Most Common Dental Procedures

Here is a list of the most common dental procedures to allow you to educate yourself on more detailed information about each process and the benefits and potential risks of each procedure.

When teeth are lost, the alveolar bone that previously housed them begins to dissolve away in a process called resorption. Depending on the rate of resorption, the remaining bone may be insufficient to replace the missing tooth with a dental implant. If the missing tooth is to be replaced with a fixed bridge, the prosthetic replacement tooth (pontic) may look artificially large if the bone and gum tissue (gingiva) have resorbed significantly.

One solution to this dilemma is to graft new bone onto the site. This process is sometimes referred to as site development, which refers to the fact that proper bony and gingival contours need to be re-established before ideal tooth replacement can be done. There are several ways of performing a bone graft.

First, bone resorption can be prevented by packing the tooth socket with powdered bone graft material (called a socket graft, or ridge preservation) at the time of tooth removal.

Bone grafting can also re-establish the height (by a limited amount) and width of alveolar bone that has already been lost following removal of a tooth. A block cortical graft involves attaching a solid piece of bone to the deficient area, and attaching it with fixation screws while it integrates into position over several months.

Roots of the upper back teeth often project up into a hollow chamber inside the cheek bones, called the maxillary sinus. When any of those teeth are lost, bone may resorb from the sinus floor, as well as the other walls of the tooth socket. It can usually be regenerated in a procedure known as a sinus lift or sinus elevation.

Bony defects sometimes occur around teeth with multiple roots. Such areas can often be treated by guided tissue regeneration (GTR).

The process of Bone Grafting

There are two common bone graft techniques for assuring an adequate volume of bone at the site of a missing tooth: ridge preservation with a tooth socket graft is used to prevent bone loss; and block cortical graft procedures are used to widen narrow bony ridges where resorption has already occurred. Other types of bone grafting procedures performed in dentistry utilize similar techniques, including the commonly prescribed sinus elevation (sinus lift) procedure. The goal of a sinus elevation is the same: to provide enough bone to place dental implants in the upper jaw, where they would otherwise be sticking up into the air space of the maxillary sinus.

Bone grafting materials

For most bone grafting procedures, powdered bone is used, at least to some extent. Human bone powder from a tissue bank (allogenic graft material) is used most commonly in the United States. After the bone is harvested from the donor, it undergoes a series of rigid sterilization and purification procedures. It is reduced to small particles, packaged in sterile vials and shipped to the dentist. The lot is traceable to the donor through the entire process by unique tracking numbers. An alternative bone material is bovine (cow) bone. Some dentists, especially those outside the United States, prefer to use synthetic materials.

Before the procedure

If you take blood thinning medications or drugs that inhibit platelet aggregation, particularly if your bleeding time is elevated (as measured using the INR value), your dentist and/or physician may require you to suspend those medications temporarily to have any oral surgical procedures, including bone grafting. This is due to the possibility for prolonged bleeding from the surgical area.

If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication. Your dental plan may not pay benefits toward sedation.

You should have a good idea what the process involves after reading this material. Your procedure may vary from that described, and you should discuss specific details with the dentist. Bone science and tissue engineering are rapidly developing areas of dentistry and medicine, and it is possible that new techniques may be available which may be of benefit to you.

Some advantages and benefits of bone grafting

  • Preserves or restores the natural bone volume where teeth have been removed, so that the most natural appearing tooth replacement (e.g. dental implant, fixed bridge) can be done.
  • Can increase the bone density at the graft site, which may increase the early stability of an implant. Increased bone density may also decrease the rate of bone loss if a significant amount of time must elapse before the missing tooth site is restored with an implant or bridge.
  • Allows the placement of dental implants into sites that would not be possible if bone grafting was not accomplished.

  • Disadvantages and risks of bone grafting

  • If you are taking bisphosphonate medications (a drug to reduce the effects of osteoporosis or treat certain cancers), you may be required to go off of the medication for a period of time prior to undergoing bone grafting procedures. Bisphosphonates decrease the blood circulation in the head and neck bones, possibly enough to impair healing and invite infection following surgical procedures like tooth extractions. This is especially true if you receive the medication intravenously, or are also taking immunosuppressive drugs like corticosteroids.
  • If you have a history of radiation treatment that may have involved the head and neck, you may be at risk for developing osteoradionecrosis following surgical procedures like bone grafting. Essentially, this means bone death secondary to radiation, which destroys small blood vessels that supply the bone. Even if you don’t develop osteoradionecrosis, the bone graft itself may fail to integrate with your bone due to poor blood flow to the graft site.
  • Bone grafting requires the use of anesthetic, which has risks of its own (generally minor ones). Your dentist may provide you with specific information.
  • Bone grafting, like any surgical procedure, has general post-surgical risks: pain, swelling, bruising, bleeding, and infection. Most of the early symptoms (pain, swelling, bruising) can be managed with anti-inflammatory medications (check with your physician or dentist before taking any unprescribed medications). Your dentist may provide other specific instructions for addressing your symptoms following tooth removal (extractions). Frequently, dentists will prescribe pain relievers for bone grafting procedures, but the specific medication will depend on the age and health history of the patient. Generally pain is not severe following bone grafting. Bleeding after bone grafting procedures is normally minimal. If you feel you’re experiencing an abnormal amount, apply direct pressure to the area and call your dentist.
  • Frequently, dentists will prescribe antibiotics to be taken a day or so before the procedure through 7 to 10 days after the procedure to minimize the likelihood of developing an infection. Infection is the most common way for bone grafts to fail. Failure by infection means a failure for the graft to be integrated into the host (i.e. 'your') bone.
  • Bone grafting in a few areas of the mouth can be accompanied by the risk of nerve injury. If this occurs, the worst case scenario includes permanent numbness in the area supplied by the injured nerve. The incidence of this is relatively low, but you should discuss the possibility with your dentist ahead of time.
  • You may experience loss of, or reduced chewing function in the surgical area(s), which is normally temporary. You may experience limited ability to open your mouth, which is also normally temporary.
  • Additional risks depend on the type of bone graft procedure you’re having done, and the area of the mouth where the graft is required. If the graft involves use of powdered bone materials only, there will be no donor site surgery, and hence no morbidity (i.e. complications) associated with harvesting the material. If the surgical plan involves using your own bone for all, or part of the graft, there will be a second surgical site—the donor site, which may also produce post-operative pain, swelling, infection, bleeding and bruising.
  • The degree to which the goals of grafting are met can determine whether the procedure is successful or not. For example, the pre-operative goal may be to obtain a wide enough bony ridge to place a dental implant. Although the graft may integrate, and some additional width may be obtained, it may not be enough width to place the size of implant that is desired, and a secondary grafting procedure may be necessary. Your dentist will be able to identify specific risks that accompany your unique situation.
  • Your health history may affect the prognosis for a graft, and may even present contraindications for surgery of any kind, including oral surgery. Among the health risk factors for bone surgery are a history of poorly controlled diabetes, radiation to the head or neck, conditions producing abnormal bone metabolism (such as osteoporosis or altered parathyroid gland function), and certain medications, like bisphosphonate drugs as mentioned. Your dentist will generally review your health history carefully with you prior to performing bone grafting procedures.
  • Although the risks of using bone graft material from a tissue bank are thought to be extremely low, due to donor screening and rigorous purification procedures for the donated bone, there is still a theoretical pathway for disease transmission from donor to host. Generally, the benefits of using tissue bank bone are considered to greatly outweigh the risks on this point. If you have concerns, you should discuss this topic in more detail with your dentist.
  • A dental bridge is a type of partial denture, built to replace one or more missing teeth. Dental bridges are held in place in the mouth by slipping them over, and cementing them to, specially prepared abutment teeth, adjacent to the missing teeth. A fixed dental bridge means the bridge is cemented onto the abutment teeth, and is not intended to be removed by the patient. Dental bridges can be made from a variety of metals, porcelain, ceramic, tooth colored resin, or combinations of these materials. They can be made to look and function very much like natural teeth.

    The process of creating a dental bridge

    The following describes the steps involved in a typical bridge preparation process. Your procedure can vary from the procedure described. The laboratory process involved in making the actual bridge is similar to the process for crowns.

    Anesthetic

    The teeth to be crowned with retainers are usually anesthetized by injecting local anesthetic around the nerve(s) that supply sensation to the teeth. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection.

    Pre-impression

    Frequently, a preliminary impression (mold) is made of the teeth before they are altered. The material used most for crown impressions is polyvinyl siloxane, a dimensionally stable and extremely accurate elastomer (meaning it’s stretchy, but returns to the shape it takes when it cures after a minute or two). Other materials may be used. The impression can be used to produce casts, from which a temporary bridge can be made. The temporary bridge will be worn while the final bridge is being made in a laboratory, a process that can take a couple of weeks. The temporary bridge holds the abutment teeth in position and reduces sensitivity after the teeth have been prepared.

    Shade Matching

    If the bridge is to be tooth colored, a shade matching guide will be used to determine the shade of your natural teeth. The shade should be matched in natural lighting, also called full-spectrum lighting. Fluorescent lights can make teeth appear blue to grey; Incandescent lights can make them appear too yellow. Dental porcelains and resins available today can produce a stunningly precise match for the shade and optical properties of your natural tooth enamel, allowing a bridge to be made that matches your teeth nearly imperceptibly.

    Isolation

    The teeth are often isolated from mouth structures like the tongue and cheeks while they’re being prepared to prevent injuries from instrumentation used to prepare the tooth. An isolation barrier known as a rubber dam or dental dam is frequently used, but there are other retraction devices in use. Some dentists may simply use cotton rolls and cheek shields. It’s important that shade matching be completed prior to isolation of the teeth. That’s because teeth lighten somewhat (temporarily) when they’ve been isolated for more than a few minutes. Shade matching teeth that have been isolated can result in a shade match that is too light.

    Core preparation

    The abutment teeth are prepared by removing old restorative materials (if necessary), removing any decay, and (if necessary) filling in any deep holes or missing corners of the teeth. It may be necessary to place small metal (normally titanium) pins in the teeth to rebuild the portion of the teeth that will be crowned. The dentist may use any of a variety of filling materials to rebuild the teeth, including composite resin, glass ionomer, and silver amalgam.

    Core buildups are considered a separate billable procedure from the bridge itself. Also, a distinction is made between buildups, which involve all or a substantial portion of the core of the tooth, and bases—those that require only a small amount of filling material in the core to build out a minor chip. Discuss with your dentist in advance whether a complete core build-up is going to be required or not to avoid unexpected costs.

    Retainer preps

    The outer surfaces of the abutment teeth are reduced in all dimensions (biting surface and sides) by 0.75mm to 3mm to make room for the retainer crowns that will be placed on the teeth. The walls of the preparation are tapered to allow the crowns to be slipped down over the teeth. A ledge (margin) is created around the circumference of the abutment teeth against which the retainer crowns will be tightly sealed.

    When you have invasive dental procedures like bridges done, the dentist will review your health history. If you have replacement joints (e.g. total knee, hip, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication.

    Impression of preps

    An impression of the prepared teeth is made, taking care to gently reflect the gum tissue away from the teeth so that a crisp imprint of the preparation margins will be obtained. Often, the dentist will place retraction cord in the trough between the gums and prepared teeth prior to making the impression. The cord will be removed after the impression is made.

    Temporary bridge

    The impression/casts that were made prior to preparing the teeth can now be used to make a temporary bridge. One technique involves the use of a denture tooth on the cast in the position of the missing tooth or teeth. From that, a vinyl tray can be made that will serve as a mold for the temporary bridge. The vinyl tray is filled with a gooey tooth-colored resin material, having the consistency of thick syrup, and placed over the prepared teeth. The resin material will gel in about a minute, and the tray can be removed from the mouth. The space between the prepared teeth and the impression of the unprepared teeth is now filled with temporary crown material, which completely hardens in about two minutes. Once hardened, the temporary bridge will be trimmed to proper fit, polished, and cemented onto the teeth with temporary cement.

    Labwork and final bridge seat

    The final bridge will generally be made by a technician in a dental prosthetics laboratory. When your final bridge is ready, a second visit is necessary to remove the temporary bridge and replace it with the permanent bridge. About half of the time, a patient will ask to be anesthetized for the second visit, to avoid any discomfort associated with removing the temporary bridge and cleaning the temporary cement from the prepared teeth. Teeth which have been endodontically treated (root canal) generally do not need to be anesthetized for the delivery of a permanent bridge, although many dentists prefer the patient to be numb for the bridge preparation due to the potential for discomfort associated with soft tissue management (gum retraction, etc.).

    Sometimes an appointment will be scheduled to try in the reinforcing framework (ceramic bridges) before the bridge is completed. This is commonly done for long-span, and multiple-section bridges to verify passive, accurate fit on the teeth before the technician invests the time to sculpt the ceramics.

    Adjust and Polish

    The functional biting relationship (occlusion) of the bridge may need to be adjusted slightly, and the crowns/pontics (prosthetic replacement teeth) re-polished. This should take just a few minutes under normal circumstances.

