Wednesday, December 6, 2017

Silver diamine fluoride SDF

What is silver diamine fluoride SDF?

Silver diamine fluoride (SDF) is a product dentists use to treat dental caries. It is new to the US but has been in use elsewhere for decades. SDF application is around 80% effective but teeth with “holes” still need to have a filling and we often use the SMART. It is a great new treatment tool for pediatric dentists.

What does silver diamine fluoride staining on back molars look like?

SDF staining looks black. It is not pretty but it does work. On back teeth it is not a big deal for most patients, however this depends on big of an area is black.

Photo of silver diamine fluoride staining on back molars

What does SDF staining on front teeth look like?

SDF staining on front teeth looks pretty bad IMHO. It looks worse than decay does to me but there may be few options until the child is old enough or mentally ready enough to fix properly.

Photo of silver diamine fluoride staining on front teeth

Silver diamine fluoride cost is usually very cheap in comparison to other dentistry.

Our fee for SDF application is $80 per visit. Some offices charge per tooth and some charge per tooth surface. The silver diamine fluoride ada code description is not specific on this, therefore how offices charge is hard to compare office to office. I image offices also charge on how difficult it is to place the SDF, which I think is the most fair.

What is silver diamine fluoride ADA code?

The SDF ADA dental code is D1354. Other dental codes that you can also use are D1999, D9910, and D1208. Those are not the most accurate and my guess is the only people using them are those that are trying to get more money out of the insurance plan.

What is silver diamine fluoride FDA approval status?

The FDA clearance is for hypersensitivity only. However, dentist in the US typically use it off label for caries treatment. This is exactly how dentists use fluoride varnish.

Where can one purchase silver diamine fluoride?

Most dental vendors sell Advantage Arrest which treats around 250 teeth if you are using one drop per tooth. One drop can theoretically treat up to 5 teeth.

Silver diamine fluoride staining will occur on most surfaces.

Keep it off clothing and all clinic surfaces since it will stain almost everything. However, if SDF touches anything quickly wash with water, ammonia, and or ethanol. It will stain permanently. It will stain skin for few days without harm.

Do we use a silver diamine fluoride staining consent form?

No, rather than more paperwork we simply tell parents the issues of staining and what it is and why we use it. That is good enough in my opinion, but you do need to find if there is a silver allergy. The most likely “bad” thing to occur would be black staining of the skin of the face for a few days, therefore try to be careful with it around skin! It may also sting intraoral tissue and may leave a metallic taste for awhile.

Silver diamine fluoride application steps

  1. Protect patient lips and cheeks with vaseline to help prevent staining
  2. Dry and apply SDF with a mircobrush, however be very careful what it touches!
  3. Should be for 1-3 minutes but in my experience will work in even shorter amount of time.
  4. Wash with water.
  5. Repeat twice a year
  6. Apply glass ionomer over if can or want to. This is the known SMART, which is simple addition to ART.
ART = Alternative restorative treatment, formerly known as atraumatic restorative treatment, is “a dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”
SMART simply adds the SDF application into the ART.

More information on SDF

AAPD guidelines for SDF to treat cavities in pediatric and special needs patients. AACDP presentation on SDF

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Monday, December 4, 2017

Teeth cleaning before braces?

Do I need a teeth cleaning before braces?

Do you need a teeth cleaning before braces? The short answer is YES!

Why do orthodontists and dentists make you get a teeth cleaning before braces?

There are many reasons that an orthodontist will want you to get a professional teeth cleaning before starting braces. Not least of which is just to ensure you have a dental home in case there is some dental emergency that they do not treat. We also want you starting off with clean teeth and the knowledge that your gums and bone are healthy enough to get braces.

Additionally, we want to know if there is decay present, prior to placing braces on the teeth. If there is decay we really want to treat it before you get braces. Braces get in the way of the dentist’s ability to properly fix your teeth. Not to mention it can be challenging to clean your teeth properly with braces on and we do not want to make a bad situation like decay worse with braces.

What is the cost of a teeth cleaning before braces?

The cost of a teeth cleaning before braces is the same as the cost of a teeth cleaning at any time. Nothing is special or different about this one. It is arguably a more important cleaning though.

The cost for your cleaning will depend on the severity of any conditions you may have. If you have not been going to the dentist regularly then you may need a debridement or a scaling and root planing if your gums are in bad shape. This is also known as a deep cleaning. If you need either of those you will need to ensure your orthodontist and dentist are working closely together to monitor any potential negative issues.

