Dental Questions and Queries

I am Dr Nina King and here I will try to answer some of the more regular questions I get asked about dentistry, dental hygiene, dental tourism and, well, anything that you always wanted to know ….but were afraid to ask!

Seriously, if you have any questions, please contact me through the surgery, the website or via the contact page below. You are assured of total confidentiality at all times.

Have confidence in your smile.

Question one

I keep getting cold sores and want to get some dental treatment done but my dentist tells me it’s best to wait until after they completely disappear. Does it really make a difference as I am keen to get on with the work?
SB

Dear SB:
As I’m sure you know cold sores, small blister like lesions around the mouth, can be extremely painful and cause the lips and surrounding areas to be dry and split. In the United Kingdom between 20-40% of people have experienced cold sores at some time. Depending on where they are situated the dentist may find it impossible not to touch them during treatment and therefore it can be quite uncomfortable for you, the patient, both during and after treatment. So in the first instance the dentist is probably looking out for your overall comfort and advises waiting until compete healing.

In addition however cold sores can be passed from person to person by close direct contact. This relatively common condition is caused by the herpes simplex viruses. The strain that usually causes them around the mouth is herpes simplex type 1 (HSV-1).In rare cases, cold sores can also be caused by the herpes simplex type 2 virus (HSV-2). There are various stages of development of the cold sore but the first signs of a cold sore appearing, when the area is tingling and/or itchy is when the herpes simplex virus is spreading and replicating itself. The lesion will then burst and leaks fluid which is highly infectious.

Fortunately all dentists now wear gloves in order to prevent transmission of infection from themselves to the patient and visa versa by direct skin contact. However case studies have demonstrated that potentially the virus can also be spread not only by direct skin contact but through aerosol. During dental treatment aerosols can be generated from the water spray from the dental drill or even from the ultrasonic cleaning equipment. Therefore there exists a real, though small, probability of passing on this virus to other patients or even to staff through this route. There are many measures that can be implemented to control the risk e.g placement of a protective dam at the time of treatment to prevent droplet spread but the safest way for all concerned is to simply postpone treatment, if not urgent, until after complete healing .
As a final thought you might want to talk to your GP about why you have repeated outbreaks and if your cold sores are particularly severe. While there are many triggers which vary from individual to individual if you have a damaged immune system (for example because you are having chemotherapy), you may be at risk of further complications.

Question 2

I want to get my teeth whitened but have heard that the process can damage the teeth. Is this true? PR

Dear PR:
The active ingredient in dental whitening gels is either hydrogen peroxide or one of its precursors, notably carbamide peroxide. Carbamide peroxide breaks down into hydrogen peroxide and urea, with hydrogen peroxide being the active ingredient.
The way that bleaching treatment works is based on the ability of the bleaching agent to permeate tooth structure to the source of the discolouration. Hydrogen peroxide has a low molecular weight and therefore passes easily through enamel and dentine. Peroxides release free radicals which interact chemically with large organic pigment molecules contained in enamel and dentine. These discolouring molecules are reduced into smaller, less pigmented molecules which then pass through the tooth.

Over the years this treatment has gained in popularity and concern has been raised over the possible negative effects on the actual structure of the enamel and dentine of the tooth as well the reaction of the inner pulp which contains the nerve and blood supply to the tooth .
The most commonly observed side effects to hydrogen or carbamide peroxide are tooth sensitivity to cold and occasional irritation of the soft tissues in the mouth, particularly the gums. In most cases though gum irritation is caused by an ill fitting bleaching tray rather than the actual bleaching agent.

With regards to potential damage to the teeth, initial studies in the 1990’s did indicate neglible changes in enamel surface texture associated with peroxide bleaching. However these changes, when observed, were minor and easily reversed through later prophylaxis or through remineralization from the saliva. As a result many modern bleaching formulations now actually include contain fluoride or other remineralising agents like ACP to counteract any possible negative demineralization effect.