    Some advantages and benefits of dental bridges

  • Replacement of missing teeth with fixed bridgework prevents the adjacent and opposing teeth from moving/drifting.
  • Replacement of missing teeth with fixed bridgework preserves the normal bite relationship between the teeth, allowing for better chewing force distribution, and preventing unnecessary tooth restoration caused by improper meshing of the teeth.
  • Prevention of tooth movement with fixed bridgework can prevent loss of vertical dimension of occlusion (bite collapse), a condition in which loss of the back teeth leads to the lower jaw rotating closer to the upper jaw than it should. Subsequent shortening of the chewing muscles causes increased chewing muscle contraction forces and frequent jaw joint problems.
  • Fixed bridgework allows near normal chewing efficiency, so that food can be properly reduced for normal digestion.
  • Fixed bridges can be made with excellent cosmetic attributes. With modern ceramics, they are nearly imperceptible in the mouth. They look and feel to the patient like their natural teeth.
  • Fixed bridges take only a couple of weeks to complete, in contrast to replacement of missing teeth with dental implants, which often take months to complete.
  • Fixed bridges do not move or shift in the mouth when chewing, like removable partial dentures can.
  • Potential disadvantages and risks of dental bridges

  • Fixed bridges require the abutment teeth to be altered through the removal of tooth structure. This introduces the possibility of inflammation and tooth abscesses for the abutment teeth. In many cases, the prospective abutment teeth are completely unrestored, and would otherwise not require any dental treatment.
  • The abutment teeth will be more heavily loaded with chewing forces when they are supporting a bridge. If the abutments have been heavily restored (and thus, substantially weakened) from previous tooth decay and other damage, they may be unable to support a bridge long term and could fail—a sort of domino effect.
  • If one of the teeth involved in a bridge fails due to decay or other reasons, the entire bridge could be lost, necessitating additional dentistry on multiple teeth due to the failure of one (domino effect again).
  • Bridges can be difficult to clean around effectively, increasing the chance that secondary (recurrent) decay might occur around one or more retainer crowns.
  • Inflammation and/or infection from the preparation procedures can occur, and may be more likely with ceramic retainer crowns, because it is necessary to remove more tooth structure than for metal crowns. This is because porcelain must be thicker than metal to have sufficient strength. Studies aiming to quantify the risk of tooth abscess following crown preparation have shown an abscess rate of about 10%.
  • If the teeth being prepared are alive (vital), they will normally be anesthetized. Local anesthetic has risks of its own, which are generally considered minor compared to the advantages of having the procedure performed comfortably.
  • Ceramic bridges can chip, requiring repair or replacement.
  • Microscopic leakage (microleakage) can occur along the interface between the retainer crowns and their abutment teeth (at the margin), leading to sensitivity and decay.
  • All dental procedures can produce lip dryness, chapping and cracking. Some patients develop cold sores following dental treatment. Some degree of post-operative discomfort frequently accompanies crown preparation, including tenderness to biting and cold which is normally temporary. Some studies have shown prolonged sensitivity of over a year in certain patients.
  • Dental casts are accurate, three-dimensional replicas of a patient’s teeth which are made by pouring dental plaster or acrylic into impressions (imprints, or molds) of the teeth, and allowing it to harden. Dental casts can be created from many types of dental stone, metal or plastic, depending on the intended use and the durability requirements of the cast.

    Dental casts are created whenever the dentist needs to study the size and relationship between the teeth, gums and dental arches. This is the case whenever the dentist is studying a patient’s growth and development, or when significant dental treatment is being contemplated. They are used to make crowns, fixed bridges and dentures. Dental casts are also made when the patient needs an athletic mouthguard, an orthodontic retainer, or fluoride/ tooth whitening trays. If the dentist wishes to communicate with a laboratory about a patient’s teeth, dental casts will be made. They are also a great tool for recording treatment progress.

    The process of creating a dental cast

    Generally, a dental assistant will measure the size of your mouth to determine how large an impression tray to use. The tray is what holds the impression material in place around the teeth while it is solidifying in the mouth. Lip balm will often be applied to your lips to keep the sticky impression material from adhering to dry skin surfaces. If you have fixed bridgework, it is a good idea to remind the dental assistant, so that the impression material will not flow under it, set up, and be locked into place in the mouth. Next, the impression material will be mixed and poured into the tray. The tray is inserted into the mouth, and gently pressed over the teeth and gums so that the flowable impression material will extrude into undercuts, pits, and other details of the tooth and gum tissue.

    Depending on which type of material is being used to make the impression, the tray will be left in your mouth for one to several minutes. It is then removed in a quick snapping motion. Any residual material that is left in your mouth can be rinsed away. The impression is then taken to the laboratory, where it can be poured with a variety different materials to produce accurate replicas of your teeth and gums. It can also be silver plated to produce metal-surfaced replicas that are durable.

    Some advantages and benefits of dental casts

  • Accurately reproduce the teeth, gums, and relationships between the upper and lower dental arches.
  • Provide an inside-the-mouth view of how the teeth fit together that wouldn’t be achievable without sophisticated computer imaging hardware.
  • Allow many different types of dental restorations (e.g. crowns, inlays, etc.), retainers, mouthguards, and trays to be made with great accuracy.
  • Establish a point of reference to which future changes can be compared if needed.
  • Potential disadvantages and risks of dental casts

    A small number of people don not tolerate impressions very well due to sensitive gag reflex. Your dentist may be able to offer a number of suggestions to overcome a sensitive gag reflex.

    Cosmetic dentistry is a general term for a variety of dental procedures that do not necessarily have medical benefits, but have the benefit of improving a patient’s smile.

    Cosmetic restorations (which may include crowns, fillings, inlays, onlays, bridges and veneers) are done to improve the appearance of the teeth. There may or may not be other reasons for doing them, such as tooth decay, chips (Figures 1a and 1b) or cracks. Cosmetic restoration of a single tooth is sometimes achievable with modern dental materials (even in highly visible areas of the smile). It may be possible to re-create the shade, transparency and optical characteristics of uniform natural tooth enamel, although it can be challenging.

    The dentist may recommend crowns, veneers, or other types of restorations on neighboring teeth to better match the restoration placed on a damaged or discolored tooth. It may be true that the overall appearance of a patient can be enhanced with multiple restorations (e.g. intrinsically stained teeth that can’t be whitened can often be beautified with veneers).

    However, if only one tooth is a problem, and cost or invasiveness are of concern, matching the involved tooth to the others, to the satisfaction of the patient is often achievable. Doing so requires skill, artistry, and close collaboration between the dentist and others involved in the procedure (e.g. a laboratory technician). If lab procedures are needed, precise blending of the single restoration usually involves a custom shade match, in which the patient visits the laboratory technician who will be making the restoration. This may not always be feasible. When it is, the technician will evaluate the patient’s teeth for basic shade, intensity of shade (chroma), shape, light/dark balance (value), and any subtle characteristics that will need to be re-created in the restoration to make it blend imperceptibly.

    The restoration will be evaluated in different lighting conditions, because teeth can look noticeably different under different light sources. Usually, these will include incandescent sources (which have a yellow cast); fluorescent light (which looks blue); and full spectrum light (e.g. the sun). Full spectrum lighting is available for dental office light fixtures, and is often used for shade matching as it is the most natural light source.

    If a visit to the lab isn’t an option, the dentist may be able to communicate with the lab using both black/white photographs (to establish value); and color images to show the shade, optical properties, etc . It is important that the color profiles of the camera, the computer, and the printer (if used) be synchronized to produce consistent color characteristics from the patient’s mouth, to the dentist’s imaging equipment, to the lab. To learn more about synchronizing color monitors (so the lab and dentist are seeing the same colors), search on “synchronize color monitors” and “display calibration.” It is essential that the monitor records the true color and lighting properties observed in the patient’s mouth to achieve a perfect match in the restoration.

    The process of cosmetic procedures

    Cosmetic dentistry is a general term for a variety of dental procedures. The process for each procedure is different.

    Commonly prescribed dental procedures that may have a cosmetic focus include: crowns, fixed bridgework, dental implant restorations; fillings; onlays, orthodontic procedures; certain periodontal surgery procedures; removable dentures that involve visible teeth; tooth whitening; and veneers.

    Your dentist can discuss with you the procedures that would be appropriate options in your case.

    Some advantages and benefits of cosmetic dentistry

    If an acceptable cosmetic result can be achieved by restoring only one tooth, the patient is spared the expense, treatment time, potential discomfort, potential complications, and maintenance issues associated with restoring more than one tooth. While the dentist’s goal is generally to treat a condition in the least invasive way possible, it may not always be practical to restore a single tooth and achieve the cosmetic expectations of the patient.

    Modern dental materials and techniques are true bioengineering marvels, and generally allow teeth to be imperceptibly restored to the esthetic expectations of the patient. They are durable, color stable, and match the optical and shade properties of natural teeth with incredible precision.

    Ultra-conservative tooth preparation techniques have been developed which do not always require removal of sensitive tooth structure. In appropriately selected cases, these can completely eliminate the need for local anesthetic, and the risks and discomfort associated with it.

    Complete “smile makeovers”—involving crowns, onlays, and/or veneers on all or most of the visible teeth—have become commonplace in dentistry, and the results can be stunning. Smile makeovers and dental rehabilitation are usually indicated when multiple teeth are damaged, decayed or cosmetically unacceptable to the patient in ways that cannot be corrected less invasively. If an acceptable cosmetic result can be achieved less invasively, the need to reshape multiple teeth and place multiple restorations (that may need to be replaced multiple times over the life of the patient) can be avoided.

    Bleaching, bonding of tooth-colored composite resin filling material, and minor adjustments to the shape of a patient’s teeth can often be achieved very economically, with outstanding cosmetic results that require little (if any) maintenance.

    Potential disadvantages and risks of cosmetic dentistry

    Custom shade-matching may be required in order to achieve the best cosmetic result for single cosmetic restorations. This requires the patient to visit the laboratory technician who is making the crown, which may not always be feasible. Multiple visits to the lab may be required.

    Teeth that have irregular features, such as discolorations, dark shading, mottling or speckling can be very challenging to match, but a good ceramist can often do it. It is important that the patient decide whether masking such irregularities in the teeth is a treatment goal. If so, more than one tooth may require treatment. Restoring multiple teeth adds to the cost, complexity, and potential complications of treatment.

    A beautiful, natural appearance is generally among the treatment goals whenever a visible tooth is restored (metals are still commonly used in non-visible areas). However, restoring teeth purely to improve the cosmetic outcome should be done as conservatively as possible in consideration of the patient’s expectations. Cutting away any sensitive tooth structure can cause the affected tooth to be sensitive after it is restored, and can lead to inflammation of the tooth pulp, which is not always reversible.

    In such cases, additional treatment such as root canal therapy may be needed to alleviate the symptoms. These unfortunate occurrences are reported in the literature to happen in about 10% of teeth being prepared for a crown. They may surprise a patient who is unaware of the possibility with significant additional cost.

    Depending on the type of cosmetic treatment the patient and dentist decide upon, local anesthetic may be needed. Local anesthetic may be uncomfortable, and has risks of its own which are generally minor, but which should be understood.

    Cutting the teeth for dental restorations means the patient will have to maintain the restorations for life. It is likely that the original restorations will require replacement at least once during the patient’s lifetime, involving additional time and expense.

    Dental restorations (crowns, fillings, bonding and veneers) can chip, discolor or dislodge from the tooth, requiring repair or replacement. Teeth can also decay beneath dental restorations, often requiring additional procedures to correct—in addition to replacement of the original restoration.

    Your dentist may know of specific risk factors based on your individual medical or dental history, which you should understand, and which should be managed before treatment is begun.

    The (natural clinical) crown of a tooth is the portion of the tooth which is covered with tooth enamel and projects through the gums into the mouth. It is the part of the tooth you can see, as compared to the tooth root which is generally below the gumline. When a dentist mentions a “crown” as an option for repairing a tooth, they are talking about a prosthetic crown.

    If a tooth has been extensively decayed, chipped or cracked, and cannot be restored to its proper shape, function and appearance another way, the dentist may recommend placement of a prosthetic crown.

    Crowns are most often made in a laboratory by a skilled dental technician, and the process is very detailed. Use of computerized milling devices to make ceramic crowns is becoming more common, but they may not be appropriate in all applications.

    The tooth is first prepared for a crown by removing any decay, and filling in any voids. It is then reduced in shape to a tapered stump, which the new crown will slip down over.

    Crowns for baby (primary) teeth differ significantly from crowns for permanent teeth, from the shape of the prepared tooth stump, to the way the crowns are made and the materials they’re made of.

    The process of creating a dental crown

    Before the procedure

    When you have invasive dental procedures like crowns done, the dentist will review your health history. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication.

    The following describes the typical crown preparation and laboratory process (if applicable) in detail. Your procedure may vary a bit from the procedure described.

    Anesthetic

    The tooth to be crowned is usually numbed by injecting local anesthetic around the nerve(s) that supply sensation to the tooth. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection.

    Pre-impression

    Frequently, a preliminary impression (mold) is made of the teeth before they are altered. The material used most for crown impressions is polyvinyl siloxane, a dimensionally stable and extremely accurate elastomer (meaning it’s stretchy, but returns to the shape it takes when it cures after a minute or two). Other materials may be used. The preliminary impression can be made of silicone or other elastic materials. It can be used to make a temporary crown for the tooth while the final crown is being made in a laboratory, a process that can take a couple of weeks.

    Shade matching

    If the tooth is to be crowned with a tooth-colored crown, a shade matching guide will be used to determine the shade of your natural teeth. The shade is generally matched in natural lighting, also called “full spectrum” lighting. Fluorescent lights can make teeth appear blue to grey; Incandescent lights can make them appear too yellow. Dental porcelains and resins available today can produce a stunningly precise match for the shade and optical properties of your natural tooth enamel, allowing a single crown to be made that matches your teeth nearly imperceptibly.

    Isolation

    The tooth is isolated from mouth structures like the tongue and cheeks to prevent injuries from instrumentation used to prepare the tooth. An isolation barrier known as a rubber dam or dental dam is frequently used, but there are other retraction devices in use. Some dentists may simply use cotton rolls and cheek shields.

