Big Red Tooth – Dr Candice Schwartz

Where teeth and health meet

What is a nesbit denture?

A nesbit denture is used to replace a lost single tooth, on one side of the mouth. Often teeth which have had a root canal treatment many years prior, present to me with a recurrent abscess. The treatment options are limited and depend of the size of the abscess and the extent of damage. If patients live with type of condition for a long time is becomes chronic (occurs over a long period of time) and they do not notice the pain. This is coupled with resultant bone loss around the tooth root. In these cases tooth extraction is needed. Sometimes patients want to hold on to their teeth and it may be viable to refer to patient to a specialist to have an apicectomy procedure. This may prolong the lifespan of the tooth, however the abscess generally will recur a few years down the line and the tooth will need to be extracted.

When a single tooth has been extracted there are a few different options for replacing it. A dental bridge, a dental implant or a removable partial denture may be used. These patients may not be ready for implant placement if a large amount of bone loss occurred, or they may not want an implant. The solution to replacing a tooth temporarily or a removable long term option is a nesbit denture. Traditionally these appliances contained metal clasps. However the nesbit denture is constructed completely out of an acrylic vinyl material. It is light and if made properly has good retention capabilities. These are now commonly used as interim replacements while patients are waiting for implant restoration.  They do require a natural tooth posterior and anterior to the edentulous space and are not appropriate for “free end saddle” situations (patient has no posterior tooth to support the partial denture).

 

The procedure for making a nesbit denture is very simple and requires some dental impressions which are then sent to the laboratory. After a week or two most patients are comfortable and used to wearing their nesbit denture. The nesbit denture is a cost effective, quick solution to tooth replacement.

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Dental fear

The large majority of my patients (particularly new patients who I am seeing for the first time) arrive stricken with fear for the dentist. It seems that this fear stems from negative childhood experiences. However there is a stigma attached to dentists, that we are sadists, massachists of the oral cavity, gloved and masked demons waiting to cause pain and terror. It is in reality quite the opposite. Each and every dentist has their own methods and means of creating a happy patient experience and reducing the pain associated with dental treatment. I have a few tricks up my sleeve when it comes to painless injection techniques, patient calming strategies and a generally happy & peaceful environment in my surgery. With time, I hope, more and more people will enjoy their dental experiences as technology moves forward and the standard of dentistry increases. But until then, we, as dentists, try to shake off the stigma and change perceptions of fearing the dentist, one patient at a time.

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What is the best toothpaste to use?

I usually stick to one brand of toothpaste that I recommend to all my patients. The best toothpaste on the market, in my opinion, is Elgydium Anti Plaque. Elgydium has a unique combination of ingredients that actually prevents plaque from adhering to the tooth surface. Chlorhexidine is the active ingredient in this toothpaste which is responsible for the inhibition of harmful bacteria that causes tooth decay and harms gums. When you use Elgydium Anti Plaque you will notice your teeth are smoother (fur-free!) for much longer.

If your teeth are free of plaque, they are less likely to decay. The presence of plaque is what results in dental decay. So Elgydium may be slightly more expensive, but in the long run it will certainly cost you less in dental bills. In addition, only a very small amount of toothpaste is required for it to be effective. You only need a “pea size” blob of toothpaste on your toothbrush for it to be effective.

Elgydium also makes a ‘sensitive’ toothpaste. This is a very good alternative when you suffer with tooth sensitivity. I usually recommend you use Elgydium Anti Plaque in the morning and Elgydium Sensitive at night.

If you use this toothpaste, a mouthwash is usually not needed (unless otherwise prescribed by your dentist if you are for example in the process of having periodontal treatment). Other brands of mouthwashes may give you that fresh breath feeling, however this is a false sense of freshness that is achieved by the evaporation of alcohol in the ingredients. The mechanical removal of plaque during flossing and brushing combined with the anti plaque effects of Elgydium will ensure a clean mouth and healthy gums.

