It is estimated that as many as 75% of adults in the U.S. have some degree of anxiety related to dental care.  Approximately 5-10% of U.S. adults have what can be described as severe anxiety such that they avoid dental care at all costs.

While there are several causes for dental anxiety, research indicates that the most common cause is direct experiences the person has had in the past.  My own 25 years of treating patients with dental anxieties bears this out.  In fact, my own experiences as a child patient support this! 

I recently saw a patient who had awful dental experiences as a child.  As we discussed her experiences further, she came to realize that in her case, it wasn’t the treatment itself that created her anxiety but HOW she was treated by the dentist and staff.

Research indicates that while an upcoming dental procedure can cause anxiety, the manner of the dentist and staff is very important.  Dentists who were considered impersonal, uncaring, uninterested or “cold” were found to produce high dental anxiety among patients even if the dental procedure was not painful.

For this reason, choosing a dentist can be a daunting task.  How do you know that the dentist you choose will be receptive to your concerns?

Our dental practice has evolved into one that caters to those persons with significant concerns regarding dental care.  It initially started with anxious patients entering our practice by chance but as our reputation for success has spread, we now have therapists who refer their patients directly to our office.

I don’t see our approach to patient care as some sort of magic trick.  It simply begins with taking the time upfront to listen to our patients’ concerns and developing trusting adult-to-adult relationships.  I like how one patient described our office as a “safe” place.

While real and sincere “TLC” is important, I would be remiss if I didn’t touch on technology.  It is wonderful how dentistry has changed and improved over the years.  Technology allows us to do great dentistry in a comfortable and more efficient manner.

Lastly, I am supported by what I honestly feel is the best staff around.  They have a caring, empathic nature which adds to our success and the betterment of our patients’ health and well-being.

It’s no wonder that we have many patients who state that they are no longer afraid to come to the dentist.  It’s awesome!

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I am so blessed.  I’ve got the best patients, my staff is awesome and I am fortunate to work with some talented laboratories and specialists.

The case I am showing you today exemplifies the importance of the teamwork that is necessary for a stellar treatment result.

Congenitally missing front tooth

This teen patient initially presented with mal-aligned teeth and a missing lateral incisor tooth (the tooth next to the two front teeth).  The tooth was congenitally missing, which means it never formed in the jaw.  For this case, a dental implant was a great option to replace the missing tooth but long before the crown was placed, it was up to the specialists to “set the stage”.

A beautiful and natural looking implant crown

We consider this area of the mouth to be in the “esthetic zone” where appearance is very important.  Thus, we wanted to do everything we could to make sure the replacement tooth would appear natural in position, shape and color. 

As I have come to expect with the specialists I work with, the stage was set as perfectly as the clinical situation would allow.

Now it was up to us to bring it all home by creating a natural looking crown.  For this case we used our CEREC CAD/CAM one-visit crown technology to make the crown.  In the right hands, this technology can shine when esthetics is important because I can use various colorants and stain to customize the crown to match the adjacent teeth – and we do this right in our office.  While matching a single front tooth to the adjacent natural teeth is one of the more difficult things to do in dentistry, I have come to enjoy the process. 

As a team, we wound up hitting a home run with this case.  The crown looks like a natural tooth and not like – well, a crown!  The patient was very happy and can now smile with confidence.

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In my previous article, I discussed concerns that patients have regarding the safety of amalgam fillings (dental mercury fillings).  Specifically, patients have voiced concerns about mercury vapors from the fillings entering the body and potentially causing health issues. 

In my dental practice, it has been over 15 years since I placed an amalgam filling.  Simply, I believe there are superior alternative materials available today.  

amalgam fillings

porcelain fillings

One of the problems I have with the amalgam material is that it must be of a minimum size to resist breaking or falling out.  For the same sized cavity, composite resin tooth-colored fillings can be more conservative.  Essentially, I only need to remove the “bad” tooth structure.  The less healthy tooth structure that has to be removed, the better it is for the health of the tooth. 

There is also less drilling and the filling can be smaller.  This is usually not possible with amalgams.

For small cavities, composite resin tooth-colored fillings have come a long way and are now not only esthetic but very durable. 

Let’s look at the other end of the spectrum.  What about large fillings?  While large amalgam fillings appear to hold up, over the years, significant damage can occur to the underlying tooth.  Realize that amalgams aren’t bonded to the tooth and do nothing to strengthen a tooth; they just plug a hole.  In addition, when I remove an old amalgam filling, it is rare that I don’t find a cavity underneath the filling.

On the other hand, composite fillings and porcelain restorations bond to and strengthen the tooth.