    Core preparation

    The tooth is prepared by removing old restorative materials (if necessary), removing any decay, and (if necessary) filling in any deep holes or missing corners of the tooth. It may be necessary to place small metal (normally titanium) pins in the tooth to rebuild the portion of the tooth that will be covered by a crown. The dentist may use any of a variety of filling materials to rebuild the tooth, including composite resin, glass ionomer, and silver amalgam.

    Core buildups are considered a separate billable procedure from crowns. A distinction is made between buildups that involve all or a substantial portion of the core of the tooth, and those that require only a small amount of filling material in the core to build out a minor chip (called “basing to proper contour”). It’s a good idea to know in advance whether a complete core build-up is likely to be required, to avoid unexpected costs.

    Crown preparation

    The outer surface of the tooth is reduced in all dimensions (biting surface and sides) by 0.75mm to 3mm to make room for the crown that will be placed on the tooth. The walls of the preparation are tapered to allow the crown to be slipped down over the tooth. A ledge (margin) is created around the circumference of the tooth against which the crown will be tightly sealed.

    Impression of the prepared tooth

    An impression of the prepared tooth and the teeth that bite against it is made, taking care to gently reflect the gum tissue away from the prepared tooth. Often, the dentist will place retraction cord in the trough between the gums and prepared tooth prior to making the impression. The cord will be removed after the impression is made. This technique allows the crisp outline of the prepared tooth to be recorded in the impression, so that a precise fit can be achieved between the crown and tooth.

    Temporary crown (if needed)

    If the crown is not going to be made by a computerized milling device in the office (often the case), the impression that was made prior to preparing the tooth can now be used to make a temporary crown. This is done by filling the pre-impression with a gooey tooth-colored resin material, having the consistency of thick syrup, and placing it over the prepared tooth. The resin material will gel in about a minute (in the shape of the un-prepared tooth), and the impression can be removed from the mouth. The temporary crown completely hardens in another minute or two. Once hardened, it will be trimmed to proper fit, polished, and cemented onto the tooth with temporary cement.

    Lab work and final crown seat

    Although some dentists now have computer-controlled milling machines for making ceramic crowns in their offices, a more common scenario is that the crown will be made in a dental prosthetics laboratory. Essentially, the lab work involves the following:

    Cast fabrication

    The impression of the prepared tooth and the teeth that oppose it is poured with lab plaster and allowed to harden.

    Articulation

    The stone casts of the teeth are assembled into a hinged jaw simulation device known as an “articulator” in their proper bite relationship.

    Die Preparation and fabrication of a wax pattern

    The cast of the prepared tooth (working die) is inspected closely for undercuts and any other irregularities. The technician will create a crown from wax using sculpture techniques. This wax pattern will be used in any of a variety of ways to produce the final crown, depending on whether the crown is to be made of ceramic, metal, or a combination of those.

    Production of the actual crown

    Depending on which type of crown is to be fabricated, the crown may be cast from a variety of metal alloys, pressed from ceramic, or made of ceramic fused to the metal alloy.

    Finishing

    Depending on which type of crown is made, it may require metal finishing and polishing, or other staining and glazing procedures (tooth colored crowns) to make the tooth match the patient’s natural teeth as closely as possible.

    Delivery of final crown

    When your final crown is ready, a second visit is necessary to remove the temporary crown and replace it with the permanent crown. About half of the time, a patient will ask to be anesthetized for the second visit, to avoid any discomfort associated with removing the temporary crown and cleaning the temporary cement from the prepared tooth. Teeth which have been endodontically treated (i.e. root canal) generally do not need to be anesthetized for the delivery of a permanent crown, although many dentists prefer the patient to be numb for the crown preparation due to the potential for discomfort associated with soft tissue management (gum retraction, etc.).

    Adjust and Polish

    The occlusion (i.e. functional biting relationship) of the crown may need to be adjusted slightly, and the crown re-polished. This should take just a minute or two under normal circumstances.

    Some advantages and benefits of dental crowns

  • Since they are made in a laboratory (or computerized milling machine) and not your mouth, it is easier to rebuild the ideal contours of the natural tooth than it is with large fillings.
  • Crowns can prevent cracks from spreading through a tooth.
  • Porcelain crowns can restore the tooth to its natural contour, function, and appearance.
  • Metal crowns will not generally chip, and provide the tooth with a surface that is durable.
  • Porcelain fused to metal crowns offer a good combination of durability and esthetics.
  • Porcelain fused to zirconium crowns arguably offer the best combination of durability and esthetics.
  • Potential disadvantages and risks of dental crowns

  • Compared to fillings, onlays and crowns are relatively expensive. However, they generally afford better protection against tooth fractures, and can make it more predictable to achieve contact with adjacent teeth (versus leaving a gap). It may also be easier to sculpt an ideal tooth shape working outside the mouth.
  • Traditionally, onlays and crowns require two visits to complete. Often, this means being “numb” at both appointments. Computer-milled inlays, onlays and crowns, which are delivered the same day the tooth is prepared, eliminate the need for a second appointment; however, these may not be appropriate for all teeth, and are still not widely available.
  • Preparing a tooth for an onlay or crown involves reducing the sides of a tooth and its biting surface. Depending on how thick the remaining walls of the prepared natural stump are, the tooth itself can be weakened, reducing its long-term prognosis.
  • Inflammation and/or infection from the preparation procedures can occur, and may be more likely with ceramic onlays and crowns, because it is necessary to remove more natural tooth structure than for metal ones. This is because porcelain must be thicker than metal to have comparable strength. Studies aiming to quantify the risk of tooth abscess following crown preparation have shown an abscess rate of about 10%.
  • If the tooth being prepared is alive (vital), it will normally be numbed with local anesthetic. Local anesthetic has disadvantages of its own, which are generally considered minor compared to the advantages of having the procedure performed comfortably.
  • Fillings, inlays, onlays and crowns can fall out and be lost, requiring replacement. Modern bonding adhesives and cements used in dentistry have significantly reduced this risk.
  • Ceramic and composite resin inlays, onlays and crowns can chip, requiring repair or replacement. This is particularly true in patients who grind (brux) their teeth, or use them inappropriately (e.g. chewing ice, popcorn kernels, etc.).
  • Leakage can occur along the interface between an inlay, onlay or crown over time, and the prepared tooth (margin), leading to sensitivity and decay. Poor oral hygiene is often a significant factor in such cases.
  • All dental procedures can produce lip dryness, chapping and cracking. Some patients develop cold sores following dental treatment. Some degree of post-operative discomfort frequently accompanies tooth preparation, including tenderness to biting and cold which is normally temporary. Some studies have shown prolonged sensitivity over a year in certain patients. Such cases are relatively rare.
  • Dental implants may be thought of as replacement tooth roots. Although they are available in many shapes and sizes, depending on the specific problem to be solved, by far the most common type in use today is the “root-form” implant. Dental implants are among the most significant advancements in the history of dentistry for their versatility at replacing one tooth, several teeth — even all of the teeth.

    Implants are a viable treatment option for most patients, regardless of how many teeth are missing.

    The process of placing a dental implant

    Before a dental implant is placed, your dentist will review your medical and dental history thoroughly to rule out any contraindications to the procedure. These are discussed more fully below. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with specific antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take a specific antibiotic pre-medication prior to the procedure. Due to the risks and complications of infections with dental implants, your dentist may place you on antibiotic medication a day or two prior to the procedure, and for a week or so afterwards.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication. Your dental plan may not pay benefits toward sedation.

    If you decide to be sedated with oral medication (pills), you will arrive at the dentist’s office with some degree of sedation already having taken effect. This may inhibit your ability to understand the “informed consent” paperwork you will be required to read and sign. Therefore, the dentist will likely have you read and sign the paperwork ahead of the surgical appointment. You will be given an opportunity to discuss any questions you may have ahead of time, so that you are not signing consent forms while under the effects of sedation. If you are sedated, you will also be required to have an escort to and from the dental office.

    When you arrive at the dentist’s office for placement of the implant(s), you will rinse your mouth thoroughly with an antiseptic rinse, and wash your face with an antibacterial scrub.

    If you are to be sedated by a method other than ingestion of a pill, the sedation procedure will be performed next.

    Local anesthetic will be given in the area of implant placement, both to numb the surgical area and to minimize bleeding for good visibility of the implant site. Bleeding from an implant surgical site is normally insignificant anyway, but can be reduced even more by the vasoconstricting ingredients found in certain local anesthetics.

    With traditional implant surgery, an incision through the gums is generally made, exposing the underlying bone. Implants are currently available which are designed to be placed without the need for an incision, but they are meeting with mixed success. Your dentist will be able to provide more information on such techniques.

    A series of successively larger drills are used to establish and enlarge the hole into which the implant is placed. The hole is called the “osteotomy”. Depending on the type of implant being placed, and the density of the bone, a bone tap (thread forming device) may or may not be used to establish threads in the osteotomy. The implant is then inserted into the osteotomy. A “single-stage” implant is one that extends through the gums, and is not covered by them during the healing and osseointegration period (while the implant is fusing to the bone).

    A “two-stage” implant (the traditional kind) will have a very thin cover screw inserted into the implant at the time of placement, and the gums will be closed over it with stitches (sutures). The cover screw keeps the gums from growing down into the center of the implant during the healing phase. Several radiographs may be exposed during the surgery, to allow your dentist to visualize the depth and angulation of the implant as it goes into place.

    About four to six months after placement into the jaw (depending on the density of the bone and other factors), the implant will be ready to be restored. There are several variations on implant placement that your dentist will discuss with you. When the implant is ready to be restored, it is uncovered, and a temporary crown may be placed on the implant to sculpt the gums to proper shape. Crowns, fixed bridges and removable dentures are attached to implants by means of “abutments.”

    Abutments can be made of white ceramic or metal. The abutment is attached to the implant with a retaining screw. Generally, silicone, wax, or other soft compound will be placed in the head of the retaining screw to keep cement from the crown from filling it. Crown cement dries extremely hard, and can be difficult to remove from the retaining screw if this step is not done.

    In the case of single tooth replacement, the final crown will generally be made in a lab and cemented onto the abutment. Implant crowns can also be screw-retained, with the advantage of easy retrievability and the possible disadvantages of bulkiness and compromised esthetics. With screw-retained implants, the screw head extends through to the surface of the crown. Your dentist can help you decide which type would work best for you.

    Some advantages and benefits of dental implants

    Dental implants offer many advantages:

  • They preserve the tooth-bearing (alveolar) bone.
  • They avoid cutting healthy teeth to support fixed bridgework.
  • They prevent drifting of adjacent teeth, preserving the patient’s normal bite.
  • They restore normal chewing function.
  • They can provide excellent cosmetic results.
  • They are not susceptible to tooth decay (caries).
  • Potential disadvantages and risks of dental implants
  • Time

    The biggest disadvantage of dental implants is the amount of time that must elapse from surgical placement to placement of the final dental restoration. Typically three to six months are necessary to allow the implant time to heal (osseointegrate) into the bone, although the timeline can sometimes be reduced. In appropriate cases, an implant may be placed and restored with a temporary crown the same day, with an increased chance of the implant failing in the first two years.

    Cost

    Cost can be another concern with dental implants, although given their excellent track record for long term success, is usually justifiable.

    General risks

    Risks of placing dental implants into the jaws include the usual risks of having a surgical procedure accomplished: pain (usually mild), post-operative infection, bleeding, swelling, and bruising. Most people do not experience severe pain, swelling or bruising.

    Nerve injury

    Depending on where in the jaws the implants are being placed, other risks may include nerve injury, resulting in partial to complete numbness (which may be temporary or permanent) of the tissues innervated by the injured nerve; sensory changes in the lip, chin or tongue; temporary muscle trismus (inability to open your mouth fully) secondary to swelling; jaw joint pain (normally temporary), and poor healing, which may result in loss of the implant. Most of these complications are avoidable by careful treatment planning and appropriate diagnostic imaging.

    Dental implant failure

    Although the failure rate of dental implants is low, failures do occur. What defines failure may not always be intuitive. The implant itself may break (very small chance) or may integrate into the bone in an un-restorable position. It may also integrate into the bone in a position that would provide non-ideal function or esthetics. Any of these situations may require surgical removal of the implant at a later date. Failure of the implant to integrate into the bone, while unfortunate and inconvenient is typically not complicated to resolve. In most such cases, the implant may be easily removed, the site grafted with bone, and another implant may be attempted (if desired by the patient), either at the time of implant removal, or two to four months later.

    In general, two things cause implants to fail: Heavy bite stresses on the implant (especially if the implant(s) is/are placed into function too soon); and infection. Smoking reduces the prognosis for success with implants, mainly because it impairs good circulation that is essential to good healing and immune response. Bruxing (grinding your teeth) reduces the success rate of dental implants. Implants should not be placed in a patient with active periodontal disease. Poorly controlled diabetes and poor general health are two of the few medical contraindications to the placement of dental implants.

    Bisphosphonate medication / radiation

    If you take bisphosphonate medications, or have undergone radiation to the head or neck, you may not be a good candidate for dental implants without significant medical interventions. However, there are protocols for altering medications, and methods of avoiding jaw bone necrosis secondary to radiation which may allow dental implants to be considered. You should check with your dentist and primary care physician before ruling them out as an option.

    Your unique dental and medical situation may introduce other specific risk factors which you should discuss thoroughly with your dentist and/or physician prior to undergoing implant dentistry. It’s important to understand the risks, benefits and consequences of not replacing your teeth before deciding with your dentist on the most appropriate course of treatment.

    Desensitizing medications are applied by dentists and seal the exposed microscopic pores in the dentin layer of teeth that cause sensitivity.

    Desensitizing medications are applied to sensitive teeth by the dentist. It is dispensed from a small bottle and applied with a fine brush.

