of Maryland Dental School with a biochemistry professor. My job was to grow Streptococcus mutants (the most important bacteria to the creation of cavities in teeth) and study their adherence to smooth surfaces in different concentrations of sucrose similar to concentrations found in nature.

The goal was to determine how these bacteria stick to the smooth part of teeth and enable other bacteria to stick to the tooth surface. I obtained sugar cane juice from the government agency that quarantined it and found the sucrose concentration to be around 20 percent. I made up samples of 20 percent,10 percent, 5 percent, and 2.5 percent sucrose by diluting the sample with distilled water and used control samples of the same concentrations drawn up with pure sucrose(cane sugar) and distilled water.

My hypothesis assumed that adherence of the bacteria would be less with the natural juice than with pure sucrose. This unpublished study gave us two results: the bacteria had similar results to adherence between the pure sucrose and sugar cane juice, but surprisingly, the bacteria in the sample showed more adherences in the sample at 2.5 percent than at 20 percent (The bacteria glued themselves to a smooth surface easier at a lower concentration of sugar.).

The application of this knowledge to the mouth shows us that the bacteria’s activity is not that high at higher sugar concentrations. Still, as sugar in the mouth becomes more diluted with time, it promotes more adherences of Streptococcus mutants. So if you had fruit or some juice with sucrose and you did not brush right away, the lower concentration of sucrose (dilution) would make the bacteria more active (with time, bacteria sticks to teeth better) and cause more holes in your teeth.

Many parents are health-conscious, and sometimes it works to the detriment of their children. Some refuse to have their children drink fluoridated water, and instead, they use bottled or filtered water. These children not only lose the benefit of the hardening properties of fluoride when their teeth are developing, but they should use topical fluoride more often at a time when they are more likely to have dental cavities.

Care of Your Child’s Permanent Teeth

At approximately six years of age, the first permanent teeth start appearing in the mouth, and it is essential to have them sealed to protect them from cavities when children are not very good at cleaning their teeth. Baby teeth are often partially covered with gum tissue, and because it hurts to brush, some children neglect the proper cleansing of the area.

The first large back tooth is called the first molar. The first molar is one of the most important teeth for stabilizing the bite, and it usually appears when the child is six years old. It is the most important back tooth, and it represents the sweet spot for chewing.

The first molar is the tooth that is most often filled, extracted, or in need of root canal treatment because it is one of the first permanent teeth that appears in the child s mouth. Loss of the first molar is a common reason for posterior bite collapse (back teeth don t fit together well, so the bite is not as efficient as it could be). If it is lost, immediate replacement with an implant is of extreme importance.

The bone grows with the adult teeth’ eruption, and because of this continually growing as a child continues to grow, it is not a good idea to place an implant in the growing patient. Until the end of the growth spurt, bone development could change the relationship of the crown of the tooth with the developing bone.

Suppose a first molar or any primary tooth is lost early. In that case, have your child evaluated for a space maintainer (a device to maintain the space for an erupting tooth, prosthesis, or implant).

The mixed dentition stage is a confusing time for most parents. The primary teeth are being lost as permanent teeth are erupting into place, and the child is going through a growth spurt. Puberty gingivitis is common as hormonal changes, as well as poor flossing habits (non-flossing) by children, promote excessive plaque buildup.

Lack of flossing leads to more cavities between the teeth, so teeth sealed on top can still have cavities through the sides. Root canal treatments, as well as large fillings, are common during this time.

Your orthodontist will begin treatments during this transitional time for many reasons. Growth spurts can be used to correct malocclusions, and loss of teeth allows the orthodontist to move teeth into more ideal positions.

Levels of Occlusion

There are generally three classifications of occlusion (the way teeth come together). 

Class one occlusion is one in which the relationship between the upper and lower teeth is ideal. The upper teeth should be on the lower teeth cheek side, and the teeth relate correctly.

Class two occlusion is a relationship where the upper jaw and teeth stick out too far from the lower teeth, and the connection is one of a protruding upper jaw.

In a class three occlusion, the lower teeth stick out ahead of the upper teeth and give the appearance of a strong jaw. 

  • An overjet is not an abnormal condition. When the distance between the upper and lower front teeth is so far apart, it makes incising (biting) difficult or stresses the lower jaw to move extremely forward to touch the upper jaw. Overbites should be treated.
  • An overbite is the measurement of the upper front teeth closure over the lower. When an overbite is extreme, the lower teeth sometimes hit the upper gum near the mouth’s roof. Severe overbites should be corrected.
  • A crossbite can exist with one or more teeth when the upper teeth relationship is on the lower teeth tongue side. A slight overlap (degree) may not be harmful, but your dentist can determine whether it should be evaluated or not. A crossbite left untreated could result in facial deformities and improper development of one or both jawbones.

During the mixed dentition stage, the primary challenge is to get the child to brush after every meal and floss once or twice per day. The environment and parents attitudes set the tone for early-adulthood habits and determine how much it will cost for dental care in the future.

 

 

Implant Dentistry Guide – What You Should Know

Dental implants come in many various forms. There are subperiosteal implants, ramus frames, blades, and root form implants. A subperiosteal implant is used for areas where the bone is not sufficient to accommodate root form implants. Subperiosteal implants are also used in shrunken lower jaws. The ramus frame and blade implants are mostly used in the lower back jaw when the patient is not an ideal candidate for advanced bone grafting-techniques, or the doctor is proficient with this procedure and offers it as an option. The most common type of implants used most of the time are root-form implants that mimic the tooth’s root. The reasons given in this chapter are addressed primarily to the root form implant.