The most compelling reason though that I no longer place amalgams is patient preference.  At one time, amalgam fillings were the norm but no longer.  I can’t remember the last time a patient asked me to place a grey amalgam filling instead of a tooth-colored filling.  We are a society that values our appearance including that of our teeth.  Choosing composite or porcelain over amalgam can make a smile much more pleasing to the eye.

Form, function, appearance and patient satisfaction are superior with this solution.

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mercury amalgam fillings

Every once in a while, I have a patient ask me if they should have all of their amalgams (dental mercury fillings) replaced.

Dental amalgam is an alloy made up of liquid mercury and a powdered mixture of silver, tin and copper.  Most of the filling composition is elemental mercury (approximately 50%).  This type of mercury releases mercury vapor and has been the cause for concern with amalgam fillings.  It was first used in the 19^th century in France.  For many years it was the dental material of choice because of its strength, workability and low cost. 

Over the years, there have been claims that the mercury in dental amalgam leaches out, enters the body and contributes to a wide variety of ailments such as depression, epilepsy, multiple sclerosis, lupus, leukemia and more.  While dental amalgam does release mercury, in the words of 16th century Swiss physician Paracelsus, “The dose makes the poison.”

According to Dr. Rod Mackert, professor of dental materials at the Medical College of Georgia School of Dentistry Department of Oral Rehabilitation, “a person would need between 265 and 310 amalgam fillings before even slight symptoms of mercury toxicity could be felt.”  A person with seven fillings, which is average, absorbs only about one microgram of mercury daily. About six micrograms are already absorbed daily from food, water and air, according to the Environmental Protection Agency. 

In other words, people are exposed to more total mercury from food, water and air than from the minuscule amounts of mercury vapor generated from amalgam fillings.  The American Dental Association (ADA) continues to support the use of amalgam as “a safe restorative option for both children and adults.”  In 2009, the U.S. Food and Drug Administration (FDA) deemed amalgam fillings a “safe and effective treatment option for the general population.”  

Granted, in Europe, Denmark and Sweden have completely banned the use of dental amalgam.  Germany and Norway have restricted its use.  Note that this is not because of safety concerns for amalgam itself but as a very small part of an overall effort to decrease environmental levels of mercury.  In fact, the European Union also continues to support amalgam as a safe restorative material.

Still, the reality is that amalgam use in both the United States and Europe continues to decrease.  Look for my next article where I will tell you why I haven’t placed a dental amalgam in over 15 years.

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Harry is a 14 year old high school student who had recently completed orthodontic treatment.  He is a fine young man, very personable and polite.

In Harry’s case, the orthodontics was done well to place the teeth in their proper position.  However, there were other concerns that could not be corrected with braces alone.   The upper front teeth were undersized and as a result, spaces remained after the orthodontics.  In addition, Harry and his mom had concerns regarding the general discoloration of his teeth.  The teeth appeared stained.

Spaces between teeth

As we always do with cases such as this, I sat down with both patient and parent, in this case, Harry and his mom to discuss their objectives and the options for treatment.  Harry and his mom desired for the spaces to be closed and his smile brightened.

In this kind of a case, there are usually two options to discuss: porcelain veneers and composite bonding (resin veneers).  Each option has its’ own set of advantages and disadvantages and we like to take the time go over these with our patients so that they can make the best decision for their particular situation.

A bright and happy smile!

In discussing the options for treatment, we decided to whiten the lower teeth a bit and then place composite resin veneers on the upper front teeth. 

As a rule, whenever we do a “combination” case where we want to place veneers and whiten the remaining teeth, we always want to whiten the teeth first.  These kind of cases can many times be completed very conservatively as well with minimal removal of any tooth structure.

The result was awesome!  The treatment was completed in just a few hours, but made a dramatic improvement in Harry’s smile.  Harry and his mom were ecstatic with his new and vibrant smile.

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I’ve had interesting conversations with some of my patients lately regarding the topic of headaches and teeth grinding.  We all get headaches, some more frequently than others and some more intense than others.  

While there are numerous causes of headaches, few people make the connection that teeth grinding can cause headaches, specifically muscle tension headaches.  

Many times, it comes down to an unbalanced bite or one that is not in harmony with the proper position of the jaw joints (TMJ).  This misalignment causes the jaw muscles to become hyperactive and just like any other muscle that is overworked, they eventually become fatigued and sore.  The result is that we complain of a headache. 

It takes a trained dentist to determine if in fact the bite is in harmony with the jaw joints or it is not. 

It may have everything or nothing to do with how your teeth look.  I’ve seen what appeared to be a rather nice smile but the bite was off by a mile… without the patient even realizing it. 

Interestingly enough, headaches are just one of many signs and symptoms of a bad bite.  Other signs include worn teeth, loose teeth, chipped teeth or even teeth that have moved over time.  I have even seen patients with sensitive teeth who thought they needed a root canal, only to find that their bite was the culprit.  The bite was adjusted and the pain went away. 