    If a patient is experiencing more than a mild sensitivity to temperature extremes or sweets, and the dentist has ruled out pulpitis (inflamed tooth pulp), tooth decay (caries), infection, or gum disease as a cause, desensitizing medications may be used to seal the microscopic pores of exposed root surfaces.

    Desensitizing medications are also frequently used on freshly cut dentin during restorative dental procedures (for example fillings or crowns) before the restoration is placed on the tooth to help prevent later tooth sensitivity. The patient’s tooth is typically numb for such procedures.

    The process of applying Desensitizing Medications

  • Your dentist will review your health history, and may ask questions about your dental history—tooth whitening, use of multi-care toothpastes, etc. These can cause sensitivity, and the dentist may recommend modifying or discontinuing their use to eliminate the underlying cause(s) of your sensitivity.
  • The dentist will perform diagnostic tests to rule out more serious conditions, like pulpitis, tooth decay (caries), gum disease, and infection (abscess). The tests will generally include an objective evaluation of your reaction to hot, cold and mild electrical stimuli. This is known as “vital testing”. The test is performed to see whether the nerve tissue in the tooth pulp is living (vital), and expected to remain living (viable).
  • One or more dental X-rays (radiographs) will often be exposed to look for changes in the hard tissues. Tooth decay (caries) and bone changes from infection will appear dark on an X-ray.
  • If the dentists determines that you are an appropriate candidate for desensitizing medication, he or she may administer local anesthetic to numb the affected tooth/teeth. Many people do not require the tooth to be numb for the procedure, and can tell the medication is working immediately, during the application process.
  • The tooth will be isolated to protect the soft tissue (i.e. gums, lips, tongue, cheeks). Your eyes should be protected—some dentists may simply ask you to close your eyes while the medication is applied.
  • Desensitizing medication is applied to the tooth with a small brush, and air dried. Several coats may be applied:
  • The area will be thoroughly rinsed with water.
  • The isolation device(s) will be removed.
  • Sometimes multiple applications are necessary to provide complete relief of symptoms.
  • Your dentist may prescribe the use of a supplementary desensitizing toothpaste, following the application of desensitizing medications.
  • Some advantages and benefits of Desensitizing Medications

  • In some cases, desensitizing medications can permanently relieve the sharp pain associated with exposed tooth roots, without placing any dental restorations (such as fillings) over the exposed root, or undergoing gum surgery to cover the exposed tooth root. It may be advisable to have the gum surgery for other reasons, which your dentist can explain to you.
  • Desensitizing medications can eliminate the thermal sensitivity that frequently results after a tooth has been worked on (post-operative sensitivity).
  • Desensitizing is a quick and easy procedure to undergo, that can bring permanent relief from symptoms.
  • Desensitizing is completely non-invasive (no removal of tooth structure is necessary).
  • Desensitizing can be done prospectively during restorative dental procedures to prevent the problem from occurring at all.
  • Potential disadvantages and risks of Desensitizing Medications

  • Desensitizing medications may not be used in patients who are allergic to any of the ingredients (glutardialdehyde and 2-hydroxyethyl-methacrylate, 4-META, etc.).
  • Rarely, patients may become sensitized to the ingredients through inhalation or skin contact.
  • Materials safety data sheets (MSDS) for commonly used desensitizing medications disclose that certain ingredients may be harmful if inhaled. However, case reports for actual occurrence of such problems are difficult to find. This may be because dentists typically use high volume suction devices during application of desensitizing agents, which control both fumes and moisture.
  • MSDS for commonly used desensitizing medications also disclose that certain ingredients may present a risk of serious damage to eyes if it comes in contact with them. Simply avoiding eye contact by careful technique and use of safety glasses can help avoid this possibility. Typically, such a small quantity of the desensitizing medications is used, the risk of it coming in contact with the eyes is low.
  • Skin contact should be avoided. Your dentist will generally isolate the affected tooth or teeth from mouth moisture, which will also help protect the gums from contact with the ingredients. Typically, minor incidental exposure of the desensitizing medication to the gums will result in an asymptomatic white to red area that disappears within hours.
  • For the most effective results, use of desensitizing medications requires good isolation of the affected tooth or teeth from moisture, and from the oral soft tissues.
  • Desensitizing agents must be applied by, or under the supervision of, a dentist.
  • This is the text for these categories.

    The most common type of endodontic treatment is root canal treatment. It is a procedure in which access to the hollow interior of the tooth (pulp) is made, in order to remove inflamed, infected or necrotic (non-living) nerve and blood vessel tissue. The root canals are disinfected, enlarged and hermetically sealed to the root tips with a rubbery filling material. Finally, the access hole into the tooth is filled with any of the available filling materials like silver amalgam, composite resin, porcelain or gold (usually at a separate appointment).

    Your dentist may recommend that the tooth be crowned following endodontic treatment, especially if it has multiple cusps or multiple roots, and is structurally compromised. Normally the front six teeth in both jaws only have single roots, and many times those teeth don’t need to be crowned after endodontic treatment.

    Endodontic treatment is prescribed for teeth that have been diagnosed with an abscess, irreversible pulpitis, chronic apical periodontitis, inflammatory resorption or are necrotic (filled with non-living blood vessel and nerve tissue). Endodontic treatment is also prescribed if the clinical crown of the tooth (the part that is visible protruding through the gum tissues) is badly broken down and would require structural posts to be placed in order to restore the tooth to normal function.

    Sometimes a tooth that requires endodontic treatment will be obvious from an X-ray image, if there are obvious changes in the bone near the root tip(s)—even in the absence of symptoms. Sometimes teeth with deep decay (caries) require root canal treatment even though they may not hurt or be sensitive. A tooth that is particularly sensitive to hot temperatures, but is relieved by cold likely has gas from bacteria inside of it, most likely from an infection. Heating the tooth heats the gas, which, constrained by the hard shell of the tooth around it, cannot expand.

    The result is that the pressure in the tooth increases and puts pressure on the nerve that you feel as pain. Teeth with such symptoms typically require root canal treatment to eliminate the infection. Teeth that produce continuous dull, achy pain frequently require root canal treatment. Teeth that have a prolonged, aggravated pain response to cold may need root canal treatment.

    If you have been taking bisphosphonate medications, and require a tooth to be removed, you may not be a candidate for tooth removal without suspending the medication for a period of time in advance of treatment. In such cases, your dentist may recommend endodontic treatment of the tooth as an option, if it requires immediate treatment.

    The process of endodontic treatment

    Who will perform the procedure, and how will it be billed?

    Before undergoing treatment, you should be aware that accessing the tooth, performing the root canal procedure, filling the access hole, and crowning the tooth (if necessary) are all separate, billable procedures. If the dentist who accesses the tooth is the same one who completes the root canal procedure, you will generally not be charged for the access separately.

    The reason for this ambiguity is that one dentist may open up (access) your tooth to relieve the pressure (and pain) inside. Due to potential complexities, that dentist may elect not to complete the root canal procedure. Instead, you may be referred to an endodontist—a dentist with two to three years of additional training, who specializes in problems arising inside teeth. Both dentists have provided you with a valuable service for which they are entitled be paid.

    If the same dentist performs the root canal procedure and the access filling, separate charges typically apply. However, you will generally not be charged separately when the same dentist accesses the tooth and completes the root canal procedure.

    Many general dentists perform straightforward root canal procedures, referring to an endodontist only those patients whose root canals look especially difficult to treat. Some general dentists don’t perform root canal procedures at all. As with any dental treatment involving more than one dentist, it’s important to have a clear understanding of who will perform what treatment, and what the fees will be for each. If you’re not certain, ask your dentist or their care coordinator to clarify it for you.

    Before the root canal procedure is started

    When you have invasive dental procedures like root canal treatment done, the dentist will review your health history. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication. Your dental plan may not pay benefits toward sedation.

    The following describes the basic steps involved in root canal treatment. Your procedure may vary from the procedure described.

    Anesthetic and X-rays

    The tooth to be treated will be anesthetized by injecting local anesthetic around the nerve(s) that supply sensation to it. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection.

    A preliminary X-ray image (radiograph) is exposed to evaluate the length of the tooth, and study the root canals for obstructions, points of divergence, and other potential complexities. Additional images may be needed during the procedure, and a final radiograph will be exposed when the procedure is completed.

    Tooth isolation and access cavity

    The tooth to be treated is isolated from mouth structures like the lips, tongue and cheeks with a rubber dam (also called a dental dam), in order to prevent injuries from instrumentation, and to prevent the tooth from being contaminated with mouth moisture.

    A hole is made into the tooth (called an access cavity), penetrating to the hollow pulp chamber and root canal(s) inside. If the tooth already has a crown, filling, or other restoration, the hole is usually made through it, and restored after the root canal procedure is completed.

    Pulp removal

    Using specialized instruments, the nerve tissue and blood vessels (pulp) are removed from inside the tooth’s root canal(s). A common misconception is that “all of the tooth’s nerve tissue” is removed. However, the ligament fibers that connect the outer tooth root surfaces to the bone and gum tissues is also supplied with sensory nerve tissue that remains until the tooth itself is removed from the jaw, so the tooth will always be able to sense biting pressure as long as it remains.

    There are two popular methods for establishing the proper length for instruments. The first involves insertion of a file to a depth equal to the root length as measured on the preliminary X-ray image, and exposing another X-ray image to check the file’s position. The file position could appear slightly inaccurate due to the angle at which the X-ray is exposed. The second involves use of a digital “apex locater”, which uses a low level electrical current applied to the root canal file. The microcircuit is closed when the file reaches the tooth’s apex.

    Disinfecting, cleaning, shaping, and drying

    Antibacterial agents like dilute Sodium Hypochlorite (household bleach), or chlorhexidine may be used to disinfect the root canal.

    The root canal is further cleaned, shaped and enlarged by using flexible tapered files of successively larger diameter (debridement).

    When the canals have been enlarged and shaped to the desired outcome, they are rinsed to remove the fillings and dried with absorbent paper points.

    Sealing the root canals

    The root canals are sealed and filled with a biocompatible resin material (most commonly Gutta Percha) that hermetically seals the tooth against bacterial infection at a later date (obturation). The goal of endodontic treatment is to completely fill the inside of the canals all the way to the tip of the roots, and to seal any accessory; canals, which may be present. Accessory canals are smaller side canals that join the root canals mid-root.

    Access Filling/Core Buildup/Final Crown

    Root canal with structural posts.

    Sometimes the dentist will enlarge one or more of the sealed canals to make room for placement of structural posts, if needed to help reinforce the core of the tooth. The posts usually extend to within 5mm of the root’s now-sealed apex. The posts are cemented into the canal, and the access hole of the tooth is filled.

    Depending on which tooth required treatment, and the extent to which it was damaged, the final step can range from simply filling in the access cavity that was made into the tooth, to rebuilding all or most of the core of the tooth (core buildup), to covering the entire tooth with a crown or onlay. Normally these steps are not completed by an endodontist, and they are billed as separate procedures.

    Multi-root, multi-cusp teeth (the back teeth) generally will have an onlay or crown prescribed following root canal therapy to prevent them from cracking in pieces and being lost. Studies have shown that the brittleness of teeth is unaffected by endodontic treatment, despite widespread beliefs to the contrary. However, the anatomic shape of, and heavier bite stresses on back (posterior) teeth makes them more susceptible to cracking than the front (anterior) teeth.

    If cost is a concern, it may be possible to have a bonded or pin-retained filling placed, which can stabilize the tooth structurally long enough to allow the patient to budget for the cost of an onlay or crown. This is especially true if the enamel cusp anatomy of the tooth is reduced and covered with filling material, such that dividing forces cannot easily be developed that would split the tooth.

    Your dentist is the most qualified to counsel you on the risk of your tooth fracturing following root canal treatment.

    Some advantages and benefits of endodontic treatment

    Endodontic treatment is performed to:

  • Eliminate pain
  • Eliminate swelling
  • Eliminate numbness that may have been caused by swelling
  • Eliminate infection and recurrence of infection
  • Preserve the tooth and its shock-absorbing periodontal ligament in the mouth
  • Potential disadvantages and risks of endodontic treatment

    The following general risks of endodontic treatment may or may not apply in your case. Your dentist can answer any specific concerns you may have:

  • Bruising at the anesthetic injection site
  • Post-operative pain and/or swelling (generally temporary)
  • Breakage of files or other instrumentation inside of the tooth. These instruments may or may not be recoverable from the tooth. If they are not, the prognosis of the treatment can be limited.
  • Inability to completely instrument canals due to obstructions (e.g. calcification)
  • Inability to complete the root canal procedure due to unexpected findings within the tooth (e.g. cracks)
  • Development of secondary infections following treatment
  • Numbness which may accompany swelling. Generally this is not permanent.
  • Fracture of the tooth following endodontic treatment, but before a permanent restoration (e.g. crown or onlay) has been placed. In some cases, a large fracture can make the tooth un-restorable after the time and expense of performing root canal therapy have already been completed. Odds of this are not high, but it is certainly not an uncommon occurrence.
  • The term equilibration literally means “to establish balance or equality.” With regard to the jaw joints, jaw muscles and teeth (the stomatognathic system), it means adjusting the way the teeth mesh such that when the jaw muscles are at rest, and the jaw joints are in a stable, neutral position, the teeth are engaging uniformly with equal contacts between the upper and lower teeth.

    The importance of equal forces on the teeth is intuitively easy to understand. If only a few teeth engage when a person bites together, those teeth will endure much more force than they are structurally able to withstand. They will wear excessively (a condition called attrition), chip, crack, or the patient will (often subconsciously) continuously move their jaw in an attempt to locate a position where the forces are more in balance. Unfortunately, repositioning the jaws to provide balanced force distribution on the teeth may not be possible, due to crowding or misalignment of the teeth. The problem of poorly distributed bite forces on the teeth is magnified if teeth are lost.

