Dr. Brian Saby's Dental Blog

Once a dentist has finished a comprehensive dental examination, he must come up with a treatment plan to help meet the patient’s dental goals.  These usually are:  Comfort, function, stability and esthetics.  More plainly: Look good, feel good, chew well and last a long time. 

To reach these goals, we often divide dental treatment in to two phases.  Phase one treatment involves the treatment of active disease.  Phase two treatment involves repair of damage caused by the previous disease.  In some cases, phase one treatment will be all that is required, in other situations, phase one and phase two treatment can be accomplished at the same time.  Sometimes, phase one treatment must be completed prior to phase two treatment.

Phase one treatment…stopping disease.

Creating healthy gums.  This usually involves gum treatment.  The goal is to have healthy gums that do not bleed.  This usually means a trip to the dental hygienist for a deep cleaning.  If the gums are still inflamed after initial gum therapy, laser gum therapy, chemical gum therapy or surgical gum therapy may be needed.

Creating healthy teeth.  This involves fixing any cavities that have formed.  These can be new cavities, or cavities under and around old fillings.  Worn teeth must be examined and the cause of the wear determined.  If it looks like the wear is due to grinding the bite must be stabilized.  If the damage is caused by acids, the source of the acids that dissolve the teeth must be found and eliminated or reduced if possible. 

 Creating a healthy bite.  This part of dental treatment is not as familiar to the general public.  In order to function properly and to reduce wear, the bite must be checked to ensure that the lower teeth move into the upper teeth in a way that maximizes the biting forces and reduces the strain on the muscles and jaw joint.  Many times the phase one treatment for this problem may be an appliance that is worn at night to help relax the muscles and prevent wear.  Phase one bite therapy may involve balancing the bite by selective tooth adjustment.

 After the disease is halted phase one treatment is either completed, or the final part of the phase one treatment may be to move the teeth.  This is done to allow the bite to be as good as it can be.  Teeth are moved with braces. 

Following phase one dentistry, the teeth and gums should be in a state where they are not infected or inflamed and the teeth are where they need to be. At this point, all treatment is either completed and only regular check ups and maintenance is required or it is time to start restoring the teeth to their ideal form and function…phase two treatment. 

I will discuss more about phase two dentistry in our next segment.

Once a dentist has finished a comprehensive dental examination, he must come up with a treatment plan to help meet the patient’s dental goals.  These usually are:  Comfort, function, stability and esthetics.  More plainly: Look good, feel good, chew well and last a long time. 

To reach these goals, we often divide dental treatment in to two phases.  Phase one treatment involves the treatment of active disease.  Phase two treatment involves repair of damage caused by the previous disease.  In some cases, phase one treatment will be all that is required, in other situations, phase one and phase two treatment can be accomplished at the same time.  Sometimes, phase one treatment must be completed prior to phase two treatment.

Phase one treatment…stopping disease.

Creating healthy gums.  This usually involves gum treatment.  The goal is to have healthy gums that do not bleed.  This usually means a trip to the dental hygienist for a deep cleaning.  If the gums are still inflamed after initial gum therapy, laser gum therapy, chemical gum therapy or surgical gum therapy may be needed.

After the disease is halted phase one treatment is either completed, or the final part of the phase one treatment may be to move the teeth.  This is done to allow the bite to be as good as it can be.  Teeth are moved with braces.

Following phase one dentistry, the teeth and gums should be in a state where they are not infected or inflamed and the teeth are where they need to be. At this point, all treatment is either completed and only regular check ups and maintenance is required or it is time to start restoring the teeth to their ideal form and function…phase two treatment.

I will discuss more about phase two dentistry in our next segment.

What do dentists mean when they talk about comprehensive treatment?

Once you have had your thorough complete dental exam, which includes examination of the teeth, the gums and other soft tissue, occlusion—how the teeth fit together in function, the jaw joint and the muscles used for chewing and support of your jaw, your dentist will review all pertinent findings and make an evaluation of the overall health of you chewing system.

