So many people are afraid to go to the dentist that it is almost enough to consider it normal.  The apprehension levels vary from slight to extreme.  Many people will put up with considerable pain, discomfort and loss of function because of “dental phobia”.

There are a number of reasons for dental phobia.  The most common being a past experience that was unpleasant.  I would like to meet the “old horse doctor who put his knee on my chest to pull a tooth”.  I think he traveled around, inflicted pain and then took off.  The old knee on the chest method of yanking a tooth has not been used for a number of years.  The perception of a previous bad experience is very real, even though the actual experience may have been quite different.  Our memories are not the most accurate instruments.

Today, almost all dental procedures can be accomplished with little or no pain to the patient during the procedure.  Modern local anesthetics and local anesthetic techniques are very reliable and produce profound anesthesia.   There may be some discomfort after some procedures, but most of this pain is usually short lived and can be handled using pain medications.

Many people will avoid the dentist because they are afraid of the needle.  Again, the new techniques involved in delivering the anesthetic are quite amazing and can be accomplished with little or no pain.  Strong topical anesthetics prior to injection and new equipment like the computer-controlled injection have made dramatic improvements to anesthetic comfort.

One of the main reasons for fear of dental procedures is the loss of control.  When one is having dental work, they must become totally reliant on the dentist.  They must sit still and quiet while he or she works on one of the body’s most sensitive areas.   With not much else to do, they get to concentrate and postulate on what is going on.  Of course, there are some pretty wild sounds to help the imagination during the procedure. Watching television during the procedure helps to take your mind off what is going on.

There are a number of things you can do to overcome your dental phobia.  The first and most important is to find a dentist with whom you are comfortable.  You should interview any prospective dentists and make sure that this is a person who you can trust and feel comfortable with.  Set up an appointment just to meet the dentist, just to talk.  Let him or her know about your fears and what your expectations are regarding your dental care.  You can then evaluate if this is the dentist for you.

Once you have determined that this a dentist you would like to try, set up another appointment to have a full evaluation of your mouth.  This would include a dental examination and any x-rays that would be required.  If you and your dentist establish that you have some dental work to be done, you can come up with a plan to do it in such a way that it is most comfortable for you.  You may want to start with something simple like a cleaning appointment, or maybe even a small filling.  This would be an excellent way to establish a trusting relationship, which would help you overcome your fear.

Sometimes, it is necessary to use some form of sedation to help you.  Nitrous oxide or oral medications are available to help lower anxiety levels and have been used effectively for many patients. 

It is possible to overcome dental phobia sufficiently to allow you to have any required dental work completed.  Our experience has been that some patients even forget that they used to be scared to come to the dentist.  They may not enjoy it, but it is no longer a big deal.

Why is it that dental fear is so prevalent?  Nearly everyone knows a person who has an exaggerated negative dental experience.  Of course the entertainment industry has not helped quell the fears of dental patients and even Blue Cross the dental insurance company uses a subtle reference to dental fear to help keep you from using your dental benefits.

Almost every dentist has heard the story of the “old horse doctor who put his knee on my chest to get the tooth out!”  Yet no dentist I know of has ever had to put a knee on a chest to extract a tooth, nor would this ever help get a tooth out. 

To some dental fear may arise from the belief that the procedure will be uncomfortable, while others fear the feeling that they have no control over the situation.  Some people associate the sterile smell of a dental office with medical facilities that may trigger associative fears. 

In the early years of dentistry, good pain management was unavailable and there was pain associated with dental procedures.  As science progressed, the effectiveness of dental procedures and local anesthetics became better and better resulting in more comfortable dental appointments.  Today, it is possible to perform dental procedures in a totally comfortable manner.  Excellent topical anesthetics and computer controlled local anesthetic systems allow for comfortable delivery of local anesthetics with profound effects.

In the modern caring dental office, the dentist must make every effort to make the patient feel relaxed.  It is important to establish a relationship with your dentist prior to having your work done.  You should feel comfortable with your treatment plan and be confident that this is the right treatment for you.  You should also have a signal worked out with your dentist to ensure that he or she will stop the procedure should you feel any discomfort or simply need a break.