The implant consists of a titanium alloy that is biocompatible to the bone and encourages the bone to form around it, holding it in place. The healing process is referred to as osteointegration.

Once the implant becomes osteointegrated, it helps to preserve alveolar bone. Approximately 60 percent of the bone in your jaws grew in response to the erupting teeth. When a tooth is extracted, you go through a process of losing bone in that area that can last a lifetime. An implant helps to preserve this bone structure by slowing down the shrinkage. It also helps to prevent malocclusion. When you lose a back tooth, you set up shifting in the other teeth. Teeth adjacent tend to move into space, and the teeth opposing drift up or down into the newly formed space. Some spaces become food traps and contribute to bad breath and periodontal disease.

Implants can slow facial atrophy- shrinkage which occurs in facial muscles when they are not adequately exercised. Roughly 150 newtons of force are applied on normally functioning back teeth, while only 50 newtons are applied on the front teeth. This force keeps the facial muscles toned and maintains our looks. If missing teeth are replaced with implants, this force is restored, and good facial muscle tone is preserved. Additionally, the ability to chew correctly vastly improves the digestion process.

Teeth are more efficient at chewing than dentures, sometimes two or three times more. There is an increased risk of aspiration of food if you have false teeth. Aspiration of food is one of the causes of death in the elderly that hardly gets mentioned, except in CPR courses. To keep false teeth more stable, many denture users will place denture adhesive inside their dentures to help keep them in place. In America, about $148 million is spent on denture adhesives every year.

Complete lower dentures usually move about ten to twelve millimeters during chewing and contribute to the need to chew softer foods that may be less nutritious. Many denture wearers develop anti-social tendencies because of their limited ability to chew a wide variety of foods. Many are unwilling or are uncomfortable when they go out for a meal.

Dental implants will stabilize dentures, crowns, and bridges and allow for more efficient and confident chewing.

Many general dentists in the United States of America do not surgically place implants, although many advertise one of their services to be dental implants. What they mean is they will plan and restore your implant after a specialist surgically placed the implant. When I did it this way twenty years ago, the disadvantage is that if the patient had a problem with the implant, they did not have a direct recourse with one dentist. A concern for the patient is when the restoring doctor and the specialist disagree on who should take responsibility for defective materials or accidental damage to the implant. I have found that most good dental teams are willing to help the patient restore their dentition by redoing the work at a reduced fee.

Note: The patient’s responsibility is to keep the information on the size and make of the implant if the patient relocates or their dentist(s) retire, leave the practice, or change locations.

In the long run, implants are the most cost-effective and efficient option. Some patients choose bridgework to restore dentition because they lack the bone needed for an implant or think this is a less costly option. However, when a dentist prepares one tooth for a crown,’ the chances of needing a root canal is about 3-5% in five years. When at least two teeth are prepared for a three-unit bridge, it increases the odds of needing a root canal over the next five years from 3 percent to about 15 percent. The additional cost and the possibility of needing to redo your bridge after root canal treatment could end up costing you more than you thought you were saving over the cost of doing an implant. Cost is measured in money, but more costly is the inconvenience and time away from your other activities.

Did Grandma die early because she did not have implants?

In 1999 my grandmother passed away at the age of seventy-nine on the way to work. She was a firm believer that If you are not sick, you should have a job. She also had a great sense of adventure and often accompanied me on my mission dental trips or visiting another state or country. Although we had arranged for her to live with my mom and dad, she insisted on turning her key in her door.

Like many those born in the 1920s, Grandma got her dentures by the time she was forty years old, and like a lot of people, she did not like her bottom denture because it had no suction. I was not insistent on her having implants because she wanted to save her money to support her independence. In retrospect, this might not have been the best long-term decision because not having implants meant she could not crush her food correctly to receive the best nutrition. Studies show that dentures are about 30 percent efficient at crushing food, implant-supported dentures around 70 percent, and natural teeth around 90 percent.

Grandma complained about the loss of appetite, stomach pains, and irregular bowel movements. She had a medication that needed to be taken with meals to prevent further stomach irritation. On that fateful morning, her lack of appetite meant she did not eat to take her medication, and her increased blood pressure led to a stroke from which she did not regain consciousness.

I miss my grandmother and wish I could have done more for her. I have committed myself and my practice to promoting the benefits of having dental implants because I think it can make a difference in people’s lives. No amount of money saved was able to keep Grandma with us for additional years, but money invested correctly in making sure she could eat more than soups and mush might have given me additional years with her.

If you are missing some teeth and your dentist suggests implants, you should consider it a good option. Listen with an open mind. My Grandma would have wanted me to give you the option of implants, and I hope you agree.

Evaluating the Bone

As soon as a tooth is extracted, blood forms a clot in the socket, and new bone cells migrate into the socket area, accompanied by immune cells and cells that form supporting tissues. Remodeling leads to the formation of new hard and soft tissue.

At initial healing, the most significant amount of bone loss occurs at the extraction site, and then bone-loss slows but continues gradually over the years. The jawbone is composed of alveolar and base bone. Alveolar bone forms in response to the erupting teeth and starts to go away when the tooth is lost. Base bone provides the foundation on which the alveolar bone develops.

When we look at the series of pictures of an edentulous jawbone (a jawbone without teeth) over time, we notice that bone loss progresses after losing a tooth and can be accelerated when pressure is placed on the tissue by wearing a denture. We recommend that implants be placed, preferably after the extraction sockets are grafted.

People wearing any type of denture should be evaluated for implants. The national standard of care recommends that if you wear a complete lower denture, you should have at least two implants for lateral stabilization and more, if possible, for bone preservation.

