Before Teeth Whitening

We do a lot of cosmetic consultations in our office and during those appointments, we go to great lengths to make sure that we understand exactly what the patient is looking for.  I like to tell my patients that they are the “pilot” (telling us where they want to go) and we are the “navigator” (telling the patient how we can get there).  Cosmetic dentistry is definitely not one size fits all. 

We look at the tooth position, shape and color of the teeth.  We also look at the gum position as often irregularities in gum position can itself affect the appearance of the overall smile.  And we especially take a close look at the bite as many times it is the bite that is the underlying cause of the esthetic problems.

For the patient who is happy with everything but the color of their teeth, teeth whitening is typically the answer and I have never found a process that has been as effective as KöR Deep Bleaching™.  Believe me when I say that I’ve tried a bunch of systems and products over the past twenty plus years.  This teeth whitening system was developed by a friend and colleague of mine in California and it has certainly taken off.  KöR Deep Bleaching™ was recently ranked highest as the most effective, reliable way to whiten teeth by a respected dental products journal.  I’ve even seen this process work on tetracycline stained teeth. 

After Teeth Whitening

As you can see with this patient, the results are pretty dramatic.  In the “after” photo, I used the shade tab that shows how dark the teeth were prior to the KöR Deep Bleaching™ just to emphasize how effective this teeth whitening process is.  By the way, for this patient, the teeth whitening process required only two weeks time.

If you’re too embarrassed to smile, have dark-stained teeth, or just simply want a whiter smile, the superiority of KöR Whitening is just what you need.

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!

I got a call last night from a new patient in a panic. She was just playing with her dog and it jumped up on her – the dog’s head hitting her front teeth. Low and behold one of her porcelain veneers chipped. To make matters worse, she was heading out of town this week on an important business trip.

 With her regular dentist being out of town, she turned to me for help. Fortunately, we begin seeing patients at 7 a.m. on Tuesdays, so I scheduled her for an early appointment this morning, allowing us to immediately assess the damage.

The bad news was that the veneer had to be replaced. The damage was beyond the point where we could just smooth it out. The good news was that with the technology we possess, we were able to create the new veneer for her in 90 minutes. By balancing artistry with technology, the new veneer is a beautiful color match to her existing veneers. 

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.

Q: Dr. Van Gurp, I understand that today’s focus is on hormones and women’s oral health.

Dr. Van Gurp: Women have an increased propensity for oral health problems because of the hormonal changes that take place throughout their lives.

In general, these hormonal changes affect both the blood supply to the gum tissue and the body’s response to the toxins (poisons) that result from plaque build up.  As a consequence of these changes, women are more susceptible to the development of periodontal disease at certain stages of their lives, as well as to other oral health problems.

Q: Are there specific times in a woman’s life that one should be particularly concerned about these hormonal changes and their dental health?

Dr. Van Gurp: Actually, it is not confined to one specific point in time but more like several situations in the course of a woman’s life where there is an increased sensitivity to oral health problems.  They are: puberty, the monthly menstrual cycle, during the use of oral contraceptives, pregnancy and relative to menopause.

Q: Let’s hit this one at a time.  Tell me first about the effects of puberty.

Dr. Van Gurp: The body’s production of the hormones estrogen and progesterone increases dramatically during puberty.

The result of this can be an increase in blood flow to the gums.  It can also alter the manner in which the gum tissue reacts to bacterial plaque.  So what one might notice is gum tissue that is more red, tender and swollen.  And you are more likely going to see bleeding of the gums during brushing and flossing.

The presence of plaque on the teeth can worsen this response. This underscores the importance of good brushing and flossing habits learned at an early age, combined with periodic dental visits and cleanings. The tendency for inflammation and swelling associated with puberty appears to decrease as a young woman gets older.

Q: Let’s move on to the monthly menstrual cycle.  What kind of oral health concerns do you have there?

Dr. Van Gurp: Hormonal fluctuations during the monthly menstrual cycle can have a significant effect on the oral cavity.  Usually, these changes take place a few days prior to menstruation when progesterone levels are high.

Q: What does the progesterone do to the gums?

