Archives for April 2012

Is it possible to save a few dollars on a beautiful smile makeover?

Posted on April 30, 2012 by David A. Hall.

Dear Dr. Hall,
I had braces as a child however I never wore my retainer after they were removed due to the lisp they caused when I talked. As an adult, I’m now paying the price as my upper teeth are slightly crooked and my lower teeth have lots of crowding. My general dentist has also said I’ve worn the enamel off most of my teeth due to grinding/clenching. And to make everything worse, I have some yellow discoloration that my dentist has blamed on the large doses of antibiotics I was on as a child (was treated with IV antibiotics for several years on and off).

I also have a mild phobia of dentists and don’t go as often as I should.

The older I get, the more I realize that my smile is affecting my self-confidence and I really want to do something about it. I wouldn’t trust the guy I’m going to now for any cosmetic work, since reading your blog and looking at dozens of before and after shots from other dentist, I’m beginning to understand that you really need a professional who has a passion to get good quality work. A family member of mine has recommended me to his dentist, who did a lot of cosmetic work and gave him a beautiful smile makeover, but cost him upwards of $30,000+. I don’t have this kind of money to spend, and I personally think my family member was overcharged.

My question to you is can you recommend someone in my area that I can trust? I see a lot of advertisements in my area (I live close to NYC) for these “top rated” cosmetic dentists, but it seems like they all overcharge you so they can put another fountain in their office. I appreciate any feedback you can provide and I found your blog very knowledgeable!

Thanks,
Randy from New Jersey

Randy,
We have a variety of dentists that I recommend on mynewsmile.com as far as the fees that they charge. I don’t know the relative fees of most of the dentists we list – I do know some.

The ones we recommend in Manhattan are all expensive. And any dentist who markets heavily is likely to be expensive.

To get a handsome smile, it sounds like you will need a smile makeover with either porcelain veneers or porcelain crowns. Probably porcelain crowns – since you say you have worn your teeth down from grinding your teeth.

Here’s what I would do. You’re in New Jersey. Call the dentists on our New Jersey page and ask what their fee is for a porcelain crown. Some won’t give you a fee over the phone, but some will. And use that to find a dentist who fits your budget.

All the dentists I recommend have passed my careful screening, so I have confidence in all of their work. But not all of them are expensive. So give that technique a try.

If a dentist is really expensive, it’s not an indication that they do great work. Some mediocre dentists charge high fees. However, if a dentist is really cheap, it is generally a good indication that the work is poor. Some excellent dentists have moderate fees, and some have high fees. But that is the extent that the old maxim “you get what you pay for” works. What you want to find is that excellent dentist in your area whose fees are moderate.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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I’m an adult with baby-sized teeth

Posted on April 30, 2012 by David A. Hall.

Dr. Hall,
If you’re an adult with baby sized teeth. Can tooth bonding make them Adult size? If so, what is an estimate price for enlarging 4 teeth and closing a Gap?
Tiffany from California

Tiffany,
The best solution for making small teeth larger would be porcelain veneers. While dental bonding could be used, that’s not the best solution, and I’ll explain why.

The dental bonding material is relatively soft, compared to, say, tooth enamel, which is very hard. It will feel hard to the touch, but it is susceptible to scratching, and it can also absorb stains. So it won’t look that good for very long. Porcelain, however, is even harder than tooth enamel and less susceptible to staining. So what you would have with dental bonding would be a smile that would look really great for a year or two and then it would start to look dull and stained. But with porcelain veneers, with proper care they will stay shiny and bright for 10, 15, 20 years or more. Dental bonding can be less expensive – done well it may cost maybe 2/3 of what porcelain veneers would cost. But by the time you replace it or resurface it 4 or 5 times it ends up being considerably more expensive.

For a beautiful job, expect to pay $1000 to $2000 per tooth, maybe a little more on the higher end where you are in southern California.

And be very careful where you go for your porcelain veneers and absolutely do not try to look for bargains here. While many dentists claim to be able to place porcelain veneers, only about one in fifty is artistic enough to do a good job with them. If the procedure is too expensive for you, the best choice would be to do nothing. Your own natural, small teeth will look better than a poorly done set of porcelain veneers. But if you go ahead and get veneers and then don’t like how the final result looks, you will have no legal recourse. Look for our cosmetic dentistry horror stories section to read more, if you’re not convinced.