People are living longer, and they will need to preserve their oral structures longer. The loss of even one strategic tooth could make for long and miserable golden years. After all, what are the golden years like without the ability to chew, digest, and receive proper nutrition

The same principle of implanting new teeth for accident victims or people born with congenitally missing teeth applies. Congenitally missing teeth is a condition where the patient has fewer than a full complement of teeth. With recent advancements in implants, it is getting easier to find an implant to replace the missing teeth.

Mini-Implants

Any implant with a diameter less than three millimeters is considered a mini-implant. An implant needs to be surrounded by bone if it is to have the best chance of surviving over a long time. Historically, many implants were small because patients had lost bone due to extractions and/or wearing fixed or removable dentures.

As the ability to grow (graft ) new bone has increased, the need for smaller implants may decrease. Initially, smaller implants were considered temporary implants to stabilize temporary teeth until the larger implants could integrate with the bone. The mini-implants were then removed, and new dentures were attached to the larger implants.

Today the technology for mini-implants is so good. We are finding that you can place the implant and, on the same day, attach the patient denture crown or bridge and have a high degree of success. Several years ago, I started to use the best of both worlds. I would place mini-implants while I placed standard implants and attached the denture to the minis while letting the larger implants integrate. In many of the cases we completed, we found that the minis’ aggressive threads that allowed you to use them right away, along with the latest technology and surfaces, made it difficult to remove the minis, so we incorporated them into the final prostheses (dentures).

Suppose a patient had a well-fitting lower denture that moved during chewing and did not want to wait four to six months until their implants integrated. In that case, they could have an initial evaluation and the necessary diagnostic X-rays and/or CT scan so they could be sized based on the remaining jawbone for implants. On the day of the surgery, they could be pretty confident that they would leave with an implanted denture with some degree of stability.

The Sterngold Company, a longtime manufacturer of attachments for dentures and crowns, came up with their version using mini-implants with conventional implants adapted to work with their ERA (Extra-coronal Resilient Attachment) system that allows the prosthesis a small range of movement and enhances their longevity. A rigid attachment puts a lot more force on the implants than a resilient attachment, and replacing the resilient part of the attachment is an advantage of the ERA system.

The Zimmer dental company has since bought this system. Implant Direct also manufactures a similar system that already has the attachment for the popular locator attachment.

If you could see a series of models of the lower jawbone just before and after teeth were lost, you would see a consistent pattern. Initially, the jawbone is at its maximum height and width and supports the patient’s facial features very well.

When a tooth is extracted, the alveolar bone that grew in response to the erupting tooth starts to shrink also. When the first denture is made, it is usually the best, because most of the alveolar bone is there for support; however, as bone loss continues, the denture sinks further into the soft tissue, and the height of the lower face contracts, giving the patient an aged appearance. The next denture should be made larger to compensate for the shrinking bone. But when the dentist does this, the patient usually complains because they slowly adapted to the first denture over time.

At that point, the dentist usually cuts back the new denture so it could feel like the first denture, except it does not feel as secure because some of the bone was lost. This bone loss continues until the jawbone’s nerve is close to the surface and causes the denture wearer discomfort.

At that point, the patient usually suffers from one denture after another, looking for a dentist who could give them the feel of their first denture. The way to slow this bone loss and aged look are to place socket grafts and/or implants as soon after extraction as is possible because alveolar bone stays around implants as if it was the root of a tooth. In effect, implants only help to retain dentures but help to maintain as well.

What Are Combination Cases

Our office prides itself in our ability to take care of multiple problems in a reasonable period, with or without sedation. Over the last few years, we had several cases that involved sinus surgery. With our current technologies, we can assess the amount of bone in the upper jaw before we encounter the sinus membrane. The sinus membrane is very forgiving and can repair itself in six weeks. If there is enough bone, seven millimeters or more, we can use blunt instruments to lift the membrane-like a blanket and insert bone grafting before placing the implant. If the amount of bone left is seven millimeters or less, I may elect a two-stage technique.

In the two-stage technique, bone is grafted below the sinus by displacing the membrane upward through a small hole made in the bone’s side. A collagen liner then protects the membrane, and a bone graft is packed, leading to a new bone growth of ten to twenty millimeters. Six months later, implants of varying lengths are placed and allowed to integrate as the grafted bone continues to mature.

After integration of the implants, implant-supported teeth are placed. The patient does not go without teeth because they wear a transitional prosthesis (temporary dentures or bridges) while waiting on the body to heal. We use several implant systems in our office, depending on the results we are trying to achieve. Sometimes we have to do extractions, bone graft s, root canals, fillings, or gum treatments; place implants or place transitional appliances all during the same visit. If the case warrants it, we can use mini-implants to hold initial devices securely until the long-term implants heal. A lot of prior planning goes into providing these treatments for combination cases.

Some patients who live a long distance from the office or even in another state can have a CT scan made, and the results emailed to us to do the virtual surgery and have all the supplies needed to perform the procedures before they arrive at our office.

 

Young Adults and Dental Care

Young adulthood is the period when proper early care makes the most significant impact. Those who have not learned how to brush or floss properly will become concerned about bleeding gums, bad breath, removal of unnecessary wisdom teeth, and their first bout with a real toothache. This is also the stage during which exploring or new activities lead to accidents requiring swift and expensive action to ensure proper dentition preservation. This period is also when those who had braces and did not practice proper oral hygiene will require cosmetic work. The growth spurt is nearing its end or is complete, and implants’ placement to replace missing teeth can start.

For many, this is the time when they find themselves in a place other than home for purposes of college, job, or relationships. Many will neglect dental care by trying to save money or by not spending. Some have skipped out on the extraction of wisdom teeth earlier and now find that they will have to take time off from their job or school to pursue extractions and recovery.