The majority of the more recent studies using sophisticated scanning electron microscopy during the last years showed no significant changes in enamel surface structure following bleaching even with one of the highest concentrations of hydrogen peroxide (35%) (Sulieman et al., 2004). Other physical properties such as surface hardness and resistance to acid attack after bleaching have also been extensively studied with the vast majority indicating that there are absolutely no detrimental effects. Those that have produced contrasting evidence are generally agreed to be flawed in terms of the design of the research which can be a very common problem when analysing and isolating the effects of a product in a human trial.

With regards to the inner pulp core of the tooth, it is well established that a common adverse side effect of tooth bleaching is sensitivity. However evidence shows that bleaching may either have no effect or may cause an initial, mild, localised pulp reaction which is reversible several weeks post treatment. Although hydrogen peroxide is capable of diffusing through the tooth into the pulp laboratory research shows that the level of concentration reached within the pulp tissue is almost 1000 times below that which causes irreversible damage to the pulp enzymes. So the safety margin is widely accepted as being very high. The use of desensitising agents containing fluoride or different bleaching gel formulations can address the sensitivity problem.

If you are considering any whitening treatment though be sure to have a thorough dental examination first .This will allow you to discuss whether the procedure is suitable for you but also very importantly allow the dentist to check that you do not have any specific dental problems that can be made worse with the treatment e.g. leaky fillings which need to be fixed beforehand.

Question 3

I started some complicated dental work but to be honest I just can’t afford to finish it right now. I have some temporaries in place which seem ok but I just wanted to know if there is any serious problem with leaving them as they are, for the next few months, until I can find some money to continue. YL

Dear YL;
Without knowing the exact nature of your case I would say that in general temporary or provisional restorations may remain in place for several months without any long term damage to the teeth and underlying structures.

In fact in some complicated cases this is actually advisable so we can really assess the bite and the appearance etc. before we commit ourselves to progressing to the definitive work. However you do need to be aware that some of the problems that can occur over time can be quite significant and compromise the final result. These are:

Leakage of the temporary restorations. By design the provisionals are made to be removed at a later date and are usually bonded on only with a temporary cement. This will dissolve slowly over time and you will lose the seal so that bacteria may now pass from the saliva and food to below the temporary restoration and start to attack the actual underlying tooth surface. Of course this process happens slowly over time but remember that these prepared teeth are already compromised and further bacterial attack and decay may weaken them to such an extent that the original treatment plan cannot then be followed in a few months’ time and you may even end up losing teeth…

Fracture of the temporary restoration. This of course depends on the occlusion “ bite” and location and material of the provisionals. Generally the material used is a form of acrylic modified in the mouth but they can also be made in the laboratory whereby they have increased strength. Where there is heavy biting contact on a temporary restoration or the contact is uneven then fracture is more likely. In addition for certain types of preparations like onlays and veneers where the temporaries are quite thin repeated fracture can occur if they are left for a long period. This then leaves the underlying tooth preparation weaker and the surface exposed to bacteria.

Irritation of the gums with resulting gum disease. This depends on the state of the gums before the temporaries were fitted. If there was underlying gum disease before then it can be made much worse if the temporaries are in place for long periods. This is because the temporary material can be rough around the edges. They can also be linked together for strength purposes which makes it very hard for you to clean bacteria and plaque from the surface leading to irritation. However if gums were healthy before starting treatment (as should always be the case) then this will usually be a reversible condition once definitive work is not delayed too long.

Staining of the temporaries. If you are a heavy smoker or eat a lot of strongly coloured foods like curries then you will find that the temporary material can take up staining and become unsightly after a period of time as the stains are incorporated into the actual material. For longer term cases we often consider making the provisional restorations in the laboratory as they are “sealed” better and hence not as amenable to staining.