Dr. Hall

Links: Look for more blog posts about cosmetic dentistry horror stories.

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What is your opinion of Premium Home Whitening products?

Posted on April 25, 2012 by David A. Hall.

Dr. Hall,
I got an offer through Groupon for a product called Premium Home Whitening, for whitening your teeth. Is this a worthwhile product?
– Ann from Arkansas

Ann,
I looked at their website, and I have a couple of comments.

First, their teeth whitening agent is 35% carbamide peroxide. This is a valid whitening agent – it will whiten your teeth. And, with the exception of the “cold blue light” that they add to the process, which I don’t believe will accelerate anything, I don’t see any hocus-pocus in the technique or the products they offer. However, I can’t endorse what they are doing for a couple of reasons.

First, their price is kind of high. They are charging $158.00 for the whitening kit. While some dentists charge more than this (some charge a lot more), some charge less. If your dentist charges more than this and you just don’t want to pay that fee, I’d just shop around for another dentist. Sometime, just after you’ve had your teeth cleaned and checked, just call around. Tell the new office you’ve just had a cleaning and an exam and just need the whitening. How much would it be? Go to that dentist for your whitening, and back to your regular dentist for your other care. Or, another approach would be to level with your dentist. If it were me, I would just say, ‘Hey, I found this offer for a kit I can buy for $158, and I read comments by a dentist online who said this would really whiten my teeth. If you can come down on your fee to something close to that, I’ll get it from you.”

You see, there are two problems with buying this kit over-the-counter. The first is the tray that they make is not going to fit nearly as closely as the one a dentist will make for you. So you are going to have a lot of leakage, which causes three problems. First, there is a reduction in effectiveness when the tray leaks. Second, you waste a lot of gel, which drives up the cost even more. Third, there is a greater chance of irritating the gums.

And then there is the safety issue. I published a report a couple of years ago of a woman who needed a root canal on her front tooth because of the side effects of an over-the-counter whitening system. It’s always best to use this kind of thing under professional supervision. There are issues about existing dental work, exposed root surfaces, open margins on fillings, etc., that should be checked before starting whitening.

For those reasons, you are much better off getting this service from a dentist. You do not need an expert cosmetic dentist for most routine whitening cases – this is one area of cosmetic dentistry where almost any dentist will do.

– Dr. Hall

Links: Can I whiten my teeth while nursing or pregnant?
Three types of teeth stains.

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Tips for root canal treatment on a porcelain veneer tooth

Posted on April 24, 2012 by David A. Hall.

Dr. Hall, For the past two months I have been experiencing slight pain, pressure, discomfort and even feeling as if my two front teeth are going to fall off. Hot or Cold do not bother my teeth. Approximately 9 years ago I chipped one and also had decay on my two front teeth. As a result, veneers were placed. Never had any problems until now. I went to a dentist that has been doing my cleanings and she did an x-ray and noticed inflammation on a nerve. Advised to take ibuprofen for 7 days for inflammation. I followed her instruction and it did work for 1-2 weeks until the same symptoms came back. I went back she took another x-ray, noticed the same inflammation. She stated if it continued then possible root canal would be the next step. However nerve had no damage, which it confused me as why she would do a root canal? I was advised from a friend that sometimes the nerve can be infected. I had some amoxicillin at home and took it for 5 days the pain once again was gone. Now 2 weeks later symptoms are back. My biggest fear is that veneers are going to fall off, is that possible? Even saliva feels weird around my front teeth only. Can you tell me if it may be possible for root canal?
– Sylvia from California

Sylvia,
I’m at a little bit of a disadvantage not being able to see this myself, but at least from what you’re telling me it seems pretty clear that your tooth needs a root canal treatment. And I will tell you why I think that.

I am interpreting the “inflammation on a nerve” that you are telling me about as signs on the x-ray of pulpal inflammation. When the pulp of a tooth is inflamed, often the first sign is either a widening of the periodontal ligament space around the end of the root, or a breakdown in the bony lining of the socket of the tooth, also occurring at the end of the root. When anything shows up on the x-ray like this that indicates inflammation of the pulp of the tooth, it is pretty certain that you are going to sooner or later need to have that root canal treatment.