Should you need a little more than TLC to help you with your dental appointment, there are other avenues that could be explored.  Today, many dental practices are marketing “Sleep Dentistry” to aid nervous patients.  Sleep dentistry is simply the utilization of medications to help a patient through the appointment.  A medication such as Atavan, or Halcion produce a sleeplike state but still allows enough alertness for response to verbal or physical commands.  In some patients, there is also an amnesic effect that results in little or no memory of the appointment.  The utilization of these medications has allowed for even very nervous dental patients to have great dental appointments.

If you have a fear of dentists and would like to find more information about techniques to help you get the dental care you desire, ask your dentist.

I have been practicing dentistry for over 29 years.  I learned early on that people don’t really like coming to the dentist.  They do however love the benefits that available through today’s dentistry.

When a person visits the dentist, they are not looking for fillings, gum treatment or any of the other treatments we provide….They are looking for  comfort, function, stability and beauty.   How we get there may involve fillings, gum treatment, crowns, and what not. 

To achieve your dental goals, your dentist must first do an examination.  The thorough dental exam will include an inspection of your face, head and neck. We will be looking for anything that may indicate a problem or potential problem.

Following the outside examination, your dentist will do an examination inside your mouth.  This will include an oral cancer screening, looking at your soft tissue, tongue, throat, floor of your mouth, palate etc.  He will be looking for anything that is not considered normal or may indicate pathology.

The examination continues with an assessment of your chewing muscles.  Palpation, or pressing, on the muscles of mastication (as we like to call them) should produce no pain or discomfort.  He will also ask about frequency of headaches as this may often be associated with painful bite muscles.

Your dentist will examine your jaw joint, listening for sounds such as clicking or popping.  He will want to know the frequency of the noises and if you have any pain in your jaw or ears.

An examination of your bite will occur.  This is often called an occlusal exam.  Here, the dentist will assess how your teeth come together.  He will look at how the upper teeth relate to the lower teeth, both in function and when the jaw is seated in the socket. He will also see how the teeth bite together and work when chewing side to side.

After these assessments, the dentist will examine your gums and supporting tissues around the teeth.  This will involve measurents called probing, where we see how deep beneath the gums the teeth are attached.  He will look for areas of gum infection and check for mobility of your teeth.

Next the dentist will look at the teeth and see if there are any areas that exhibit decay, cracks, or potential for fractures.

You and your dentist will also look at your smile to see if it is the way you desire.

Your dentist will also review any x-rays that were taken.

Armed with all this information your dentist will be able to make a treatment plan that will help you achieve your long term dental goals.

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.

When we were in dental school, esthetic dentistry was not even discussed except when we were setting up a denture.  When we were restoring teeth, the goal was to make the front teeth acceptable in appearance, and little or no consideration was given to the appearance of the back teeth.

At that time, it wasn’t that dentists were unconcerned about the appearance of our patients; it was that the materials and techniques available to us were limited.  Back fillings were either silver amalgam or gold.  Front fillings were available in tooth coloured material, however, the material was not that great and a limited number of tooth shades were manufactured. 

The goal when placing a restoration in a tooth is to have a seal that will prevent leakage of the oral fluids.  Gold restorations could be constructed to have a mechanical seal; gold is malleable and can be burnished to obtain the excellent fit required.  Silver amalgam restorations seal the filling by corroding.  The corrosion layer between the filling and the tooth has enough thickness to seal the cavity.  Both of these restorations have a great track record and still function as acceptable restorative materials, however they are not always acceptable in appearance especially in front teeth.

White fillings were made of composite resins filled with finely ground glass particles.  The problem with these fillings was that they did not stick to the tooth, therefore there was limited usage and the fillings did not last very long.

Things were changing quickly.