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Full mouth rehabilitation – Case report

Before
This patient came to see me and wanted a brighter, whiter smile. When he smiled, he did not like the colour of his teeth, especially the contrast in color between his natural teeth and the crowns. He had no pain. His concern was only esthetic.

Diagnosis:

The upper and lower anterior natural teeth have intrinsic staining. Intrinsic staining occurs naturally with age. It is unlikely that tooth whitening will make any substantial improvement on the shade of these teeth. There is also a colour discrepancy between the natural teeth and the adjacent dental crowns. The crowns also have a very opaque “dead” look to them in comparison to the natural teeth. The posterior teeth (molars and premolars) have mild to moderate gingival recession. This shows a distinct line where the natural tooth meets the tooth margin. This is very unsightly and also leads to sensitivity. On radiographic examination secondary decay was visible at the margins of some of the existing crowns.

Treatment plan:

Replacement of all existing crowns and crowning of the remaining natural dentition was the only way a uniform colour and brilliant dentition could be achieved. I discussed with the patient that the anterior teeth were “virgin teeth” (never been drilled/filled) and a large proportion of tooth structure would be sacrificed in the crown preparation process. However he was adamant that he wanted a “bright white smile”. For this reason I chose to place Emax(all-ceramic) full coverage crowns on the upper and lower 6 anterior teeth and porcelain fused to metal crowns on the posterior dentition. I choose the porcelain fused to metal crown as it is stronger and I believe the marginal seal between the crown and tooth is superior to all ceramic crowns in the posterior teeth. This reduces the risk of secondary decay and fracture under high occlusal stresses.

The chair time for this type of treatment is very long, for the dentist and the patient. Frequent breaks between drilling are essential and a sense a humour is always a great advantage!

The results are beautiful and the patient is very pleased.On the right side of the mouth there is still staining visible on the last upper and lower molar teeth. I did not place crowns on these teeth as they are not visible at all when the patient talks/smiles and they were completely healthy teeth. A bite plate was made and i recommend it is worn every night. Because almost every tooth in the mouth is crowned, these precious pearls need to be protected and a bite plate will prevent any porcelain fracture during tooth grinding at night. The shade of the teeth is A2. I felt that the shade A1 would be too light for this patient. I always try and persuade my patients to choose the most natural looking shade instead of unrealistic whiter colours.

I am very happy with this result and enjoyed every step of the treatment process. (:

After

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Types of treatment for a dental abscess

What is a tooth abscess? A dental abscess is a collection of pus that can form in the teeth or in the gums as a result of a bacterial infection. But what exactly is pus? If an infection forms in a part of your body, the battle between your immune system and the infection will create a collection of dead cells, which form pus. An abscess is your body’s natural way of keeping the pus in one place, therefore localizing the infection and stopping it from spreading to other areas of the body.

There are two different types of abscess which may occur in relation to the teeth, namely a periapical abscess and a periodontal abscess.

Periapical abscess: This can present as a very acute, intensely painful infection where the face swells and the patient is in agony and sometimes cannot even open the mouth. This is caused from a rapid influx of pus to the area accompanied with the swelling and inflammation of the surrounding tissues. The site of a periapical abscess is at the apex of a tooth root (this is where the nerve enters the tooth). The soft area at the centre of a tooth (the pulp chamber) is alive and filled with blood vessels and cells, so once infection reaches the tooth pulp it “goes rotten”and ultimately leads to abscess formation. Bacteria enters the pulp of the tooth through a communication between the mouth and the pulp chamber, namely a cavity. This allow bacteria to move into this sensitive area and populate it, leading to infection. A periapical abscess can also occur on a previously root treated tooth. Root canal treatment is unpredictable and a weak area of the tooth. Secondary infection after a root canal treatment is completed is quite common.