For many patients the key is in balancing the bite with the proper position of the jaw joints.  There are several ways to do this depending on the severity of the bite discrepancy.  Only a comprehensive bite analysis will reveal the best route to take. 

Patients can typically find some relief with custom made bite guards.  However, it is important to note that these bite guards must be fitted properly or they can cause more harm than good.  And regardless, even a custom-made bite guard won’t correct the underlying problem.  In fact problems can still worsen. 

The first step in correcting the problem is a comprehensive examination and bite analysis by a dentist trained in this discipline to determine if indeed an unbalanced bite may be causing headaches.

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Woman’s Day Magazine may not be a scientific journal but in this December’s issue, a friend of my wonderful wife Amy found an article that piqued her interest.  The article entitiled “Take care of your teeth and protect your health” by Sara Reistad-Long addresses a health topic that continues to get exposure.  Your dental health affects your overall health.

There’s no escaping the fact that the health of your mouth affects the health of your entire body.  As my staff and I have professed to our patients, research indeed indicates a link between dental disease and your systemic health and in particular four of the top ten leading causes for death according to the Centers for Disease Control.  These include heart disease, stroke, diabetes and Alzheimer’s disease. 

Your mouth houses a lot of bacteria, which cause cavities and periodontal (gum) disease.  If you have inadequate dental health, the gum around each tooth can be weakened and thinned, thus allowing bacteria to seep from the mouth and into your body.  The bacteria then settles in susceptible areas of the body including your heart and blood vessels and leads to what can be pretty major problems.

 Woman’s Day is but one of several magazines that have had articles on this important topic.  Some of our new patients are coming to us specifically because of concerns they have for their overall health and not just their dental health.  

For example, we have known for many years that diabetics are three times more susceptible to periodontal (gum) disease.  But research is now showing that periodontal (gum) disease increases one’s susceptibility to diabetes!  It’s a vicious cycle. 

We pay particular attention to the “oral-systemic connection” and when red flags come up regarding a patient’s periodontal (gum) health, we may bring the patient’s physician into the loop just to make sure there aren’t any other systemic problems going on. 

So when you are brushing and flossing, you are not only saving your teeth, you may very well be saving your life!

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By now most of us have heard that the actor Michael Douglas has Stage IV oropharyngeal cancer.  In his case he has a walnut-sized tumor at the base of his tongue.  For treatment, Douglas will require the works – surgery, radiation therapy and chemotherapy.  Needless to say, he has a tough road ahead of him for recovery. 

But as usual, it’s only when someone famous gets a disease that the world finally notices. 

While most Americans probably never even heard of this type of cancer, the reality of it is that the incidence of this disease is growing at an alarming rate. 

According to the American Cancer Society, oral cancer occurs about as frequently as leukemia.  More people die of oral cancer than from melanoma or cervical cancer. 

According to the American Dental Association, the incidence of oral cancer in the under-40 population has grown almost five-fold, with many patients with no known risk factor.

 Going back to my dental school days (more years ago than I care to admit), we had always thought that it was the people who either smoked too much or drank too much alcohol who got oral cancer.  As a side note, Michael Douglas apparently indulged in both smoking and drinking.

 Today, research is showing us that the increase in the disease may be attributable to the human papillomavirus (HPV).  In fact, according to the Centers for Disease Control (CDC), 25% of mouth and 35% of throat cancers may be linked to HPV.  And although the topic may be uncomfortable, what you might not realize is that HPV is a sexually-transmitted virus.  In fact, according to the Centers for Diseased Control (CDC), HPV is the most common sexually transmitted virus in the United States.

 According to Brian Hill, the executive director of the Oral Cancer Foundation “Social and sexual behaviors have changed.  Oral sex is more common.  The virus is spreading, especially among young people because sexual contact is more common, that this virus is not only ubiquitous in our society, but the mechanism of transfer is simple.”

 But still, 25% of those who develop oral cancer do not use tobacco or alcohol and have no other lifestyle risk factors.

 What makes this disease so dangerous is that unless someone (like your dentist) is actually examining and looking for it, oral cancer often goes unnoticed until the later stages.  Why?  Because often there are no symptoms in the early stages.

 Sadly, according to a study by the CDC in 2008, less than 30% of adults aged 18 years orolder had ever had an oral cancer examination. 

 Finding these abnormalities early strongly improves prognosis.  It is the key to success.  In our office, not only do we perform oral cancer screenings on each adult patient, we also use a specialized rinse and light that makes abnormal tissue stand out.  It’s called Vizilite Plus and you can find more information on it at www.vizilite.com.  It’s painless, fast and may save your life.

