Literature | Larry R. Goldstein, D.D.S., P.C.
Despite the great improvements over the last few years in the areas of adhesive dentistry (bonding) and implants, a few other milestones were reached long before these achievements. It is interesting to review these accomplishments in order to bring current dentistry into perspective.
The first 10 years of the 20th century saw local anesthesia widely replace general anesthesia in dental offices. In 1884, medicine began using cocaine and it followed into the dental profession. The shortcomings (addiction and tissue sloughing) were realized early on and the development of Novocaine in 1904 by the German chemist Alfred Einhorn, revolutionized dentistry. Over time as allergies manifested themselves to Novocaine's use, basic chemical changes were made to develop Lidocaine, resulting in far lower rates of adverse reactions.
Most dentists had X-ray machines in their offices by the 1920’s. After World War II, the panoramic X-ray machine was introduced to allow both entire jaws to be viewed on one film. Since the early times, improvements in X-ray technology allow faster film speed and localized beams to reduce the radiation exposure to patients and staff. Most people over 30 years old remember the short pointed X-ray machine cone tips which have developed into the long columns of refined beams of shorter exposure times. The current technology has developed digital X-rays, which are viewed immediately on computer screens with up to 90% less radiation. As their clarity improves and costs decrease, this will be the standard of all dental offices.
The preventive effect of the fluorine ion against decay was recognized as early as 1874 in Germany where studies on dogs revealed a change in their enamel. In Colorado in 1904, a dentist observed brown mottling, or “Colorado stain”, on people of certain areas and attributed it to something in the drinking water. The cause was not defined as fluoride until 1918, but the lower incidence of decay was noted at this time. Through various follow-up studies, he suggested in 1925 that this water that caused the mottled enamel also inhibited decay. Large scale controlled studies proved this claim true using the towns of Grand Rapids & Muskegon, Michigan and Newburgh & Kingston, NY in the 1940’s. Fluoridation of public water has since been adopted in many cities in the US and abroad, and by the 1980’s 100 million people drank it in their tap water. Decay is reduced by 65 % for these areas, but some groups feel the potential toxicity and lack of choice are a danger, and subsequently protest fluoride in public water despite the proven safety and benefits. As more and more people choose to drink bottled water in areas of public fluoridated water supplies and decide not to supplement their children with Fluoride drops, a new set of data is emerging showing the benefits and cost effectiveness of fluoride in drinking water.
These advances in the dental profession were as profound to their time as the new developments are today. As in any field, the future has tremendous potential: the cavity vaccine has been under development for over 25 years and the genetic engineering is diving into the world of cloning enamel for dental use. The dental office of tomorrow will be a vastly improved health care center for all.
The field of dentistry has been fortunate to experience a vast amount of dramatic changes. Modern procedures that are able to be performed are wonderful. It used to be that changing an unattractive smile was a major undertaking, often taking years to accomplish. Today, these changes can be accomplished in days. No longer do we have to live with an unattractive smile because the process required was too much to endure, and the results were often obvious unnatural replacements. Today, to paraphrase an old hair color commercial, "only your dentist knows for sure". The smile is the gateway to our personality and is usually the key to a good first impression.
One of the he most revolutionizing developments in dentistry is the ability to bond to existing tooth structure. This allows restorations to be placed without the dentist having to grind down most of the tooth to have the restoration stay in place. Today, aesthetic restorations can be created with minimal preparation. Although dentistry has been able to bond to the enamel (the outer portion of the tooth) for years, it wasn’t until relatively recently that predictable and confident bonding of the inner layer of tooth, the dentin, was perfected.
The other revolutionizing changes in dentistry have been in the area of materials. Porcelains, ceramics, and resins have been developed that can eliminate the need for any metals in the mouth. The improved physical properties of these materials mean that aesthetic restorations can be placed that not only are superior to conventional restorations, but look like natural tooth structure. They are, however, much more technique sensitive and proper protocol must be followed in order to insure success.