Those who had never had a bad dental experience and did not practice the habit of brushing after all meals and flossing twice per day will start to struggle with bad breath, gum disease, and cavities. Long hours on the job or at school make the terrible habits worse. Treatment by the dentist for repeated bouts of teeth and mouth infections is commonplace. Those with good habits may try to improve their teeth by doing bleaching or cosmetic bonding.

Braces and Dental Care

Braces make performing proper hygiene more complex, and I always recommend that during active orthodontic treatment, instead of cleanings twice per year, the patient receives cleanings four times per year. The savings of proper oral hygiene and the need for minor gum surgery afterward will more than pay for the two additional treatments per year. 

Without proper and additional hygiene measures, the breakdown of enamel around the brackets will result in the enamel’s deterioration. The process is similar to the breakdown from pregnancy or excessive soda use without proper and immediate brushing and flossing afterward.

Activities That Pur Your Teeth At Risk

Motorcycling, partying, skiing, contact sports of all types, seizures, and altercations can lead to the immediate destruction or loss of teeth. This will need immediate treatment to minimize the damage, and many young people may not have saved up an emergency fund for a situation like this. 

Many end up in later years spending tens of thousands of dollars to take care of defects that they were unable to take care of at the time of the emergency. Others will end up in dentures or temporary appliances of various types. These temporary measures can affect the social life of a young adult and decrease their self-confidence.

Even Dentist Have Poor Dental Habits As Young Adults

One of the rites of passage from being a dental student to being a dentist is practicing a procedure for the first time on your lab partner. We practiced impressions on each other. We practiced cavity detection on each other. We practiced injections on each other. One day, my lab partner was doing a periodontal (gum disease) evaluation on me.

“Bert! You have gum disease!”

“What,” I said.

“Gum disease. You have bleeding, lots of bleeding points. Have you ever been treated for gum disease?”

“No,” I said. “How bad is it?”

“You have some pocketing and bleeding from the pockets. Here, let me go over it with you.”

I spent numerous visits in the clinic getting my gum disease treated and perfecting my brushing and flossing techniques. It was disheartening, and I felt lousy for neglecting my dental health for so long. I was happy that I did not have to go through the trauma of extractions again because of my neglect.

Gum Disease in Young Adults

Young adults often ignore a bloody toothbrush, but that is a mistake. Gum disease starts slowly and painlessly. In smokers, it can be undetected because of nicotine’s effect in constricting blood flow; therefore, they may not see bleeding as readily as nonsmokers. Smokers also need more regular check-ups to detect oral cancers.

A traditional cleaning will not be sufficient to decrease gum disease. Additional treatment of scaling and root planing with local anesthesia and/or conscious sedation may be needed. You may need repeated treatments or more advanced surgery. More than two visits to the dentist per year may be required to keep gum disease at bay. Sulcular (space between the tooth and the gum) and oral antibiotics, as well as rinses, may be necessary. A visit with a periodontist (dental specialist in treating gum disease) is in order in cases that do not respond appropriately. Gum disease is the most common cause of bad breath.

Dealing With Toothaches

Toothaches can occur for the first time during this transitional time. As I refer to it, a real toothache is one in which decay breaks down the teeth to the point where bacteria get into the nerve and cause irreversible pulpitis(inflammation of the tooth pulp). The options at this time do not include a filling; remove the tooth’s nerve or extract the tooth. 

The removal of the nerve and subsequent post buildup and then a crown usually takes care of the problem, but the dentist will usually do an extraction if it does not. Filling the extraction site with bone-grafting material preserves the bone, and in several months a replacement tooth implant can be placed.

Cosmetic Dentistry for Young Adults

Altercations or on-the-job accidents can cause broken teeth, and the treatment usually requires some type of cosmetic restoration of the teeth. Some teeth may need to be extracted if the fracture line extends below the gum into the supporting bone. Other teeth may need root canal treatment if the fracture is just into the nerve of the tooth. We can treat an un-salvageable tooth with an immediate implant that can have a temporary done immediately after placement. Grafting helps to maintain or create new bone for the implant’s order or provide the bone’s shape, removing large spaces that trap food when using a dental bridge.

Delivering a denture or removable prosthesis to a patient can be very stressful for both doctor and patient for the first time. Sometimes a denture is all they can afford.

I feel very sad when I have to remove a tooth with no cavities because trauma has made it non-restorable. The last choice for a patient is to leave the dentist with the missing tooth’s space unoccupied.

I feel a sense of loss and a bit of remorse when I assist a patient in losing a part of their body, albeit a tooth. After all, someone who loses a part of their body is starting a journey. This is the beginning of a long road that is going in the wrong direction.

Should You Get Dentures?

I will just pull my teeth, which will be the end of my teeth problems, is one mantra that I used to hear a lot. When teeth go, bone and supporting tissues will go also; then, we have to deal with a prosthesis (fixed or removable bridgework). The bone in which teeth erupt is called alveolar bone, the supporting bones of the jaws we call base bone. If you keep your teeth intact throughout your lifetime, you will preserve most of your jawbones. As you lose teeth, the alveolar bone also shrinks, and it shrinks even more if you have a denture putting force on it.

How Dentures Affect Your Mouth and Jawbone

Along with the loss of jawbone, you have movement of teeth into the now-empty space. Fewer teeth mean more collapse of the bite and a more aged, more collapsed look. Generally, the first denture will fit better than subsequent dentures because there is more bone support. Since most people do not strictly adhere to denture removal for six to eight hours per day and replacement of dentures every five to eight years, they will wear away the jawbone even more.