Question 4

Does anyone else find it hard to have Xrays taken inside their mouth? I hate them! They are very uncomfortable and I prefer to have the larger one taken of my whole mouth but the dentist says the smaller ones inside are better? Why? NM

Dear NM:
Like everything there is not a single investigation that is suitable for every case. The xrays you refer to inside the mouth are called “intra-orals” and indeed can sometimes be quite uncomfortable for patients even causing some people to gag slightly. Fortunately they are often in the mouth for only a few seconds at a time and most people can tolerate them as needed. You are not alone as it is a common complaint despite manufacturers trying to come up with “rounded edges” and different sized films etc. At the end of the day sometimes it is just a question of the limited space present due to the shape of the mouth. If the film/sensor is too small then it would not show the whole area we want, making the investigation pointless.

As you mentioned one way around that is the panoramic Xray which shows the whole mouth and is a type of “extra-oral” Xray. Hence it is far more comfortable as the film/ sensor is placed outside the mouth and the machine rotates around your head and body without even touching you.
In rare cases for difficult areas we may have to settle for the extra-oral Xray if it is proving too difficult to take an intra-oral one.
However the indications for each are different. As the name suggests the intra-oral Xray provides us with a close up detailed image of an area. This may allow us to see bone levels if we are concerned about gum disease or visualise small areas of decay between teeth or at the junction of crowns.

The extra-oral Xray is a general overview only. In addition it is a lot more radiographic exposure for you than a single intra-oral Xray although some of the modern machines can cleverly only produce an image of the quadrant in question e.g. upper right side and not radiate the whole mouth. The extra oral Xray is absolutely essential in some cases such as for planning implant treatment where we need to assess bone height and positions of important structures like the sinuses. However it is a two dimensional image (flattened) of a 3 dimensional area and as such the Xray is subject to distortion and artefacts so it often not as accurate and useful for diagnosis of a specific area as is the close up intra oral Xray.

Question 5

My breath smells. It’s becoming embarrassing but I am scared to go see the dentist as it might be serious and I don’t know what I might have to have done. SC

Dear SC:
The source of bad breath (halitosis) may be a dental problem but it may also be an underlying medical problem. By this I mean that there is a bacterial inbalance in the mouth and throat or it may be from the digestive tract and stomach. In any case however it is a sign of a problem and while I understand your fears it is also important to get a diagnosis and at least understand what your treatment options are and possible consequences of not treating it.

The most common cause of bad breath is poor oral hygiene. The bacterial build up tends to be in the soft tissues of the mouth usually on the surface of the tongue as well as the gums. This will result in periodontal (gum) disease which has many further symptoms in addition to bad breath such as bleeding gums and eventual loosening of the teeth.

If this is the case then to eliminate these bacteria causing bad breath you will need to improve your oral hygiene and also get professional help in scaling and polishing the teeth to remove build up in all areas of the mouth. Your dentist will be able to explain more to you about periodontal (gum) disease and treatment is undertaken with local anaesthetic to make the deep cleaning more comfortable for you. If you are a nervous patient you might also want to consider sedation during your treatment.

However most people have bad breath when they wake up in the morning and this is normal. Overnight the flow of saliva is reduced and bacteria break down any bits of food left in the mouth, releasing an unpleasant, stale smell. The flow of saliva usually increases once you start eating. However if you persistently have a dry mouth you may find that the halitosis is more severe as again the washing effects of the saliva are diminished. In this instance it is important to diagnose and treat the cause of the dry mouth. However in the short term improving oral hygiene by mechanically removing bacteria, drinking plenty of water and stimulating your salivary flow by chewing sugar free gum will all help. Mouthwashes of simple salt water or even hydrogen peroxide can also help to reduce the level of anaerobic bacteria causing bad breath.

Heavy smoking and alcohol intake as well as eating strongly flavoured foods like garlic will also contribute to bad breath so you may want to reconsider your diet and social habits. Crash dieting, fasting and low-carbohydrate diets, such as the Atkins diet, can also cause bad breath. These cause the body to break down fat, which produces chemicals called ketones that can be smelt on the breath.

