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General

Do I need to replace my set of precision partial dentures because of tooth decay , or is there some other option you can think of?

I have bones that are growing out of my lower jaw. What are they, and can they be removed?

I was in a discussion the other night with some friends and we couldn't agree on how many teeth there are in the mouth. Can you clear this up for us?

Is it true that kissing causes tooth decay?

I have recently been told by my doctor that I have a very bad sinus infection. At about the same time of my sinus infection I have developed pain on both sides of my upper jaw. Is it possible I also have a problem with my jaw?

I have recently heard of a laser being approved for use in dentistry. What are your thoughts on this?

I am 54 years old and would like to have a nicer smile. Right now I have dark teeth and some ugly fillings. Can you give me some options on how I can proceed with this?

I had extensive dental work done 10 years ago on all my teeth. I am embarrassed to say that since then I haven't been to a dentist and now have problems. Can you make any comments that may help me feel better about going to the dentist to get this looked at?

Do you know where the term wisdom tooth came from?

I have just been told that I have mitral valve prolapse and my cardiologist told me I need to take antibiotics before my dental appointments. Can you tell me why this is necessary?

I have silver fillings on my upper right. I brush and floss every day. Lately when I floss on the upper right between my fillings I get an odd taste. What could be causing this?

I have had a gum boil in one of my molars twice in the past 6 months. I went to the dentist and she gave me some antibiotics. The boil went away only to come back recently. How come antibiotics do not take care of the situation?

Q. I am 73 years old and have one of those precision partial dentures you have talked about in the past.  In the past 3 months I had a root canal done on my upper canine due to decay.  My partial is on the top and it is attached to my front six teeth that are capped and tied together.  Since I have decay in the canine I now have a space between the gums and the cap.  I have been told that the only thing that I can do is replace everything.  Is there any other option you can think of?  Your quick response is greatly appreciated since I need to do something soon.  Thank you.

A. The scenario you just explained is one that I have come across in the past.  In many cases the only way to fix the problem is to remake the dental work as you have been told.  In some cases the decay is not too extensive and the dentist can clean out all of the decay, place a post in the tooth that had the root canal and pack the cap with a filling starting from the top of the tooth until it comes out the bottom and then finishing it off as good as possible under the circumstances.  This solution can last for years or it can end up being a temporary repair to buy some time.  It is much less involved than remaking the whole case and significantly less costly.

Q. I have bones that are growing out of my lower jaw, under my tongue.  They are so large, that they are almost touching.  They cause no discomfort.  My dentist said, however, because of them I could never wear dentures.  What are they?  Should they be removed and if so, what is the procedure?  Thanks for any info you can provide.

A. The outgrowths of bone you are referring to are called mandibular tori.  Depending on the type of denture and the position and size of the tori you may or may not have to have them removed.  If you are referring to a full denture it is very likely that you will need to have them removed.  If on the other hand you need a partial denture removal may not be necessary.  I have made many people partial dentures with tori present. 

In the event that you need to have the tori removed you will need to see an oral surgeon who will separate the tissue on top of the tori and smooth it down with various instruments.  Once completed the tissue is placed back in an ideal position so your dentist can make you a denture.  Your dentist can recommend whether or not you need the tori removed.  If you are in doubt you may want to seek out a second opinion.  In many cases the oral surgeon who you will be referred to can offer you that opinion.  I should mention that if your general dentist is comfortable with this type of surgery he or she many be able to do the procedure in his or her own office.  Each dentist should know their capabilities and when they need to make a referral to a specialist.

Q. I was in a discussion the other night with some friends and we couldn't agree on how many teeth there are in the mouth.  Can you clear this up for us?

A. There are 32 teeth in the adult mouth.  On both the top and bottom there are 4 incisors, 2 canines, 4 premolars or bicuspids and 6 molars.  There are 20 teeth in a child's mouth up to the age of about 6.  On both the top and bottom there are 4 incisors, 2 canines and 4 molars. After the age of about 6 they will start to get their adult teeth in.  In some cases these adult teeth will replace baby ones and in others they will not.

Q. Is it true that kissing causes tooth decay?  Please discuss this in your Chronicle column.  Thank you.

A. This is a difficult question to answer with a yes or no.  There have been some studies that  I have read that say that with kissing there is a transfer of the bacteria that causes dental disease.  My feelings are that this can certainly happen. However, things like poor home care and the passing of genes from your ancestors are more the reasons for the presence of tooth decay.

Q. I have recently been told by my doctor that I have a very bad sinus infection.  At about the same time of my sinus infection I have developed pain on both sides of my upper jaw.  This pain is worse when I do something like jump up and down.  Do you think that I have a problem in my teeth or is it just my sinuses?

A. This is a great question and one that we get asked quite often.  Your upper teeth are very close to and sometimes right into the sinus.  When you have a sinus infection there is a build up of pressure in the sinus that can directly affect your teeth.  I am pretty certain that the pain in your teeth is a result of the sinus infection and the pressure that is built up.  However, you should see your dentist to be certain that there is no underlying dental problem that has been brought to surface because of this.

Q. I have recently heard of a laser being approved for use in dentistry.  What are your thoughts on this?

A. The laser that has been approved for use in dentistry by the Food and Drug Administration is called the Erbium Laser System marketed by Premier Laser Systems.  It is different than the other lasers approved for dentistry in that this is the first laser to be approved for use on hard tissue (the tooth).  All of the past lasers have been approved for soft tissues only.  The erbium laser was approved for the removal of decay and cavity preparation, as well as the roughening of the tooth surface, in order to improve the bonding of various restorations.  Dentists are limited to using the laser in adults 18 years and older.  The FDA did not approve the laser for the removal of amalgam (silver) fillings, however.  What this means for you, the patient, and me is that the only time this device can be used is to remove new decay in a tooth.  I have found that in most cases, in patients 18 years and older, decay is found around or under a silver filling.  In order to use the laser in a situation like this I would have to remove the filling using conventional methods, most likely to include anesthesia, and then use the laser to remove the decay.

I think that the entry of the laser into dentistry for use on teeth is a great advancement.  With continued research we will eventually see it become every-day dentistry.  The American Dental Association has yet to give this laser approval for use because of the following concerns:

1.Will it be safe to the tissues, particularly the nerve tissue, based on the rapid temperature rise at the site where the laser strikes the tooth.

2.Will the tooth crack due to shock waves moving through the tooth after exposure.

3.How will the laser perform in comparison to the high speed handpiece.

You can get additional information on the laser by going to the American Dental Associations web site.  Their address is www.ada.org

Q. I am 54 years old and would like to have a nicer smile.  Right now I have dark teeth and some ugly fillings.  Can you give me some options on how I can proceed with this?

A. This is usually a pretty straight forward scenario with a couple of options, depending on the specific situation you might have.  I will give you my ideas and hope that they will apply to you in some way.

In most cases, a patient with dark teeth would benefit from home whitening.  In order to accomplish home whitening your dentist would make a duplicate model of you mouth by taking impressions.  On these duplicate models he or she would make a tray that fits snugly on the teeth and has a receptacle on the face of each tooth to hold a whitening gel.  You would place the gel in the receptacle and  the tray onto your teeth.  This would be done just before you go to sleep and the tray would stay in for the night.  Upon rising you would remove the tray and brush and floss as usual.  I should comment that the tray is very comfortable and not bulky at all.  You would do this for approximately 5-7 nights.  You would then return to the dentist for an evaluation, at which time both you and your dentist would decide if that is all that is needed or if you need to continue.

Once your teeth are whiter you can go ahead and remove the old fillings that are discolored and replace them with ones that match the newly whitened teeth. 

If the fillings were too large to be replaced your dentist might recommend porcelain veneers.  Porcelain veneers are like fake fingernails.  The biggest difference between the two is that with porcelain veneers the dentist removes the same amount of tooth that the veneer will replace.  The amount removed is about 1.5 mm on the face of the tooth and extending between the teeth.  This is done so the end result is one that looks natural and not bulky.  Veneers are a very strong restoration once cemented onto your teeth. 

There may be times that your dentist recommends you have a crown because there is hardly any tooth left.  A crown strengthens the tooth because it is a cover that goes completely around the tooth.  Most crowns are made of a combination of metal and porcelain.  The metal is used for strength and the porcelain for its beauty.

You should also know that any combination of the above procedures can be used together.  In either case, what you are looking for is very possible and predictable when planned appropriately.

Q. I am 63 years old and had extensive dental work done 10 years ago.  To my recollection the work involved included root canals, posts and caps on all my teeth.  I am embarrassed to say that since then I haven't been to a dentist and my husband is urging me to go.  I am not in pain but I know that things are going on because when I rub my tongue along my teeth I feel sharp ridges and holes where my tongue will fit.  Can you make any comments that may help me feel better about going to the dentist to get this looked at?  Thank you.

A. First, let me say that current day dentistry is not like it was 10 years ago.  There are so many things that can be done to make your visit a very positive one.  These things include different anesthetics, different techniques for many of the procedures we do, the use of headphones to listen to relaxing music, watching a video while having your dentistry done, and finding a dentist that will spend the time necessary with you to explain what is going on and what your options are.

Based on what you have written you may have decay starting under the crowns that were placed 10 years ago.  The reason that things do not hurt could be that you had root canals done and therefore the nerves are out of the teeth.  I would urge you to find a dentist that you are comfortable with and listen to what his or her suggestions are.  Don't feel bad about asking questions because it is the ability for you to ask a question and get an answer that will make you feel comfortable with the dentist you choose.

Q. Do you know where the term wisdom tooth came from?

A. I need to tell you that I didn't know the answer to this question so I did what a lot of us are doing these days - I went to the Internet.  After e-mailing about 6 dental schools and various other organizations I received only one response.  The answer they gave me is the one I thought of as well.  I am still not sure that it is correct but it is all that I have.  They said that the age that the wisdom tooth (or third molar) comes into the mouth is 18 years of age and by that age a person should have acquired some wisdom, hence, the name wisdom tooth.

Q. I have just been told that I have mitral valve prolapse and my cardiologist told me I need to take antibiotics before my dental appointments.  Can you tell me why this is necessary?