Porcelain Veneers (The “Smile Lift”)
Porcelain veneers are thin shells of porcelain bonded to the existing teeth. Like false fingernails, although much more durable and lasting, they cover the front of the teeth and are able to whiten the teeth, fill gaps, change shape, eliminate crooked teeth, lengthen short teeth, and dramatically improve unattractive smiles. This very conservative treatment ( since little tooth reduction is usually necessary) is very aesthetic as no metal is used; therefore, the translucent appearance of teeth is maintained. The dark gumline appearance seen with so many of the conventional crowns is also eliminated because the natural light is allowed to enter the tooth and reflect down the root surface as there is no metal to block this from occurring.
This procedure involves a minimum of two appointments, the first being the preparation and impression appointment. Depending on the correction necessary, a thin amount of the surface of the teeth is removed so that when the porcelain is placed, the tooth will not be any thicker than the original teeth. For the proper “smile lift”, 8 to 10 teeth are often included. A common mistake is to only include the front 4 or 6 teeth, leaving the smile incomplete and therefore, phony looking. The color and shapes of the teeth are determined and instructions are sent to the laboratory for proper construction.
The second appointment involves the seating or bonding of the veneers to the existing teeth. This is the critical appointment as a thorough understanding of the principles of bonding must be applied. The teeth are cleaned and undergo a series of steps to prepare the surface to be bonded. The veneers are permanently attached to the tooth surface using a composite resin material, which becomes incorporated into the tooth structure as well as the porcelain. Using different colors of resins, the color of the veneers may be subtly altered for maximum aesthetics. Using a high intensity light or laser curing light, the resin is cured, or hardened, and the veneers become bonded to the teeth.
When too much tooth structure is damaged for a porcelain veneer, it becomes necessary to crown the tooth. In the past, this would be done with a porcelain fused to gold crown that would often look opaque and unnatural, as well as having the problem of a dark line at the gumline. The crowns were opaque or chalky white because stark white material would have to be painted on the metal to block out the dark layer as the layer of porcelain placed over it is translucent. Utilizing the same principles as the porcelain veneer, the all porcelain crown can be attached to the tooth structure, creating the strength necessary to eliminate the need for a metal substructure. Just like a ceramic kitchen tile, it is fragile by itself, but when “bonded” to the concrete floor, you can put all your weight on it without it breaking. Bonding the porcelain or ceramic to the tooth accomplishes the same thing.
Another advantage of the all porcelain/ceramic crown is that since the margins are invisible as no metal is used, they can be placed above the gumline. With the metal substructure crowns, they had to be placed below the gums to hide the margins. This invaded the integrity of the gums and would often cause inflammation. The health of the tissue is enhanced by keeping the margins above the gumline where they can easily be cleaned and prevented from causing inflammation of the tissue. Having a tooth crowned can now be a natural, cleansable result that rivals what mother nature creates.
For the back teeth, the common way of filling cavities was with the silver-mercury filling. With the controversy surrounding the mercury in these fillings, alternatives have surfaced that now surpass these fillings, not only in looks, but in function.
The controversial debate lies in the question of whether the mercury absorbed in the body by its release from the fillings is enough to cause any health problems. Because of mercury’s toxicity, the World Health Organization opposes using the silver-mercury fillings. The American Dental Association supports it. Silver-mercury fillings are being banned in Sweden and Japan. Likewise, scrutiny is occurring in Germany as their equivalent to the Surgeon General is advising the material not to be used on any women of child bearing age because of the ability for the mercury to be absorbed by the fetus. Many follow-up studies are currently being performed worldwide with interesting results. This debate may never reach an answer, but with the superior new materials available, the controversy becomes a moot point.
For small restorations, a composite resin material can be utilized in a direct technique. This means the filling can be done in one appointment. For larger restorations, the indirect method is best as the physical properties are enhanced with heat and pressure. This, however, requires two appointments.