Lower dentures are notorious for moving and should be anchored by implants to preserve bone and prevent denture movement. So a lot of denture wearers spend millions of dollars on denture adhesives. Some’denture adhesives have a high zinc concentration, and because they use more than the recommended dose, wearers get more zinc in their system. Zinc competes with copper for absorption and depletes the amount of copper in the body. Low levels of copper can lead to neurological problems, and there have been incidences where paralysis cases are linked  to copper deficiency. Denture adhesive companies are developing new formulations to reduce and eliminate zinc.

Dentures and Chewing Efficiency

Most denture wearers will not let you know, but the efficiency of chewing using a set of complete dentures is about 35 percent, while normal-functioning teeth are over 90 percent. Nutrition and longevity also suffer because food that is not crushed correctly is more challenging to digest. The diet of most denture-wearing patients contains little in the way of raw leafy vegetables and nuts. This translates into suffering for most denture wearers.

Nutrition suffers. Neurological function suffers. Proper functioning of the gastrointestinal system suffers. Social interactions suffer. Physical beauty suffers, and longevity suffers.

More than ninety years ago, the Mayo Clinic found a positive correlation between natural teeth and length of life in their study of longevity. Better nutrition, better health, and better appearance result from taking care of natural teeth. Loss of appetite, a drying of the mouth from medication and aging, and poorer health result from poor dental hygiene and maintenance.

Other Issues with Dentures

Other particular problems with dentures include a decrease in taste, change in salivation, allergies to acrylic, sore spots, bone shrinkage, and risk of nutritional deficiencies. Health issues increase, shattering the perception that dental health is not essential. Bad breath and dehydration are part of the world of denture wearing.

My best advice for denture wearers is to keep as many teeth as possible; use implants where you can to retain dentures and maintain the alveolar bones of the face.

Cosmetic Dentistry Guide – What You Should Know

For as long as I have been a dentist, I have been taking classes and teaching other dentists the value of cosmetic dentistry. In 1988, my job was to solve our patients’ cosmetic problems in our hospital general practice. Some of these patients had teeth broken after intubation for general surgery. My job was not only to give them new teeth but to make them look good. During those years, I learned the importance of working with various dental specialists and knowing what was needed to get the final results. The doctors doing the treatment were recent dental graduates in their first years of practice.

Since the doctors were graduates of dental schools from all around the United States, they sometimes presented various ways of solving the same problem. I learned just as much as I taught in that program.

Composites

Tooth-colored fillings are what we call composites. These are taking over from acrylics as the long-term filling materials because they can match your teeth’ color and last longer. Composites used in dentistry are basically hydrocarbons with quartz and glass particle fillers.

Composites are widely used in aerospace and other industries to provide lighter, strong materials formed into various shapes. Porcelain is the other long-term material that we use for crowns and bridges, mostly tooth-colored. In the past, porcelain fused to metal or all-metal crowns was the technology for crowning teeth. This technology has served us well and is still the treatment of choice when you have decay or fillings with margins below the gums. Porcelain fused to metal is also the technology used to build porcelain bathtubs.

Other Cosmetic Dentistry Technologies

With the advent of Cad Cam technology and zirconium use as a substructure to porcelain, we now have many options to make teeth look beautiful. 3M Company uses technology to color the zirconium substructure the same color as the root structure, and then lab technicians apply porcelain to it, creating beautiful teeth. The resulting crown maintains the tooth color over a long time and is very aesthetic. It costs a little more, but it is well worth the investment.

Cad Cam technology uses a camera to picture the prepared tooth and fabricate the tooth’s missing part, using computer correlation technology to mill it. In-office Cad Cam machines are used to restore posterior (back) teeth.

Most cosmetic anterior aesthetic crowns or veneers are still finished by the artistic skills of trained lab technicians. Some technicians use the Cad Cam technology to fabricate the substructure and then apply porcelain for the final result.

A patient came to my office with an interesting request.

“Hey, Doc, I want a smile just like yours,” she said.

“Do you mean the shade of the teeth or the shape?” I asked.

“I just like the look of your smile.”

I completed my examination and found she had no upper teeth and only the lower front teeth. The remaining bone in the upper was enough to support an upper denture. However, on the lower, I would have to place some crowns and a lower appliance.

“Do you have any pictures of you in your late teens or early twenties? One where you have a full smile,” I asked.

“Yes! And yes, I would like to smile like that again.”

I collected all the information and proceeded to make an upper smile that showed teeth when she smiled. I shaped the contour on the appliance like real gums and made contours of her teeth like her own teeth from the pictures. No metal clips showed on her lower appliance, and we later took pictures together that showed that indeed she could smile as well as I did.

How Cosmetic Dentistry Works

Cosmetic dentistry involves smile creation, and the materials are not always porcelain veneers. All restorations can be used as cosmetic enhancements. I encourage bone grafts after extractions because it creates the contours that we need to enhance the cosmetic result. All dentistry that is considered functional can also be cosmetic.

Is Cosmetic Dentistry Art or Science

Dentists have long known that different styles of teeth fit people with other facial structures. We have used the Golden Proportion concepts to help us with rebuilding an aesthetic and functioning smile. Dentists who are very serious about cosmetic dentistry benefit from joining and participating in the various programs set up by the American Academy of Cosmetic Dentistry. The more an office combines the science of materials and techniques with the artistic talents of sculpting a pleasant smile, the closer they get to great results and a satisfied patient.