A. Mitral valve prolapse is a condition of the mitral valve of the heart that causes the valve to not open and close properly.  When this happens there is a chance that the bacteria normally present in the mouth enter into the blood stream and upon passing the valve, adhere to it.  This can lead to an infection in the heart.  By giving you antibiotics before your appointment we can lower the amount of bacteria in the bloodstream and thereby decrease the possibility of infecting the mitral valve. 

You would need to be pre-medicated with this antibiotic whenever there is a chance of bleeding  during a dental procedure.  There are also some other medical procedures that would require you to pre-medicate.  Some podiatric procedures and well as a colonoscopy are two that come to mind.

Q. I have silver fillings on my upper right.  I brush and floss every day. Lately when I floss on the upper right between my fillings I get an odd taste. What could be causing this?

A. The most probable reason for this taste is decaying food remains.  Although you are flossing, you may very well have broken a piece of tooth and/or filling and during chewing you are forcing food between the teeth and below the gums which you cannot reach with daily flossing.  This food gets trapped and the body breaks it down causing an odd taste and maybe even an odor which is released when you floss.  If there is no broken tooth or filling, you may have an open contact between two teeth which will cause food to get trapped, also causing this taste.  You can determine if you have an open contact very simply.  If you get a snap when placing the floss between the teeth you probably do not have an open contact.  On the other hand, if upon placing floss between your teeth it passes freely, you have an open contact that needs to be repaired.

If neither a broken tooth or filling, nor an open contact are the culprit for packing food, you may have a ledge where the filling meets the tooth, also causing food to get trapped.  If your floss shreds when you pass it between your teeth, chances are that you have a ledge that needs to be repaired.

Q. I have had a gum boil in one of my molars twice in the past 6 months.  I went to the dentist and she gave me some antibiotics.  The boil went away only to come back recently.  My dentist told me that there was an infection in the bone because of gum disease and that the tooth needed to come out.  Once it was out she suggested a bridge between the tooth in front of it and the one behind it.  First, how come antibiotics do not take care of the situation and second, does what I am telling you make sense?

A. This is a good question that comes up a lot.  The reason the antibiotics do not fix things for good is that the antibiotics take the number of bacteria in the area down significantly to make things comfortable but they do not take away the source or reason for the infection.  Unless the source of the infection is removed the area will not heal.  Some things that could cause what you are going through are a crack or fracture in the tooth or root, periodontal disease (an infection of the gum and bone that supports the tooth) or an infection in the pulp or nerve of thetooth.  There are times when the source of the infection can be removed and there are times that the only thing to do is remove the tooth, as has been suggested to you.  I am sure that all options have been thought of and discussed with you.  If this is so this makes perfect sense.  An extraction and a bridge to follow is exactly what I would do.  It is important to wait until significant healing has taken place before the impression is made for the bridge.  If this was done prematurely you could end up with an area where a lot of food will pack and be uncomfortable.  I have had an article in the past that addresses this.  I will mail it to you.  Thank you for this question - it is one of those questions that everyone has but doesn't usually ask.

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Dental Hygiene

My spouse brushes his teeth daily and uses a mouthwash regularly. Despite these efforts he seems to always have bad breath. What do you think we should do?

Is there a particular toothbrush that you recommend? How about floss and mouth rinse?

My daughter is a hygienist and she was telling me about a special program that she and her dentist have for people with gum disease. Can you explain this to me?

My dentist suggests deep cleaning and periodontal surgery and told me nobody in this area knows anything about antibiotic treatment. Please advise!

What is the best technique for brushing?

Should I use soft or hard bristles?

How long should I brush?

Should I brush at work?

I have been looking at some of the battery operated toothbrushes in the stores recently. Do you have any preferences on which is the best to use?

Is it true that a gum graft can be done using your own gums, as well as tissue from a cadaver?

I have had some questions about dental x-rays or radiographs so I thought I would discuss some of the more common questions.

Q. My spouse brushes his teeth daily and uses a mouthwash regularly.  Despite these efforts he seems to always have bad breath.  What do you think we should do?

A. If your spouse has not had a dental examination within the last 6 months I would urge you to have him do so.  More often than not what you are describing is a result of gum and bone disease.  As mentioned in an earlier column, this is normally very treatable and predictable.  The odor could be due to the presence of plaque (broken down food particles) on his teeth and below his gums. If this is the case, having his teeth scaled is all he may need.  A scaling in combination with good home care instructions can bring his mouth to a healthy state.  Once healthy, all you need do is thorough home care and regular visits to your dentist.

If after your spouse sees his dentist, he or she does not feel the reason for the odor is  in his mouth,  I would encourage you to see your family medical doctor.  He or she will do an examination and run some tests that may uncover the reason for the bad odor.

Q. Is there a particular toothbrush that you recommend?  How about floss and mouth rinse?

A. The main thing to look for in a toothbrush is the bristles.  Contrary to what some people may believe, it is important that the bristles be soft so as not to damage both the gum tissue as well as the enamel.  There are so many tooth brushes on the market today with different shapes, head sizes and angles.  However, none of these features are as important as your brushing technique. 

In my practice I find that battery operated toothbrushes can make a large difference in some patient's overall oral hygiene

Floss also comes in many different types.  Your choice of floss should depend on the size of the space between your teeth.  For those of you with extremely tight contacts there is a Teflon coated floss called Glide.  For those with larger spaces between their teeth I find that dental tape works very nicely.  Most patients find that waxed floss is easier to use and some prefer the taste of flavored floss.  As with tooth brushes, the technique is more important than the type of floss.

Mouth rinses are an important part of your home care routine.  I suggest that my patients rinse with a stannous fluoride rinse.  This happens to be a prescription, however, it is by far the best rinse to use.  Among its benefits are its ability to kill some of the bacteria that cause both gum disease and decay. It will also help harden the outer surface of the tooth, thereby decreasing the possibility of decay.  It also tightens up the tissues, making your mouth a healthier environment.  The rinse that I recommend, PerioMed, has a pleasant taste that causes my 3 year old son to ask me to brush his teeth "with the tasty, tasty stuff".

Q. My daughter is a hygienist in North Carolina and she was telling me about a special program that she and her dentist have for people with gum disease. Do you know what she is talking about and if so can you explain it to me?

A. During a new patient examination your dentist will be taking measurements of what we call a "pocket" between your tooth and gums. These measurements are in millimeters and start at 1 and can go as high as 10 to 12. If you have pockets greater than 4 millimeters there is a good chance you have periodontal disease. When detected early, like many diseases, there are a lot of things that can be done to treat it. One of these things is probably what your daughter is talking about. In broad terms, it can be called non-surgical periodontal treatment. You may also hear it referred to as a "soft tissue management program" or "root planing and scaling". All of these terms refer to the treatment of your gums when affected by periodontal disease or, as called in the past, pyorrhea. To follow is a brief explanation of what a dentist and hygienist might do for you. They will typically get you numb and clean out all the areas around your teeth in two to four sessions. Depending on the severity, you will be treated by quadrant (1/4 mouth) or by half mouth. These sessions will take between 3 and 4 hours collectively. In may cases you will return for some additional sessions to review proper home care and to check that you understand what the hygienist expects of you at home. This understanding and ability to perform good home care is critical to the success of the treatment. The hygienist will also review the use of many different home aids - all of which depend on your particular circumstance. Some of these aids might be: a toothbrush, floss, an electric toothbrush, fluoride, gum stimulators, special toothbrushes for between your teeth and many more. At the end of these sessions you will be re-evaluated by re-recording the measurements that were taken at the start of treatment. You should see a decrease in the depths of the pockets around the teeth. If this didn't occur to the satisfaction of your dentist and hygienist, your dentist will probably make some additional suggestions for you. I hope this helped clear up what you and your daughter were talking about.

Q. My dentist suggests deep cleaning and periodontal surgery and told me nobody in this area knows anything about antibiotic treatment. Please advise! Many thanks and best regards.

A. The above question comes as a result of an article in the February 1997 issue of Esquire magazine. In this article it is stated that there is a way to potentially avoid gum surgery through the use of antibiotics taken orally and in some cases applied directly to the gums. To follow is my response to this question:

There are situations in which the use of antibiotics can prevent the need for periodontal surgery. The most common sequence of events would be as follows:

1. The diagnosis of periodontal disease by your general dentist or periodontist
2. Discussion of your situation with your dentist along with the presentation of alternative treatment plans
3. Assuming you do have some degree of periodontal disease you would go through some type of root planing and scaling. Each dentist has a different approach to this - some very basic and some more elaborate.
4. You would then be re-evaluated for the results of the root planing and scaling. You should have had an initial set of periodontal probing depths along with some other data gathered during a comprehensive periodontal examination. Depending on these results, additional treatment would be discussed. It is at this point that, if the periodontal disease has not been halted, your dentist may recommend periodontal surgery.

Lets talk a little bit about the possibilities at this point:
A. Your dentist could use fibers impregnated with antibiotics. These would be placed in the pocket around the teeth that have not responded completely to the root planing and scaling. This procedure is done without knowing the specific bacteria involved. B. Your dentist could also culture the pockets to see which bacteria are living there. Once cultured, your dentist would send the specimen to a laboratory for not only the specific bacteria growing, but for their sensitivity to different antibiotics. The laboratory would typically be able to tell your dentist which antibiotics to use in your specific case.

After reading the article you sent me I think it is "B" that they are talking about. Please be aware that it is not as simple as taking the antibiotics and away goes the disease. You would need to be diagnosed, root planed and scaled, re-evaluated, cultured, put on antibiotics for a period of time and re-evaluated again. Even after all of this you may still end up needing periodontal surgery, but it is certainly worth the try in some cases.

For those of you who have had periodontal surgery in the past and still have recurring deep periodontal pockets, you may benefit from being cultured as well.

To follow are some ideas gathered from various publications that I thought might interest you. They concern the possibility that periodontal (gum) disease can be a contributing factor in the delivery of pre-mature, low-birth-weight babies, as well as coronary heart disease. Though neither of these correlations have been scientifically proven, the literature seems be headed in the direction of finding a direct correlation.

You can find a very good article in the June 8th, 1997 edition of the Ocala Star-Banner, as well as the August 11th, 1997 edition of Newsweek. There are scientific articles available, however, the two mentioned previously do a great job of discussing the issues at hand. The overall message is that the presence of the bacteria involved with periodontal disease can be correlated to an increased incidence of heart attack or sudden death and the delivery of low birth weight babies. It has also been stated that the oral infection has effects throughout the body and may contribute to coronary heart disease.