A normal cleaning cost can be found on fair health consumer. Fees vary from practice to practice and from area to area.

What things are we looking for at the teeth cleaning before braces?

There are several important things that we want to check when getting a cleaning before braces. The first is to ensure that your bone support for your teeth is proper. If it is not, braces can cause you to lose your teeth! Secondly, we want to ensure you are decay free. Next, we want to ensure there is no faulty dental work. Finally, we want your gums to be in excellent health so that when we bond the brackets to the teeth we do not run into excessive bleeding that will cause the brackets to fail.

Th x-rays below show someone that is starting braces but did not get the cleaning before. In red you can see calculus build up in between many of the teeth. This is a sign of poor gum health.

Why you need a teeth cleaning before braces.

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Saturday, December 2, 2017

Replacement dental veneers

Can you replace dental veneers?

Replacement of dental veneers is a common procedure that we perform. Technology and the ability of both the cosmetic dentist and lab tech determine how well the dental veneers actually match.

Why would someone want to replace dental veneers?

There are two major reasons that we see for why people want to replace dental veneers. The first reason is that they do not like the look of the dental veneers. Usually the patient lost faith in the previous dentist or has come to realize better esthetics are available. The other reason is that a dental veneer has broke.

Below is a before and after dental veneer replacement photo showing two veneers that were no longer esthetically pleasing.

Before and after photo of replacement dental veneers

Can you replace dental veneers?

Yes, of course you can replace dental dental veneers! One can theoretically even remove dental veneer with a laser without having to cut into more tooth structure. In my hands that does not work well for a variety of reasons that are not worth discussing here. However, removing old dental veneers is easier than preparing them the first time. That does not mean that the entire process of replacing dental veneers is easier than doing the first time. Actually, I think it is likely more difficult. It is more difficult for several reasons. First of all, almost everything is more difficult when fixing or changing someone else’s work. Secondly, it is highly likely that the esthetics that you are looking for a second time around are much higher or more specific.

Below is the smile of a young man who recently had 10 denatl veneers placed in Texas. He was unhappy with the results and wanted something that looked more natural, as if nothing had been done. The first veneers in the top photo are fake looking.  They are flat, square, monochromatic, and lacking life. We were able to remove all ten denatl veneers and replace just four to give him a more natural look. We also did some minor bonding as well.

Can you replace dental veneers?

What does it cost to replace dental veneers?

The fee will vary greatly from office to office. Some dentists add a fee for the removal of old dental veneers. I do not do that but think it is very reasonable and fair if a dentists does charge. The fee for a dental veneer in your zip code can be found at fair health consumer by typing in code D2962 or just type in veneer.

The replacement dental veneer fee should be the same or very similar to whatever the dentist’s original fee for a porcelain veneer is. However, shopping for dental veneers by fees alone is not very smart. Asking what is the fee for a dental veneer is like asking what is the price of a car. The range of esthetic results and abilities of the dentist to provide those results varies enormously. You can get a cheap veneer that looks like crap but resembles a tooth or a work of art that looks gorgeous AND looks like a real tooth.

The dental veneer replacement cost in our office is $1500 in 2017.

This fee is per tooth, however, the fee does go down if you do a lot of teeth.

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Thursday, November 30, 2017

Blood blister on lip

Blood blister on lip that won’t go away?

Blood blister on lip that won’t go away is probably not a blood blister at all but a venous lake. Venous lakes are common venous malformations that look like blood blisters but they do not go away and actually slowly grow over the years.

Blood blister on lip that won’t go away – well maybe not a blood blister!

We are all familiar with blood blisters. Often we will get one on a finger that gets an injury but does not get cut into. We also know how they heal, the blood blister gets hard, crusts up, and falls off. The whole process is usually done in a couple weeks. However, what about those blood blisters that do not go away? Maybe it is not a blood blister at all, but a venous lake. If it is on one of your lips then the chances are very good that the thing you believe is a blood blister is actually a venous lake.

How do we treat a blood blister on lip that won’t go away?

The procedure is actually very quick and effective. We use a laser that targets the blood that is inside the lesion. The energy of the laser cauterizes the blood vessel, destroying it.

What is the healing time for this treatment?

Healing time is typically 2-3 weeks, during which a scab will form and then fall off. The images below are the pre treatment photo and a 2 week follow up sent in by the patient.  The last bit of scab has not fallen off yet at this point but is only a few days away from total healing. The image quality for the followup is poor because patients just send me cell phones shots as they usually live far away.

Image of blood blister on lip that won't go away.