A comprehensive treatment plan should address not only current issues such as active decay, and gum problems but also potential problems.

The comprehensive treatment plan will be devised to obtain the optimum functional and esthetic result. 

It is the dentist’s responsibility to present an optimal treatment plan.  This discussion should include benefits of ideal treatment, potential risks of treatment and potential risks if the treatment is not done.  This allows you, the patient to make an informed decision regarding their dental treatment.

This summer I had to replace some outdoor stairs at my home.  When these stairs were built about 12 years ago, we did not use treated lumber, as a result, there were signs of rot.  The stairs were still functional, but I had some concern that they could break.  Not wanting to have a stair failure as Aunt Tilley was climbing down, I decided to tear out the old stairs and build new ones.

Many readers are now saying: “Brian, did you whack your head while windsurfing on Friday?  This is a dental column.  While we find your stair story fascinating, what has it got to do with teeth?”  Let me explain.

Many times after examining someone’s teeth and going over treatment options, I hear the line “If it ain’t broke, why fix it?”  While it may be true that there are no clinical symptoms at the present time, there may be advantages to treating some teeth before they cause problems.  Much the way we replaced the stairs before an accident occurred.

We can often predict which teeth will eventually fail.  By taking action before failure we are able to prevent dental emergencies and restorative complications and treatment of the affected teeth can be scheduled at a convenient time. (more…)

The following article was published in the Boise Beauty Examiner:

A smile is the universal form of communication. With a smile we can portray happiness, excitement, approval, energy, and love. Smiling is sexy- and if we smile with confidence, it’s one of the most beautiful things we can do!

The color, shape, and alignment of the teeth all contribute to a beautiful smile. Tooth whitening or bleaching has become one of the most popular beauty treatments, and thanks to our Idaho cosmetic dentists, we can have straight teeth without even needing braces! The first step to getting the smile of your dreams is to consult a cosmetic dentist specializing in aesthetics.

Choosing the right cosmetic dentist, one with extensive training, substantial experience and a gentle approach that understands clients’ needs, is the key to achieving a successful outcome through whitening or bleaching your teeth, or for achieving straight teeth and a beautiful smile! Below are some guidelines for successfully choosing a cosmetic dentist.
Does the dentist have credentials in cosmetic dentistry?
Many dentists perform some sort of cosmetic work as part of their services, but how do you know if you are paying someone who is qualified to perform tooth whitening, bleaching, or give you straight teeth and a beautiful smile? In cosmetic dentistry, as in medicine, specialties exist that are indications of a high level of education and training. Presently, however, no specialty in cosmetic dentistry recognized by the American Dental Association exists. In 1984, however, the American Academy of Cosmetic Dentistry (AACD) was formed and has the filled the need for credentials in the area of cosmetic dentistry. The organization currently has 7,000 members in the U.S. and in 40 countries around the world. It is the largest international dental organization dedicated specifically to the art and science of cosmetic dentistry, and it administers the leading accreditation program for cosmetic dentists. This accreditation process requires dentists to attend many continuing education courses in cosmetic dentistry, to be tested and to submit a number of cosmetic cases to be judged by a panel of cosmetic dentistry experts.

(more…)

Have you ever wondered what dentists do to keep up and get ahead in the wonderful world of dental science?

When most dentists get out of dental school, they are ready to start practice and save the world’s teeth.  It seems almost universal that a new graduate feels that they are up to date on all there is to know about teeth and that everyone else is behind the times.  “You are better off seeing a new graduate, who knows everything, rather than one of those old timers who must be behind.” is a common thought often expressed by the new dentist.

Of course it only takes about a week or two in practice to realize that maybe you don’t know everything.  In a few more weeks, you quickly discover that your dental school education prepared you for private practice in only the very basic sense.  Actually, your dental school training gave you a very good foundation on which to grow, learn and eventually become a very good dentist.  What it cannot give a young dentist is experience.

To learn more and to keep current, dentists take continuing education courses.  Local dental societies and universities traditionally gave these courses. Over time there has evolved a large business of supplying dental courses to dentists and dental staff. These are either through private businesses or non-profit organizations.