It is hard for me to comment on this specifically because there isn't enough research done to date. From what I have read so far there does seem to be a correlation that will be uncovered as additional research is completed. For any patient that has or thinks they have gum disease, as mentioned in past articles, you should certainly seek out the care of a dentist for treatment. Not only will you be treating the gum disease in order to save your teeth and get all the benefits of having your own teeth, but you may also be helping decrease the possibility of heart disease and premature low birth weight babies. If after reading this you come up with any questions, please feel free to send me your questions.

I've taken the liberty to ask two of our local periodontists, Dr. John Darby and Dr. Timothy Johnson, specialists in the treatment of periodontal disease, what they thought about this topic.

To follow is their opinion:
As the article in the Tampa Tribune-Times states, "About three-quarters of adults over age 35 have some degree of periodontal disease, a painless condition that often gives off few warnings except, perhaps, red gums and bleeding." What the recent studies have begun to show is that there is a significantly higher amount of heart disease and low birth weight babies among people with periodontal disease. While many more studies must be done before this link can be completely validated, it is better to be safe than sorry. Our suggestion is that you ask your general dentist if you have periodontal disease and follow his/her recommendations regarding care. There are many things the general dentist can do to help control your gum infection. He/she will also know best if you should be referred to a specialist in gum disease, like ourselves.

Q. What is the best technique for brushing?

A. There are a number of effective brushing techniques.. One effective, easy-to-remember technique involves using a circular or elliptical motion to brush a couple of teeth at a time, gradually covering the entire mouth. Place a toothbrush beside your teeth at a 45 degree angle and gently brush the teeth in a circular motion. Brush the outside of the teeth, inside the teeth, your tongue and the chewing surfaces and between the teeth. Using a back and forth motion causes the gum surface to recede, or can expose the root surface or make the root surface tender. You also risk wearing down the gum line.

Q. Should I use soft or hard bristles?

A. In general, a toothbrush head should be small (1" by 1/2") for easy access. It should have a long, wide handle for a firm grasp. It should have soft, nylon bristles with round ends. Some brushes are too abrasive and can wear down teeth. A soft, rounded, multi-tufted brush can clean teeth effectively. Press just firmly enough to reach the spaces between the teeth, as well as the surface. Medium and hard bristles are not recommended.

Q. How long should I brush?

A. It might be a good idea to brush with the radio on, since I generally recommend brushing 3-4 minutes - the length of an average song. Using an egg timer is another way to measure your brushing time. You would be surprised how long 3-4 minutes is when you are actually timing it. Patients generally think they are brushing longer, but most spend less than a minute brushing. To make sure you're doing a thorough job I recommend you brush a good 3-4 minutes two times a day rather than 4 or 5 times quickly. You might also remember those little red tablets we used as children. I like to recommend that, for about two weeks after your hygiene appointment, you chew one of these disclosing tablets before brushing and then brush until you get all the red off. This will help teach you where you build up plaque. After 2 weeks I suggest you brush and floss as usual and then disclose with a tablet. Hopefully, you will have gotten all the red off and are doing a good job. If not, you will find the spots you need to work on. This can be used on all ages and ,for the children, it can become a sort of game you play.

Q. Should I brush at work?

A. Definitely, but most Americans don't brush during the workday. I would suggest that you keep a toothbrush at your desk, which will increase the chances that you'll brush during the day by 65 percent. Getting the debris off the teeth right away stops sugary snacks from turning to damaging acids, and catches starchy foods, like potato chips, before they turn to cavity-causing sugar. If you brush with a fluoride toothpaste in the morning and before going to bed, you don't even need to use toothpaste at work. You can just brush and rinse before heading back to the desk. If you don't have a toothbrush, rinsing your mouth for 30 seconds after lunch also helps. The following tips may improve your work-time brushing:

• Post a sticky note on your desk or computer at work as a reminder to brush your teeth after lunch
• Brush your teeth right after lunch, before you become absorbed in work
• Store your toothbrush and toothpaste at work in a convenient and handy place
• Make brushing your teeth part of your freshening up routine at work.

What about those battery operated toothbrushes - do you recommend them?

For some people battery operated toothbrushes are a must. Many of my patients use a battery operated toothbrush dipped in a fluoride rinse. By not using toothpaste they do not get a lot of foaming and ,therefore, get a better result. I have seen a significant reduction in the amount of plaque we see on recall as well as the occurrence of new decay in my patients that are faithful to this routine.

Q. I have been looking at some of the battery operated toothbrushes in the stores recently. Do you have any preferences on which is the best to use?

A. I am glad that your asked this question. I do in fact have a preference in choosing a battery operated toothbrush. I have recommended various toothbrushes in the past but, presently, the one that I feel stands out above the rest is the Sonicare. The Sonicare has a rechargeable battery that sits in base to keep it charged. Its head is the size of a conventional toothbrush and oscillates back and forth 31,000 times a minute. The professional model has a built in timer that beeps every 30 seconds to signal you to move to the next quadrant of your mouth and turns off after 2 minutes. The head is replaceable making it ideal to share among a family. There are many other benefits to the Sonicare. If you would like a brochure on the brush I would be happy to send it to you. The Sonicare toothbrush is available in many department and discount stores. You can also get it at many dental offices. If you purchase it at a dental office you will get the professional model, as well as instructions on its use. You should check with you dentist to see if he or she has the brush available. If you decide to get it I am sure that you will be thrilled. The company is so sure that you will like it and that it will work that they offer you a money- back guarantee if you do not get a better check-up in 3 months. It is a great brush that I use every night.

Q. The following is a question I received from someone in the audience at a Kiwanis meeting where I presented a brief synopsis on periodontal disease: Is it true that a gum graft can be done using your own gums, as well as tissue from a cadaver?

A. The most common use of a gum graft is to augment the gum tissue around the teeth that is attached to the bone below. If someone is deficient in this tissue a dentist can do a surgical procedure that replaces the lost tissue. The tissue is generally harvested from the patient's own mouth, typically from the palate or roof of the mouth. In the event that a lot of tissue is needed it may make sense not to take it from the patient's mouth and instead utilize tissue from a tissue bank. The tissues in this bank are generally taken from cadavers and processed in such a way as to make the procedure very safe and predictable. If there is any discomfort associated with a graft it is typically from the donor site. If the graft is from a tissue bank there will be no donor site and therefore less discomfort.

I thought that I would discuss something I read about in a dental journal years ago and has now surfaced again. The medical and dental community has suggested that a standard panoramic x-ray may be useful in identifying patients at risk for fatal heart attacks and strokes. A panoramic x-ray is used in a dental office as a routine part of a comprehensive dental exam. It gives the dentist an overall view of the upper and lower jaws, as well as the sinuses and surrounding structures and tissues.

Researchers have found that calcifications found in the carotid arteries can show up in a standard panoramic x-ray. These calcifications can be a warning sign of a potentially fatal event. I have noticed these calcifications in some patients' x-rays and made them aware of it. They in turn went to their physician and, in fact, found that they were at risk for cardiovascular disease. Similarly, I have noticed areas of bone loss on a panoramic film that lead us to believe that a patient may have osteoporosis. In one case we did, in fact, have a patient with osteoporosis that was a risk for breaking her hip. With the proper medication she is now doing significantly better.

The research done in regards to the risk of stroke and heart attack has shown that people with plaque in the carotid arteries were twice as likely to die from hearts attack or stroke than those with no plaque.

The next time that your dentist suggests that you take an x-ray you now know that not only will he or she be looking for dental disease but will also be screening for osteoporosis, heart disease and stroke.

Q. I have had some questions about dental x-rays or radiographs so I thought I would discuss some of the more common questions.

A. There are 2 common x-rays taken while you are at the dentist. One is called a full mouth series and the other a panoramic x-ray. A full mouth series consists of a series of bite-wing and peri-apical x-rays.

A bite-wing x-ray is an x-ray that helps your dentist look between the teeth for decay. Bite-wings are the x-rays that you have taken at your periodic hygiene appointments. Many people think that these x-rays are taken every six months, however this is not necessarily true. Your dentist will make a decision on how often bite-wings are taken based on the condition of your mouth at your recall appointments, as well as how prone you are to cavities. If you are known to be prone to cavities you will probably have these x-rays taken every 6 months. On the other hand, if you rarely have decay your dentist will probably recommend a different schedule for you.

A peri-apical x ray is one that is used to assess the bone around the tooth and especially at the bottom of the root. It is this type of x-ray that you will typically have taken at an emergency appointment. If you presented to your dentist with a throbbing ache your dentist would typically find an infection at the bottom of the tooth. The peri-apical x-ray is the perfect x-ray for diagnosing this.

A panoramic x-ray is an x-ray that gives your dentist a broad view of the structures around your mouth. Some of the areas visible on a panoramic x-ray are as follows:

• all of your teeth
• your upper and lower jaw
• your sinuses
• the joint that makes your lower jaw open and close

Your dentist can point out other interesting areas on this x-ray as well. The panoramic x-rays is very useful when assessing the amount of available bone for the placement of dental implants. The panoramic x-rays is also used to visualize the position of the third molars or wisdom teeth. An orthodontist will use a panoramic x-ray to see where the adult teeth are in relationship to the baby teeth when planning braces. A panoramic x-ray is also very useful to see the extent of a cyst or abscess. There are many instances that you can see a cyst or abscess on one of the smaller films (bite-wing or peri-apical) but only through the use of a panoramic film can you see the entire lesion.

Let's talk a bit about a patient's concern for the exposure to radiation. Through the use of state-of-the-art technology and choice of different film types, your dentist can minimize the amount of radiation. When a patient goes to the dentist it is the dentist's responsibility to be thorough and arrive at a good diagnosis. This sometimes requires numerous radiographs. As mentioned before, I firmly believe that you have to have 100% confidence in your dentist. If this is so, you will realize that he or she is doing what is needed to do in order to properly diagnose your situation.

You want to avoid getting the gel on the cap if possible. This could be accomplished if you were to make a custom tray for him.

There are a few benefits to making a custom tray, they are as follows:

1. You can selectively choose which teeth get whitened.

2. You build the tray with a receptacle for the gel. By doing this the gel has a place to stay and doesn't flow all around the mouth.