The advantage of either solution is that they are bonded in place. The tooth with a silver-mercury filling is 30% as strong as a healthy tooth, but the bonded filling restores the tooth to over 95% of the original strength of a healthy tooth. Kinder, less aggressive preparation designs exist for the tooth receiving the resin fillings. Finally, the expansion/contraction ratio of metal fillings is far greater than natural tooth structure creating tremendous destructive forces each time a temperature change occurs (cold and hot foods and drinks). This is a major reason of tooth fracture leading to eventual crowns. Composite resin filling ratios are much closer to natural teeth.
These restorations are also technique sensitive, and require meticulous protocol for success. If done properly, they create a much better seal than the silver-mercury fillings and can better prevent decay (cavities) from occurring under the filling. Of course, these fillings look better than the metal ones, but like the mercury controversy, this is almost a secondary consideration at this time, although not one to be ignored.
Dentistry has come a long way over the past few years. We are fortunate to have these materials and techniques at our disposal and as in any growing field, the future is limitless.
Implant Dentistry - Introduction
Think of dental implants as artificial titanium tooth roots, similar in shape to screws. When dental implants are placed in your jawbone (A), they integrate (bond) with your natural bone. They become a sturdy base for supporting one or more artificial teeth, called crowns.
As an alternative, several implants can support a specially made denture, vastly improving the function and aesthetics for patients suffering with inadequate denture stability. The gains in comfort, nutrition, and confidence are phenomenal.
Modern dental implants have been used successfully for over 30 years. They are the strongest devices available to support replacement teeth – and even better, they allow these new teeth to feel, look, and function naturally.
When performed by a trained and experienced dental implant surgeon, dental implant surgery is one of the safest and most predictable procedures in dentistry.
Interesting Dental Implant Facts:
· Ancient dental implants have been traced back to around 600 AD, when tooth-like pieces of shell were hammered into the jaw of a Mayan woman.
· Dental implants are the only dental restoration option that preserves natural bone, actually helping to stimulate bone growth.
· In 1952, Swedish orthopedic surgeon P.I. Branemark discovered that titanium naturally fuses with bone, eventually switching his research focus to the mouth from the knee and hip.
· 3 million people in the United States have implants, a number that is growing by 500,000 annually.
Diagramatic view of a single toth implant restoration.
Implant Dentistry - Treatment Sequence
1. Initial consultation: Dr. Goldstein and your implant surgeon will thoroughly examine your mouth, including taking X-rays or 3D images, discuss the various implant options, and develop a customized plan for your implant surgery and restoration.
2. Dental implant placement: At your next scheduled appointment, your implant dental surgeon will place the dental implant in your jawbone where your tooth is missing. Although each patient’s experience is unique, most people find they experience less pain and discomfort than they expect, and typically return to work the next day. Local anesthesia or IV sedation can be used to keep you comfortable, depending on the procedure. Post-implant surgery discomfort is similar to that of any other dental surgery. It may include swelling, bruising, minor bleeding and/or pain, but most patients usually manage any pain with over-the-counter medications.
3. Osseointegration: Throughout the healing phase, your implant and jawbone will grow together in a process called osseointegration (os-e-o-in-tuh-GRAY-shun), forming a strong, long-lasting foundation for your replacement teeth. During this process, which can take up to a few months, you go on with your normal life. You will be on a soft food diet for the first few weeks to make sure your implants heal properly. In some cases, your surgeon may approve placement of temporary teeth during this period, if you choose.
4. Abutment placement: Once your implant bonds with your jawbone, a small connector – called an abutment – is placed on the dental implant. The abutment is custom milled to address the specific requirements of a patient’s situation. The surface adjoining the integrated implant is machine made to the specifications and tolerances of the specific implant placed by the surgeon to maximize biocompatibility and functional longevity.