Taking some amoxicillin you had at home for a tooth infection isn’t a good idea. But the response of your tooth – the pain went away and then came back two weeks later – is another pretty certain indication that the tooth is infected, which means you need a root canal treatment. The problem with having taken the amoxicillin is that now you are that much more likely to have an amoxicillin-resistant infection in your tooth. You can never wipe out a tooth infection with antibiotics alone because the antibiotics have no way to get inside the tooth. So the infection will always come back, and the next time it’s always more likely to be an antibiotic-resistant infection.

Your porcelain veneer won’t fall off this tooth if you get a root canal treatment. But let me give you some helpful advice on how to have this done so that you preserve the esthetics of your smile. And this is something that many dentists don’t know, unless they are really expert in appearance-related dentistry. There is a strong potential for a tooth with a root canal treatment to turn dark. That dark color will show through the porcelain veneer and will require it to be done over again unless the dentist takes this simple precaution. After the root canal treatment, the dentist needs to clean out all root canal filling materials and cement from the insides of the visible part of the tooth – the part that shows above the gumline. Then she should cement a translucent fiberglass post inside the tooth to reinforce it and fill up the rest of the inside of the tooth with a light-colored composite material that will preserve the original color of the tooth. It is the root canal filling material and cement inside that cause most of the discoloration of the tooth. But by cleaning all that out and filling it as I have described, it won’t permanently prevent any discoloration of the tooth, but it may put it off for a good five to ten years. At that point you can get new porcelain veneers or go to a crown on the tooth.

Show this e-mail to your dentist, and she can contact me if she has any further questions.

Having this delayed response to the traumatic injury and decay you experienced 9 years ago isn’t unusual at all. Most dentists have seen this sort of thing before.

Dr. Hall

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How long after cosmetic dental work should I feel pain?

Posted on April 17, 2012 by David A. Hall.

One month ago, I went to Mexico for cosmetic dentistry. The dentist completed 12 lower crowns and 6 veneers on the front upper teeth. Since getting the work completed (2 1/2 weeks ago now), my lower jaw has been extremely painful. It’s not in the gums, but my jaw itself. One tooth hurts to chew anything (even something soft, like bread). I asked the dentist about it and she said to take ibuprofen for a few weeks because so much work was done in such a short amount of time; and that the crown on the tooth that’s sensitive to chewing may have high contact, or need a root canal. That tooth does not touch any of the top teeth when I clench. I’m concerned that I’m having to take so much ibuprofen, and that it’s not really helping the real issue. Should I still be experiencing pain at this point? I take 800mg of Ibuprofen every 4-6 hrs – that can’t be good!!
– Julie from Iowa

Julie,
This doesn’t sound good.

The dentist told you to take ibuprofen for a FEW WEEKS??? Are you serious? So much ibuprofen over that long a period of time can damage your liver or your kidneys. You are taking 3200 to 4000 milligrams a day. I think the maximum recommended dose is about 2400 mg per day over short periods.

No, this kind of pain after getting crowns or porcelain veneers is not normal. Something is wrong. Some tenderness or soreness for a couple of days maybe could be expected. And your teeth should all be touching evenly.

You need a second opinion from a reputable American dentist. You have two excellent cosmetic dentists near you. [Names not included in this post]. Have one of them look you over and see what is wrong before this gets out of control and so you can get off this ibuprofen immediately. It does sound like you may need a root canal treatment. Don’t have that done in Mexico, please.

Only about one out of every fifty dentists in the United States is capable of doing a beautiful smile makeover. However, most of our dentists are fairly competent in general dentistry. If you go to Mexico, your chances of getting in trouble with even basic general dentistry are high, and there are probably only a handful of good cosmetic dentists in the entire country. I know of a couple, so it is possible to get quality work there. But clearly you didn’t end up with one of the good ones.

Dr. Hall

Links: Read more about cosmetic dentistry costs.
Read more about the quality of dental care outside the US.

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Should I go to Clear Choice or Costa Rica for my dental implants?

Posted on April 12, 2012 by David A. Hall.

Your website only discusses Clear Choice as a provider of the all-on-4 implant procedures. I went in for a 3d x-ray and initial eval at both Clear Choice (CC) and EON. My experience with CC was consistent with the experiences of others reflected on your website. EON seemed much better. In particular, the head of the EON clinic spoke with me. Apparently he used to be associated or partnered with CC. He stated that he left CC because he did not like the practice of abandoning the patients once they had the procedure done. Also according the the “evaluation done at CC and reported to me by the sales rep, I was a fine candidate for the procedure. The dentist from EON referred to the x-ray and mentioned several consideration that needed to be evaluated. Ultimately he stated that they could make the necessary modifications to allow insertion of the implants without bone grafting. If any of this seems odd or false, please let me know. I figured you might benefit from my description of the initial meetings with the 2 local competitors in Chicago area. Thank you. Mike Burke My next step, in addition to scouring the internet for justification and knowledge is to consider going out of the country to have the implants put in. Costa Rica?