3. The tray is so comfortable that you hardly know that it is in your mouth.

If you are considering whitening your teeth please seek out the advice of your dentist. There are so many variables to be considered that the only way to get a safe, predicable result is by consulting a professional. In addition, this person paid a considerable amount of money for this kit. She would not have had favorable results and may have actually had a very disappointing worse result.

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Whitening

I am a 63 year old woman and have noticed that my teeth have gotten considerably darker over the years. I have been a very diligent patient, going to my dentist every 4 months. I have been very fortunate to have very few dental needs through my life. What do you think I can do to make my teeth whiter?

I am 35 and happy with my teeth except for the color. What are your feelings on whitening teeth?

Q. I am a 63 year old woman and have noticed that my teeth have gotten considerably darker over the years. I have been a very diligent patient, going to my dentist every 4 months. I have been very fortunate to have very few dental needs through my life. What do you think I can do to make my teeth whiter?

A. First, let me say congratulations not only on having few dental needs but also on your obvious commitment to preventive dentistry. There are a number of ways in which a dentist can whiten teeth. They are as follows: 1) bonding, 2) bleaching (also know as whitening), 3) porcelain veneers 4) crowns or caps and 5) a combination of any of the above.

Because you have noted that you have had very few dental needs throughout life, it is most likely that you are a good candidate for whitening. There are two methods to whiten teeth that are available. The first method is a procedure that is done in the dental office through the application of whitening solutions directly on the teeth. Depending on the degree of staining you can get beautiful results from as little as one visit. The other method used is an at home whitening system. The procedure for this system is as follows. You would have impressions made of your teeth whereby the dentist could make a duplicate model of your teeth. Utilizing this model, your dentist would fabricate a gel tray that intimately fits your teeth to the point that you might not even know it is on. Your dentist would dispense a whitening solution to be placed in this tray and then on your teeth. Typically, a patient would do both upper and lower teeth at once during their sleeping hours. Upon rising they would remove the trays, rinse out their mouths and carry on with their normal daily activities. You can expect beautiful results in 5 to 14 days depending on the system your dentist is using and the condition of your teeth.

One thing to be aware of when whitening your teeth is that if you have white fillings in your front teeth that are noticeable upon smiling, they will not whiten with this procedure. What is normally done is they will be replaced once the desired result is attained. If you have crowns or caps the same holds true, except that to replace a crown is more costly than replacing a filling.

It is important to realize that a thorough examination by your dentist is imperative. There may be things going on that need to be addressed prior to initiating whitening. Because of this I would discourage anyone from using any over-the-counter product without consulting their dentist first. The results attained through proper whitening or a combination of the above techniques are very predictable and can greatly improve one's self image

Q. I am 35 and happy with my teeth except for the color. What are your feelings on whitening teeth?

A. Whitening teeth has become very easy and predictable over the last few years. It has been my experience that the new whitening solutions work very well when used in conjunction with a whitening tray that is made by your dentist. The tray is designed with little receptacles that hold the whitening gel in place while you wear it. Typically the patient wears both trays overnight for 7 to 10 nights. In most cases you can expect visible results that are long lasting.

AN ACQUAINTANCE TALKS TO ME ABOUT HOME BLEACHING KITS BOUGHT THROUGH THE TELEVISION

This was not a question that was sent to me through the mail but asked directly of me. She came to me and asked me if she could show me something to see what I thought of it. Well I must say I was wondering what she was going to show me. What she showed me was a home bleaching kit to whiten her teeth that she bought from a television commercial. The kit had a whitening tooth paste, a cleansing rinse, a cleansing paste, a whitening gel, two trays, a shade selection guide and an instruction manual. I immediately looked to see what was in the tube of whitening gel to find out that the ingredients were no where to be found.

Lets talk about each of the components of this system:

1. The whitening toothpaste is probably very similar to all of the other whitening toothpastes in the pharmacies locally. Like many other toothpastes the active ingredient in this toothpaste was sodium fluoride. This is probably a very nice toothpaste, however, I wouldn't expect it to whiten her teeth. This is also true for all the other whitening pastes in the pharmacies.

2. The Cleansing paste is probably an abrasive paste the will remove some topical staining. As long as it isn't too abrasive it should be fine to use this. The removal of these topical stains is probably better handled by your dentist or hygienist.

3. The cleansing rinse is probably a nice tasting rinse with very little value in whitening teeth.

4. As with all whitening systems, the bleaching gel is the most important part. Depending on what is actually in this kit will depend on its efficiency.

5. The trays were very basic and of course not customized. They were actually so small that it looked as though they were made for my 4 year old son. The other problem is that the instructions suggested you put the whitening gel in the tray and leave it in for 10 minutes 3 times a day. Because the tray was made to adapt to everyone's teeth the gel would wash out in the 10 minutes you were to keep it in your mouth. I have a few concerns with this:

A. Will you swallow the gel and is it wise to do this.

B. By keeping the gel in your mouth for 10 minutes I doubt you will get any results. You need more time than this to get any sort of predictability.

C. When you don't get any results they are hoping that you will buy more gel. They conveniently have an order form for additional gel at a significant cost.

This particular person was someone who had a gray discoloration in the 1/3 of the tooth closest to the gums as well as a relatively dark color through the rest of the tooth. As I told her, even if the system she bought worked great she would not have eliminated the gray area near the gums. All she would have done was whiten the whole tooth by the same amount. What this means is she would still have had difference in shade from the top to the bottom of the tooth even though it would have been lighter. She then went on to ask me about her husband who had porcelain caps and asked if it would have been good for him. I explained to her that the caps would not change color with the gel and that as an end result he would have different color teeth in his mouth after whitening. If the cap was lighter than the other teeth you could whiten the others to match the cap but ideally you would want to avoid getting the gel on the cap if possible. This could be accomplished if you were to make a custom tray for him.

There are a few benefits to making a custom tray, they are as follows:

1. You can selectively choose which teeth get whitened.

2. You build the tray with a receptacle for the gel. By doing this the gel has a place to stay and doesn't flow all around the mouth.

3. The tray is so comfortable that you hardly know that it is in your mouth.

If you are considering whitening your teeth please seek out the advice of your dentist. There are so many variables to be considered that the only way to get a safe, predicable result is by consulting a professional. In addition, this person paid a considerable amount of money for this kit. She would not have had favorable results and may have actually had a very disappointing worse result.

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Gum Disease

I have just moved to Florida and have been told that I need a deep scaling. I find this hard to believe because I have always been regular with my dental appointments. Can you help me understand why I might need a deep scaling.

I am a 45 year old woman and have some severe TMJ problems. I've been to many dentists who have many varying opinions as to what I should do. I realize that it is difficult for you to comment on this without seeing me but I hope you can shed some light on this for me.

I have just returned from my dentist and we have been watching an area on the roof of my mouth for the past 4 months. My doctor said that it is a growth of bone that some people have not only on the top but also on the bottom. The problem is that the tissue that covers it is very white and has been so for awhile now. My dentist suggested that I go to an oral surgeon for a biopsy. I am hesitant to do this. What do you think?

Q. I have just moved to Florida and have been told that I need a deep scaling. I find this hard to believe because I have always been regular with my dental appointments. Can you help me understand why I might need a deep scaling.

A. This is a situation that is relatively common and the only explanation I can offer you is a difference in philosophy of practice. I am going to make a few assumptions in answering your question. If you received an initial examination that included a gum exam you probably heard the dentist or hygienist read off a series of numbers. These numbers indicate the amount of support the teeth get from the surrounding bone and gums much like a foundation helps support the house that is built on it. Depending on these numbers and a number of other factors you will be categorized in one of five categories relating to your gums. They are as follows:

1. Healthy

2. Gingivitis

3. Early Periodontitis

4. Moderate Periodontitis

5. Advanced Periodontitis

To briefly explain these terms, gingivitis is a disease that affects the gums, specifically, inflammation of the gums. Periodontitis is a disease of the bone that supports the teeth and gums. Periodontitis is a combination of inflammation of the gums along with a loss of the bone that supports the teeth. There are differing degrees of periodontitis as mentioned above.

Depending on the dentist, you may or may not be examined for the above mentioned diseases routinely. If you did, in fact, have a gum exam and have been diagnosed with periodontitis, your dentist probably recommended a deep scaling. This, in fact, is the proper recommendation and may actually avoid the need for gum surgery in the future. If in the past you have never been examined for gum disease you were probably never told of the need for a deep scaling.

ORAL CANCER

I feel compelled to let you know that in the past month I have had a number of patients have biopsies due to areas found during a routine oral cancer screening. All but one of these came back as non cancerous. However, one of them came back as precancerous. The reason I bring this up is that it is because this patient had a routine oral cancer exam that we found the lesion and that, in all likelihood, it will not pose a long term threat. If you have not had an oral cancer exam recently please see your dentist for one. The examination is very easy and should take no longer than a minute or two. The most common areas for oral cancer is below the tongue and the side of the tongue. To follow are some statistics about oral cancer:

Oral and throat cancer account for 2 to 4 percent of all cancers diagnosed annually in the United States.

Oral cancer seems to begin, in many cases, with exposure to cancer causing agents, predominantly alcohol and tobacco. However, oral cancers occur in some patients with no history of tobacco or alcohol usage and no other apparent risk factor.

A 1982 Cancer Prevention Study concluded that male cigarette smokers had a relative risk of oral cancer 27.7 times greater than males who had never smoked; the rates among woman who smoked were 6 times greater than for nonsmoking women.

The average age of diagnosis is 60 years.

TMJ DISORDERS

Q. I am a 45 year old woman and have some severe TMJ problems. I've been to many dentists who have many varying opinions as to what I should do. I realize that it is difficult for you to comment on this without seeing me but I hope you can shed some light on this for me.

A. As you have mentioned, TMJ or tempero-mandibular joint problems are very complex and certainly I would need to see you to comment for you specifically. Considering that you have stated that you have a severe problem I would probably end up referring you to a specialist in this area. We happen to be very fortunate that an internationally known expert in this field has his office in St. Petersburg. If someone in my family were in the situation that you are in, I would, without a doubt, refer them to this office. If you would like his name and phone number please give my office a call.