The treatment of a periapical abscess in a vital (alive) tooth is root canal therapy. During this procedure your dentist will clean out and remove all of the infected debris and fill it with an inert substance (gutta percha). The treatment of a periapical abscess in a root treated tooth is a little more extreme. Once an infection recurs, the options are increasingly limited. Re-root treatment of the tooth may be attempted (I would recommend only by an endodontist) however this is rarely successful long term. The second option (in some teeth) is a minor surgical procedure called an apicectomy, where the tips of the infected roots are removed and filled by a maxillo facial surgeon. This may prolong the lifespan of the tooth, but infection will likely set in again a few years down the line. My recommended treatment for a periapical abscess on a root treated tooth is extraction of the affected tooth, followed by implant placement.

Periodontal abscess: This is quite different from the previously mentioned periapical abscess. The source of this infection lies within the gingiva (gums). When oral hygiene is poor, a small space develops between the tooth and the gum. This is an ideal space for bacteria to breed and grow in. If oral hygiene is not improved this rapidly develops into a periodontal pocket. If bacteria in the pocket increases and debris and food becomes trapped in the pocket, an abscess will developed. Unfortunately a periodontal abscess is accompanied with underlying bone loss, so the damage becomes permanent. Treatment depends on the extent of the damage. If not too severe and if caught in the early stages, your dentist can debride and clean the area leading to healing. However in more complicated cases a periodontist may be needed to surgically debride and clean the infected area. All patients who have had periodontal problems should be placed on a long term maintenance program to prevent recurrence and maintain the health of their mouths.

Perio-endo lesions: This occurs when a periapical abscess and a periodontal abcess occur in conjunction. Sometimes it is difficult to definitively say which type of abcess occurred first. The treatment consists of root canal therapy combined with periodontal treatment at a periodontist, albeit the prognosis is generally poor and the tooth may not be salvageable.

The use of antibiotics in the treatment of an abscess is common practice. The reason for this is that the pus accumulation in the infected site makes the environment very acidic. The efficacy of the local anesthetics within this acidity is greatly reduced, therefore it is difficult for the dentist to make you numb. In these cases an antibiotic is prescribed first and then the root canal treatment/extraction can be completed far easier after a few days of taking the antibiotic.

A dental abscess is usually a dental emergency and requires immediate attention from a dentist. All the pain killers in the world cannot take away this type of pain. The best cure is prevention (apologies for the cliche!). My advice is regular, 6 monthly dental check ups to prevent these types of painful experiences.

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Case report

 

 

 

 

 

 

 

Before

 

 

 

This patient came in for treatment to restore the esthetic appeal of his smile. He felt his teeth were not visible enough and they had been neglected over the years. He wanted to be able to smile confidently again.

Dentist talk: The staining and severe wear you are seeing on this dentition is not caused from dental decay. The severe tooth wear is caused by attrition, abrasion and erosion. Abrasion is the loss of tooth structure by mechanical forces from a foreign element, namely a toothbrush. When your toothbrush is too hard and you use it too aggressively, it leads to gingival (gum) recession. Gingival recession exposes the root surface of the tooth, which is a lot softer than the tooth crown because it does not have a hard enamel covering. As you continue to brush in an abrasive manner, tooth structure is destroyed at the gumline. Attrition is the loss of tooth structure by mechanical forces from opposing teeth. Tooth grinding is directly related to stress levels. With the ever increasing stresses of daily life, jaw clenching and tooth grinding have become a common problem. The immediate problem is the vertical loss of tooth height as grinding continues. The flat occlusal plane (biting surface) seen in the above pictures is an excellent example of the results of years of tooth grinding when it goes untreated. Erosion is caused by excessive consumption of acidic foods and drinks ‘dissolving’ away the surface of the tooth, like fruit juice, coca cola and dried fruit. This is more commonly seen on the palatal surface of the teeth, however this patients’ diet did consist of a lot of acidic foods and it did contribute to the overall tooth wear.