Finally, far less commonly, not all causes of halitosis are dental. Certain medications as well as medical conditions can be associated with bad breath. The medications include some chemotherapy drugs, nitrates (used sometimes to treat heart conditions) and tranquilizers (phenothiazines).Infections in the lungs, throat or nose, sinusitis,diabetes, liver and gastric problems are also known to be associated with bad breath,

Question 6

There are spaces between my teeth which I really don’t like. Can I get them filled in? MN

Dear MN:
Some people do have an naturally spaced dentition where the teeth are all present and are of normal size and shape however due to a difference in the shape and size of the jawbone structure there are spaces between them. In other cases however spaces exist because there are simply not a full set of teeth developed: this is known as hypodontia . In Caucasians between 3 and 7 percent of adults are missing teeth. The most common missing teeth are the wisdom teeth (25-35%) followed by the upper lateral incisors (2%) either side of the main two front teeth. In other situations while the jawbones are in correct proportion and all the teeth themselves are present but have been incompletely developed: a condition known as microdontia. In this case the spaces will still exist as they are less the size of the normal teeth. This can affect all the teeth or sometimes just a few teeth are smaller than normal, commonly again it is the upper lateral incisors and wisdom teeth.
It is important to first diagnose in which category you are located.

If the teeth are all present and of normal shape and size than trying to fill in spaces by adding to the existing teeth in some way may make the teeth simply appear too large. In these cases usually the only way to close spaces is to consider braces to move the teeth closer together but this can sometimes be a complicated procedure and you may end up needing to have a permanent retainer to stop the spaces re-opening or prevent relapse of the movement.

In the second scenario of hypodonta it does depend on when the problem was identified. If it was noticed at an early age that you were missing adult teeth (e.g they were not present on the Xray) then space maintenance can be planned so that when your adult teeth start coming through then there is still space present to fill in normal sized adult teeth later.If however this anomaly was not noticed until after all your adult teeth came through then it is common for the other teeth to drift and start occupying the excessive space. In this case you may need some preliminary orthodontics ( braces) to realign all the existing teeth into their correct places and then you can think of a long term solution to fill in the gaps. For example an implant might be a solution is you were missing the two upper lateral incsors.
The third scenario of microdontia this can sometimes be the easiest to treat as the existing teeth can simply be added to with white filling material or veneered or crowned to make them appear normal size and also fill in all the spaces.

Question 7

My dentist is talking about an implant to fill in a space I have at the bottom but I see such a huge difference in the prices in implants….. is there really such a difference between them or are dentists just trying to rip you off?

Dental implants are one of the closest things we now have to recreating your own natural tooth. The implant part is placed in the bone and a restoration fitted on top to mimic the appearance and provide the functions of a tooth.

Dental implants have been around on the market now for over 30 years or so and the larger well established companies have an impressive track record of documented research and well conducted trials. Over this time these well established companies have actively worked on their products e.g modifying the surface of the implant so that it bonds more effectively and completely to the surrounding bone and also creating a more precision fit of the overlying structure which resembles the tooth part.

With any product as market demand goes up then generally prices will go down as more and more competitors enter the market and copy the technology at a lower price.

I personally have lost track of the number or representatives that cross my door on an almost weekly basis trying to sell me their new implant system at a reduced rate. Usually a system I have never ever heard of and one that will probably no longer be in circulation in five years’ time.To be fair though at last count there were over 300 dental implant systems in circulation worldwide and of these I currently regularly only use three. I do believe that it is best to find an exceptional product and perfect your skills in using it rather to try and chop and change too often.

Newer is definitely not always better and in a rush for some of the smaller competitors to get their implant systems out on the market they will have a fair less detailed record of clinical trials and history. There is an old adage that you get what you pay for … if something has only been in existence for 1 year how can they guarantee you that it will last in your mouth for the next twenty years? However fortunately dental implants must meet certain basic criteria before being granted a license to be used clinically in Spain or any other country.

The idea though is that the actual implant should be around for a lifetime but with any system the components bits that are attached on top will need replacing at some stage . In other words the crown or denture or the bits you actually see and use will wear away over time or need replacing. The difficulty then lies in where do you get the replacement bits if the company has gone out of business?
The different systems are very like mobile phone chargers and one screwtype will often be incompatible with another system. So if something fractures or breaks you may be stuck.