Dr. Van Gurp: Progesterone causes dilation of blood vessels, which in turn results in inflammation and thus obstructs the normal repair mechanisms of the gums.  So as with the puberty signs above, one finds red, swollen and tender gums that may bleed easily.  Note that if there is pre-existing periodontal disease present, these changes can be severe.

Q: What if the condition does doesn’t get better?

Dr. Van Gurp: If the condition doesn’t resolve soon after menstruation, you may want to consult your dentist.  Women that experience changes in their gums during their menstrual cycle may be more susceptible to a condition called Rapid Progressive Periodontitis.  This rather aggressive form of periodontal (gum) disease can cause rapid bone loss around the teeth.

Q: Are there other problems aside from periodontal disease that can occur during the menstrual cycle?

Dr. Van Gurp: A few days prior to the menstrual cycle, some women may develop cold sores on the lips or aphthous ulcers on the soft tissue inside the mouth.  Both of these will typically heal themselves within a few weeks.  During that two week period, topical ointments can be applied to relieve the discomfort.

Some women may also notice swelling of the salivary glands – in particular the parotid gland on the cheeks.  If the swelling is related to the hormonal changes experienced during the menstrual cycle, the changes are temporary and should be reversed within a few days.

The key to resolving the gum disease-related changes is good oral hygiene to remove any plaque that is present on the teeth.

Q: How do birth control pills affect a woman’s dental health?

Dr. Van Gurp: Women who take certain oral contraceptives that contain progesterone may experience inflamed gum tissue due to the body’s exaggerated reaction to toxins produced by bacterial plaque.  These changes are most pronounced during the first few months of taking birth control pills.

As a side note, women who take oral contraceptives should also bear in mind that antibiotics can reduce the effectiveness of birth control pills.

Q: I am seeing a pattern here.  Increased levels of certain hormones and in particular progesterone can lead to inflammation, the body’s exaggerated response to the toxins or poisons produced by plaque on the teeth and gums.  The result may be significant gum disease.

Dr. Van Gurp: That is correct.  And this also holds true during pregnancy when there are significantly elevated levels of estrogen and progesterone. I cannot emphasize enough the importance of good oral hygiene during pregnancy. In the presence of plaque, women who are pregnant are more prone to gum inflammation and periodontal disease. This appears to be more likely during the second through eight month of pregnancy.

In addition, studies show that women with periodontal disease may be at risk for pre-term, low birth-weight babies.

Q: What kind of oral changes take place due to menopause?

Dr. Van Gurp: There are a number of changes that can take place in the mouth as a result of menopause.  As estrogen levels decrease during menopause, women can find themselves at a greater risk for osteoporosis and periodontal disease that includes bone loss from around the teeth.

Jaw bones exhibiting osteoporosis may be unsuitable for dental implants and/or conventional prosthetic devices.  Other oral changes include altered taste, a burning sensation in the mouth and an increased sensitivity to hot and cold foods and drinks.

In addition, women might find that they do not produce as much saliva in their mouths as they did prior to menopause.  The result is a dry mouth, which in turn can lead to periodontal disease and dental decay because insufficient saliva is available to cleanse the mouth by neutralizing the acids and toxins produced by bacterial plaque on the teeth.

Preventing or at least decreasing the likelihood of the dental problems discussed above comes down to good oral hygiene – brushing and flossing.  See a dentist on a regular basis for cleaning and exams. And watch your diet. Eat a well balanced diet and avoid sugary snacks.

Q: I think that most parents recognize that fluoride is a proven means to protect the dental health of children primarily by making teeth more resistant to cavities. But today, you wanted to talk about how fluoride can benefit adults as well.

Dr. Van Gurp: That’s right. Research now indicates that everyone – children and adults – can benefit from fluoride.

Q: Now, when you talk about fluoride, are you focusing on fluoride in our community water supply, in toothpaste or are you talking about additional supplementation?

Dr. Van Gurp: It depends. For the healthy individual without a history of or any current dental problems, fluoridated water and toothpaste may be enough. But for the dental patient who has issues with cavities, sensitive teeth and/or gum disease, fluoride supplementation may be prudent.

Q: Most everyone knows that fluoride helps to prevent cavities in younger children because their teeth are still forming. How does fluoride help the adult patient whose teeth are already formed?