As a dental resident at Long Island Jewish Medical Center, I clearly remember a young lab technician who worked on developing thin porcelain wafers to cover unattractive teeth, telling us how they could solve cosmetic problems. They were called porcelain veneers. I became one of the early adopters of this conservative treatment mode, with my longest case that I know of still in place since 1989. Later on, I studied with Larry Rosenthal, who gave hands-on courses for other dentists. His techniques on straightening rotated teeth were beneficial then and are still helpful today. Good fundamentals are always useful. In North Carolina, Ross Nash and Rob Lowe have passed on valuable information to dentists, from photography to lasers used to enhance your results.

Cosmetic dentistry may involve working with various dental specialists to get a cosmetic and functioning occlusion. New types of braces, invisible and internal, can provide answers to adults who may be self-conscious during treatment. The most important part of your cosmetic treatment is that one dentist is in charge of coordinating all the treatment that leads to the patient’s result.

Sometimes part or parts of your treatment have to be done by another dental specialist, and your cosmetic dentist will do the final restorations. A periodontist may be needed to treat your gum disease or sculpt your gums so that the amount of gum shown is not unattractive when you smile. An oral surgeon may be required if you have lost a considerable amount of bone, need your jawbone repositioned, or impacted teeth extracted. A prosthodontist may be necessary if you have had extensive tissue loss from cancer treatment or an accident requiring a unique prosthesis. An oral and maxillofacial radiologist may be needed if a 3-D model shows an unidentified artifact. An endodontist may be necessary if you require a root canal treatment or retreatment of a previous root canal to make your cosmetic restoration feasible.

Most of the cases treated in our office require combination treatments, with or without sedation. Sometimes we have to do an extraction, place an implant, do a bone graft, root canal a tooth, place a fiber post, and then choose the right type of porcelain for each tooth to get the smile to look uniform. Many patients ask for veneers or lumineers; however, they may not be a candidate for those options because several teeth require several other types of treatment.

The more patients know about what they want, the more we can advise them if it is achievable or unrealistic.

Sometimes the achievable requires a little more perseverance on the part of the patient and doctor. Cosmetic Dentistry is a combination of science and art.

person writing in a notebook

Book Reviews

What Are People Saying About Dr. Bonnick’s Books

Dr. Bonnick’s most recent book, How To Overcome Fear Of The Dentist – A Patient’s Guide To Understanding Dentistry, focuses on educating patients on various dental procedures, good oral hygiene habits, and what the options are under various circumstances. Sometimes lack of understanding makes things look more imposing, and there are not always simple avenues for dental patients to obtain greater knowledge.

Overall, an excellent work. In a day where some books are more like a mere waste of paper than literature, this surprising book stands apart. Though the title seems like the book may appeal to a young audience, it is in fact, a tool for adults. “How to Overcome…” finds a delightful balance between scientific explanation, professional advice, and personal anecdote. It is a book that redefines the expectation of what qualifies as “hard to put down.” Most readers would not consider a medical text to be good bedtime or stuck-in-a-waiting-room reading. In fact, most readers, when caught in a waiting room, have either brought their own book or reach for a quick-skim magazine. If you find yourself in a waiting room with a copy of “How to Overcome…”, save your personal book for later, put down the Redbook or Highlights, and pick it up! I almost guarantee that in one chapter, you’ll be wondering how you can take it with you. Bonnick certainly has the qualifications to write a dental-advice text, but what surprises you is how readable and enjoyable his writing style is. Well worth every page!
Sarah
In many instances, people fear their annual and/or initial visits to the dentist. By having a resource to turn to, a person can find answers to their questions and educate themselves about what the dentist is doing. This book will allow a person to understand dental procedures, allowing them to make the first step toward healthy hygiene and a beautiful smile.
David Yu, DDS
Unfortunately, many people are unaware of how negatively poor dental hygiene impacts their overall health. In this book, Dr. Bonnick takes a big step towards helping people to understand holistic health maintenance.
Andre Spence, M.D.
Overall, an excellent work. In a day where some books are more like a mere waste of paper than literature, this surprising book stands apart. Though the title seems like the book may appeal to a young audience, it is in fact, a tool for adults. “How to Overcome…” finds a delightful balance between scientific explanation, professional advice, and personal anecdote. It is a book that redefines the expectation of what qualifies as “hard to put down.” Most readers would not consider a medical text to be good bedtime or stuck-in-a-waiting-room reading. In fact, most readers, when caught in a waiting room, have either brought their own book or reach for a quick-skim magazine. If you find yourself in a waiting room with a copy of “How to Overcome…”, save your personal book for later, put down the Redbook or Highlights, and pick it up! I almost guarantee that in one chapter, you’ll be wondering how you can take it with you. Bonnick certainly has the qualifications to write a dental-advice text, but what surprises you is how readable and enjoyable his writing style is. Well worth every page!
Sarah
In many instances, people fear their annual and/or initial visits to the dentist. By having a resource to turn to, a person can find answers to their questions and educate themselves about what the dentist is doing. This book will allow a person to understand dental procedures, allowing them to make the first step toward healthy hygiene and a beautiful smile.
David Yu, DDS
Unfortunately, many people are unaware of how negatively poor dental hygiene impacts their overall health. In this book, Dr. Bonnick takes a big step towards helping people to understand holistic health maintenance.
Andre Spence, M.D.
Overall, an excellent work. In a day where some books are more like a mere waste of paper than literature, this surprising book stands apart. Though the title seems like the book may appeal to a young audience, it is in fact, a tool for adults. “How to Overcome…” finds a delightful balance between scientific explanation, professional advice, and personal anecdote. It is a book that redefines the expectation of what qualifies as “hard to put down.” Most readers would not consider a medical text to be good bedtime or stuck-in-a-waiting-room reading. In fact, most readers, when caught in a waiting room, have either brought their own book or reach for a quick-skim magazine. If you find yourself in a waiting room with a copy of “How to Overcome…”, save your personal book for later, put down the Redbook or Highlights, and pick it up! I almost guarantee that in one chapter, you’ll be wondering how you can take it with you. Bonnick certainly has the qualifications to write a dental-advice text, but what surprises you is how readable and enjoyable his writing style is. Well worth every page!
Sarah
In many instances, people fear their annual and/or initial visits to the dentist. By having a resource to turn to, a person can find answers to their questions and educate themselves about what the dentist is doing. This book will allow a person to understand dental procedures, allowing them to make the first step toward healthy hygiene and a beautiful smile.
David Yu, DDS
Unfortunately, many people are unaware of how negatively poor dental hygiene impacts their overall health. In this book, Dr. Bonnick takes a big step towards helping people to understand holistic health maintenance.
Andre Spence, M.D.
Overall, an excellent work. In a day where some books are more like a mere waste of paper than literature, this surprising book stands apart. Though the title seems like the book may appeal to a young audience, it is in fact, a tool for adults. “How to Overcome…” finds a delightful balance between scientific explanation, professional advice, and personal anecdote. It is a book that redefines the expectation of what qualifies as “hard to put down.” Most readers would not consider a medical text to be good bedtime or stuck-in-a-waiting-room reading. In fact, most readers, when caught in a waiting room, have either brought their own book or reach for a quick-skim magazine. If you find yourself in a waiting room with a copy of “How to Overcome…”, save your personal book for later, put down the Redbook or Highlights, and pick it up! I almost guarantee that in one chapter, you’ll be wondering how you can take it with you. Bonnick certainly has the qualifications to write a dental-advice text, but what surprises you is how readable and enjoyable his writing style is. Well worth every page!
Sarah
In many instances, people fear their annual and/or initial visits to the dentist. By having a resource to turn to, a person can find answers to their questions and educate themselves about what the dentist is doing. This book will allow a person to understand dental procedures, allowing them to make the first step toward healthy hygiene and a beautiful smile.
David Yu, DDS