Q. I have just returned from my dentist and we have been watching an area on the roof of my mouth for the past 4 months. My doctor said that it is a growth of bone that some people have not only on the top but also on the bottom. The problem is that the tissue that covers it is very white and has been so for awhile now. My dentist suggested that I go to an oral surgeon for a biopsy. I am hesitant to do this. What do you think?

A. I think that you should go the oral surgeon and have a biopsy performed. If it comes out negative everyone has peace of mind. If it is positive you have probably caught it early in which case the chance of cure is better.

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Root Canals

I've been told by my dentist that I need four root canals in order to save my teeth. Unfortunately he didn't explain anything to me and I am not sure that I want to go through with this. You should know that I have no missing teeth and would prefer to keep it that way. Can you explain what a root canal is and help me make this decision?

I had a root canal done at least ten years ago and just came back from a consultation with a new dentist. She told me that there is an abscess at the bottom of the tooth that had the root canal in it. It was recommended that I go to a root canal specialist for some sort of surgery. Does this sound correct and, if so, can you explain what they are proposing for me to have done?

I have a root canal on my tooth. My dentist tells me I need a crown now. Why do I need a crown if the tooth is dead?

My husband recently had a toothache and went to our dentist. The dentist told him that he needed a root canal. They started the root canal last week. All during the root canal he was in pain. He has also been in pain since the root canal was started. The dentist gave him some pain medicine but no antibiotics. My husband doesn't want to go back to the dentist because of the level of pain he was in. Do you have any suggestions for him. He feels as though there is an abscess starting - it just doesn't seem right.

Q. I've been told by my dentist that I need four root canals in order to save my teeth. Unfortunately he didn't explain anything to me and I am not sure that I want to go through with this. You should know that I have no missing teeth and would prefer to keep it that way. Can you explain what a root canal is and help me make this decision?

A. Stated very simply, a root canal is the process by which a dentist removes the nerve of the tooth. The nerve of the tooth usually goes through the center of the tooth and down the root. A dentist will place an apparatus called a rubber dam over the tooth to isolate it from the other teeth and the rest of the mouth. A rubber dam is a thin piece of flexible rubber approximately 6 inches square. It is held in place by a clamp that fits over the tooth and a frame that holds the piece of rubber comfortably in place. The dentist then gains access to the nerve through the top or crown of the tooth. Once in the nerve canal the dentist will remove the nerve and go through the process of widening the canal by using a series of files that progressively get larger. Once the dentist is comfortable with the shape of the canal he or she will fill this space with the root canal filling. Once the root canal is finished there are a number of alternatives for restoring the tooth

As for whether or not you should save your teeth, I would encourage you to go ahead with the root canals as long as your dentist is confident it is in your best interest that they be done. One important reason for me recommending saving your teeth is that you have not lost any thus far. This would mean that the need for a fixed bridge or a partial removable denture can be avoided. As always, I would encourage you to talk with your dentist about your concerns. Together you will be able to come up with a solution that makes good sense.

Q. I had a root canal done at least ten years ago and just came back from a consultation with a new dentist. She told me that there is an abscess at the bottom of the tooth that had the root canal in it. It was recommended that I go to a root canal specialist for some sort of surgery. Does this sound correct and, if so, can you explain what they are proposing for me to have done?

A. What you have explained is very possible. For various reasons you may, in fact, have a residual infection at the tip of the tooth. The procedure that they are recommending is called an apicoectomy. The dentist will flap back the gums thereby exposing the bone below. They will then gain access to the bone at the tip of your tooth. This area will be less hollow than the rest of the bone because of the presence of the infection. The dentist will spoon out the infected tissue and scrape the bone clean. He will then seal the tip of the tooth and suture the tissues' back in place. This procedure is very predictable and successful.

Q. I have a root canal on my tooth. My dentist tells me I need a crown now. Why do I need a crown if the tooth is dead?

A. You are among the great majority of the population that thinks that because a tooth has had a root canal the tooth is now "dead". Though the main blood and nerve supply to the tooth is removed in the process of doing a root canal, the tooth still has nourishment going to it. Let us talk about the reasons why you may need a crown on a tooth that has had a root canal. If the reason for the root canal was a large amount of decay that went to the nerve of the tooth, there is a good chance that you also had a filling in place already and therefore there is very little supportive tooth left. If this is the case, the reason for the crown is to protect the tooth from the forces of chewing and thereby avoiding its breakage beyond the point that it can be repaired. Your dentist will probably suggest that he or she either place a post in the tooth and build it up or simply build the tooth up without a post. Both of these procedures are used to reestablish the contours of the tooth so that a crown can be made.

Q. My husband recently had a toothache and went to our dentist. The dentist told him that he needed a root canal. They started the root canal last week. All during the root canal he was in pain. He has also been in pain since the root canal was started. The dentist gave him some pain medicine but no antibiotics. My husband doesn't want to go back to the dentist because of the level of pain he was in. Do you have any suggestions for him. He feels as though there is an abscess starting - it just doesn't seem right.

A. It sounds as though your husband needs to be on antibiotics. Have him give his dentist a call and explain what you have told me. I am sure the he or she will call a prescription in for him. If he simply doesn't want to go back to this dentist have him see an endodontist (a specialist for root canals) or a general dentist who does root canals routinely. I am surprised to hear that he was in pain all through the procedure - there are many different techniques and anesthetics available these days to make a patient feel comfortable. I am also surprised that the root canal was not completed in one visit. Most root canals can be performed in one visit though there are some circumstances where you would be better off having it done over two visits. In addition, your husband could have a fracture in the tooth that is keeping the area irritated. A fracture can usually be seen during the procedure - I am sure that your dentist would have discussed this with you. All in all, my suggestion would be to go back to the dentist to discuss his concerns. I am sure that once discussed there will be a solution or explanation. I have found that there are so many times that a lack of communication leads to unnecessary anxiety.

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Restorative Dentistry

I am 63 years old and presently wear an upper denture and only have 6 teeth on the bottom in the front. I have been to a new dentist after not being to the dentist for 20 years. He has told me that I need some gum work on the bottom and a new denture up top. We have not yet discussed any other treatment on the bottom. I am not very happy with the way my teeth look on the top and would like to know what options I have on the bottom. I would rather not have a partial denture on the bottom because in the past one was made and I couldn't wear it. Can you give me some ideas on how to fix me?

About ten years ago I had facings put on my front teeth and never liked the way they looked. They make me look like I have buck teeth. In addition, I am missing all but my back two molars and wear a partial denture with wires hooked on to my eye teeth. Do your have any thoughts on what I can do to make this look better. My granddaughter is getting married in July and I would like to have the smile I've always wanted for it. Please give me your thoughts on this. Thank you.

I was just to a new dentist and he recommended that I have most of my back teeth root canaled and crowned. I realize that most of these teeth have large old fillings with decay around them, I just don't know if I want to spend all the money needed to fix them. I talked with him about extracting all of my back teeth and making partials. Can you give me any insight?

I am 87 years old and have just had a filling fall out of one of my remaining 6 lower teeth. I have a denture on the top that will only stay in with Sea Bond adhesive. I also have a denture on the bottom that replaces my back teeth. I had not been to the dentist in 6 years before going to a dentist to have my filling replaced that came out. After going there the dentist said that I have decay in all of my teeth and that they should come out and a denture should be placed as I have on the top, immediately. At my age I really do not want to have the rest of my teeth taken out. I have heard that lower dentures are a problem to keep in and I already have a problem with my uppers. I hate to think of what the bottoms would be like. Do you have any ideas for me to keep my lower teeth?

Q. I am 63 years old and presently wear an upper denture and only have 6 teeth on the bottom in the front. I have been to a new dentist after not being to the dentist for 20 years. He has told me that I need some gum work on the bottom and a new denture up top. We have not yet discussed any other treatment on the bottom. I am not very happy with the way my teeth look on the top and would like to know what options I have on the bottom. I would rather not have a partial denture on the bottom because in the past one was made and I couldn't wear it. Can you give me some ideas on how to fix me?

A. It is quite obvious that you need a new denture on the top. In making this denture many things can be done to improve your cosmetics. You simply need to let your dentist know what changes you would like and he or she will let you know if it can be done. As for the bottom, you need to do whatever is necessary to bring those teeth into periodontal (gum) health. I am assuming that you have no decay.

There are a couple of ways to handle the bottom - they are as follows:

1. Make a conventional partial denture with clasps on your natural teeth.

2. Crown your front teeth and make a partial that has precision attachments. One half of the attachment is in the denture and the other half is attached to the crowns. They will fit together like a key fits into a lock. When done this way there are no clasps and the forces to the teeth are better distributed.

3. Crown your front teeth and as part of the crowns hang and an extra tooth off the back of each side. By doing it this way you avoid the partial and still get an extra tooth on each side.

4. Leave your teeth as they are and place implants in the back bone so that crowns can be placed on them. By doing this you also avoid a denture and replace all of the back teeth with as close to a natural tooth as you can.

Each of these options have their pluses and minuses. It is a matter of which method is best for you, specifically.

Q. About ten years ago I had facings put on my front teeth and never liked the way they looked. They make me look like I have buck teeth. In addition, I am missing all but my back two molars and wear a partial denture with wires hooked on to my eye teeth. Do your have any thoughts on what I can do to make this look better. My granddaughter is getting married in July and I would like to have the smile I've always wanted for it. Please give me your thoughts on this. Thank you.

A. Both of the treatment plans you have outlined make sense and can work. The real question is one of cost versus comfort. The root canal and crown option will be more costly, though it will also be more comfortable. If the root canals seem as though they will be predictable and long lasting I would encourage you to move in that direction, assuming you can afford it. If cost is a great concern for you then the option of extraction followed by partials will work very nicely, too. This option should be less costly and quite predictable. Realize that the partials will move to some degree and will not be perceived as your own teeth like the crowns will. What I usually tell my patients in this scenario is that, in either case, you will be getting the same quality of dentistry - the difference is in the procedure along with the inherent advantages and disadvantages associated with it.

Q. I was just to a new dentist and he recommended that I have most of my back teeth root canaled and crowned. I realize that most of these teeth have large old fillings with decay around them, I just don't know if I want to spend all the money needed to fix them. I talked with him about extracting all of my back teeth and making partials. Can you give me any insight?

A. It sounds as though you have had porcelain veneers placed on your front teeth. The reason they are bulky is probably that when the dentist put them on they didn't shave down a little of the tooth to make up for the thickness of the veneer placed. When veneers are done in this fashion you end up with bulky teeth as you have described.