Besides the obvious esthetic problem, the bigger dental issue is the loss of vertical tooth height. Due to the excessive grinding habit, the teeth are much shorter than they were originally. This leads to the bite becoming “closed”. As the vertical height gets shorter, the face will begin to collapse which ages the patient tremendously and adversely affects chewing functions and parafunction. In order to treat the problem, the vertical height needs to be restored to its original height. Therefore the “bite needs to be opened”. Opening the bite requires increasing the height of every tooth in the mouth with full crown coverage of the entire dentition. Because the patient is a chronic bruxer (grinder), porcelain fused to metal crowns are used as these are stronger. Dental implants will be placed into the areas where there are missing molar teeth.

After

 

 

 

 

 

 

 

 

 

 

 

 

 

There is one more lower mandibular tooth that requires a crown. This will be completed once the implants have been placed and all the molar teeth will be restored at one time. You will notice that this patient only has teeth up to his premolar teeth. This is in fact adequate for chewing and gives sufficient chewing surfaces for normal function. The molar teeth implants will complete the dentition for the perfect result. A bite plate was also made for the patient to wear at night to prevent porcelain fracture and ease the grinding habit. After opening the bite 3mm, the patient was extremely happy with the increased length of teeth that are now far more visible during speech, smiling and function. I was also very pleased with the good result.

With attention to fine detail and careful planning this type of case is very exciting to treat and so rewarding when patients’ lives are changed by their new smiles (:

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And dont forget to floss…..

Have a great weekend ! (:

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Tooth Sensitivity…..

Tooth Sensitivity is a common problem I am faced with on a daily basis. Patients come in and complain of varying degrees of sensitivity and seek help and solutions. The treatment of tooth sensitivity is a tricky one. The most common cause of tooth sensitivity is gingival recesion resulting from aggressive brushing techniques. The susceptibility of the gums to recession increases with age. As the gum recedes upwards, the root surface of the tooth becomes exposed. The crown of the tooth is covered by a protective layer of enamel. The root however does not have this enamel covering and is thus far more sensitive (particularly to changes in temperature).

All the television adverts for sensitive toothpastes claim to cure patients instantly and miraculously of their painful sensitive teeth. It would truly be a miracle if these toothpastes worked so well! However the fact is, they dont. The other ugly truth is that once the gum has receded it will never move back down into its original position- the damage is therefore permanent.This means its time to trade in your frayed and aged brush, for a soft gentle brush which will not cause further damage to your gums. If you are battling to find a really soft toothbrush, just buy something from the kiddies range!

There is only one product (which is not available from retail stores but only through dentists) that I feel truly treats and improves tooth sensitivity. It is not the purpose of this blog to market any specific products, so I will not mention the name, however if you email me I will gladly provide you with the name of the product.

The “sensitive brand’ toothpastes on the market do, in theory provide some relief, but it is minimal in my experience. Most of the time, patients just learn to live with the fact that they have sensitive teeth. They steer clear of ice cold drinks or ice creams and just take a lot more care in choosing the colder foods. Some people are so sensitive (like myself) that they cannot even bite into a piece of fruit that has been inside the fridge.

The most important thing is to not let the gum recession get any worse. Your dentist will provide you with specific oral hygiene instructions to ensure this. The good news is, with time, the longer the root is exposed to the oral environment the less sensitive it becomes. As you get older the sensitivity will ultimately decrease, however this may take years.

In closing, brush gently to prevent tooth sensitivity. Prevention is better than cure- especially when there isnt one!

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HealOzone Revealed! Say goodbye to cavities and goodbye to painful dental visits

HealOzone is the best news for any patient who does not like visiting the dentist. Oxygen kills the decay causing bacteria that cause dental caries. These bacteria (known as anaerobic bacteria) thrive in an environment where there is little or no oxygen. Cavities develop as the environment below the surface of the tooth becomes acidic. Ozone not only kills the acid-making bacteria, it also neutralizes their acidic waste. Many municipal drinking water systems kill bacteria in the water using ozone. Also ozone is at least ten times stronger than chlorine as a disinfectant. The medical community — especially in Europe — have been using ozone for decades to speed up wound-healing and to treat a variety of diseases.