 Let me leave you with this:  Only 57% of all diagnosed oral cancer patients will be alive five years after their diagnosis.  I strongly believe that this is because of delayed diagnosis.  Make sure you have an oral cancer screening when you visit your dentist!

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Undersized lateral incisor tooth

Matching a single veneer or crown on a front tooth to the adjacent natural teeth is one of the most difficult procedures to do in dentistry.  This patient had recently finished wearing braces for a few years but found himself dissatisfied because of an undersized lateral incisor tooth.  He wanted the gap filled but wanted the treatment to be long lasting.  Together we decided that a porcelain veneer would fit the bill.

Whenever we do a case like this, we carefully evaluate the adjacent teeth first.  We don’t just look at the color or shade, but also the size and shape and even little nuances such as the white splotching on the teeth so that the veneer seems to disappear when it is placed.

Porcelain Veneer to fill the gap

Using our CAD/CAM technology, we made the actual porcelain veneer in our office and then color-matched the veneer to the patient’s natural teeth.  We have the technology that allows us to do that as well.

The result was awesome, the patient was happy and it was all done in one appointment.  I love it when a plan comes together!

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Let’s see if you remember some of your high school chemistry.  pH is the measure of acidity or basicity of a solution.  Pure water is neutral and has a pH of 7.0.  Solutions with a pH less than 7.0 are considered acidic.  Solutions with a pH higher than 7.0 are considered basic or alkaline. 

The lower the number the more acidic a solution is.  The important thing to understand here is that when the pH of a solution on a tooth surface is less than 5.5, tooth surface damage occurs. 

Gatorade, for example, has a pH of 3.3.  In fact, research by a British dentist, Dr. Milosevic, found the pH levels of sports drinks ranged from approximately 4.5 to 2.4. 

Why do sports drinks have such a high acid content to begin with?  My understanding is that the acidity improves the taste and increases the shelf life of the products. 

But the acid components are just one part of the equation.  Sports drinks can also have a rather high amount of refined sugar.  Any beverage that has high acid content can weaken the enamel.  Sugar can worsen the situation by encouraging bacterial growth.  So acid is bad, sugar is bad and many of these sports drinks have both.  Together, they cause tooth decay. 

Realize that there are a lot of liquids that we consume that contain acid – sodas, sports drinks, wine.  So why aren’t everyone’s teeth just rotting away?  Your saliva contains minerals that naturally re-mineralize or re-harden teeth after they have been exposed to acid solutions.  But in the presence of a significant exposure to acid, there is only so much repair that saliva can do. 

Fortunately, there are sports drinks out there that don’t have so much sugar and aren’t so acidic.  One that I have personally used is HEED made by Hammer Nutrition.  This company has been around since 1987, developing a wide range of nutrition products for the endurance athlete. 

For sweeteners, HEED contains Xylitol and Stevia, which are both healthier alternatives to the refined sugars and/or artificial sweeteners found in most sports drinks.  In addition, HEED doesn’t contain the high amounts of citric acid found in most sports drinks.  The result of these modifications, according to Steve Born at Hammer Nutrition, is that the pH of HEED is 7.04 – almost neutral.   Pretty impressive. 

So what exactly is Xylitol and Stevia?  Xylitol and Stevia are both natural sweeteners.  Xylitol can be found in a variety of fibrous fruits and vegetables.  The human body even naturally produces some Xylitol via normal metabolic processes.  Stevia comes from a plant found in subtropical and tropical Central and South America.

From a dental standpoint, Xylitol and Stevia are very “tooth-friendly”.  Remember, bacteria in the mouth love refined sugars.  They metabolize it to create acids that cause cavities.  On the other hand, oral bacteria are unable to ferment Xylitol and Stevia. 

The result is that the number of cavity-causing bacteria is remarkably reduced, no acid is created, and thus no cavities are formed. 

“Tooth-friendly” sports drinks can be found in almost any triathlon, running and cycling store. But for those people who continue to drink sports drinks that are high in refined sugar and acid components, There are things you can do to at least reduce their risk of damaging your teeth. 

First, use the sports drink for its intended purpose during and after extended exercise, training or competition, and not as an everyday beverage. Second, one of the most important factors is how long one holds the liquid in their mouth.  The longer the drink sits in the mouth, the more damage it will cause. Third, there are some toothpastes on the market that are designed to re-mineralize teeth that have been exposed to liquids that contain acid such as wine, soda and sports drinks.Lastly, research suggests that brushing your teeth immediately after consuming a sports beverage can actually make tooth erosion matters worse. 

 Better to rinse with water to dilute the acid and then wait 30 minutes before brushing your teeth to allow softened enamel to naturally re-harden via the minerals in saliva.

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