Question 8

Why would my mouth be so dry all the time? GB

Dear GB:

The condition of xerostomia is defined as a dry mouth resulting from reduced or absent saliva flow. Xerostomia itself is not a disease, but rather it is a symptom of various conditions and side effects of drugs and treatment. Some of the conditions are relatively common and can be easily resolved. Xerostomia is a common complaint found often among older adults, affecting approximately 20 per cent of the elderly. However, xerostomia does not appear to be related to age itself as much as to the potential for elderly to be taking medications that cause xerostomia as a side effect.

Most people will experience a reduction in salivary flow during periods of anxiety and stress, dehydration and also if they are a chronic mouth breather. In this case breathing through the mouth rather than the nose, e.g in chronic sinusitis, will cause evaporation of moisture from the soft tissues of the mouth and a drying out effect.

Perhaps the most prevalent cause of xerostomia is medication. Xerogenic drugs can be found in 42 drug categories and 56 subcategories. More than 400 commonly used drugs can cause xerostomia. These include antihistamines, antidepressants,and anti-Parkinson agents. Fortunately while there are many drugs that affect the quantity and/or quality of saliva, these effects are generally not permanent. If you are taking medication and you feel you have had an unusually dry mouth since starting it then you should speak to your GP and they may be able to suggest an alternative which you can tolerate better.

Many disease processes also affect the salivary glands in the mouth and the most common of these is Sjögren’s syndrome (SS), a chronic inflammatory autoimmune disease that occurs mainly in postmenopausal women. It is estimated that as many as 3 percent of Americans suffer from Sjögren’s syndrome, with 90 percent of these patients being women of an average age of 50 years. There is no cure for the disease. Once diagnosed the goal of therapy is to manage symptoms. It is possible to stimulate a reduced salivary flow by chewing sugar free gum or several salivary substitutes are also on the market to mimic some of the lubricating effects of saliva. Certain types of oral cancers also manifest symptoms of dry mouth and treatment involving radiotherapy can also worsen the condition. If you have been diagnosed with salivary disease then your doctor and dentist will work together to try and keep you comfortable.

Saliva possesses many important functions including antimicrobial activity, mechanical cleansing action, control of pH, removal of food debris from the oral cavity, lubrication of the oral cavity, remineralization and maintaining the integrity of the oral mucosa. Therefore having an unsually dry mouth for a persistent period of time can cause many problems in the oral cavity. If left untreated, xerostomia decreases the oral pH and significantly increases the development of plaque and decay. Thrush is one of the most common oral infections seen in association with xerostomia. It is estimated that three in ten of every adults will develop gum disease and experience tooth loss as a direct result of xerostomia. So it is extremely important to seek professional help and treatment.

Question 9

I have heard a lot of stories about dentists’ and doctors’ surgeries not being very clean. How can I tell that my dentist is doing a good job cleaning his surgery? EH

Dear EH:

You have every right to be concerned as the risks of cross infection in dentistry are real and cross infection control should be every dental clinic’s priority. Saliva is a potentially infectious fluid and has transmitted Hepatitis B, Herpes and many other infections. The most serious infections in dentistry are transmitted by blood to blood contact through accidental sharps injuries. Dentistry always has the potential to transmit infection from patient to patient, from staff to patient and also for the patient to infect staff and hence Standard Precautions (Formerly Universal Precautions) must always be observed.

The four most common routes of transfer for infectious agents being transferred within the dental environment are:
•Hands
•Eyes
•Aerosols
•Blood to blood contact (sharps injuries)

The chain of cross infection control is easily broken when simple procedures are not observed.

At the Oasis Dental clinic there are many, many things we do “ behind the scenes” so to speak to ensure the highest standard of cross infection control. As measures are continually changing we also update ourselves by going on courses regularly to make sure we are following the strictest measures. As a patient I would advise you to look out for a few things which would give you some idea of how much attention your dentist and the staff are paying to cross infection control

Turn over time: If there is a patient in the chair immediately before you when you arrive does your dentist get the next patient in just a few seconds afterwards?