Another way for a dentist to learn and improve is to pursue a fellowship or accreditation by a recognized organization.

An example is the American Academy of General Dentistry.  This organization is dedicated to dental continuing education and has set a standard for quality in this area.  The AGD has set up a system to track and record the courses taken by a dentist member.  When the dentist has taken 500 hours of course study, they are then eligible to write the fellowship exam.  After successfully writing and passing the 400-question examination the dentist would be awarded a Fellowship in the Academy of General Dentistry.

Another organization is the American Academy of Cosmetic Dentistry.  The AACD is an organization dedicated to appearance related dentistry.  This organization has a credentialing procedure that recognizes achievement in the art and science of esthetic dental care.  A written examination, clinical case presentation and an oral examination are required to achieve accreditation.  

While it is kind of cool to be awarded a fellowship or an accreditation status, the real benefit of pursuing these is the education and professional development that occurs in the process.  The true benefactor is the patient of dentists who go through these processes.

If you are in the process of choosing a dentist, be sure to ask your dentist about the continuing education he or she pursues.

If you were to take a survey of the “over 40” crowd.  You would find that the majority of people over 40 have had numerous fillings in their teeth, especially the back teeth.  You would also find that most of the old fillings are silver amalgam and likely quite large. (Feel free to try this at your next summer barbeque; it will make you the topic of conversation for months.)

The prevalence of dental restoration in that demographic group is largely due to the fact that this group missed some important dental developments during their formative years.  Fluoridation, dental sealants and the importance of flossing and brushing in the pre-teen years being the main advances in protection against tooth decay that were advanced shortly after this age group got their first cavities.

Fortunately, dentists have been very successful in the treatment of dental decay.  For many years now we have been proficient in placing fillings teeth that have been affected by decay.   Unfortunately, fillings have a limited life span and fail over time.  Each time a filling fails the next filling needs to be bigger.  At a certain point, there may be too much filling and not enough tooth to produce a good result.

Dental fillings were designed to fill a hole in the tooth using the remaining tooth to support the filling.  When the filling exceeds a certain size the remaining tooth structure is too brittle to hold the filling without fracturing under the strain of chewing.  This results in fracture of the remaining tooth.  To prevent tooth fracture or to repair a tooth that has fractured the dentist will recommend that the tooth have a crown.

A crown (also called a cap) is a restoration that covers the outside of the tooth.  The crown acts to hold the tooth together and replace the missing tooth material.  Think of it as a casing for the tooth.

To produce a crown, a thin veneer of tooth material is milled from the outside and the top of the tooth.  This produces enough space for the restorative material and allows for the crown to be shaped so it can function like a tooth.  Usually, 1 to 1.5 mm of tooth is removed around the tooth and 1 to 2mm removed from the biting surface.  A very accurate rubber-like impression is taken of the tooth and a plaster model is produced that is exactly like the prepared tooth.  A dental lab technician will then construct the crown that fits the model, and therefore the tooth precisely.  The crown is then cemented over the tooth preparation, any you are on your way to years of happy chewing.

Crowns can be made of a number of materials.  The most conservative, longest lasting material is still gold.  The malleable nature of gold allows for final finishing in the mouth that makes for best seal.  The main drawback of the gold crown is the colour. 

If esthetics is a concern, a veneer of porcelain can be made over the gold of a crown.  With modern, porcelain technology, these teeth can be made to be indistinguishable from natural teeth.  New technology even allows for all porcelain crowns that fit well, are strong and have the maximum esthetic potential.  This is especially helpful when the tooth to be crowned is near the front of the mouth.

Dr. Saby can help you decide if it is best for you to have crowns on some of your teeth and if so, what type you should have.

It appears that there are still many people out there who are slightly misguided when it comes to complete loss of teeth.  I would like to spend this week’s column discussing dentures and the common misconceptions surrounding these artificial body part replacements.