5. Custom-make and attach new teeth: After your gums heal, Dr. Goldstein will make impressions of your mouth and remaining teeth to custom-make your artificial teeth. These teeth – which can be an individual crown, implant-supported bridge, or dentures containing multiple replacement teeth – will be attached to the abutment(s). Often, the custom abutment and custom crown are fabricated simultaneously to ensure their congruence. Although the abutment and restoration do not decay, your new teeth will need the same routine care, checkups, and cleanings as your natural teeth to avoid periodontal disease and perio-implantitis.
6. Periodic check ups: Depending on the number and type of implants and replacement teeth you receive, the entire process can take four to twelve months. After your dental implant placement is finished, you’ll visit your dental implant team periodically for follow-up checkups, just as you do your regular appointments.
The most common alternative to dental implants for a single tooth is a fixed bridge and involves grinding away healthy adjacent teeth that are used to attach and support the bridge. The tooth-supported bridge does not stimulate natural bone growth beneath it; therefore, the bone may deteriorate over time. Bridges often fail after 5-10 years because patients have difficulty flossing under them, which makes the root surfaces below and around the bridgework highly susceptible to decay.
A resin-bonded bridge is also called a Maryland Bridge, and are sometimes considered for replacing certain front teeth that do not endure the biting and chewing demands of back teeth. It has wings on each side to attach to healthy, adjacent teeth but usually do not involve preparing, or grinding down, other teeth as much as a fixed-bridge. A resin-bonded bridge looks and functions better than a removable denture, but isn't as strong as fixed bridgework and typically doesn’t function or last nearly as long as dental implants. Over the past 10 years, this restoration is usually considered a temporary fix until a more stable option is decided upon.
Although these are less expensive and do not require grinding down adjacent teeth, removable partial dentures are not nearly as stable or comfortable as dental implants and can affect speech and eating. Furthermore, they do not look as natural or function as well as implant-supported crowns. The bone underneath a removable partial denture may deteriorate over time, changing the appearance of your smile and face, especially if multiple teeth are missing. Larger partial dentures require metal substructures and clasps which often create aesthetic compromises and increased stress on the supporting teeth. Removal is required while sleeping to allow the gum tissue and clasped teeth sufficient time to recover from the forces placed during the day.
A traditional complete denture sits on top of the gums where the missing teeth previously existed. It can be uncomfortable, affect your ability to experience the full taste of food, cause sore gums, and shift and click in your mouth when you speak, eat, smile, yawn or cough. While the initial costs are low, they only last an average of 7 to 15 years, and the replacement costs can be significant over the long term along with regular periodic relining procedures. They must be removed regularly for cleaning and left out of the mouth for periods of time to maintain tissue health. Also, as with a partial denture, the natural bone underneath a complete denture may deteriorate over time, permanently changing the appearance of your smile and face.
AGD Fact Sheets to Download
Informative sheets complements of the Academy of General Dentistry
AGD-FactSheet-Acid-Reflux (pdf)Download
AGD-FactSheet-Aging (pdf)Download
AGD-FactSheet-Allergic-Reactions (pdf)Download
AGD-FactSheet-Allergies (pdf)Download
AGD-FactSheet-Bridges (pdf)Download
AGD-FactSheet-Bruxism (pdf)Download
AGD-FactSheet-Childrens-Oral-Health (pdf)Download
AGD-FactSheet-Dentures (pdf)Download
AGD-FactSheet-Erosion (pdf)Download
AGD-FactSheet-Nutrition (pdf)Download
AGD-FactSheet-Oral-Cancer (pdf)Download
AGD-FactSheet-Oral-Hygiene (pdf)Download
AGD-FactSheet-Periodontal-Disease (pdf)Download
AGD-FactSheet-Root-Canal-Therapy (pdf)Download
AGD-FactSheet-Teenage-Oral-Health (pdf)Download
AGD-FactSheet-Tobacco (pdf)Download
AGD-FactSheet-Tooth-Trauma (pdf)Download
AGD-FactSheet-Wisdom-Teeth (pdf)Download