It takes time to disinfect the surgery effectively between patients. This may mean spraying and wiping down the chair, changing the barriers, setting up new handpieces etc etc On average this can take a couple of minutes. Unless the previous patient was not really having any treatment done a few seconds as a general rule is insufficient time.

Wearing of gloves outside of clinical areas: Do you notice that the dentists and staff are doing non-clinical activities with their gloves on e.g. like typing on the computer, writing notes , opening drawers to take materials out and opening the surgery door?

On the odd occasion it may well be that the gloves have just been placed and before patient contact the clinician remembers he needs to do something like reach into a drawer. However, unfortunately in a busy practice too often clinicians fail to remember that once gloves have come into contact with the patients’ mouth and saliva then they are contaminated and touching that surgery door handle twenty times a day with different dirty gloves on is a major source of cross contamination.
Washing hands and new instruments: do you ever see your dentist or staff washing their hands? Do you ever see the sterilizable instrument packet being opened in front of you… just for treating you?

These are just some of the things to be aware of. Sadly sometimes some clinics do fail to reach the required standard. As a patient however you should never be ashamed to ask your dentist about current cross infection methods being used and your dentist should have no concerns openly discussing them with you.

Question 10

Over time I noticed that I can’t see my teeth as much as before when I smile. Is this because I am getting older? What can I do about it? JA

Dear JA:
Unfortunately as we get older most of us notice that the soft tissues of our faces change. We lose elasticity of the tissue (i.e wrinkles!) and may also have facial muscle changes so our lips do not retract as much; generally with age we tend to show more of our lower teeth than upper teeth.

However these facial changes on their own tend not to significantly affect our smile. Of more importance are hard tissue changes i.e. the teeth themselves. Quite often what happens is that we start to have wear of our teeth. Perhaps you have noticed that your teeth are actually shorter in length or the edges have chipped or are flatter?

It is normal to have a certain amount of tooth wear over time but normality is also relative to age. I note you did not give your age but generally a twenty year old’s teeth in good condition should show a lot less wear than those of a 60 year old adult. This wear is termed physiological i.e. normal for the average age of the patient… it starts to get more of a problem when the teeth wear to such an extent that you get symptoms such as pain or sensitivity because the outer layer of protective enamel is now lost. In addition if there is a significant amount of damage and the patient is say only in their 30’s then there would be concern over whether the teeth would last for the entire lifetime of the patient and this is now termed pathological wear.
It has been estimated that 3% of twenty year olds in the UK have severe tooth wear which requires treatment so this is a relatively common problem which many patients do not perceive until it is quite advanced and hence much more difficult to treat.

I would suggest first of all having a comprehensive examination so the dentist can take a history (e.g how long you have noticed this) and of course see what condition your teeth are currently in.

If this change has been brought about by significant pathological tooth wear then it is often important to intervene not just from an aesthetic point of view but also for long term health and function.

There are many options depending on the complexity of the case and certain investigations might need to be done like study models, diagnostic waxups and possibly imaging so the dentist can be sure of what we are trying to achieve and hence find an appropriate solution. Aside from these dental improvements in this day and age there are many other wonderful techniques you might also want to consider to improving on any facial changes you may be worried about.

Question 11

After trying to book an appointment to have a cleaning I was told that I needed to have a dental examination as well…. It seems like I’m having to pay double. I just wanted the cleaning why should I pay for an examination as well? Is there really a medical need? JS

Dear JS:
Thank you for allowing me to submit your question and my response to this column as of course we had this conversation in great detail in person but I thought it might be of use to other patients that are thinking the same.

As you know here at the Oasis Dental Clinic I have a very strict policy of always conducting an initial comprehensive examination on every new patient before undergoing any treatment : treatment does of course include cleaning and tooth whitening. The only exception to this is the emergency patient in pain or who needs to have a single issue addressed as a one off and then we deal with the issue straight away.
There are many reasons for my policy and I strongly believe that it is of great benefit to the patients.