TMJ, Headaches, and Facial Pains

(Special note to patients – this subject can be very complicated and is meant to inform you of the complexity of self-diagnosis. We seriously advise you to seek the help of a professional in this area. Consult your dental professional for further advice.)

TMJ is not a medical condition; it is a joint that articulates the lower jaw to the base of the skull. The lower jaw that articulates with a disk that articulates with the skull is called the condyle. There is a disk between the rounded joint and the base of the skull, so unless you have a worn disk, there will not be direct bone to bone contact. The condyles can come under extreme stress when the mouth is crushing food; the patient is clenching or grinding or oral habits like nail-biting, chewing gum, and trauma. A small muscle attaches in the front part of the disk and pulls it forward when the lower jaw translates forward, and damage to the disk or slipping of the disk compromises the area between the muscle and the disk and causes pain.

Temporomandibular Disorder (TMD)

Any disorder to the condyles, disk, or muscles supporting chewing is called temporomandibular disorder (TMD), and this is the correct way to talk about problems in this area. TMD can strike at any time in life but seems to show up after a traumatic event or during a time of increased stress. Close to 90 percent of TMD results from muscle spasms and can be corrected with physical therapy, bite splints, and medications. The remaining disorders may have to be treated surgically or may continue as part of a systemic condition such as arthritis.

Headaches and Facial Pains

TMD can also trigger other headaches as your body recruits other muscles to move the head and neck. Headaches can also come from referred pain from areas called “trigger points.” Infections, high blood pressure, trauma, bouts of migraine, tumors, teeth coming together in negative ways (malocclusion), and other physiological processes can all cause headaches. Your dentist may request tests, refer you to a specialist, or try to treat dental conditions that may aggravate your situation. To rule out a tumor, you will need to pay attention to pain in the head and neck region of non-dental origin.

Facial pain refers to any conditions that cause abnormal and painful conditions in the head and neck region. Some dentists limit their practice to this area, and they are very well informed and can diagnose and treat many conditions. Many medical specialists specialize in treating chronic pain, and they use many forms of therapy to help patients.

Chronic pain often has a psychological component, so referral to a professional for counseling is not uncommon when treating facial pain.

The Cost of Not Going to the Dentist

Dentistry is one of the areas of healthcare that responds readily to prevention. While many in the population have little dental fear, our culture and media are replete with dentistry images, indicating that dental treatment is bothersome for most people. Phrases like “It was worse than a root canal” or “He is not going to hurt you; he is just going to look” or “You will only feel a little pinch” are common. 

Jokes abound with references to numb lips and tongue, dentists putting their knees on people’s chest to aid in the extraction of teeth, as well as women who state that they would rather have a child than have their teeth worked on. So how soon should you start taking care of your teeth?

Some parents still believe, “If it is a baby tooth, pull it; if it is a permanent tooth, save it!” In adult life, the mantra is “If it is a front tooth, save it; if it is a back tooth, pull it!” Both beliefs lead to terrible results for patients and increase the cost of replacing teeth in the proper position. The amount of trauma and fear imprinted on people during these dental experiences adds to the mass of people who fear the dentist.

Baby teeth (primary or deciduous teeth) are essential in preserving the space for the adult teeth’ eruption (secondary teeth or permanent teeth). They are essential because early tooth loss could lead to ill-shaped and wrongly positioned teeth, which would require braces to place the teeth in the correct position. Later in life, the increased need for crown and bridge restorations to replace and preserve teeth costs more.