One of the nicest ways to restore your mouth is as follows. You could put crowns on the front teeth duplicating their original shape and position. On the back of these teeth you would have an attachment that acts as the female half of a precision attachment. The male portion of the attachment is part of a new partial that would be made. On the back teeth you could have the partial clasp onto the two remaining teeth that you have in the conventional manner. The advantages to restoring your mouth this way are as follows:

1. The clasps on the front teeth are eliminated and therefore very esthetic to the point that you would not even look as though you were wearing a partial.

2. Because you are using precision attachments the torqueing forces are greatly reduced on the teeth.

3. The dentist basically has free reign on the cosmetics of the teeth since they are all being restored at once.

The time it typically takes to restore a mouth in such a way as I described is approximately 3 to 4 months. Based on this, there should be no problem completing your new smile by your granddaughters wedding. I am excited for you in getting the smile you've always wanted and seeing your granddaughter get married. Congratulations!

Q. I am 87 years old and have just had a filling fall out of one of my remaining 6 lower teeth. I have a denture on the top that will only stay in with Sea Bond adhesive. I also have a denture on the bottom that replaces my back teeth. I had not been to the dentist in 6 years before going to a dentist to have my filling replaced that came out. After going there the dentist said that I have decay in all of my teeth and that they should come out and a denture should be placed as I have on the top, immediately. At my age I really do not want to have the rest of my teeth taken out. I have heard that lower dentures are a problem to keep in and I already have a problem with my uppers. I hate to think of what the bottoms would be like. Do you have any ideas for me to keep my lower teeth?

A. It sounds as though your dentist has recommended the best thing for you. However, in the event that root canals can be done on your teeth and restored adequately, you may have some options. One option that comes to mind is a scenario that I have written about before. You can have the root canals done, posts placed in the teeth, and crowns (or caps) put on top of them. Attached to the crowns at the ends you would have an attachment that has two halves. One half of the attachment is in the denture and the other half is attached to the crowns. When the restoration is complete the denture fits over the teeth and is well retained. One advantage to this is that there are no clasps and the forces to the teeth from the denture are minimized.

Another idea would be to extract the teeth as recommended, but place implants in the jaw bone that will hold a bar that, in turn, will hold in an implant restoration. This is a very nice way to restore a situation such as yours or someone without any teeth wearing a full denture. It can also work equally as well on the top.

It is impossible for me to give you a firm suggestion without seeing you. I would suggest that you let your dentist know that you really do not want to extract teeth. If there is a way to do it I am sure he or she will talk to you about it. If you are okay with a limited result in trade for keeping your teeth for a while longer you should let your dentist know. As dentists, we usually only want to do things that are predictable and long lasting, though there are times that, with the patients approval, we might design a restoration knowing it has a limited life expectancy. I wish you the best in making your decision.

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Crowns, Bridges and Implants

Please advise what kind of bridgework is available short of raising sinuses surgically, transplanting bone and then permanently implanting 2 upper rear teeth crowns in the new bone.

I am 53 years old and just had a back tooth removed in my lower left jaw. My dentist has suggested that I replace it with a bridge. From what I understand he will be cutting down the teeth next to the place where the tooth was removed in order to replace the missing tooth. I am not sure that I want to have this procedure done. Can you tell me if I have any other options?

I am a 62 years old and have a very loose tooth on the bottom in the front. In the past it had a root canal and then surgery to remove some infection. I have been to the dentist and he told me that the tooth is not able to be saved. When I asked him how to replace it he told me to remove the other three front teeth and make a bridge from one eye tooth to the other. I am not sure that I want to remove those three teeth to replace the one giving me a problem now. Can you shed some light on this for me. I would really appreciate it and I enjoy reading your column.

I have a one tooth partial replacing my upper front tooth. I would like to get rid of it with something that is more permanent.

I just broke a tooth and my dentist said I need to have a crown made. Can you explain what a crown is?

I am 82 years old and have had three of my front teeth capped for years. Two of those caps came off about 2 years ago and I have been that way since then. The other one seems to be loose. I am wearing a partial that I am comfortable with and was wondering if I could put two new caps on the teeth that no longer have caps and match them to my partial. Could you also tell me what you think is the problem with the other cap that is loose. You should also know that the two teeth that the caps came off of are almost broken off down to the gums.

I had a partial denture made 2 years ago and recently had a crown made that fits under the partial. Ever since the crown was made the partial hasn't fit properly. The dentist made all sorts of adjustments to the crown when he put it in and it still isn't right. Do you have any idea what this is all about and what I can do about it?

I am a 54 year old woman and I am in search of a second opinion. I have recently lost all of my back teeth on the bottom right side in the back. I have my own teeth in the front and a permanent bridge on the lower left side. I am told by my dentist that all of my teeth are okay, including my top ones, and that all I have to do is replace the missing teeth on the bottom. He is recommending using implants that will eventually get crowns on them. He says that it would be the most natural and overall be the best way to do it. He said that a partial denture would be uncomfortable at best. My biggest concern is not the money and time involved; it isn't even the pain, it is the fact that I have to be put to sleep to do the implants?

I am 53 years old and have just moved to Citrus county. A friend of mine in New Jersey just had implants put in to hold her dentures in. She was very pleased with the end result and could eat anything she wanted. Could you tell me what some of my options are. Thank you.

I have a root canal on my tooth. My dentist tells me I need a crown now. Why do I need a crown if the tooth is dead.

I have every tooth in my mouth except for my wisdom teeth and my bottom first molar. Can you help me decide how to replace this tooth. I've been told different things by different people and can't seem to make up my mind.

About 5 years ago I had a root canal, post and crown done on my front, top, center tooth. It has since come loose 2 times after being cemented by my dentist. I am frustrated with this and wonder what you think.

I just had my front top tooth extracted because a root canal went bad. The root canal was done years ago and I had some sort of surgery done to the tooth about 7 years ago . My dentist told me there was nothing else to do to save it. Now that it is out I want to replace it. My dentist gave me a few options to include a bridge or an implant. These options are simply too costly for me right now. Do you have any other ideas? Thank you.

I have a one tooth partial replacing my upper front tooth. I would like to get rid of it with something that is more permanent. Can you review my options. Thank you.

I had a partial denture made 2 years ago and recently had a crown made that fits under the partial. Ever since the crown was made the partial hasn't fit properly. The dentist made all sorts of adjustments to the crown when he put it in and it still isn't right. Do you have any idea what this is all about and what I can do about it?

I have a bridge on the upper right that was done about 7 years ago. I am now getting a bad odor and a funny taste from around the back tooth. I do not have any pain or sensitivity. What do you think this is and what should I do about it?

Q. Please advise what kind of bridgework is available short of raising sinuses surgically, transplanting bone and then permanently implanting 2 upper rear teeth crowns in the new bone. I really do not want a removable bridge that spans the entire roof of the mouth, but I also cannot afford the $9,000.00 or so price of implantation/surgery/crowns. I have 13 upper teeth - back right 2 are a cantilevered bridge held by the 3rd tooth and is loosening. Next 7 front teeth are mine - then a bridge of 2 affixed to 1 natural molar. I have bone loss and have been through periodontal surgery and scraping. Lower mouth has 14 mix and match, normal and implanted teeth. I have an appointment at the Coastal Jaw Surgery Center in Spring Hill for consultation with Dr. Pikos, but would like information for alternatives. The originating doctor wrote- "Patient has a loose cantilever bridge # X-4-5 and due to perio involvement not a good candidate for bridge to #6." He is talking about having teeth 4 and 5 crowned and teeth 2 and 3 implants after bone graft from the chin area, sinus augmentation, IV sedation etc. Can you offer any information? Awaiting your response.

A. As you can see, this is a very involved question and I will do my best to answer it without seeing the patient. To put this in lay terms, let me tell you what I think the question is. This patient has all of her upper teeth except for some of the back ones on the right side. The remaining teeth have bone loss and were treated in the past for gum disease, though apparently are doing okay and worth saving. The patient wants to replace the missing teeth with something permanent and avoid the coverage of the palate that comes along with a removable partial denture. She is also not in the position to spend the money that comes along with replacing these teeth permanently via sinus grafts and implants.

My response: Assuming that all of the other teeth are worth saving and have a good long term prognosis, it seems as though the treatment plan that has been presented to you is an excellent one. The draw backs to this plan are obviously the cost involved and the need for multiple surgeries. The treatment time for this scenario is approximately 12 to 18 months - for some people this alone would be a deterrent.

Q. I am 53 years old and just had a back tooth removed in my lower left jaw. My dentist has suggested that I replace it with a bridge. From what I understand he will be cutting down the teeth next to the place where the tooth was removed in order to replace the missing tooth. I am not sure that I want to have this procedure done. Can you tell me if I have any other options?

A. Replacing a tooth such as the one you had removed can be done in a number of ways. The way you replace it depends on the specific circumstance you present with. I will review a few of the common scenarios and hope that one of them fits you.

1. If the teeth next to the missing tooth have no decay or restorations, the way to replace the missing tooth is straightforward. The treatment of choice is to use an implant that will support a crown as a permanent replacement. An implant can be placed in the jaw bone and a post will be attached to it once the implant becomes integrated. This is the treatment of choice because you would rather not shave down the adjacent healthy teeth to place a permanent bridge. I addition, the cost differential between these two options is not enough to sway you either way.

2. If the teeth next to the space have significant amounts of decay or have large restorations that will lead your dentist to believe that the tooth itself is unsupported, and in all likelihood could fracture when under stress, the treatment of choice would be a bridge. The reason for this is that the teeth next to the space need crowns anyway, so why not make a bridge by connecting the two teeth with a fake one. This type of restoration is also permanent and only takes 3 to 4 weeks once started. An important thing to note here is that you need to allow enough healing time from the time of extraction so that all the shrinkage that is going to take place does so. If you do not wait for this to occur you will end up having the shrinkage take place once the permanent bridge is placed and consequently, catch a lot of food under your bridge. In order to keep the teeth next to the space from drifting towards the space, your dentist may want to have a temporary bridge made during the healing phase.