I do understand people’s concern that is simply a case of “ profiteering” but the initial examination is one of the most important part of any treatment. Let’s be honest, after a while a lot of dentistry can be fairly routine for an experienced dentist but the real value of the training we have undertaken comes in diagnosis and long term planning for good dental health. I believe a thorough examination is my duty to the patients as I need to let you know exactly what your dental situation is in order for you to be able to make an informed decision about what you want to do about it.

Although the dental knowledge of many patients is high you simply cannot see and be aware of what is going on in your own mouth without feedback from a professional. When it comes to your health my job is not to simply just provide the treatment you would like but to educate you as to things you might be unaware of.

Let’s take the example of cleaning. Many people like to do this to improve their smile, remove staining and generally feel “fresher” if for example they are smokers… however periodontal or gum disease is one of those conditions that often does not bother people until symptoms develop later such as loose teeth or very sensitive teeth. If you have moderate to severe periodontal disease this needs to be diagnosed at an early stage and treatment commenced to prevent it progressing. Now you may actually choose NOT to do this but it must be clear that you are really not greatly affecting the disease process and are practically wasting your time and money just getting a general cleaning every 6 months. In order to help you better I need to sit down, take measurements, possibly Xrays and most importantly talk to you about the disease process and what needs to be done and the short and long term consequences of doing nothing. In other words we need to do an examination and have a consultation and come up with an individual plan. If I just do the treatment you ask for without explaining what is best for you so you can choose, then I am doing you a great disservice. Obviously I can’t explain what is best without first examining you! At the end of the day the final decision is always yours, however the number of people I see regularly who are simply unaware of existing problems with their gum condition is rather frightening.

Similarly as sad as it is for me to say I do see a certain number of patients who have had examinations recently or who have a regular dentist but unfortunately , for whatever reason, several things were overlooked and they were not made aware of them. I need to feel comfortable that patients who are entrusting themselves to my care are receiving care that is appropriate and of a certain standard. That starts at the beginning with the thorough examination and treatment planning. There is no point just booking you in for a tooth whitening without first doing the examination to check that the treatment will give you the results you want and not make any underlying problems worse.

I do hope this example and explanation is satisfactory as at the end of the day it always advisable to start as you mean to go on!

Question 12

About 8 years ago my front tooth had a filling but now it is very dark and looks ugly. Can I just have it capped? PA

Dear PA:
A clinical decision about the best way to restore your tooth in the long term can of course only be made after actually examining you and taking a full history.

However I am assuming that you had a tooth colured filling in the past which is not very large and that it is now stained.
In general the composite materials which we use to restore front teeth have a very good appearance and longevity. They do pick up external staining from food , cigarettes etc and can often get darker. Sometimes it is possible to just polish the margins and surface of the filling, sometimes if the staining is deeper then that alone may not be enough to improve the aesthetics.

I would suggest that 8 years is a reasonable length of time for a white filling to have remained of reasonable colour and would in the first instance consider continuing along the same lines i.e a “ touch up” or a new filling.
I like doing bonding and white fillings as they are a conservative treatment option. Often only minimal tooth structure needs to be taken away as the material can be added directly. Depending on your occlusion “ bite” the new materials have superb strength to resist biting forces and as mentioned very good aesthetics.

A “cap” or crown on the other hand is an indirect restoration which is made in the lab and fits over the entire tooth. The advantage of this is there is no “join” between filling and tooth and the material itself, usually porcelain or ceramic of some sort does not take up stain and change colour.

However to create enough space for the crown to fit over the existing tooth then this tooth must be prepared i.e cut down to size. The process is far more destructive and in a tooth which has been already compromised e.g had trauma causing the damage in the first place, it can “ tip the balance” and the tooth may require root canal treatment additionally. Like the filling , no crown will last forever and while you may get a good reasonable appearance for 10-15 years at some point in your lifetime it will need to be changed resulting in more possible damage to the underlying tooth structure. As with everything the beneifts must always be weighed against long term costs.

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