A New Smile for Linda

Linda wanted a sparkling, white smile. She had old fillings that had turned brown and yellow with decay at the margins. Some of her teeth had broken, others were infected. Her teeth were worn from years of use.  A combination of modern dental techniques gave her the smile she had dreamed about! She looks fabulous and feels great.

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Sharon wasn’t happy with her smile. Her teeth seemed too small; her gums seemed too large. She wanted a makeover. She thought crowns would do the trick. We took some photos and talked about her smile.  As we spoke, she began to see that her gums were the problem – not her teeth.  Her overlarge gums covered her teeth such that the teeth appeared small.  She needed some periodontal work – what we call a “crown lengthening procedure” to scallop the bone and gums above the natural teeth.  I referred her to a periodontist who specializes in recontouring bone and supporting tissues. The work took one visit. The gums then took a couple of weeks to heal. The results were spectacular!  Sharon looks fabulous – her old teeth like new!

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See how her gums cover her teeth.

The lateral incisors look too small and she has what we call a “gummy” look.

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Now look what a beautiful smile she has!  The teeth are the same but the excess gum tissue was removed.

Sometimes a simple procedure can make a huge difference.

It’s all about proper diagnosis and treatment planning.

Here is a Question: Is it better to floss before or after brushing your teeth?

I had a hard time finding any studies that addressed this question.  But flossing first doesn’t seem to necessarily be better for your oral health than flossing after brushing. Neverhelesss dentists still weigh in on this matter.

One spokesman of the American Dental Association, Dr. Edmond R. Hewlett, recommends flossing first. His reasoning is that flossing is unpleasant so do it first to avoid the temptation to skip it.  This seemed a very unscientific rational to me – plus people who really do floss regularly don’t find it unpleasant. Diehard flossers (I confess that I am one also) love cleaning out plaque in between their teeth and don’t feel clean unless they do so.

In contrast, Dr. Philippe Hujoel, a professor of oral health sciences at the University of Washington in Seattle, recommends brushing with a fluoride toothpaste, then flossing. That way the floss will maneuver the fluoride in between the teeth.

Flossing reduces gum inflammation, or gingivitis, which can progress to periodontal disease and loss of teeth.  It is not clear what effect flossing has on dental decay. Technique is crucial for flossing to reduce plaque. You need to guide the floss along the curve of the gum line at the base of each tooth as well as flossing up and down each tooth.

Karen and Meg are sisters. They started out with almost identical teeth.  But Meg smoked a pack of cigarettes a day for over 20 years. Karen never smoked. Guess which teeth below belong to Meg and which teeth belong to Karen? You guessed it – Meg’s teeth are at the top; Karen’s below.  Smoking is connected to periodontal (gum) disease. The bone resorbs, leaving a long tooth.  Without support of bone, the teeth loosen and move out of position. In Meg’s case, the front teeth became more crowded and became very protrusive. The teeth were so loose that she knew that it was only a matter of time before they would fall out , and she had already lost a couple of back teeth.  By the time she came to our dental office the gum disease was so advanced and the teeth so out of position that dentures were the best option for her.  She was very unhappy about the condition of her teeth, and she was excited at the prospect of having new teeth that would make her look more like her younger self. We will fashion our custom immediate denture for her.  Photos to follow!

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It always strikes me that people never seem to be as concerned about losing a back tooth as they are about losing a front tooth. But back teeth also count!!  You need your back teeth so you can chew properly. Back teeth also protect the front teeth, and they help to maintain your facial structure. If even one back tooth is missing, the adjacent teeth will drift to close the space; they may loosen and a pocket of infection may form. The opposing teeth may erupt into the open space. Your bite will start to collapse. The front teeth will begin to splay forward.

The following patient was missing all of her back teeth. She was putting a lot of stress on her front teeth because she didn’t have back teeth for chewing. The front teeth were beginning to splay forward. She elected to have implants placed. We placed four implants on the top and two on the bottom and gave her new front crowns – a great result and a very happy patient:

Posterior Implants Picture

 

The following patient lost her lower back teeth, and consequently the top teeth have super-erupted into the space. This weakens the top teeth and they become susceptible to loss. We did some periodontal crown lengthening and placed five crowns on the top teeth in order to restore them to their proper position. Four implants were also placed on the bottom and will soon be uncovered so implant crowns can be placed:

Posterior Implants before and after picture

I know I talk a lot about the hazards of smoking in this blog, but that is because everyday I see how cigarette smoking contributes to gum disease and loss of teeth.  Now the latest surgeon general’s report reveals that smokers today face a higher risk of chronic obstructive pulmonary disease and lung cancer than smokers in the 1960’s. This is because the design and composition of cigarettes has been changed. Even though people on average smoke fewer cigarettes, the risk of disease is higher.  Some of the cigarettes today are more addictive than those smoked in the past.  This is because the manufacturers have designed the cigarettes so the cigarettes deliver more nicotine – thus the addiction is induced and sustained.  This re-design of cigarettes is a sneaky tactic on the part of the cigarette manufacturers.   It is a practice that demands government regulation.