3. If you have teeth missing on the opposite side of your mouth you may want to consider having a partial denture made. This would be a good option because, typically, a balanced partial (a partial denture replacing teeth on both sides of the dental arch) will be very comfortable, especially if it is totally tooth supported instead of partially tissue supported. This would also make sense if the overall investment that you make in your teeth is limited by your financial situation. I have seen many cases where a partial denture could replace all of the missing teeth in an arch for the same investment of replacing a single tooth with either a bridge or implant as discussed earlier. Please understand that both the bridge and the implant most closely mimic a natural tooth whereas a removable partial denture is recognized by most patients as foreign.

4. In the past a dentist would suggest replacing the missing tooth with a very small partial denture that attached to the teeth in front of and behind it with metal clasps. Though this does work I am very apprehensive restoring a patient in this manner. My concern is that the partial is easily dislodged. If this does happen it can be swallowed because of its small size. Worse than that would be if it were aspirated into the lungs.

Q. I am a 62 years old and have a very loose tooth on the bottom in the front. In the past it had a root canal and then surgery to remove some infection. I have been to the dentist and he told me that the tooth is not able to be saved. When I asked him how to replace it he told me to remove the other three front teeth and make a bridge from one eye tooth to the other. I am not sure that I want to remove those three teeth to replace the one giving me a problem now. Can you shed some light on this for me. I would really appreciate it and I enjoy reading your column.

A. Thank you for your thorough description. I feel as though I know exactly what you are talking about and will address some of your concerns. Incidentally, your concerns in this matter are very similar to everyone's concerns with the same circumstances. As you have mentioned, it seems clear that the loose tooth needs to come out. The three teeth beside this one are your lower incisors. These teeth have very small roots that are not very supportive. What your dentist may not have discussed with you is that there may be decay in these teeth or they may be periodontally compromised (that is they do not have a lot of bone support around them). Such a situation would not be surprising to me. If this were the case and you were going to make a bridge from one eye tooth to the other eye tooth it wouldn't make sense to include the compromised incisors. In all likelihood the incisors would fail and need extraction before the eye teeth needed treatment. In fact, a bridge made from eye tooth to eye tooth should last a very long time if done properly.

To recap - I feel as though your dentist is right on target with extracting the four incisors and making a bridge from eye tooth to eye tooth. This is a very common and predictable restoration that should last you many years. Please don't forget that your responsibility in this is good home care to include brushing and flossing as well as regular visits to your dentist. The one place this can fail is at the junction of the bridge and the tooth. If not kept clean it could decay and require repair, replacement or be lost in the future.

Q. I have a one tooth partial replacing my upper front tooth. I would like to get rid of it with something that is more permanent.

A. There are a few ways that you can replace your missing tooth with a permanent tooth. The most straight forward way to do it is with a fixed bridge. This entails shaving down the adjacent teeth, placing caps on them and suspending a fake tooth between the two of them. This would be cemented in permanently. It will take about two visits and is very predicable. The biggest drawback is that you may be shaving down teeth that otherwise wouldn't need to be shaved down. This brings me to the next option which would be to replace it with an implant. Through the use of an implant you wouldn't need to shave down the adjacent teeth and still get a permanent replacement tooth. An implant will require two surgeries and the fabrication of the cap that goes on top of it. It will take approximately 8 months from start to finish and can be very predicable if done by someone experienced with implants. Another way to replace your tooth is through the use of a different type of bridge. Your dentist will need to shave down only the back of the adjacent teeth and make a bridge with two wings that key into the adjacent teeth. It is cemented in permanently and can be done in two visits. I am not a big fan of this type of bridge because they can be unpredictable and become loose. If made out of metal it can discolor the adjacent teeth once cemented in. We are now seeing this type of restoration made out of plastic materials. If these prove to be predicable they may be a very nice alternative. I hope this info helps you make a decision.

Q. I just broke a tooth and my dentist said I need to have a crown made. Can you explain what a crown is?

A. When someone breaks a tooth and it has been determined that, due to the size or location of the break, a filling will not work, the recommendation of a crown (sometimes called a cap) is common. A crown is a prosthetic device that protects the tooth below from further fracture and potential future loss.

There are many materials that can be used in the fabrication of a crown. The most common materials used are a combination of metal and porcelain. The metal is used for its strength and the porcelain to match the existing tooth color. In the case of multiple crowns you have the option of designing a new smile because you, as the patient, and the dentist have control of the shape and color of the final result. Another type of crown available is the all porcelain crown. The benefit to this crown is the beauty you can attain due to not utilizing a metal substructure. When used in the right scenario it is an excellent restoration. Finally, another material which is very new, combines the use of porcelain along with a composite (a plastic). Again, this is a beautiful restoration when used under the right circumstances. The main benefit to this material is its flexibility due to the plastic component.

Q. I am 82 years old and have had three of my front teeth capped for years. Two of those caps came off about 2 years ago and I have been that way since then. The other one seems to be loose. I am wearing a partial that I am comfortable with and was wondering if I could put two new caps on the teeth that no longer have caps and match them to my partial. Could you also tell me what you think is the problem with the other cap that is loose. You should also know that the two teeth that the caps came off of are almost broken off down to the gums.

A. I am going to answer your question the best way that I can without seeing you. I will be assuming some things as I go along - if they are the wrong assumptions please go to a dentist for an answer that can be specific to your situation.

The assumptions that I am going to make are as follows:

1. All of the rest of your teeth are okay and the partial denture you are wearing fits properly.
2. The teeth that do not have the crowns are not broken so far down that they will require surgery to restore them.
3. None of the teeth have had root canals
4. You would rather have these teeth repaired than extracted and added to the denture.

Since the two teeth that have no crowns on are broken off near the gums you will need to have root canals done. This will allow you to place posts in them that will support a build-up material. This build-up material, along with the post, will take the place of your natural tooth structure. Once you have the post and build up in place the dentist can make crowns or caps to fit over them. By doing this you will not only have teeth that look nice but also support the remaining tooth, as well as the post and build-up.

You had mentioned that you thought that the other crown that you have in your mouth is loose. When a crown feels loose there is either decay under it that caused it to get loose or the cement that was used has washed out. If you are certain that there is no decay you can sometimes remove the crown and recement it. A very important consideration when doing this is - there is a risk of breaking the tooth that the crown is cemented onto. If this is the case I would suggest that the crown be cut off rather than tapped off. If the crown is cut off you would need to remake it rather than recement it. Lets assume that we had to cut it off and remake it. In this case it would be ideal to combine the crowns on the two teeth with the root canals, posts and crowns to the tooth that we cut the existing crown off of. This type of restoration is called a splint because you are joining all 3 teeth together as one piece. The two teeth with the root canals will be getting additional support from the other one.

You had questioned whether or not the crowns that are made can be made to fit to your partial. The answer to this is yes, however, it is something that is very difficult to do. The procedures that are done in the office need to be very precise. In addition, it is very important to use a laboratory that has a high attention to detail. If any one part is missed you will not end up with a result that is satisfactory.

Q. I had a partial denture made 2 years ago and recently had a crown made that fits under the partial. Ever since the crown was made the partial hasn't fit properly. The dentist made all sorts of adjustments to the crown when he put it in and it still isn't right. Do you have any idea what this is all about and what I can do about it?

A. When you make a crown precision is very important. The proper amount of reduction of tooth is imperative so there is enough room for the restorative material. A good impression allows the lab to make a crown with margins that meet the tooth smooth and closed. This is important so you do not get decay under the crown at a later time. When you make a crown under a partial not only do you have to do all the things that you do to make a crown but now you have to make it match the existing partial. As you probably know, a partial denture is retained with clasps around a tooth and should have a rest seat or little dimple in the tooth that the partial sets into to avoid seating of the partial into the gums. It may be the case that your crown was made in such a way that it never fit the partial and the adjustments that you mentioned were an attempt to make it fit. This is in no way an easy thing to accomplish but there are times it is the only way to restore things. It takes alot of detail on the dentist's part, as well as the lab that he or she uses. In response to what to do - you probably need to get to a dentist for evaluation. With a few more adjustments things may be okay or you may need to have a new crown made.

Q. I am a 54 year old woman and I am in search of a second opinion. I have recently lost all of my back teeth on the bottom right side in the back. I have my own teeth in the front and a permanent bridge on the lower left side. I am told by my dentist that all of my teeth are okay, including my top ones, and that all I have to do is replace the missing teeth on the bottom. He is recommending using implants that will eventually get crowns on them. He says that it would be the most natural and overall be the best way to do it. He said that a partial denture would be uncomfortable at best. My biggest concern is not the money and time involved; it isn't even the pain, it is the fact that I have to be put to sleep to do the implants?

A. Let me first congratulate you on even writing to me with this question. It is a good question and should be answered before you proceed with treatment. All too often a patient will either not go ahead with treatment or do treatment with questions in their mind when all they have to do is talk it over with their dentist or, as you are doing get a second opinion.

If I can picture your scenario, and I think I do, it seems as though you and your dentist are right on target. Implants would certainly be the nicest way to restore your mouth under the circumstances. They would, in fact, be the most comfortable, as well as the most natural. If you were to make a partial denture you would, in all likelihood, not be happy with it since it would be one sided (replacing the teeth on only one side) and therefore not be balanced. I find that patients with a denture such as this keep it out of their mouth more often than in their mouth.

To address your concern about being put to sleep, the way the oral surgeon will put you to sleep is different than if you were put to sleep for major surgery in a hospital. I am quite certain that your surgeon will be using conscious sedation rather than general anesthesia. If this is the case many of the risks associated with general anesthesia are not there. I would suggest you discuss this with the oral surgeon before the procedure - I am sure he or she will be able to put you at ease. Additionally, if you are going to the oral surgeon in Spring Hill that I am thinking of, you are in good hands. I would suggest that you discuss his or her qualifications with your dentist or the oral surgeon him/her self. Once again, it sounds as though you have been well cared for so far. I have no reason to believe that this will change either. Please discuss your concerns with your doctors - I bet everything will be cleared up for you and you can enjoy the benefit of dental implants and good restorative care for the rest of your life. You won't regret it!

Q. I am 53 years old and have just moved to Citrus county. A friend of mine in New Jersey just had implants put in to hold her dentures in. She was very pleased with the end result and could eat anything she wanted. Could you tell me what some of my options are. Thank you.