First and foremost, you do not naturally lose your teeth when you get older.  In the past, when dental care was not generally available, it became very common for people to eventually have all their teeth out.  As it takes a while for dental disease to eventually claim all the teeth, tooth loss became associated with aging. 

In reality, there is no reason to lose your teeth, as you get older, today it is generally accepted that most people will have their teeth for their entire life and the necessity to have complete dentures is most often the result of conscious decisions.

Dentures are not a substitute for natural teeth; they are a substitute for NO teeth.  It is widely believed that removable complete dentures will give the same function as natural teeth, but even the best-made dentures cannot come close to providing the function of natural teeth.  It has been shown that the biting forces generated by dentures approach only 10 – 20% of that of fixed teeth.  Dentures are by their very nature, are loose.  Even a properly fitting upper denture is not fixed in place, but held in by suction.  Lower dentures, with 1/6 the surface area for suction and a tongue moving around are even worse.

Dentures are not factory original parts but after-market add-ons.  The gums remaining after teeth have been removed were never intended to support acrylic bases and denture teeth.  As a matter of fact, immediately following tooth extraction, the bone that was there to support the teeth, starts to disappear.  The additional load from the denture hastens this shrinkage.   As this bone loss progresses, the fit of the denture will change.  The denture wearer may adapt to this change as it happens slowly so they may not notice the subtle degradation of the fit and function.

So, yes, even though you have dentures, you should see your dentist at least once a year.  At this appointment your dentist will do an oral cancer exam and soft tissue check.  He will also evaluate and clean your denture.  If the fit is not adequate, he may suggest a reline.  If the teeth are worn out he may suggest a new denture.  We recommend that a denture be relined every two years and that they be replaced every five years.

At your regular denture and gum check, your dentist will also be able to discuss with you some of the possibilities available today where you can have a fixed solution to your problem using dental implants.

Like everything else in the world, technological breakthroughs have changed dentistry.  Today, the modern dentist is doing things, which were technically impossible even five years ago and unimaginable twenty years ago.  With all this change, the average perception of a dental visit has not changed.  When most people go for a dental check up, they expect the dentist to tell them what is wrong, and what “needs to be done”.   This attitude is still shared by many dentists as well.  The dentist will look for problems and disease and fix these.  This “patch and fill” approach has served us well for many years, however, there is another approach which is better.  Give the patient some choices!

One of the first things you and your dentist should do when deciding you get together is determine your long-term objectives concerning your teeth.  Do you want to have your teeth for the rest of your life?  If you want to keep your teeth (most people do, and most should have no problem in this regard) is there anything you would change about the appearance, or function?  Would you like to prevent any future dental problems?   Once you have determined these goals, your dentist should perform a very thorough examination and give you some treatment options to help you achieve the desired results.  It is morally and ethically imperative that your dentist present to you a treatment plan which outlines the best treatment that is available in 1999 style dentistry.  This treatment plan should achieve your dental goals; cost, time of treatment, complexity or other factors should not be part of this planning phase.  You have the right to know what is the best available, and the dentist is morally and ethically obligated to let you know what you could have, if you so choose.  Now that you have an idea what could be done, you can now look at the other factors involved in making the decision: How many appointments would it take?  Would braces be required?  How much would it cost?  Would there be any discomfort?  Your dentist should be able to answer all of your questions or concerns.  If the treatment plan is not to your liking, it may be possible that there are other treatment modalities available which would be acceptable to you.  The dentist’s job is to let you know what treatment is available, your job is to determine if this is something you would like, is this the right dentist to perform the treatment, and what time frame you would like to do the treatment.       

Today, a person can have almost anything they want when it comes to how they would like their mouth and smile.  People without teeth can now have teeth implanted so they no longer require dentures.  Those unhappy with the appearance of their teeth can have their smile changed to give them a perfect smile.  Dental restoration can be constructed which will last a very long time, and broken teeth can be avoided.  Fillings can be made that look just like natural teeth, giving the appearance of having no fillings.  Unfilled teeth can be sealed to prevent cavities.  Missing teeth can be replaced easily.  Worn and aged appearing teeth can be restored to give a more youthful appearance.  All you have to do is decide what you want.