It is not always easy to differentiate between baby teeth and adult teeth. Radiographs (X-ray representation) of teeth will also reveal that some primary teeth do not have secondary successors, and many adults retain primary teeth throughout their lives. Early loss of baby teeth can lead to the non-eruption of adult teeth or their eruption in abnormal positions.

Abnormally positioned teeth are harder to maintain and do not function as well as properly positioned teeth. Abnormally positioned teeth produce a malocclusion (teeth coming together in an unfavorable mouth and supporting structures.

 

Osteoporosis and Oral Health

As the population ages, we tend to see more cases of osteoporosis and decreased bone density. Both men and women are at risk of developing this condition, making them more susceptible to fractures from everyday activity. It is possible for someone suffering from osteoporosis to break their hipbones in such a way that compromises internal organs and can lead to death. Any bone that breaks from the application of force presents a challenge to the patient, especially in an individual who enjoys an increased lifespan.

Men and women enjoy their maximum bone density in their twenties and early thirties, after which it can all go downhill. Weight-bearing exercises, proper nutrition, and medications have helped us battle the inevitable ravages of aging. The genetic factors are beyond our control at this point, but maintaining a good dentition is a big part of fighting the battle against osteoporosis.

Some bone cells build up bones (osteoblasts), while others remove old bone (osteoclasts), and the dynamic actions of both cells promote bone health. The slowing down of the bone-building process initially leads to osteopenia and then osteoporosis.

How Osteoporosis Affects Oral Health

Early loss of bones in the jaws is initially caused by losing teeth, usually followed by wearing dentures. Teeth and implants provide weight-bearing stimulus to the jawbone and enhance bone deposition where it is most needed. Early bone loss associated with the loss of teeth is not osteoporosis, but it can coincide with osteoporosis.

Regular dental care allows us to preserve teeth and bone, which helps with our nutrition. In the event of a health issue like osteoporosis, better oral health means we have fewer complications. Women seem to be at a higher risk for osteoporosis because they live longer, have more hormonal variations to contend with, and traditionally are involved in fewer weight-bearing exercises.

Treatments for Osteoporosis

Medications like Boniva, Fosamax, Reclast, and hormonal and nutritional supplements, have been used to combat osteoporosis. Complications exist with all therapy forms, but the dentist’s particular interest is complications from bisphosphonates-related Osteonecrosis of the jawbones (BRONJ).

Risk factors for BRONJ include ulcerations under dentures, infections from periodontal disease or cavities, and trauma. Eliminating these risk factors decreases the likelihood of developing BRONJ. The incidence of jawbone necrosis increases if a patient has received IV bisphosphonates and later develops infections in the jawbone area that incorporated the bisphosphonates (studies suggest lower incidences with oral bisphosphonates).

Trauma or surgery affecting the jawbone’s drug enriched areas can also start the breakdown of bone that leads to BRONJ. Some patients have ended up losing parts of their jaws while trying to increase their bone density with bisphosphonates because of oral infections.

Patients receiving osteopenia or osteoporosis treatment should make sure they have all dental work taken care of before taking bisphosphonates.

Once you start therapy, it may be too late to do primary dental treatment or prevent the adverse effects of infected teeth or gums on your supporting alveolar bone.

Dental Care for Older Adults

Dental Health in the “First Forty Years”

The first forty years is the period during which adults make sacrifices for their children, and it is a time when your priorities become secondary to those you are responsible for taking care of. Some feel guilty when they take care of their dental problems during this period because they think their resources should be spent on their dependents. During this period, emphasis should be on prevention.

Sometimes the prevention requires that you restore multiple teeth with crowns before they turn into more extensive work. This may be the period that requires that you wear a bite guard to protect your new crowns and prevent damage from clenching at night. If you have established good habits, early routine maintenance and an occasional crown or filling will be all you would need.

This is when you help your family establish good habits and keep your family’s dental costs down. It is also the time when the easy solution is not always the best.

Dental Health in the “Second Forty Years”

The second forty years put you in the position to do what you have always wanted to do for yourself. If you had poor dental care early and have taken care of the children, you now have time to take care of yourself. During this time, many patients seriously evaluate their priorities and summon the courage to make their treatment decisions based on what will be the best for the long term.

Sometimes the missing tooth that you had ignored can be restored by an implant. We have to be prepared that space cannot accommodate an implant or the bone is shrinking, or the adjacent tooth has moved partially into the area. Sometimes the bone has shrunken to the point where nothing short of a major procedure like grafting some hip bone can help you out. The consequences of the first forty years are coming back to help you or to give you regrets. Hopefully, you will never know the inconvenience of wearing a removable appliance.

You quickly rush to the bathroom after eating to try to get a seed from under your plate, and you try to be cool about it when your friend comes into the bathroom and greets you. You lock the door, so your partner never gets to see you without your plate because you have to take the plate out to get the seed from under it. You cannot go to a new restaurant because you cannot adequately chew what is on the menu.

The flip side is you never knew what it is like to be without your teeth. You are not embarrassed by your smile.

You eat nuts, salads, fruits, meats, or whatever you want. You don’t have a denture container to carry around when you go on an overnight trip, and you are convinced that it is great to be alive and have your teeth.

Dental Health in the “Third Forty Years”

The third forty years is a cautious time of your life. Your dental health has impacted your quality of life. Early in the 1900s, the Mayo Clinic found that most people who enjoy a long life have their teeth. Back then, they were not sure why, but now we know that dental disease can exacerbate other systemic diseases and affects your quality of life.

I am reminded of the gentleman who came in at age ninety-five to have his teeth restored and told me the story of why he decided to do so. At age eighty, I decided I did not have long to live, so I did not have my mouth fixed. Now it is fifteen years later, and I realized that I spent all that time in discomfort when I did not have to.