Want to see more before and after photos and learn more about venous lakes? Then click here!

Blood blister on lip? NO! It’s a venous lake and we can treat it; just give us a call!

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Tuesday, November 14, 2017

Need crown after root canal?

Do you always need crown after root canal?

Need crown after root canal from your dentist? Are you being told that you have to have a dental crown after completing a root canal? Find out when you do need one and when you may not. Also find out what your crown options are.

Which teeth need dental crowns after a root canal?

Typically the easiest way to think about whether you need a crown after a root canal is to determine where the tooth is in the mouth. Back grinding teeth, molars and premolars, typically need a dental crown after a root canal. Front teeth that we use for tearing, canines and incisors, may not need a dental crown.

What are some of the factors that determine whether you need a dental crown after a root canal?

As I mentioned above, whether the tooth is a front tooth or back tooth is one of the most important factors. However, there are several other factors to consider as well.

  1. Is the tooth a front or back tooth?
  2. Do you clench or grind your teeth?
  3. What is your history? Have you broken teeth in the past?
  4. How bad is the crack, break or decay that is causing you to have a root canal?
  5. How much of your tooth is actually left? This one is very similar to the one above.
  6. Is there a tooth opposite, above or below, the tooth getting a root canal.

How do these factors impact the need for a crown after a root canal?

If you clench or grind your teeth you are far more likely to need the protection that a dental crown will provide you. If you have broken teeth in the past then you need the dental crown. Teeth that get root canals because they are badly decayed or broken have less tooth structure and therefore need a dental crown. Basically unless the tooth died of trauma, like a hit to the face, and does not have any fillings you likely need a crown.

Is a dental crown after a root canal necessary?

Studies show that a dental crown after a root canal increases the chance of the tooth surviving. There was a 6x higher survival rate in this study. Another study shows that only about 1/3 of the molars survive without a crown at 5 years.

Is a dental crown after root canal necessary?

The vast majority of back teeth with a root canal need a crown, just like this one will.

Back tooth = Need crown after root canal almost always.

Front tooth with lots of decay or broken = Need crown after root canal.

Front tooth with very little decay and not broken = Does not need crown after root canal.

Do I need a crown on front tooth after a root canal?

This is the one place that you typically do not need a crown after a root canal. However, if the tooth has a lot of decay or is missing a large portion then you do need a crown.

Tooth already has a dental crown, does it need a new dental crown after the root canal?

That is a very good question and can be hard if not impossible to give you a great answer even if the same doctor did all the work on you. If there is decay around the edge or margin of the crown then yes you need a new crown. An example of that type of situation is right below this paragraph.  However, many cases there is not decay apparent and this causes a problem. The problem is the dentist will not know what is under the crown. In fact, no one knows how much of your actual tooth is left. Therefore recommending a new crown can be a bit of a guessing game.

Ultimately you will probably hear whatever the dentists prefers instead of what you actually need because no one can tell you that. The “best” option is to get a new crown. However, a dental crown is an expensive procedure. Add that to the fact that most people do not need a new crown and you can see why we rarely offer this best option.

Do you need crown after root canal

Decay under the margin or edge of the crown. This tooth will need both a root canal AND a new dental crown.

Personally, I never replace the crown when doing this unless I see tons of decay under the edge of a crown. One can make the argument that my protocol is under-treating, but I am comfortable with my method.

What are your options for dental crowns after a root canal?

Dental crowns come in a variety of materials today. Gold crowns are still available but are more expensive and wear down more. They are excellent for gum tissue and we can slightly modify gold in the mouth to have an excellent fit. However, we make very few gold crowns today. Porcelain fused to metal crowns were once very popular and are still in use today by some dentists but their use is disappearing and may not be around in a few more decades due to better options.

Ceramic crowns are what many doctors are going to and what future crowns will likely be made of. Emax and zirconia crowns are the two most popular. Both are strong and white in color. They both have some minor pluses and minuses and what you get is highly dependent on the dentist who does it. Emax on average is better looking but weaker, however, zirconia is caching up in the esthetics department.

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Friday, November 10, 2017

Dental veneer cracked

If your dental veneer cracked what can you do?

Dental veneer cracked? What are your options?

A cracked dental veneer can be an esthetic emergency so how do we fix it?

If caught early, we can repair a crack with bonded white composite filling material. This is a patch, not a fix, but it often lasts for a long time if done properly. If the piece has cracked off we can bond it back on the same way we bond dental veneers from the start. Some cracks we can not do much other than replace the veneer, your dentist will have to decide what the best course of action is.