For the most part, we do some pretty neat things in dentistry today.  We can help people by drastically improving their smiles; we can restore function, and provide the peace of mind that comes with having ideally restored teeth.  This is rather fulfilling for the dentist, but every now and then we treat a patient where we make a dramatic difference and are able to change their lives.  Last week was such a time.

We had been treating a lady in my practice (we will call her Mary) for the last several years.   When we first saw her, her main complaint was her poor fitting upper and lower dentures.  For you to fully understand her problem, we must first go over some things that happen when a person loses their teeth.

Traditionally, when most people lose all their teeth, they initially have a set of dentures made.  These are made of an acrylic base with either porcelain or plastic teeth.  The acrylic base rests on the gums.  The dentures are held in by the suction created by an accurate fit.  The upper dentures, with six times the surface area, suck in well, while the lower denture with less area and a tongue and cheeks to dislodge it, fits adequately. 

Most people can get by with their dentures after sufficient learning and adapting.  Even though the best dentures offer only 25% of the biting ability of natural teeth, the adaptability of people makes this a workable solution to their problem.  However, things get worse.

In the jaws, there are two types of bone, the base bone and the bone that goes around the teeth (basal and alveolar bone for you jargon junkies).  When the teeth are removed, the bone that goes around the teeth immediately begin to dissolve since the stimulus for maintaining the bone, namely the teeth is gone.  Initially, there is usually enough gum-covered bone, to form a ridge.  Over time as the bone shrinks, the dentures fit becomes poorer and poorer.  Every couple of years, a new base needs to be placed on the denture, this is called a reline.  Owing to wear of the teeth and shrinking gums, the dentures need to be replaced every 6 – 8 years.

The amount of bone shrinkage is the biggest problems facing denture wearers.  In most people, the total amount of bone loss is such that they will still be able to function with a denture. In others the bone loss is so great that they have a difficult time with their dentures.  At a certain point, it becomes impossible to construct an adequate denture. Usually, this is seen in the lower jaw since there is no palate to take some of the load.   No one can make a functional, comfortable denture when the foundation has been destroyed due to bone loss. 

Mary was such a person.  She had lost her teeth in her early 20’s.  Over time she had lost almost all the supporting bone in the upper and lower jaws.  Where there is usually a ridge on the lower jaw, she had a ditch.  She  had lost so much lower bone, that the nerve which normally runs in the middle of the jaw, was laying just under the gums causing pain when pressed upon by the denture.  Her upper gums were not anchored to much bone and were loose and flabby.

We initially made a very accurate denture for Mary.  Painstaking attention to detail with regards to fit and the bite ensured that she had the very best denture that could be constructed.  Even with this we had to use a rubbery base on the lower denture to cushion the gums.  This denture served Mary well for about 5 years but was barely adequate.

The solution to Mary’s problem was to place dental implants in her lower jaw.  Ideally we would have constructed fixed lower teeth, but financial considerations did not allow this extensive treatment.  Instead, Mary had two implants placed in lower jaw.  To these we secured a special bar.  Clips in her lower denture allow her to snap her lower denture in place so it is stable. 

The implant placement is a simple procedure that is done under local anesthetic.  The implants are simply screwed into place and left to fuse to the bone.  There is surprisingly little pain following and no pain during placement.

After a three-month period during which Mary was still able to wear her lower denture, we made the bar.  This procedure involves no pain or discomfort for the patient. 

I knew Mary would have considerably more comfort and function with her new dentures, but how much more was not evident until I talked to her sister a few days later.  She mentioned how happy she was and how she was able to eat better with no pain or discomfort.  The most telling indication, however, was when she walked into the kitchen and heard Mary for the first time in 35 years proudly say: “Hey, look at me, I’m eating an apple!”

It is often the simple things in life that we most often take for granted yet miss the most when they are taken away.  If you would like more information about how dental implants may help you improve your life, ask Dr. Saby.