The new environment that occurs following the bio-chemical change (from acidic to alkaline) in the lesion allows minerals to flow back into the tooth, hardening and reversing the effects of decay. Early cavities can heal. The minerals to assist this repair can come slowly from the saliva or much quicker from mineral-rich solutions soaked into the teeth following the ozone treatment. Research seems to indicate that once a tooth is remineralized, it is very unlikely the decay will come back. Multiple ozone treatments over a period of months can improve chances even better.

Ozone is used to treat early tooth decay before it turns into a big hole. Once the affected tooth surface has been treated with the ozone, a composite filling can be placed straight away, directly onto the treated tooth surface. NO injections. No drilling. NO PAIN.

Ozone therapy is an amazing tool for treating small areas of decay, however when cavities have become much larger, ozone treatment alone will not suffice as the only treatment. However, after the decay on these larger cavities has been removed, ozone may be used to sterilize the tooth surface. This will allow for remineralization of the tooth surface beneath the restoration and will reduce the occurrence of secondary decay beneath restorations.

Ozone may also be used to treat oral ulcers, cold sores and gum disease. When applied to the affected tissues, after just one treatment symptoms will reduce significantly and healing will progress at a much faster rate. After a second and third ozone treatment, healing will often be complete.

Dental ozone is right here, right now, and poised to make us look at traditional dentistry with a new set of eyes!

More info : http://www.quintpub.com/display_detail.php3?psku=B8830

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Tooth decay and your diet

This post looks at how to reduce tooth decay through your diet.Teeth are constantly changing. The tooth consists of different layers. The innermost core of the tooth (called the dental pulp) contains a mass of nerves and cells. These cells have a regenerative function. So teeth are able to heal themselves. This is why some cultures like the African Wakamba tribe can file their front teeth into sharp points without causing damage. The process of regeneration is slow (like the process of tooth decay). Fortunately, a decaying or broken tooth has the ability to heal itself. Pulp contains cells called odontoblasts, which form new dentin if the diet is good. Below is a copy of what Dr. Edward Mellanby commented about his wife’s research on the subject. This is taken from Nutrition and Disease:

Since the days of John Hunter it has been known that when the enamel and dentine are injured by attrition or caries, teeth do not remain passive but respond to the injury by producing a reaction of the odontoblasts in the dental pulp in an area generally corresponding to the damaged tissue and resulting in a laying down of what is known as secondary dentine. In 1922 M. Mellanby proceeded to investigate this phenomenon under varying nutritional conditions and found that she could control the secondary dentine laid down in the teeth of animals as a reaction to attrition both in quality and quantity, independently of the original structure of the tooth. Thus, when a diet of high calci­fying qualities, ie., one rich in vitamin D, calcium and phosphorus was given to the dogs during the period of attrition, the new secondary dentine laid down was abundant and well formed whether the original structure of the teeth was good or bad. On the other hand, a diet rich in cereals and poor in vitamin D resulted in the production of secondary dentine either small in amount or poorly calcified, and this happened even if the primary dentine was well formed.

Drs. Mellanby set out to see if they could use their dietary principles to cure tooth decay that was already established in humans. They divided 62 children with cavities into three different diet groups for 6 months. Group 1 ate their normal diet plus oatmeal (rich in phytic acid). Group 2 ate their normal diet plus vitamin D. Group 3 ate a grain-free diet and took vitamin D.

In group 1, oatmeal prevented healing and encouraged new cavities, presumably due to its ability to prevent mineral absorption. In group 2, simply adding vitamin D to the diet caused most cavities to heal and fewer to form. The most striking effect was in group 3, the group eating a grain-free diet plus vitamin D, in which nearly all cavities healed and very few new cavities developed. Grains are the main source of phytic acid in the modern diet, although we can’t rule out the possibility that grains were promoting tooth decay through another mechanism as well.