The journal Nicotine and Tobacco Research published an article last week with the findings that although nicotine content of cigarettes has been more or less stable for the past 10 years, the amount of that nicotine delivered to research machines as surrogates for smokers has been rising.  The researcher concluded that changes in cigarette design have increased the efficiency of nicotine delivery to a smoker’s lungs.  The effect is that people may become addicted more easily and people already smoking may find it more difficult to stop the habit.  Techniques that cigarette manufacturers use include filter design and cigarette paper that maximizes the inhalation of nicotine.  The manufacturers also add chemicals to change the taste of cigarettes so it is not as harsh and make it easier to deeply inhale.  The surgeon general’s report concludes that nicotine increases the risk for disease and affects health of the fetus.  Although the report doesn’t address dental health, just look through my blog to see how cigarette smoking destroys teeth.

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Smoker’s Teeth

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James had orthodontic treatment as a child in order to correct his protruding teeth. He is now in college and wears a bonded retainer fixed to the inside of his lower teeth.  This is a fixed wire attached with composite bonding.  It is a common way for orthodontists to fix the teeth in position without the patient having to wear a removable retainer.  The problem is: when does the retainer get removed, if ever?  The patient has long since stopped seeing the orthodontist for checkup appointments.  The retainer may not be serving its purpose; the teeth may be stabilized.

 

I recommend that the patient return to the orthodontist to have the retainer checked and to see if it is still needed or if it can be replaced with a removable retainer.  I am unhappy when a patient has been wearing a retainer for years without supervision.  The patient often has difficulty cleaning the teeth under and around the fixed wire.  The retainer is a plaque and calculus collector.  This leads to decay and gum disease – much more serious than crooked teeth.

 

I performed periodontal scaling for James in order to remove the hardened calculus deposits.  Because of the plaque accumulation which harbors bacteria, he has gingivitis, or inflammation of the gum tissue around the teeth.  The gingivitis will subside now that the teeth are clean, provided that he can keep them clean. I showed him how to use a floss threader to clean in between the teeth and also gave him a Go-Between brush by GUM Industries – a new brush that is excellent for cleaning between the teeth, when space allows. We will see James again in three months, to see how he is doing, keeping those teeth clean!

 

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Look at the calculus around this retainer. The patient thought this was part of his teeth.

 

 

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Look how we removed the calculus.  Now you can see his teeth.

Check out the all ceramic e.Max crowns and bridges that I cemented last week for Dorine (photos below).  Dorine has long-standing periodontal issues  and her teeth were drifting apart. One of her front teeth had moved forward and a space had opened up between the two front teeth.  She hated her teeth and avoided smiling for photographs.  She was missing her left canine tooth and had an old bridge that connected three teeth.  She also had individual veneers on the right front teeth.

We placed temporary crowns and Dorine had periodontal treatment to improve the health of her gums and bone.  After healing took place, we took impressions and placed the new crowns and bridge. We used e.max for superior esthetics. A very dramatic improvement.  She looks great and is ready for the holidays!

For more on crowns and bridges that we have placed in our East Setauket dental office, look at our crown and bridge page.

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After

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Good discussion of how to close the gap in today’s New York Times: http://well.blogs.nytimes.com/2013/09/12/ask-well-gap-toothed-2/?smid=tw-share

Last spring a young woman came to our East Setauket office for dental care and – as I always do – I asked about her smoking history.  Smoking is strongly correlated with gum disease, loss of teeth, and oral cancer – so smoking history is a question I always ask.  She answered that she smoked electronic cigarettes.  The electronic cigarette?  What was that? I had never heard of it!

After that incident I read up on the device.  Electronic cigarettes satisfy the nicotine addiction but without inhaling the toxic chemicals that are found in tobacco smoke.  The e-cigarette turns liquid nicotine into a vapor which is inhaled by the individual.  The liquid comes in many flavors, such as mint or bubble gum, pina colada or peach.  But unlike skin patches and nicotine gum, these e-cigarettes have not been evaluated for effectiveness or for safety.  Nevertheless sales of e-cigarettes have been on the increase in the U.S. and in Europe.  European Union regulators are planning to regulate the device with greater vigor, starting in 2016.

E-cigarettes might be safer than inhaling tobacco smoke – a known carcinogen.  But there are still risks.  Nicotine is addictive and there are quality control problems at e-cigarette manufacturers.   There is also the concern among health officials that youngsters may begin with e-cigarettes and then progress to regular cigarettes.  The FDA needs to step up its regulation of e-cigarettes by considering a ban on flavorings that appeal to youngsters and a ban on sales and marketing to minors.   The electronic cigarette manufacturer, Lorillard Technologies, placed an ad in Sports Illustrated with a warning that “these are not a smoking cessation product and have not been evaluated by the Food and Drug Administration, nor are they intended to treat, prevent or cure any disease or condition.”  Another ad stated “WARNING: This product can cause mouth cancer.”

We need studies on the correlation of e-cigarettes and gum disease.  Let’s not replace one unhealthy habit with another.