A. Congratulations to your friend. She has joined so many former denture wearers and is now experiencing the benefits of dental implants. To follow is a list of some of those benefits:

1. Confidence that your teeth will not move upon speaking or chewing.

2. Very little or nothing covering the top of your mouth thereby letting you taste foods better.

3. The ability to eat foods that a denture wearer usually can not - corn on the cob, spare ribs, etc.

Since most people are comfortable with their upper denture and unhappy with their lower, let me start by talking about the lower denture. The most common method of using implants in the lower jaw is to place 5 implants in the jaw. These implants will resemble either a bullet or a screw and are placed in the jaw after it has been prepared. These implants would stay in the jaw for approximately 4 months during which time you are wearing you own dentures. At no time during this procedure will you be left without the ability to wear your teeth. After the 4 months are up your dentist will place posts into these implants and build a bar that connects them. It is to that bar that your teeth are fastened. When your teeth are in your mouth they are very secure. The beauty of this type of system is you have the ability to remove the teeth and clean the implants and bar extremely thoroughly, thereby avoiding any problems. You can expect the entire procedure to take approximately 6 months from the time the implants are placed to the time that they are restored. Another method to restore the implants involves much of the same procedures, however, the final teeth can be placed so that only your dentist can remove them, if necessary.

In the event that there is very little bone left, another type of implant can be used. This implant is placed on top of the jaw rather than in the jaw. Once again there is a bar connected to it and the teeth are routinely fastened to it through the use of o-rings. This type of implant restoration would typically take 4 to 5 months from start to finish. Again, your have the ability to wear your own teeth during this time.

Lets discuss the top jaw. The same basic procedures apply to the top except that you would typically use 8 implants instead of 5. In the event that your sinuses are large and there is little bone, we would normally build up the bone before placing the implants. Depending on whether or not the bone was built up, it could take between 10 and 18 months from start to finish.

If you are having difficulty with your dentures and think that you could benefit from dental implants you should seek the advice of your dentist. He or she will either be trained to do both the surgery and make your teeth or they will work in conjunction with a surgeon who will place the implants. It is best to bring a list of your desires and questions to that appointment. In doing so you will be sure to be well informed and your dentist will be able to tell you if your goals are reachable through the use of dental implants.

Q. I have a root canal on my tooth. My dentist tells me I need a crown now. Why do I need a crown if the tooth is dead.

A. You are among the great majority of the population that thinks that because a tooth has had a root canal the tooth is now "dead". Though the main blood and nerve supply to the tooth is removed in the process of doing a root canal, the tooth still has nourishment going to it. Let us talk about the reasons why you may need a crown on a tooth that has had a root canal. If the reason for the root canal was a large amount of decay that went to the nerve of the tooth, there is a good chance that you also had a filling in place already and therefore there is very little supportive tooth left. If this is the case, the reason for the crown is to protect the tooth from the forces of chewing and thereby avoiding its breakage beyond the point that it can be repaired. Your dentist will probably suggest that he or she either place a post in the tooth and build it up or simply build the tooth up without a post. Both of these procedures are used to reestablish the contours of the tooth so that a crown can be made.

Q. I have every tooth in my mouth except for my wisdom teeth and my bottom first molar. Can you help me decide how to replace this tooth. I've been told different things by different people and can't seem to make up my mind.

A. First off, let me congratulate you on having all of your teeth except for the ones mentioned in your question. Your situation is not a unique one and there are some very specific thought processes that I go through when presented with this dilemma. If the teeth next to the space have no decay or very small restorations, the treatment of choice is the placement of an implant or two on which we would cement a crown. If the teeth next to the space are in the need of a crown themselves, either due to a fracture, large restoration or broken piece of tooth, then the treatment of choice is a cemented bridge. The other option that one might think of is a removable denture. I would discourage you from this because the denture would be too small and could be swallowed if dislodged. The fee for the above recommendations are so similar that money is rarely a deciding factor in this. What is most important, as always, is what is the best for the patient. I would encourage you to see your dentist and he or she can help lead you in the right direction.

CROWNS

Q. About 5 years ago I had a root canal, post and crown done on my front, top, center tooth. It has since come loose 2 times after being cemented by my dentist. I am frustrated with this and wonder what you think.

A. Since you had a root canal and a post done there is a good chance that there is very little tooth left above the gums. If this is the case we are relying on the post for much of the retention of the crown. In addition, it is in the front of the mouth where you are probably generating significant forces upon eating. The scenario that you are talking about is not too uncommon. There are a few things that can be done to minimize it coming loose, however, in many cases it is simply a difficult situation. I will list some ideas that come to mind though none may apply to you specifically:

1. Consider the type of post used and its design.

2. Be sure that the occlusion (or the way your teeth come together) is correct and not high.

3. Consider the type of cement used for the post as well as the crown. Does the post and crown fit the tooth properly or is there an opening where cement can wash out?

Q. I just had my front top tooth extracted because a root canal went bad. The root canal was done years ago and I had some sort of surgery done to the tooth about 7 years ago . My dentist told me there was nothing else to do to save it. Now that it is out I want to replace it. My dentist gave me a few options to include a bridge or an implant. These options are simply too costly for me right now. Do you have any other ideas? Thank you.

A. Your scenario brings to mind two options. They are as follows:

1. You could make a flipper to replace the tooth (refer to the above question for an explanation). This restoration would replace the tooth for now and allow you the same options your dentist recommended when you are ready. It is a removable appliance that is primarily cosmetic, though it can be reasonably functional.

2. If you know that the option of an implant is out of the question you could prepare the teeth adjacent to the missing tooth and make a temporary bridge. This would not be as costly as a permanent bridge, however, it needs to be followed by a permanent bridge in the near future. The nice thing about this scenario is the restoration is cemented in and is not removable. Because it will be followed by the permanent restoration your dentist will use temporary cement. If the temporary cement washes out you may need to have it re-cemented until you are prepared for the final restoration.

I hope this information helps you make a decision on what to do to restore your smile.

REPLACING A SINGLE TOOTH

Q. I have a one tooth partial replacing my upper front tooth. I would like to get rid of it with something that is more permanent. Can you review my options. Thank you.

A. There are a few ways that you can replace your missing tooth with a permanent tooth. The most straight forward way to do it is with a fixed bridge. This entails shaving down the adjacent teeth, placing caps on them and suspending a fake tooth between the two of them. This would be cemented in permanently. It will take about two visits and is very predicable. The biggest drawback is that you may be shaving down teeth that otherwise wouldn't need to be shaved down. This brings me to the next option which would be to replace it with an implant. Through the use of an implant you wouldn't need to shave down the adjacent teeth and still get a permanent replacement tooth. An implant will require two surgeries and the fabrication of the cap that goes on top of it. It will take approximately 8 months from start to finish and can be very predicable if done by someone experienced with implants. Another way to replace your tooth is through the use of a different type of bridge. Your dentist will need to shave down only the back of the adjacent teeth and make a bridge with two wings that key into the adjacent teeth. It is cemented in permanently and can be done in two visits. I am not a big fan of this type of bridge because they can be unpredictable and become loose. If made out of metal it can discolor the adjacent teeth once cemented in. We are now seeing this type of restoration made out of plastic materials. If these prove to be predicable they may be a very nice alternative. I hope this info helps you make a decision.

Q. I had a partial denture made 2 years ago and recently had a crown made that fits under the partial. Ever since the crown was made the partial hasn't fit properly. The dentist made all sorts of adjustments to the crown when he put it in and it still isn't right. Do you have any idea what this is all about and what I can do about it?

A. When you make a crown precision is very important. The proper amount of reduction of tooth is imperative so there is enough room for the restorative material. A good impression allows the lab to make a crown with margins that meet the tooth smooth and closed. This is important so you do not get decay under the crown at a later time. When you make a crown under a partial not only do you have to do all the things that you do to make a crown but now you have to make it match the existing partial. As you probably know, a partial denture is retained with clasps around a tooth and should have a rest seat or little dimple in the tooth that the partial sets into to avoid seating of the partial into the gums. It may be the case that your crown was made in such a way that it never fit the partial and the adjustments that you mentioned were an attempt to make it fit. This is in no way an easy thing to accomplish but there are times it is the only way to restore things. It takes alot of detail on the dentist's part, as well as the lab that he or she uses. In response to what to do - you probably need to get to a dentist for evaluation. With a few more adjustments things may be okay or you may need to have a new crown made.

Q. I have a bridge on the upper right that was done about 7 years ago. I am now getting a bad odor and a funny taste from around the back tooth. I do not have any pain or sensitivity. What do you think this is and what should I do about it?

A. Your bridge has probably lost its cement seal on the tooth that is giving off the odor. When you lose this seal food and bacteria get under the bridge, decay, and give off a nasty odor. If the rest of the bridge is loose your dentist can tap it off and evaluate the situation. If there is no decay all he or she has to do is recement the bridge after cleaning and disinfecting the teeth that support the bridge. If the rest of the bridge is firm I would recommend that the bridge be cut off, evaluated and treated as mentioned above. In the event that the rest of the bridge is firmly cemented and you attempt to tap it off, there is a great likelihood that a tooth is broken and you end up with more problems than when you started. The reason you have no sensitivity is either this was discovered early enough and there is no decay or the tooth has had a root canal and thereby will have no sensation even in the presence of a lot of decay. I would suggest you get to a dentist as soon as possible to have this evaluated. Like many things - the sooner the better.

Crowns & Bridges

"I know I did not have very attractive teeth when I first went to Dr. Vascimini," confides Elizabeth, "but as the work progressed, I realized that not only was Dr. Vascimini restoring my dental health, he was giving me a whole new,natural look. The experts at Masterpiece Dental Studio know the significance of uncompromising care and the value of a healthy smile. A positive outcome and optimum dental health for each patient are the ultimate goal.

Crowns & Bonding

"I guess my long time dentist in Connecticut thought my phobia of dentists couldn't handle this news."

"What amazed me the most was all this dental work didn't require many visits, " adds Virgina. "This was great, because even though I have great faith in Dr. Vascimini, there was still that hidden fear. And the results-well, they're nothing less than perfect.

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Dentures

I am 57 years old and a friend of mine just finished having dental treatment. In the past she wore a denture with wires around her front teeth and now her dentist made her a new denture without any wires. My friend is thrilled with the new work and does not regret the time it took or the cost involved. She can't stop saying how pleased she is. I too wear a denture like she had. Do you think that