To create a long lasting restoration that did not leak and create sensitivity, there needed to be a way to glue the filling to the tooth.  It is very difficult to glue to a tooth.  This is good for you as this keeps things from sticking to your teeth (except spinach), but creates a problem for a dentist who wants to stick a dental restoration on your tooth.  While it was discovered as early as 1955, that application of a mild acid solution to a tooth created a surface that could be bonded etching and bonding of teeth did not become routine until the late 70’s.  In the 80’s great advances were made in the science of bonding to tooth structure.   With these advances came new tooth coloured resins with greater colour matching and strength.  Light cured resins were developed to allow for greater control of placement by allowing the dentist to cure the resin on demand.  (That is what the blue light does, for those of you who have had bonded restorations.)  The advances in dental bonding are ongoing.  We are currently in the seventh generation of dental bonding resins.

Today, we can predictably bond to tooth material.  This allows for placement of restorations that are not only acceptable, but also invisible.  The modern dentist can make front and back tooth restorations out of composite resin or bonded porcelain, that not only look great but also function like a normal tooth.

Dental bonding has dramatically changed the way dentists practice dentistry.  It has opened a whole new field of esthetic or cosmetic dentistry.  Today, if you would like to change your smile to make it look better you have that option.  A dentist trained in smile design and current in the state of the art esthetic procedures can easily create for you a smile that you love.

For more information about esthetic dental restorations ask Dr. Saby 

The first phase of treatment is phase one treatment, where the object is to stabilize the existing teeth and gums.  This is achieved by placing fillings where there is decay, treating gum disease and stabilizing the bite.

After phase one treatment, it is time to move to phase two treatment.  This is where, missing teeth are replaced, damaged teeth are restored to optimum function and any esthetic improvements are made. 

To maintain proper function and stability, it is important to replace any teeth that are missing.   While it is true that many people are missing teeth and get along quite fine, this is more to do with the adaptive nature of the human body than the fact that the teeth are not necessary.  The teeth are arranged in an arch, disruption of the continuity of the arch results in aberrant biting which must be compensated for.  Loss of an opposing tooth will result in the opposite tooth drifting down.  If you have a tooth that has lost the tooth in front of it, this will result in tipping forward of the back tooth.  Over time this changes the bite and may result in excessive wear, TMJ symptoms or further tooth loss.

Teeth can be replaced with either dental implant supported crowns, fixed bridgework or removable bridgework.  The rule is, fixed is better than removable, an implant is better than a bridge.

Teeth that have been badly broken down by decay or wear, or teeth that have excessively large fillings can be restored with crowns.  A crown is much like an outside filling.  It is cast and becomes a solid unit that fits over the damaged tooth, it is shaped and acts like a tooth.  A crown can be either gold, porcelain fused to gold, milled ceramic or cast ceramic.  What material is used depends upon the situation.

Esthetics can be improved by using whitening, bonding, veneers or crowns, again depending on the situation.

While sometimes simple and sometimes complex, there are very few dental conditions that modern dentistry cannot improve.  If you want to enjoy a comfortable, functional mouth that also looks great, ask your dentist for more information.

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.

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.

Teeth are negatively affected by three diseases, decay (cavities), periodontal (gum) and occlusal (bite) disease.  Most of us are aware of the signs and symptoms of the first two, probably from personal experience.

Occlusal disease does not always present itself so obviously.  Wear, sensitivity, cracks, loose teeth, fractured teeth, painful jaw joints, headaches —these can be the effects of occlusal disease.

As you chew, your upper and lower teeth come together pushing against the skull.  If you have an uneven bite, missing teeth or improperly aligned teeth, your muscles have to work harder to bring your teeth together.  If you clench or grind your teeth the strain is even greater. 

Your dentist will have the skills to recognize signs of occlusal disease and provide appropriate treatment to halt and often reverse its effects.  Recognizing occlusal disease as early as possible increases the probability that you will have young teeth at an elderly age…and possibly require less dental treatment through your life.

Your doctor knows that looking into the future means providing you with all the information about what’s happening today and how it will impact your teeth five, ten, twenty and more years from now.

You may have a poor bite if you experience any of the following:

You clench your jaw muscles for long periods of time.