    The patient’s jaw muscles may become fatigued (myalgia) by continuously trying to achieve a position of balanced force distribution on the teeth. The muscles may also become painful. The patient may chronically grind (brux) their teeth until they wear the teeth into a position of more equal force distribution. The jaw joints themselves may be the weak link, and develop popping, clicking, grating (crepitus) or pain from the unequal balance of forces. Collectively, these symptoms represent various stages of temporomandibular joint (TMJ) dysfunction, or TMD.

    To understand the process of equilibration, it is important to understand a little bit about how the temporomandibular joints (i.e. the jaw joints) work. They are not pure hinge joints like knees or elbows. Instead, only the first 15 degrees or so of opening is rotational (hinge). With further opening, the lower jaw begins to slide along the skull base until it reaches the maximum opening. It is the only joint like this in the body.

    In order for this type of motion to be possible, the lower jaw (mandible) must be free to move in all three dimensions (forwards, backwards, and side-to-side). It does that by contraction of the different jaw muscles in a 3-way “tug-of-war”. The distance the jaw can move in any direction is limited by the length of the muscles that move it the opposite direction. The stable position is one in which all of the muscles are neutral and not contracting (pulling). If the teeth do not touch evenly with the muscles in that position of balance, problems can occur.

    The process of Equilibration

    Equilibration (complete occlusal adjustment) is usually performed in three phases:

    1. Casts of the teeth are made and the bite relationships between the upper and lower teeth (occlusion) are analyzed.

    2. Diagnostic equilibration is performed on the casts. This may include both removal of the cast stone tooth structure, and adding tooth structure using wax or tooth-colored filling material (diagnostic waxup).

    3. The equilibration procedures (tooth removal only) performed on the casts are completed on the patient’s teeth. This step may involve multiple appointments, and may be done under sedation so that the dentist can freely manipulate the patient’s jaws without resistance from the patient’s jaw muscles.

    If the patient will require restorative dental treatment (fillings, onlays, crowns, etc.) following the equilibration, those procedures will be performed and billed separately.

    Phase 1 - Articulated Casts

    Phase 1 involves duplicating the patient’s teeth in dental stone, and recording the relative positions of the upper and lower teeth when the jaw joints are in a stable position and the muscles are at rest (dentists call this the centric relation position). Traditional steps involved with that process are listed. (Note: the emerging and controversial science of neurological dentistry may involve performing certain steps in this process differently than what is listed).

    The dentist will have you rest your front teeth on a tongue depressor for a few moments to allow the jaw muscles to relax. You may notice that you cannot develop the same level of muscle contraction force when only your front teeth are in function. This is known as proprioception (nociception), and reflects a neruological feedback mechanism between your brain and the front teeth that prevents your jaw muscles from contracting too heavily when only the front teeth are in function. The dentist will be able to tell when the muscles are at rest, because it will be possible for the him/her to move your lower jaw for you.

    Once the dentist can manipulate your lower jaw without resistance from your jaw muscles, he/she will gently position it into the stable centric relation position. The relative position of the upper and lower dental arches in the centric relation position will be recorded using any of several bite registration materials (silicone, wax, etc.). The result is called an interocclusal record.

    Next, impressions will be made of your teeth, and a dental stone material resembling wet concrete is poured into them. When the dental stone hardens, it produces a very accurate replica of your upper and lower teeth.

    A device called a facebow (Figure 1) is used to record the position of the upper teeth relative to the ear hole (external auditory meatus), which is very close to the hinge axis of the mandible.

    The stone casts of your teeth will be mounted onto a jaw simulation tool called an articulator (Figure 2), with the teeth positioned correctly in the device using the facebow and interocclusal record.

    Phase 2

    The second phase is done in the dental laboratory. Here the dentist studies the way the teeth fit together, and devises a series of steps to evenly distribute the bite forces to as many teeth as possible. The plan may involve reducing certain teeth significantly, and building them back to a shorter height with crowns or onlays. Other teeth may need to be made taller.

    Once the treatment plan for equilibration has been developed, the dentist will review treatment options with you. If modifications to several teeth would need to be made, or if the teeth would need to be reduced so much that restorations (fillings, crowns, onlays, etc.) would need to be done, consider your treatment options and discuss them with your dentist. Keep in mind that orthodontic and orthognathic surgery do not involve modifications to the teeth that must be maintained for the life of the patient.

    Phase 3

    If you decide to proceed with the occlusal adjustment (equilibration) process, the third phase (the equilibration procedure itself) is generally not difficult and involves the following steps (realizing that every patient presents unique circumstances that may cause the steps to vary a bit):

    You may be sedated for the procedure if maintaining the centric relation position will be difficult.

    Using the diagnostic equilibration casts as a template, the dentist will make the same adjustments to your teeth, generally in the order they were made on the casts, verifying that each adjustment produces the corresponding new contacts on the teeth that were observed in the diagnostic equilibration.

    After each adjustment, the dentist will check the way the teeth are contacting using a bite marking ribbon, and verifying that the centric relation position of the jaws is being maintained throughout the process.

    When the adjustments are completed, the dentist may elect to administer topical fluoride to help re-establish a less porous enamel surface to help reduce the chance of post-operative sensitivity and to make the enamel more resistant to tooth decay.

    Some advantages and benefits of Equilibration

  • Reduces the stresses on individual teeth by evenly balancing the bite forces across all or most of the teeth.
  • Balances the forces applied to the temporomandibular joints, or TMJs (the jaw joints).
  • Allows the muscles that position the lower jaw not to contract excessively to align the teeth correctly—when properly equilibrated, the teeth will align correctly with the muscles at rest.
  • Can avoid chronic facial muscle and headache pain associated with muscle hyperactivity.
  • Establishes a stable muscle/jaw position, in which dental restorations can be made for dental rehabilitation patients (if needed).
  • Potential disadvantages and risks of Equilibration

  • Requires the removal of tooth structure, which may or may not require restorative dental procedures to replace. Cutting a tooth into the dentin layer usually requires the exposed dentin to be covered to make it more durable and prevent sensitivity. This implies that the tooth will need to be cut even further to make room for the restoration, and then built back part way.
  • Not all patients perceive a measurable change for the better from equilibration. Those who perceive the greatest change are usually the ones who had symptoms pre-operatively.
  • A complete equilibration of the dentition is relatively expensive, especially when it involves performing the procedure on stone casts of the teeth ahead of time (diagnostic equilibration).
  • Fillings are among the most frequently prescribed and versatile of all dental restorations. In a procedure known as cavity preparation, the dentist uses any of a variety of dental drills (also called burs), microabrasion devices, or laser tips to remove damaged tooth structure, and any tooth material that has been weakened or undermined by decay. Applying their knowledge of ideal tooth shape (morphology), dentists replace the missing tooth structure with filling material of various types.

    Fillings are placed into teeth following the removal of tooth decay (caries), and filling material can also be used to restore chipped or partially broken teeth to their normal contour and function.

    When performed traditionally, a mixture of silver, zinc, copper and mercury known as amalgam is used to fill the back teeth, and sometimes even the front ones if the decay is on a surface that is not visible when the patient smiles. Although they can be bonded into the tooth with modern dental adhesives, silver fillings are held into the tooth primarily by mechanical interlocking features cut into the tooth by the dentist.

    If replacement of multiple silver fillings is recommended, it’s a good idea to understand what’s involved and why it’s important. Diagnostic photographs of failing (for example, cracked) fillings can help you to understand why replacement may be needed. If you are having it done for cosmetic reasons, it’s important to understand the risks.

    Figure 1 shows a large silver filling in a lower molar tooth. These fillings have been the workhorse of dentistry for many years, and when properly placed and cared for, can provide decades of service. Placing silver fillings in the presence of significant moisture (for example, saliva) can cause them to outgas, resulting in pitting and voids that reduce their service life. That’s why it’s important to isolate the teeth with a rubber dam or cotton rolls when placing silver fillings in them.

    The debate surrounding the use of mercury in silver fillings continues. Because of silver amalgam’s durability, track record for long term success, ease of use, similar wear properties to natural tooth enamel, and relative inexpense, it continues to be widely used and endorsed as safe for most patients. If you have questions about the safe use of silver for you or your child, talk it over with your dentist. There are generally other options available.

    Beginning in the 1960’s a process known as dental bonding was developed. Since its inception, dental bonding has continued to improve in strength and durability, allowing teeth to be more conservatively restored. Modern bonding materials may allow teeth that have been structurally compromised to be repaired with long-lasting and cosmetically pleasing fillings. A tooth-colored material known as composite resin is currently used to restore many cavities—even those found in the back teeth (Figures 2, 3, and 4).

    Figure 2 shows where tooth decay (caries) has created a cavity in this partially prepared lower molar tooth. Blue caries detection dye has been used to identify less obvious areas of decay. Use of caries detection dye helps the dentist remove all of the decay without removing too much tooth structure.

    Figure 3 shows the cavity prepared for a filling. The decay has been removed, and the preparation stained with dye to verify complete caries removal. No dye is visible, because the decay has all been removed. If the decay is very deep into the tooth, the dentist may place a layer of base material (an insulation layer) over the yellow dentin floor. Some cavities require very thin base layers called liners.

    Bases and liners can reduce post-operative sensitivity in the tooth, and promote formation of reparative dentin (a calcified substance cells in the tooth produce to protect the pulp from damage). Some dentists apply desensitizing agents to the exposed dentin before filling the cavity. All of these techniques are considered to be part of the filling process.

    In Figure 4, a tooth-colored composite resin filling has been placed in the prepared cavity. Well placed and well taken care of, it should provide many years of service.

    The process of placing a Filling or Core Buildup

    Before teeth are filled

    When you have fillings done, the dentist will review your health history. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication.

    The following description of the filling procedure may vary from patient to patient, and dentist to dentist, depending on unique individual circumstances and preferences. However, the steps will generally resemble the following:

    On the day of, or prior to treatment, your dentist will generally review the procedure, its risks and anticipated benefits with you. Ask any questions you may have ahead of time. Understanding the procedure, and any options you may have will lead to the best possible treatment outcome.

    Anesthetic

    A dental team member will frequently apply a topical numbing gel to the anesthetic injection site, to help reduce injection discomfort. Sometimes cavity preparations can be accomplished without any anesthetic. You should discuss that with your dentist. If local anesthetic is administered, you will generally feel just a slight pinch, if anything. After that, the area will begin to tingle, and then “go to sleep”, normally for a couple of hours. Injections for lower molar teeth can produce a bit more discomfort, because the nerves to be numbed are deeper under the skin.

    If the patient is a child, don’t tell them in advance that they’re “going to get a shot.” Most of the time, children who are not pre-conditioned to fear a procedure by an adult will be unaware of the injection. Most dentists who treat kids are pretty good at talking a young patient through what to expect without making them fearful.

    Isolation of the teeth

    Once the tooth or teeth are numb, the dentist or dental assistant may isolate the area with a rubber dental dam or other barrier. Although these are sometimes awkward to place, they can enhance the procedure and the treatment outcome greatly. Rubber dams prevent contamination of the filling with saliva and warm, moist, exhaled air, which can impair the bond between the filling and the tooth. Rubber dams also prevent the patient from having to swallow bacteria-rich decay and old filling material. They protect the tongue and cheeks from injury by dental instrumentation. You can think of rubber dams as a surgical drape. Patients often express concerns that they won’t be able to breathe or swallow if a rubber dam is used; however, neither is the case. If you anticipate difficulty breathing through your nose, an external nasal dilator (for example, BreatheRight Strips®) may help.

    Decay removal/Cavity preparation

    When good isolation is achieved, the dentist will remove the tooth decay with a dental handpiece, a laser handpiece, or an abrasion handpiece. The type of device to be used reflects the dentist’s philosophy and training to a large extent; however the goal is always to remove bacterially infected and weakened tooth structure. When all of the obvious decay has been removed, and the preparation shape has been idealized to retain a filling, the dentist may use a caries detection dye, which will stain areas of less obvious decay. It helps the dentist remove all of the decay without removing excess tooth structure. Some dentists may use a cavity disinfecting solution like chlorhexidine, which can kill tooth bacteria and help remove tooth cuttings known as smear layer for a better bond.

    If the cavity is deep, the dentist may apply a base layer or liner to insulate or medicate the tooth pulp. Some dentists use desensitizing varnishes. If the filling is to be bonded into the tooth, the cavity will be etched for a short time with a phosphoric acid solution. Any of a variety of adhesives and adhesive primers will be applied. The filling will be placed, and, in the case of composite resin fillings, will be cured (polymerized) with a blue light. It will then be polished, and following removal of the isolation barrier, the bite will be checked and adjusted if necessary.

    Dental bonding

    Dental bonding is a technique used by dentists to firmly attach fillings, crowns, inlays, onlays and veneers to the teeth (Figures 1 and 2). Virtually all bonding systems combine the following steps: An acid solution is applied to the tooth to produce a microscopically roughened surface. Under a microscope, acid-etched tooth structure resembles Velcro®, with linear filaments projecting from the tooth surface.

    A liquid adhesive solution is applied, which contains long strands of resin polymers that entangle themselves among the linear filaments of enamel. When the polymer strands of the dental adhesives are exposed to light of a certain wavelength, they begin to form molecular bonds (cross-links) with one another, effectively locking themselves in among the enamel filaments. Tails of the polymer strands are left protruding from the tooth’s surface on every wall of the prepared tooth.

    The dental restoration (fillings, crowns, etc.) is also treated to produce a similar surface. When the restoration is placed in the tooth and exposed to the curing (polymerizing light), the polymer strands from the tooth and restoration cross-link, producing an ultra strong chemical bond. Different materials have been developed to enhance the process, but they all work in essentially this way.