Dental veneer cracked naturally and then repaired.

Step buy step for repairing a cracked dental veneer

  • Mechanically roughen and bevel the porcelain in the area with diamond bur with copious water spray and gentle touch
  • Optional – microetch for more mechanical retention and better cleaning of the biofilm.
  • Porcelain etch per manufacturprs’ recommendations
  • Silane agent
  • Bonding agent preferably with no HEMA
  • Composite

Why did the dental veneer crack?

First one should determine how and why the dental veneer cracked. How long has the dental veneer lasted before the crack? Is the crack a hairline fracture or are we talking about a full break? Another important question, which you can not answer is whether or not the veneer is on enamel or dentin tooth structure?

If the dental veneer is pretty new, less than a year, then your cosmetic dentist will likely just replace it. However, it is important to try and determine why it cracked. It is possible that there was a microscopic fracture in the veneer from fabrication. If so then just replacing it will likely work. Typically there is a bite issue and the individual is either a clencher or a grinder. If this is the case then it can be very difficult for all parties involved to find a workable solution. A nightguard will be mandatory. The lab technician and the cosmetic dentist will have to carefully explore the material selection options and your bite. Some people break things no matter what, especailly they do not use a nightguard religiously.

If the veneer is older than a few years then you can probably chalk it up to bad luck or normal wear and tear.

Dental veneer cracked – What is the cost to repair or fix?

If we can repair the veneer, the cost is significantly less. We charge several hundred dollars depending on the severity of the fracture. However, if the crack is unrepairable and the veneer needs replacement then we charge over $1500. Typically replacing one dental veneer is more costly per tooth than doing several together because it is harder to get just one to match.

My dental veneer cracked and it’s brand new! How long should it last?

This is a great question and the answer varies depending on who did it, what material we use, how hard you are on your teeth, and if you use a night guard. I have a post on the topic of how long dental veneers last. Research does show that bonding a veneer to enamel is important to long term success.


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Friday, November 3, 2017

Accidental tooth bud extraction

What to do for an accidental tooth bud extraction during primary tooth removal?

Accidental tooth bud extraction during removal of a primary tooth can occur. When it does it is important to replace the tooth bud into socket quickly.

How do you replace the accidental tooth bud extraction into the socket?

Step one of replacing a tooth bud or immature tooth is the separation of it from the primary tooth. Do this gently and try to avoid touching the tooth bud and immature tooth as much as possible, especially avoid touching the apical portion. Once you have only the tooth bud remaining place it back into the socket. The position is not critical as it will likely develop and erupt just as one does in an auto-transplantation case or surgical extrusion technique case. However, there is definitely a “right” position for the tooth bud.  You should try to put it back exactly where it came from. The piece should fit together like a piece of a puzzle.

How should you monitor a re-implantation of an accidental tooth bud removal during primary tooth extraction?

Follow up with patient at 1 week and 1 month. After that routine follow up at their 6 month recall is fine.

What does an accidental tooth bud removal during primary tooth extraction look like?

The tooth bud may be very small and look similar to an enamel pearl. However, the position of it should be a giveaway.

Image or accidental tooth bud extraction during primary tooth removal

You can see an immature premolar tooth bud that came out with the primary molar.

The tooth bud may also really be more mature and we can consider it an immature tooth. Efrat 2001 shows a case of accidental immature tooth removal during extraction. Tooth #28 was the accidental tooth that was removed. The 2 year follow up looks good other than some coronal pulp calcification.

accidental removal of immature tooth during primary tooth extraction

What determines if the replacement of an immature tooth re-implantation will be successful?

Basically stage of development and time out of socket are the critical factors, with earlier in the development and shorter time being better for survival.

  • Short distance from pulp horn to apical foramen
  • An open apical foramen
  • Short extraoral time, which may be less than 45 min or less than 2 hours depending on source of information
  • What was tooth storage medium for the tooth while it is out? Preferably saliva, saline, milk or HBSS4).

List of some accidental immature tooth removal during primary tooth extraction literature.

The is not much literature on this exact topic but auto-transplantation has a lot of literature and since the procedure is so similar one can consider them a good source of information.

Efrat 2001 describes a case of immature premolar tooth removal during extraction of primary tooth roots in the Dental Trauma journal. Kemp 1977 also describes a case of immature premolar tooth removal during extraction of a primary molar in JOE.

Andreson has a lot of literature on tooth avulsion and auto-transplantation. The recommendation is non-rigid splint for 2 weeks if tooth is erupted.

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