Dr. Van Gurp: The positive effects of fluoride against cavities in adults are twofold. First, topically, in areas where a cavity is just starting to form, fluoride can cause re-mineralization or repair of the tooth. It may prevent the cavity from getting bigger or even reverse the process.

Secondly, systemic fluoride in one’s saliva provides a reservoir of fluoride that can infiltrate the tooth surface to prevent the formation of cavities.

Additionally, no other agents have been so thoroughly reviewed and found safe and effective for the prevention of tooth decay.

Q: What if I already have caps or crowns on my teeth? Don’t crowns protect my teeth from new cavities?

Dr. Van Gurp: A common misconception. Even if you have crowns on some or all of your teeth, cavities can still form at the margin of the crown — where the crown meets the tooth.
And recurring decay on teeth that are supporting a crown or a bridge threatens the entire restoration and can require costly replacement. Fluoride can help to protect these critical areas and help protect the investment that patients have already made in crowns and bridges.

Q: What about the roots of the teeth? Are they more or less susceptible to cavities?

Dr. Van Gurp: When it comes to protection from cavities in adults, we have to take into account that a lot of adults have gum recession, where the gum has pulled away from the teeth thus exposing the roots.

This can be a problem in two significant ways. First, the roots are not nearly as mineralized as the natural crowns of the teeth. In other words, the roots are not as strong and are more susceptible to cavities. Thus, cavities on a root surface may progress rapidly. As with the crowns of the teeth, fluoride can also be incorporated into the roots of the teeth, making them stronger and more resistant to decay.

Q: How does fluoride help those people with sensitive teeth?

Dr. Van Gurp: That’s the second issue related to gum recession. Exposed roots can be very sensitive, particularly to cold. Microscopically, think of the roots as being porous with channels or tubules that lead to the nerve of the tooth. Studies show that by regularly treating these areas with stannous fluoride, the pores of the tubules are filled with fluoride ions.
The fluoride that does penetrate the pores (tubules) serves as a catalyst that helps build strong and resistant mineral in dentin root surfaces and within the tubules. That serves to block or inhibit the stimuli from reaching the nerves and causing sensitivity.

Q: I thought that fluoride would only help with the teeth. How can it help someone who has gum disease?

Dr. Van Gurp: Studies, even dating back to the mid 1980’s, show that fluoride supplementation can decrease the levels of bacteria that cause not only cavities but also gum disease.
Fluoride does so by altering bacterial metabolism at low concentrations and actually killing the bacteria at high concentrations.

Q: What kind of fluoride supplementation are you recommending? Can an adult basically use the same type of fluoride as children?

Dr. Van Gurp: Remember that for all patients, I recommend using a fluoride containing toothpaste recommended by the American Dental Association. Fluoride in one’s drinking water is also a plus. But for those who qualify, I do recommend fluoride supplementation.

As for using the same type of fluoride in adults as one would use for children, not necessarily.

For children, since we are focusing for the most part on cavity prevention, we have the option to use stannous fluoride, sodium fluoride or sodium monofluorophosphate. These are all indicated for tooth decay.

For adults, we only use stannous fluoride, because it is the only one of the three fluorides above that help to treat all three problems we discussed – cavities, sensitive teeth and gum disease.

In treating adults, we recommend a two-prong approach. At hygiene appointments, we do a treatment that involves a higher concentration of fluoride. This may involve a swish or the application of a fluoride varnish. This acts as an initial boost.

For many of our patients, we then recommend the use of a fluoride rinse on a daily basis. This is more the maintenance phase, which keeps the fluoride levels up. This rinse also provides antimicrobial activity for up to 8 hours.

Q: This sounds like the triple force for fluoride as it can be a benefit for those patients who are concerned about any or all three of the problems you’ve discussed –cavities, gum disease and sensitive teeth.

Dr. Van Gurp: That’s right.

Dr. Richard Van Gurp, a Charlotte area dentist and regional leader in Dental Care and Technology, maintains a general dental practice in Charlotte, North Carolina at the Belle Grove Office Park at the Arboretum. He can be contacted at 704-542-2884.