Dr. Mellanby was quick to point out that diet 3 contained some carbohydrate (~45% reduction) and was not low in sugar: “Although [diet 3] contained no bread, porridge or other cereals, it included a moderate amount of carbohydrates, for plenty of milk, jam, sugar, potatoes and vegetables were eaten by this group of children.” This study was published in the British Medical Journal (1) and the British Dental journal. Here’s Dr. Edward Mellanby again:

The hardening of carious areas that takes place in the teeth of children fed on diets of high calcifying value indicates the arrest of the active process and may result in “healing” of the infected area. As might be surmised, this phenomenon is accompanied by a laying down of a thick barrier of well-formed secondary denture… Summing up these results it will be clear that the clinical deductions made on the basis of the animal experiments have been justified, and that it is now known how to diminish the spread of caries and even to stop the active carious process in many affected teeth.

Dr. Weston Price also had success curing tooth decay using a similar diet. He fed underprivileged children one very nutritious meal a day and monitored their dental health. From Nutrition and Physical Degeneration (p. 290):

About four ounces of tomato juice or orange juice and a teaspoonful of a mixture of equal parts of a very high vitamin natural cod liver oil and an especially high vitamin butter was given at the beginning of the meal. They then received a bowl containing approximately a pint of a very rich vegetable and meat stew, made largely from bone marrow and fine cuts of tender meat: the meat was usually broiled separately to retain its juice and then chopped very fine and added to the bone marrow meat soup which always contained finely chopped vegetables and plenty of very yellow carrots; for the next course they had cooked fruit, with very little sweetening, and rolls made from freshly ground whole wheat, which were spread with the high-vitamin butter. The wheat for the rolls was ground fresh every day in a motor driven coffee mill. Each child was also given two glasses of fresh whole milk. The menu was varied from day to day by substituting for the meat stew, fish chowder or organs of animals.

Dr. Price provides before and after X-rays showing re-calcification of cavity-ridden teeth on this program. His intervention was not exactly the same as Drs. Mellanby, but it was similar in many ways. Both diets were high in minerals, rich in fat-soluble vitamins (including D), and low in phytic acid.

Price’s diet was not grain-free, but used rolls made from freshly ground whole wheat. Freshly ground whole wheat has a high phytase (the enzyme that degrades phytic acid) activity, thus in conjunction with the long yeast rises common in Price’s time, it would have broken down nearly all of its own phytic acid. This would have made it a source of minerals rather than a sink for them. He also used high-vitamin pastured butter in conjunction with cod liver oil. We now know that the vitamin K2 in pastured butter is important for bone and tooth development and maintenance. This was something that Dr. Mellanby did not understand at the time, but modern science has corroborated Price’s finding that K2 is synergistic with vitamin D in promoting skeletal and dental health.

In these early studies, it is clearly evident that diet is a huge contributing factor to tooth decay. This fact seems to have fallen to the back of most dentists’ minds and their patients. It is important to remember that tooth decay needs a substrate of carbohydrate to occur. Without this, the decay process cannot take place. It is almost impossible to eliminate this carbohydrate substrate from our diet entirely and from our mouths, however when it is reduced, the impact is exponential and the decay process is halted in its tracks.

More emphasis needs to be placed on diet. A combination of a caries-preventing diet and good oral hygiene practices will inevitably result in a reduction and elimination of decay.

Some elements to bring into your new and improved “decay reducing” diet I have recommended below:

  • Bread and refined grain products (like cereals) should be limited/avoided.
  • Limited nuts; beans in moderation, only if they’re soaked overnight or longer in warm water (due to the phytic acid).
  • Increase your intakes of GREEN, leafy vegetables
  • A limited quantity of fruit and especially fruit juice
  • At least two portions of cooked/raw vegetables daily
  • Vitamin D3 supplements (this also boosts the immune function)
  • Eliminate all processed and “fast” foods from the diet.
  • Constant sipping of water throughout the day.
  • Eliminate all fizzy cool drinks and “sticky sweets” (like toffees and fizzers)
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