    Bonding has ushered in a new era of minimally invasive dentistry, in which teeth can now be fixed without the need to cut away healthy tooth structure, just to hold a filling or crown onto the tooth.

    Some advantages and benefits of Fillings and Core Buildups

    The following are advantages and intended benefits of fillings in teeth:

  • They restore the affected tooth to its normal contour and function.
  • Bonded fillings are minimally invasive and can strengthen the teeth to help prevent them from breaking—in some cases delaying the need for crowns or onlays indefinitely.
  • Removing decay and filling the cavities reduces the number of active bacteria in the mouth.
  • Early intervention by filling cavities before they get bigger preserves tooth structure and extends the tooth’s life.
  • Preserving the teeth preserves the jaw bones, and the contours of the face.
  • Preserving the teeth prevents unwanted tooth movement and changes in the bite.
  • Fillings are the most economical way to restore teeth. They can also be among the most cosmetically pleasing, and in certain applications, can last decades.
  • Potential disadvantages and risks of Fillings and Core Buildups

    Preparing teeth for fillings involves the removal of both diseased and healthy tooth structure. Ideally, the amount of healthy tooth that is removed is kept to a minimum, especially when caries detection dye is used. However, teeth are living tissues, and working on them is considered a surgical procedure. Surgical procedures of any kind have the following risks:

  • Discomfort, either during or after the procedure. Generally, this is minor and easily controlled.
  • Risks associated with local anesthetic (if used). These are also generally minor.
  • Sensitivity to biting, cold, or heat, following the procedure. Normally this is temporary. The risk of post-operative sensitivity is greater if a tooth is not isolated from mouth moisture for fillings which are bonded into place.
  • Inflammation of the tooth pulp (pulpitis), which may be temporary (reversible), or irreversible. If your tooth sensitivity does not resolve, the tooth may require root canal treatment. The risk of developing irreversible pulpitis and/or infection (abscess) is also greater if bonded restorations are placed in a tooth without isolating the tooth from mouth moisture.
  • Infection of the tooth pulp or the surrounding gum tissues following the procedure. Unless the decay extends deep inside the tooth, the risk of pulp infection is relatively low for routine fillings. Whether or not a tooth gets better on its own afterward depends on many factors, including age of the patient, immune status of the patient, restorative history of the tooth (i.e. whether it has been worked on before). In general, young, healthy patients will have more healing cells and immune cells per liter of blood volume, and are less likely to develop complications post-operatively (with a wide degree of variation).
  • Deep decay may extend into the tooth pulp (nerve and blood vessel tissue inside the tooth). If so, the tooth may require root canal treatment, and a crown or onlay may be recommended after the root canal treatment is completed.
  • Some teeth have small offshoots of nerve tissue called ectopic pulp horns, which may be encountered even in a routine cavity preparation. These are rare, but when encountered can result in the need for root canal treatment.
  • Fillings can break and require replacement.
  • Large fillings involving surfaces that touch the adjacent teeth may result in an open contact with the neighboring teeth. This can lead to a food compaction injury. There are usually options to placing large fillings, however the cost may be greater. Your dentist is the most qualified person to tell you whether your tooth could get by with a large filling, or whether some other type of restoration would be more appropriate.
  • New fillings may have overextended areas called overhangs or flash, which can shred dental floss and collect food. Left uncorrected, flash can lead to inflammation of the periodontal tissues and a re-occurence of decay in the tooth. Generally, flash is easy to remove/re-contour, so be sure to let your dentist know if you’re experiencing this problem.
  • Fluoride is a naturally occurring element which helps to harden tooth enamel and make it more resistant to acid exposure. It helps protect against cavities (caries) and can reduce tooth sensitivity.

    Topical (applied to the surface of the teeth) fluoride is generally recommended twice a year for children through their adolescent years to help prevent cavities. A dentist is the best person to assess the patient’s individual risk for cavities, and the developmental status of the patient’s teeth.

    Topical fluoride supplementation is also recommended in patients who suffer from chronic dry mouth (xerostomia), generalized gingival recession, and sensitive teeth.

    When fluoride is incorporated in the diet of young children (mainly through water fluoridation programs), the entire enamel thickness may be less porous. When applied topically, only the surface enamel benefits. However, surface fluoridation of the teeth is believed to be the most effective at reducing cavities.

    The process of a Fluoride Treatment

    Administration of topical fluoride can be done in the dental office, and generally is recommended for children through the age of 18 twice a year. Some dental plans may not provide benefits for topical fluoride, or may not provide the benefit past the age of 16. Plans vary widely, and regardless of what your plan pays, you should follow the advice of your dentist, who is the best person to assess the patient’s individual risk for cavities, and the developmental status of the patient’s teeth.

    The most frequent method for applying fluoride topically to the teeth involves dispensing fluoride-containing foams or gels into disposable foam trays, placing them over the teeth in the patient’s mouth, and having them bite down gently on the trays to effectively force the medication between the teeth and into the pits and fissures. The dental professional should provide suction to remove saliva during the procedure, so the patient does not swallow the fluoride medication. The trays are generally left in place for one minute, after which the mouth is thoroughly suctioned to remove as much of the medication as possible. After the treatment, the patient is requested not to eat or drink anything (including water) for thirty minutes so that the greatest deposition of fluoride into the teeth may occur.

    Topical fluoride for home use comes in a variety of formulations and delivery systems, including tooth pastes, gels, and oral rinses. Regardless of how the medication is applied to the teeth, they all have in common that they are meant to be topical (applied to the surfaces of the teeth), and not swallowed in large doses. Follow your dentist’s advice on how to achieve the maximum benefit from the topical fluoride he/she has recommended for you.

    Some advantages and benefits of a Fluoride Treatment

  • Hardens the surface enamel of teeth, making it more resistant to destruction by acids, and thus less likely to decay.
  • Helps reduce tooth sensitivity.
  • Has a weak anti-bacterial activity, which may promote healthy gums (gingiva).
  • Potential disadvantages and risks of a Fluoride Treatment

    Fluoride is a prescription drug for a reason. If taken internally in large enough doses, fluoride can be lethal. If taken at appropriate doses, or used topically, but not swallowed, it can be very beneficial.

    Fatalities involving fluoride are not unheard of; however deaths related to the use of dental fluoride are extremely rare. Nonetheless, all supplemental fluoride tablets, chews, suspensions and other forms of fluoride should be kept out of the reach of children, and used properly as directed—even if a child is the intended recipient.

    If swallowed, a normal dose of topical fluoride applied by your dental professional can cause nausea and vomiting, especially in kids. Topical fluoride applied by dentists contains about 15,000 parts per million fluoride ion. This is about three times as much as is found in prescription formulations for home use by adults, and about ten times the amount found in regular fluoride toothpaste.

    Of more practical concern (accidents and negligence aside), there is potential to view fluoride as a “magic bullet” in preventing tooth decay. However, there is no substitute for excellent oral hygiene and proper nutrition, meaning the frequency of sugary/acidic food and beverage exposures per day should be minimized.

    A fairly common condition known as fluorosis can occur as a result of chronic over-exposure to fluoride, such as might occur if a child drinks fluoridated water and (against recommendations) ingests daily fluoride supplements. Some parts of the world have abnormally high fluoride concentration occurring naturally in the drinking water. In fact, that’s how its benefits were discovered. If you’re not sure, you can have your water tested. Your dentist can help.

    Some formulations of supplemental topical fluoride have a disagreeable metallic taste.

    Fluoride isn’t as effective at reducing pit and fissure cavities as it is at reducing smooth surface cavities. Unfortunately, some 80% of tooth cavities originate in deep pits and fissures.

    Inlays are indirectly fabricated dental restorations for the repair of chipped or decayed teeth. Indirect fabrication means that the tooth is prepared for the inlay, an impression (mold) of the prepared tooth is made and poured in dental stone, and the restoration for the tooth is made in a laboratory on the stone replica rather than the tooth itself. The inlay is then glued (luted) into the tooth, generally at a separate appointment. Inlays can be made from composite resin, gold and other metals, or various ceramic materials.

    Inlays are typically prescribed when it will be difficult to restore a tooth to its proper shape and re-establish proper contacts with the adjacent teeth. Less tooth structure is removed than would be necessary for crowns or onlays. Inlays are very similar to fillings, except that they’re usually made in a lab, which adds to the cost and complexity of the procedure.

    Some dental offices use Computer Aided Design and Computer Aided Manufacturing (CAD/CAM) technology to create restorations like inlays, onlays, and crowns right in the dental office. This avoids the need for a temporary restoration and a second appointment to place the restoration. While more convenient for the patient, dental CAD/CAM can often not produce the same results that a dentist working with a dental lab can produce. You dentist will likely prefer one method over the other – and some dentists may use both solutions.

    The process of placing dental Inlays

    When you have an inlay procedure done, your dentist will review your health history. If you have replacement joints, such as a knee or hip, you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication.

    The following description of the inlay procedure may vary from patient to patient, and dentist to dentist, depending on unique individual circumstances and preferences. However, the steps will generally resemble the following:

  • On the day of the treatment, your dentist will generally review the procedure, its risks and anticipated benefits with you. Ask any questions you may have ahead of time. Understanding the procedure, and any options you may have will lead to the best possible treatment outcome.
  • A dental team member will frequently apply a topical numbing gel to the anesthetic injection site, to help reduce injection discomfort. Ask for it—it really does help! Sometimes inlay preparations can be accomplished without any anesthetic. You should discuss that with your dentist. If local anesthetic is administered, you will generally feel just a slight pinch, if anything. After that, the area will begin to tingle, and then “go to sleep”, normally for a couple of hours. Injections for lower molar teeth can produce a bit more discomfort, because the nerves to be numbed are deeper under the skin.
  • Once the tooth or teeth are numb, the dentist or dental assistant may isolate the area with a rubber dental dam. Although these are sometimes awkward to place, they can enhance the procedure and the treatment outcome greatly. Rubber dams prevent the patient from having to swallow bacteria-rich decay and any old filling material. They protect the tongue and cheeks from injury by dental instrumentation. You can think of rubber dams as a surgical drape. Patients often express concerns that they won’t be able to breathe or swallow if a rubber dam is used; however, neither is the case. In some patients, use of an external nasal dialator strip may provide more comfortable nasal breathing.
  • When good isolation is achieved, the dentist will remove the tooth decay with a dental handpiece. The goal is to remove bacterially infected and weakened tooth structure. Different techniques can be used to achieve the same goals, depending on the dentist’s training and treatment philosophy. When all of the obvious decay has been removed, and the preparation shape has been idealized to allow for insertion of an inlay, the dentist may use a caries detection dye, which will leave stain on areas of less obvious decay. It helps the dentist remove all of the decay without removing excess tooth structure. Some dentists may use a cavity disinfecting solution like chlorhexidine, which can kill tooth bacteria and help remove tooth cuttings known as smear layer.
  • If the cavity is deep, the dentist may apply a base layer or liner to insulate or medicate the tooth pulp. Some dentists use desensitizing varnishes.
  • An impression of the inlay preparation will be made, so that a stone cast replica of the prepared tooth can be produced.
  • An interocclusal record of the way your teeth fit together will be obtained, using a fast-setting, elastic bite registration paste.
  • If the inlay is to be made in a laboratory, a temporary filling will be placed in your tooth.
  • If the inlay is being made in-office, you may be asked to wait while the inlay is being made.
  • At the final inlay delivery appointment (if there is one), you may be re-anesthetized to prevent sensitivity. Temporary filling material will be removed, and the inlay will be bonded or traditionally cemented (luted) into the tooth.
  • Your bite may be adjusted a minor amount to prevent heavy forces on the new restoration.
  • Some advantages and benefits of dental Inlays

    Here are some of the advantages and benefits of dental inlays:

  • Restores the affected tooth to its normal contour and function. Inlays may make it easier to restore the contact between two adjacent teeth than a filling would (in cases where a significant amount of the tooth structure is missing).
  • Inlays are tooth sparing when compared to onlays and crowns. When composite resin or ceramic are used, bonding the restoration in place is possible, and may provide more strength than a traditionally cemented (glued) metal inlay would provide.
  • Removing decay (caries) reduces the number of active bacteria in the mouth.
  • Early intervention by restoring cavities before they get bigger preserves tooth structure and can extend the tooth’s life.
  • Preserving the teeth preserves the jaw bones, and the contours of the face.
  • Preserving the teeth prevents unwanted tooth movement and changes in the bite.
  • Potential disadvantages and risks of dental Inlays

    Preparing teeth for inlays involves the removal of both diseased and healthy tooth structure. Ideally, the amount of healthy tooth that is removed is kept to a minimum, especially when caries detection dye is used. However, teeth are living tissues, and working on them is considered a surgical procedure. Surgical procedures of any kind have the following risks:

  • Pain, either during or after the procedure.
  • Risks associated with anesthetic, which are usually minor (if used).
  • Sensitivity to biting, cold, or heat, following the procedure. Normally this is temporary.
  • Inflammation of the tooth pulp (pulpitis), which may be temporary (reversible), or irreversible. If your tooth sensitivity does not resolve, the tooth may require root canal treatment. If the tooth requiring root canal treatment is a back tooth, it may also require a crown or onlay afterwards, instead of an inlay, to avoid cracking.
  • Infection of the tooth pulp or the surrounding gum tissues following the procedure. Unless the decay extends deep inside the tooth, the risk of pulp infection is relatively low for inlays. Whether or not a tooth gets better on its own afterward depends on many factors, including age of the patient, immune status of the patient, restorative history of the tooth (i.e. whether, and how extensively it has been worked on before). In general, young, healthy patients will have more healing cells and immune cells per liter of blood volume, These patients are less likely to develop complications post-operatively, though there is a wide degree of variation.
  • Deep decay may extend into the tooth pulp (nerve and blood vessel tissue inside the tooth). If so, the tooth may require root canal treatment, and a crown or onlay may be recommended (instead of an inlay) after the root canal treatment is completed, to prevent the tooth from cracking.
  • Some teeth have small offshoots of nerve tissue called ectopic pulp horns, which may be encountered even in a routine cavity preparation. These are rare, but when encountered can also result in the need for root canal therapy.
  • Disadvantages of inlays

  • The cost of an inlay is usually greater than that of a filling, and the inlay may not always provide significantly greater longevity, functionality or esthetics.
  • Inlays can fall out or break, making a replacement restoration necessary.
  • In some cases, inlays have been blamed for fracturing teeth. Your dentist will minimize the risk of fractures by ensuring that the inlay fits passively (without binding) in the tooth.
  • Inlays, like all dental restorations, may begin to leak over time (microleakage), causing new decay (recurrent caries). It’s especially important to maintain excellent oral hygiene and see your dentist regularly for checkups if you’ve had any type of dental restorations placed.
  • Local anesthetic is normally used to eliminate discomfort during a dental procedure. The word “local” means that it is used in close proximity to the area being treated. A local anesthetic will temporarily disconnect signals from nerves, essentially “numbing” any pain. Local anesthetic is typically given by injection. While patients may be familiar with the drug Novocain, there are several other local anesthetics in common use in dentistry today.