When you wake up in the morning your jaw muscles are tiered and sore

You experience pain behind your eyes

You grind your teeth while sleeping

Your jaw clicks and pops

Your head or scalp feels painful when you touch it

Your ears ache or you hear ringing

You have neck shoulder or back pain

You feel dizzy.

If you have any of these symptoms, we can evaluate your bite to determine if it is a probable contributing factor.  If so, we will recommend an effective plan of 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.

The most obvious indication that a tooth will eventually have a problem is presence of decay.  Tooth decay is a slow progressive disease that does not usually present any symptoms until it is quite advanced.  Most new cavities occur on the biting surfaces of teeth or between the teeth.  Most cavities are easily diagnosed during a dental exam by using the little dental pick or by looking at dental x-rays.  More difficult to diagnose but very common are cavities around old dental restorations.  Once the seal on a filling or crown is no longer intact, the tooth around the restoration may start to slowly decay.  This is more difficult to detect as the restoration often blocks x-rays and it is hard to detect the extent of the new decay.  Often, the decay under an old dental restoration may be quite extensive.  The treatment for this problem is to replace the dental restoration or crown the tooth if the restoration is quite large.

One of the things we try to prevent is tooth fracture.  A common cause of tooth breakage is stress fracture.  This is related most often to the presence of large fillings in the teeth.  Intact teeth are very strong and very resistant to fracture, however, if we compromise the original integrity of the tooth, they can become prone to breaking.  It has been shown in numerous studies that the strength of a tooth is dramatically decreased once a filling has been placed.  In most instances, a filled tooth is still strong enough to function normally.  We do, however, start to be concerned about the long-term resistance to breakage in teeth that have very large fillings (over ½ the biting surface).  With the lack of support of the underlying tooth material, the glass like enamel is prone to crack. Continual flexing of the unsupported tooth creates small cracks that eventually get larger leading to a fracture.  This usually takes time and for some reason, the final fracture occurs while eating bread or some other soft food while at the airport or in some third world country.

Placement of a cast metal, cast porcelain or metal fused to porcelain restoration is the treatment of choice for teeth that have excessively large restorations.  These restorations are called crowns or onlays.  The function of a crown or onlay is to hold the tooth together much like a casing.  Placing a crown or onlay on a tooth with a large filling or evidence of a crack, before the tooth fractures will likely prevent the tooth from breaking.  Waiting until the tooth actually breaks before restoring the tooth may cause some problems, mainly that there is no control over where the break will occur.  Many times the tooth breaks diagonally from the filling to under the gum.  This may require that gum surgery and additional restorative procedures be undertaken to fix the tooth, or worse, the tooth may break in a way that does not allow restoration resulting in loss of the tooth.

Tooth wear is slow progressive tooth failure.  Most people exhibit some signs of wear of their teeth, whether from tooth grinding (bruxism), poor bite alignment, acid erosion, or some other noxious oral habit.  Excessive tooth wear can be a major dental problem.  Once tooth wear has progressed through the strong outer enamel to the soft inner dentin of a tooth, the rate of wear greatly accelerates.  Back teeth loose their functioning cusps (the pointy part of the back tooth that does the work), and front teeth get short and start to chip.  Tooth wear often happens so slowly that even though a person has worn away as much as 1/3 to ½ of their front teeth, they may not even be aware that this has occurred.   (It is sort of like gaining weight, it usually happens slowly so you have time to get used to it.)  The front tooth wear is often not even and produces a crooked smile line.  

Early treatment of wear would include wearing of a night guard to protect the teeth from night-time grinding, control of acids, alignment of the bite through selective bite adjustment or orthodontics and possible minor restoration of worn teeth.  If wear is severe, there are restorative options available, which can restore function and beauty.

Early prevention of dental problems is always our first choice. So even if you do not have symptoms sometimes it is desirable to fix it even if it ain’t broke.  If you would like to know more about preventative options available to you to help you achieve your long-term dental goals, ask Dr. Saby.