    Certain local anesthetics contain ingredients (called vasoconstrictors) used to reduce localized bleeding for surgical procedures. This also helps to keep the local anesthetic confined to the area of the dental procedure, reducing their potential to cause issues in other parts of the body.

    The process of administering Local Anesthetic

    Many dentists use a topical numbing gel, applied to the soft tissues overlying the nerve(s) to be put to sleep. This is done to minimize discomfort from the needle stick. If the topical anesthetic is swallowed, the throat can become numb (the type of sensation produced by a cough drop) temporarily. Some patients find this unpleasant. Topical numbing agents can also cause sensitivity in teeth with exposed roots or cavities that are near the site of application. For most, however, the topical gel makes injection of the local anesthetic much more comfortable.

    Some dentists use a technique called gate control to make injections reasonably pleasant. Basically, this involves wiggling the lip or cheek vigorously immediately prior to inserting a needle into the tissue. The nerves are stimulated by the wiggling, and it takes them a couple of seconds to be able to re-fire. Because of that the needle stick goes largely un-detected by the patient.

    In general, upper (maxillary) teeth are easier and less painful to anesthetize than lower (mandibular) teeth. This is mainly due to the fact that the maxilla bone is a less dense bone than the mandible, and the nerves that run through it to the upper teeth can usually be put to sleep with fairly superficial injections applied near the tooth (or teeth) to be treated. Anesthetizing lower molars can be more difficult, due mainly to the depth of the injection required to put the inferior alveolar nerve (supplying sensation to all of the lower teeth) to sleep. Also, a certain percentage of people will have accessory (extra) innervation to lower molars, typically from the floor of the mouth, and may not be completely anesthetized by an inferior alveolar nerve block. Chances are, if you’ve had difficulty “getting numb”, it was probably on a lower molar.

    Before injecting the anesthetic into areas where large blood vessels (especially arteries) are located, the dental provider will draw backward on (aspirate) the syringe to see if any blood enters the syringe. If so, the provider will typically withdraw the needle and re-angulate it for insertion to avoid the vessel. Some people perceive this as multiple injections, and may be irritated by it. However, it is normal, and generally does not add to the discomfort if done slowly and gently enough. Providers who do this are being considerate, not indelicate.

    Once the injection is given, the teeth and soft tissues will begin to lose sensation immediately, and the dental procedure can usually be started within moments.

    Depending on the type of anesthetic used, the anesthetized area may not regain its sensation for several hours after administration. Unless local anesthetic reversal agents are administered, there is no way to accelerate the return of normal sensation, so you should not bite or pull on the cheeks or lips to try and stimulate it. Doing so may result in discomfort later on, when the area does regain sensation.

    Modern disposable needles have made injections all but undetectable, because they are always sharp. In earlier times, needles were sterilized and re-used, and required sharpening. If a dentist didn’t sharpen them frequently enough, they could be quite uncomfortable to get through soft tissue, helping to perpetuate the bad reputation of dental injections. Even today, a disposable needle remains sharp enough to penetrate the tissue comfortably only a few times before it should be discarded.

    Another way to make injections more comfortable is to dispense the anesthetic solution slowly, over a period of approximately one minute per injection. Rapid injections may seem desirable, but are actually more uncomfortable because the anesthetic needs time to absorb into the tissue to anesthetize it. If the anesthetic is dispensed ahead of the needle, and the tissue is allowed to lose sensation before the needle is inserted further, a comfortable injection results. Computer-controlled anesthetic delivery systems are becoming more popular because of their non-intimidating pen-like appearance, and nearly imperceptible delivery of the numbing agent.

    Some advantages and benefits of Local Anesthetic

    Allows dental procedures to be accomplished without pain.

    Allows the teeth to be comfortably isolated from mouth moisture, for better treatment outcomes.

    Controls localized bleeding during surgical procedures, for better visibility of the surgical area.

    Reduces the likelihood of complications due to general anesthesia.

    Potential disadvantages and risks of Local Anesthetic

  • Injections can produce mild discomfort during administration.
  • Bleeding and/or bruising may occur at the injection site(s). Both are generally minor.
  • Injury to the nerve’s protective sheath can occur. This can produce sensations in the nerve’s distribution area ranging from pain to numbness. Generally, this is temporary.
  • Biting injuries to soft tissue (e.g. lip, tongue) can occur after the procedure is completed, before the numbness has worn off.
  • Allergies to ester-based local anesthetics are fairly common; however, these anesthetics are rarely used in dentistry any more. Allergies to amide-based local anesthetics (the large majority of those used in dentistry today) are rare. However, their use in patients with liver disease may not be recommended.
  • Most reported allergies to local anesthetics are psychogenic (from the mind) in origin, but there are local anesthetics in use that some people should not have.
  • Fainting (syncope) is the most frequently reported adverse reaction to local anesthetics, mainly due to fear of the injection. If you are afraid of dental injections or dental procedures, you should discuss your concerns with your dentist before scheduling treatment. This is especially true if you are avoiding dental care because of your fears. Modern dentistry has many techniques at its disposal for alleviating the concerns of fearful patients.
  • There are reports of certain anesthetics known as prilocaine and articaine having rarely produced prolonged numbness, and their use may not be advisable near major nerve branches.
  • Certain local anesthetics can produce dangerous elevations in blood pressure when combined with certain medications.
  • If you have severe ischemic heart disease, or have had a recent heart attack, ask your dentist whether the anesthetic to be used contains epinephrine, as it may not be recommended.
  • Antibiotics are drugs which, when prescribed at traditional doses, either kill or prevent reproduction of bacteria. Antibiotics are important in dentistry, because most dental illness (including tooth decay and periodontal disease) is caused by bacteria. Antibiotics are not designed to kill viruses or fungi, although some of those organisms may be susceptible to certain antibiotics.

    There are many different types of antibiotics, which function in different ways and target specific types of bacteria. For example, the penicillin family of antibiotics share a functional molecule called a beta lactam ring, which binds to certain bacteria and prevents them from being able to build the cell wall necessary for their survival.

    Through many years of over-prescription, some bacteria have developed resistance to certain antibiotics (including the penicillin family). To overcome this, new methods of delivering antibiotic drugs only to infected tissue (instead of system-wide) have been developed, along with ways to prevent the undesirable activity of bacteria, without killing them outright. Suppressing a certain species of bacteria with antibiotics can allow unsusceptible species to flourish, upsetting the delicate balance that exists among the species that live in our mouths, stomach, and intestines. It can also encourage the targeted bacteria to mutate into forms which are resistant to antibiotic treatment.

    An example of this newer technology is the use of low-dose doxicycline (20mg) to suppress human-generated enzymes that form in response to bacteria from destroying the periodontal tissues (gums and bone). At this dose, the bacteria themselves are not killed or prevented from reproducing, but their harmful activity is halted. Because the balance of bacterial flora is not being altered, it is believed that the drug may be safely taken in pill form without the risk of resistant strains of bacteria developing. This drug is commonly used as a supplement to traditional periodontal treatment to control periodontal disease (periodontitis).

    Another relatively new method of preventing tissue-destroying bacterial activity around the teeth is to place antibiotics into gum pockets around the teeth in any of several time-release systems that are currently available. This is commonly being done as a supplemental procedure to traditional periodontal treatment, such as scaling and root planing.

    When scaling and root planing alone does not decrease inflammation of the periodontal structures, treatment of the gum pocket(s) with locally applied, time-release antibiotics may be prescribed. Some dentists prescribe the antibiotics at the time scaling and root planing is performed, believing that those bacteria which are not removed through mechanical debridement will be killed or prevented from multiplying by the drug.

    Opponents of this concurrent treatment protocol cite it as a sort of belt-and-suspenders overtreatment approach. However, with many studies showing that scaling and root planing alone is not completely effective at removing all of the calculus and diseased cementum, localized antibiotic administration may be a good thing to consider. This is especially true in deeper pockets, where some studies show that scaling and root planing may remove as little as 11% of the calculus!

    Localized antibiotic administration may not help individuals with aggressive periodontitis, and has been shown to be most effective in adults with chronic, localized periodontitis.

    The process of administering Localized Antibiotics

    Typically, treatment with locally administered antibiotics is done either at the time of, or following scaling and root planing. Before scaling and root planing procedures are done, it is necessary to establish a diagnosis of periodontal disease (periodontitis).

    On the date of scaling and root planing, your health history will be reviewed. You may require pre-medication with systemic antibiotics if you have prosthetic joints, prosthetic heart valves, or certain types of heart murmurs. Your physician may also recommend pre-medication if you have certain other medical conditions (e.g. transplants).

    If you take blood thinning medication, your dentist may recommend suspension of the medication prior to scaling and root planing. This should be coordinated with your physician, of course.

    Due to the potential for discomfort in instrumenting tooth root surfaces, local anesthetic is typically given for scaling and root planing procedures. If local antibiotic treatment is being performed at a subsequent appointment to the scaling and root planing procedures, it is often not necessary to have local anesthetic.

    There is presently controversy about whether or not use of lasers to clean the gum pockets produces better results than scaling and root planing alone. It is not currently clear whether or not there is any long-term advantage. Many doctors have cited positive results in their own practices, but prospective, randomized, multi-center studies that are the foundation of “good science” are currently lacking.

    When the gum pockets have been cleaned, administration of locally applied antibiotics can be performed. There are a number of systems available for delivering the antibiotics into the gum pocket, and the process of placing them is different for each. Ask your dental professional which method they recommend for your specific needs.

    Following treatment with localized antibiotics, your dental professional will often give specific instructions on how best to manage your unique dental situation. Frequently you will be instructed not to floss in the area of application for the period of activity of the drug, which varies by product. There may be other specific instructions.

    When plaque and calculus removal is deemed to be effective, and no inflammation remains, probing pocket depths will be measured, and an appropriate interval for periodontal maintenance visits will be established.

    Some advantages and benefits of Localized Antibiotics

    Localized antibiotic administration to infected periodontal pockets:

  • Can help prevent or delay the need for surgical periodontal treatment.
  • Kills bacteria in the pockets around teeth, allowing the tissues to heal.
  • May help to prevent bacteria from generating compounds that cause blood vessels to constrict and blood clots to form throughout the body. This means that the general health issues which are now believed to arise in an unhealthy mouth (including cardiovascular disease, strokes, poor control of blood sugar among diabetics, peripheral vascular disease, and pregnancy issues) may be avoidable by improving and maintaining oral health.
  • Scaling and root planing is known to produce a temporary increase in the number of bacteria in the blood (bacteremia). In patients with a healthy immune system, this is not likely to be a problem. However, in immune compromised patients, or patients with certain types of heart murmurs, prosthetic heart valves, or joint replacements, it can be a problem. Those patients are typically given systemic antibiotics prior to treatment. Concurrent treatment with locally delivered antibiotic drugs may also reduce the significance of transient bacteremia with scaling and root planing procedures.
  • Some antimicrobial treatments suppress the production of acids and enzymes produced by the body in response to the presence of bacteria, which contribute to tissue destruction.
  • Can help to eliminate bleeding and swelling of the tissues that are part of the body’s immune response.
  • May control or prevent gingival recession that frequently occurs following scaling and root planing.
  • Allows the patient better access to brush, floss and otherwise clean the teeth, according to individual instructions from the dentist and dental hygienist.
  • Delays or prevents progression of periodontal disease.
  • Preserves the teeth and as importantly, the tooth-supporting bone.
  • Potential disadvantages and risks of Localized Antibiotics

  • Localized antibiotics may cause the teeth to be sensitive or achy for a period of time. Other side effects are listed by drug under the procedure overview.
  • Localized antibiotics may be incorrectly perceived as a “cure” periodontal disease“. Localized antibiotic treatment by itself will not produce long-term periodontal health.
  • Patients with known allergies or sensitivity to a certain antibiotic family should not receive localized antibiotic treatment with those medications.
  • Patients who are pregnant or nursing should not be treated with locally delivered antibiotics unless a clear need has been demonstrated, and in all cases, drugs of the tetracycline family should be avoided, due to their potential to cause permanent deep staining in the teeth of the fetus.
  • It has been said that control over periodontal disease is 25% up to the dental professionals managing the problem, and 75% up to the patient. Although localized antibiotic treatment can help a patient retain their teeth long-term, if a patient is not motivated to keep the teeth, and cannot commit to the practice of effective daily oral hygiene, treatment is unlikely to succeed.
  • If you have been diagnosed with, and treated for periodontal disease, you should be evaluated more frequently than usual to be sure the condition is under control. Most commonly, periodontal patients are seen three to four times per year for periodontal maintenance procedures once the condition has been treated. Maintenance involves a thorough periodontal assessment and appropriate disease management procedures to prevent progression of periodontitis.
  • Typically, more than one administration of locally administered antibiotic drugs is needed to gain and maintain control over active periodontal disease.
  • Localized antibiotic administration is only suggested for cases of chronic adult periodontitis. It should not be used in children, and may not be effective in cases of aggressive periodontitis.
  • Your dental professional(s) may know of specific risk factors associated with localized antibiotic administration that are related to your unique dental and medical history. Talk it over with them.
  • Athletic mouth guards are tough, flexible vinyl coverings for the teeth and gums which are thick enough to absorb the impact of blows sustained in contact sports, and protect the teeth from being knocked loose or fractured. They can be purchased at sporting goods stores, or may be custom made by a dentist.

    Mouth guards are appropriate whenever a patient is involved in activities that are potentially dangerous to the teeth, gums and tooth-supporting (alveolar) bone.

    The process of fitting Mouth Guards

    Over-the-counter athletic mouth guards are simple to make by following the package labeling. Some require no customization and are ready to use right out of the packaging. Others are semi-customizable. Generally, semi-customizable mouth guards are placed in hot water to soften them. The patient bites into the softened plastic, which then forms itself around the teeth. As it cools, the mouthguard takes on a tough, yet springy consistency similar to a tire.

    The edges of the athletic mouth guard can then be trimmed with a scissors to eliminate any pressure points or areas of discomfort. It’s important not to trim them so short that they lose their effectiveness.

    Custom dentist-made athletic mouth guards are a little more involved. Typically, only impressions of the upper teeth are made. Stone cast replicas (casts) of the teeth are then made from the impressions. A heated vacuum former is used to soften and closely adapt heavy vinyl over the casts. After the vinyl has cooled it returns to a tough, elastic state, and is trimmed to the appropriate extension such that all the teeth and gums are covered beyond the ends of the tooth roots.

    Some advantages and benefits of Mouth Guards

    Athletic mouth guards offer the following advantages/benefits:

  • They help protect against injuries to the teeth and tooth-supporting bone
  • They are simple to make, or to have made by a dentist
  • The are generally comfortable to wear
  • Over-the-counter athletic mouthguards are cheap and afford reasonable protection.
  • Custom dentist-made athletic mouthguards may fit a little better and their protective coverage can be verified by the dentist who makes them.
  • Potential disadvantages and risks of Mouth Guards

    Disadvantages of athletic mouth guards may include:

  • Inconvenience factor-people may not remember to include them with their sports gear, and thus they may not be available when needed. In many youth sports, officials are enforcing their required use for participating in the games; however, they are too often left home from practice.
  • They increase saliva flow temporarily when first inserted.
  • The should be cleaned regularly to keep them germ-free
  • Custom dentist-made athletic mouthguards may be comparatively expensive—particularly for children, whose jaws and teeth are still developing. Custom mouth guards may need to be remade several times during a child’s development for best fit.
  • An onlay is a type of cusp-covering dental restoration that is made in a laboratory by a skilled technician, or by a computer controlled milling machine. Onlays can be made of ceramic, composite resin, gold, titanium or other metals. Metallic onlays are generally cemented (glued) onto the tooth, at a separate appointment from the tooth preparation appointment.

    Ceramic and composite resin onlays are generally bonded (fused with adhesive) onto the tooth, either at the preparation appointment (if CAD/CAM is available for ceramic onlay production) or at a second appointment (more commonly the case). If you need two appointments, it will often mean having to numb the tooth at both appointments, and having a temporary restoration placed between appointments.

    Onlays are like crowns, in that they afford protection against cracking to the tooth; but they’re more conservative in the amount of natural tooth structure that needs to be removed to make room for them. They’re also similar to inlays, except that they cover at least one of the pointed chewing cusps of the tooth.

    The process of creating and placing Onlays

    Before the procedure is started

    When you have restorative dental procedures like onlays done, the dentist will review your health history. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

    If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills like Valium®; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication, such as Versed®. Your dental plan may not pay benefits toward sedation.

    The following describes the typical onlay/partial crown preparation and laboratory process in detail. Your procedure may vary a bit from the procedure described.

    Anesthetic

    The tooth to be restored is usually numbed by injecting local anesthetic around the nerve(s) that supply sensation to the tooth. Discomfort from the injection can be minimized by applying a topical numbing gel for a minute or two prior to the injection.

    Pre-impression

    Frequently, a preliminary impression (mold) is made of the teeth before they are altered. The material used most for onlay/partial crown impressions is polyvinyl siloxane, a dimensionally stable and extremely accurate elastomer (meaning it’s stretchy, but returns to the shape it takes when it cures after a minute or two). Other materials may be used. The impression can be used to make a temporary onlay for the tooth if the final restoration is being made in a laboratory (a process that can take a couple of weeks).

    Shade Matching

    If the tooth is to be restored with a tooth-colored onlay/partial crown, a shade matching guide will be used to determine the shade of your natural teeth. The shade is generally matched in natural (full spectrum) lighting. Fluorescent lights can make teeth appear blue to grey; incandescent lights can make them appear more yellow. Dental porcelains and resins available today can produce a stunningly precise match for the shade and optical properties of your natural tooth enamel, often allowing a single restoration to be made that matches your teeth nearly imperceptibly.

    Isolation

    The tooth is isolated from mouth structures like the tongue and cheeks to prevent injuries from instrumentation used to prepare the tooth. An isolation barrier known as a rubber dam or dental dam is frequently used, but there are other retraction devices in use. Some dentists may simply use cotton rolls and cheek shields.

    Core Preparation (core buildup)

    The tooth is prepared by removing old restorative materials (if necessary), removing any decay, and (if necessary) filling in any deep holes or missing corners of the tooth. It may be necessary to place small metal (normally titanium) pins in the tooth to rebuild the portion of the tooth that will be covered with the onlay/partial crown. The dentist may use any of a variety of filling materials to rebuild the tooth, including composite resin, glass ionomer, and silver amalgam.

    Core buildups are considered a separate, billable procedure from onlays/crowns. A distinction is made between buildups that involve all or a substantial portion of the core of the tooth, and those that require only a small amount of filling material in the core to build out a minor chip. It’s a good idea to discuss with your dentist in advance whether a complete core build-up is going to be required or not to avoid unexpected costs.

    Onlay/Partial Crown Preparation

    The outer surface of the tooth is reduced in all dimensions (biting surface and sides) by 0.75mm to 3mm to make room for the material that will be placed on the tooth. The walls of the preparation are tapered to allow the onlay/partial crown to be slipped down over the tooth. Sometimes internal walls will be prepared in the tooth to provide inlay retention. A ledge (margin) is created around the circumference of the preparation against which the crown/onlay will be tightly sealed.

    Impression of Prep

    An impression of the prepared tooth and the teeth that bite against it is made, taking care to gently reflect the gum tissue away from the prepared tooth. Often, the dentist will place “retraction cord” in the trough between the gums and prepared tooth prior to making the impression. This clearly exposes the preparation margins. The cord will be removed after the impression is made.

    Temporary Onlay/Partial Crown

    If the final onlay or crown will be made in a laboratory, the impression that was made prior to preparing the tooth can now be used to make a temporary onlay/partial crown. This is done by filling the pre-impression with a gooey tooth-colored resin material, having the consistency of thick syrup, and placing it over the prepared tooth. The resin material will gel in about a minute, and the impression can be removed from the mouth. The material will completely harden in another minute or two. Once hardened, the temporary restoration will be trimmed to proper fit, polished, and cemented onto the tooth with temporary cement.

    Labwork and Final Onlay/Partial Crown Seat

  • Cast Fabrication: the impression of the prepared tooth and the teeth that oppose it is poured with dental stone and allowed to harden into a cast of the teeth.
  • Articulation: the casts of the teeth are assembled into a hinged jaw simulation device known as an articulator in their proper bite relationship.
  • Die preparation and fabrication of a wax pattern: The cast of the prepared tooth (working die) is inspected closely for undercuts and any other irregularities. The technician will create a crown from wax using sculpture techniques. This wax pattern will be used in any of a variety of ways to produce the final restoration, depending on whether the onlay/partial crown is to be made of ceramic, metal, or a combination of those.
  • Production of the actual onlay/partial crown: Depending on which type of onlay/partial crown is to be fabricated, the restoration may be cast from a variety of metal alloys, pressed from ceramic, or made of ceramic fused to the metal alloy.
  • Finishing: Depending on which type of restoration is made, it may require metal finishing and polishing or (if ceramic) other staining and glazing procedures to make the tooth match the patient’s natural teeth as closely as possible.
  • Delivery of Final Onlay/Partial Crown

    When your final onlay/partial crown is ready, a second visit is necessary to remove the temporary restoration and replace it with the permanent one. About half of the time, a patient will ask to be numb for the second visit, to avoid any discomfort associated with removing the temporary onlay and cleaning the temporary cement from the prepared tooth.

    Teeth which have been endodontically treated (i.e. root canal) generally do not need to be anesthetized for the delivery of a permanent onlay/partial crown, although many dentists prefer the patient to be numb for the tooth preparation due to the potential for discomfort associated with soft tissue management (gum retraction, etc.).

    Adjust and Polish

    The functional biting relationship (occlusion) of the onlay/partial crown may need to be adjusted slightly, and the restoration repolished. This should take just a minute or two under normal circumstances.

    Some advantages and benefits of Onlays

  • Since they are made outside of the mouth, it is easier to rebuild the ideal contours of the natural tooth than it is with large fillings.
  • Onlays and crowns can prevent cracks from spreading through a tooth.
  • Porcelain onlays and crowns can restore the tooth to its natural contour, function, and appearance.
  • Metal onlays and crowns will not generally chip, and provide the tooth with a surface that is durable.
  • Onlays have the advantage over crowns of leaving more natural tooth structure intact.
  • Potential disadvantages and risks of Onlays

  • Compared to fillings, onlays and crowns are relatively expensive. However, they generally afford better protection against tooth fractures, and can make it more predictable to achieve contact with adjacent teeth (versus leaving a gap). It may also be easier to sculpt an ideal tooth shape working outside the mouth.
  • Traditionally, onlays and crowns require two visits to complete. Often, this means being “numb” at both appointments. Computer-milled inlays, onlays and crowns, which are delivered the same day the tooth is prepared, eliminate the need for a second appointment; however, these may not be appropriate for all teeth, and are still not widely available.
  • Preparing a tooth for an onlay or crown involves reducing the sides of a tooth and its biting surface. Depending on how thick the remaining walls of the prepared natural stump are, the tooth itself can be weakened, reducing its long-term prognosis.
  • Inflammation and/or infection from the preparation procedures can occur, and may be more likely with ceramic onlays and crowns, because it is necessary to remove more natural tooth structure than for metal ones. This is because porcelain must be thicker than metal to have comparable strength. Studies aiming to quantify the risk of tooth abscess following crown preparation have shown an abscess rate of about 10%.
  • If the tooth being prepared is vital (“alive”), it will normally be numbed with local anesthetic. Local anesthetic has disadvantages of its own, which are generally considered minor compared to the advantages of having the procedure performed comfortably.
  • Fillings, inlays, onlays and crowns can fall out and be lost, requiring replacement. Modern bonding adhesives and cements used in dentistry have reduced this risk significantly.
  • Ceramic and composite resin inlays, onlays and crowns can chip, requiring repair or replacement. The risk is significantly greater in patients who grind their teeth (brux) or use them inappropriately (chewing ice, popcorn kernels, etc.).
  • Leakage can occur along the interface between an inlay, onlay or crown over time, and the prepared tooth (margin), leading to sensitivity and decay. Poor oral hygiene is often a significant factor in such cases.
  • All dental procedures can produce lip dryness, chapping and cracking. Some patients develop cold sores following dental treatment. Some degree of post-operative discomfort frequently accompanies tooth preparation, including tenderness to biting and cold which is normally temporary. Some studies have shown prolonged sensitivity over a year in certain patients, although such cases are relatively rare.
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    Anim pariatur cliche reprehenderit, enim eiusmod high life accusamus terry richardson ad squid. 3 wolf moon officia aute, non cupidatat skateboard dolor brunch. Food truck quinoa nesciunt laborum eiusmod. Brunch 3 wolf moon tempor, sunt aliqua put a bird on it squid single-origin coffee nulla assumenda shoreditch et. Nihil anim keffiyeh helvetica, craft beer labore wes anderson cred nesciunt sapiente ea proident. Ad vegan excepteur butcher vice lomo. Leggings occaecat craft beer farm-to-table, raw denim aesthetic synth nesciunt you probably haven't heard of them accusamus labore sustainable VHS.

    Anim pariatur cliche reprehenderit, enim eiusmod high life accusamus terry richardson ad squid. 3 wolf moon officia aute, non cupidatat skateboard dolor brunch. Food truck quinoa nesciunt laborum eiusmod. Brunch 3 wolf moon tempor, sunt aliqua put a bird on it squid single-origin coffee nulla assumenda shoreditch et. Nihil anim keffiyeh helvetica, craft beer labore wes anderson cred nesciunt sapiente ea proident. Ad vegan excepteur butcher vice lomo. Leggings occaecat craft beer farm-to-table, raw denim aesthetic synth nesciunt you probably haven't heard of them accusamus labore sustainable VHS.


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