Mike from Chicago

Mike,
I don’t understand. You are unhappy with the idea that you would go to Clear Choice and get dental implants and they wouldn’t have any follow-up. And for THAT you are going to Costa Rica? What kind of follow-up do you think they have in Costa Rica? Do you think THEY will call you for a checkup and a cleaning?

Having dental implants placed, even in the United States, is a risky procedure. We are seeing so much malpractice in this area. Dentists are getting into it without adequate training, and the standards of care are not well established because it isn’t a recognized specialty and is fairly unregulated.

But take the worst dentists you have in the United States, and remove ALL quality control standards that even they have, and that’s what you’ll have when you go to Costa Rica. If you are a brave soul, you could try getting crowns or bridgework done in Costa Rica, because you could always have those re-done if something goes wrong. But when something goes wrong with implant dentistry, you could end up a dental cripple, maybe with practically no jawbone. They could accidentally place implants in your nerve canal, in your nasal sinuses, they could perforate the bone. Infection could set in. The implants could be too short or too thin. They could be placed under load prematurely. They could come loose. If they place cheap fixtures, they could lack precise tolerances, which would leave openings for infection and coming loose. The fixtures could corrode. You could get peri-implantitis. There are so many things that could go wrong with dental implants. At least in the United States you might have some legal recourse if things go bad.

I am not a fan of Clear Choice. As you were told, they do not have any follow-up contact with you. We have numerous reports of high-pressure sales tactics. And the all-on-4 procedure has some risks – if anything goes wrong later with any one of the four implants they place, the entire case will have to be re-done. But you are far better off having this done by Clear Choice than going down to Costa Rica. If you want the best care, my recommendation would be to find a solo practitioner with expertise in dental implants. Look for credentials from either the International Congress of Oral Implantologists or from the American Academy of Implant Dentistry.

There are other dentists who do the all-on-4 procedure in the Chicago area. Dr. Anthony LaVacca in Naperville is one. He is a board-certified prosthodontist and is also implant surgery trained. Another option could be to get a second opinion from Dr. William Cohen in Glenview, who used to be my dentist when I lived in Iowa.

But please, please, don’t go down to Costa Rica for dental implants, not if your quality of life is important to you.

Dr. Hall

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A dentist is ethically obligated to give you all your options

Posted on April 10, 2012 by David A. Hall.

When I was a child I was hit in the mouth twice, once from falling out of a wooden school swing and the other time from throwing a croquet ball up in the air and catching it with my front tooth. Needless to say the older I’ve gotten the more yellow brown it has become. My dentist told me I would have to get an implant because there was no root but yet I still have the VERY UGLY BROWN TOOTH.

I also have several back teeth that need filings and at least 2 that need to be capped. I don’t have a lot of money to be putting into just one tooth when I have several others that need to be fixed, although the one that gives me an UGLY SMILE is the one everyone can see. PLEASE HELP ME.

Thank You so very much for your time.
Sincerely, THE GIRL WITH THE UGLY BROWN TOOTH
Danielle in Tennessee

Danielle,
I would switch dentists, and I will explain why.

One of these two traumatic incidents with your front tooth jarred it enough to sever the nerve and blood supply that go to the tooth. This would cause the tissue inside it to die, which would then cause it to become infected. It’s possible that if this tooth had received a root canal treatment at that time, it could have prevented the root of the tooth from being eaten away, but it’s also possible that would have happened anyway, as a side effect of the traumatic injury. The process is called root resorption, and it can happen because of an untreated infected tooth, or because of traumatic injury to the tooth.

But now that the tooth has no root left, you can’t save it.

There are three basic ways, however, to replace a missing tooth, and your dentist is negligent in only presenting one of them to you. He or she has an ethical obligation to give you all the options that would work. And while the implant option is probably the best choice for you, it is also the most expensive. Did you tell your dentist that this was too expensive for you? If you did, and you still didn’t get any options given to you, then it shows not only negligence but a lack of character on the part of your dentist.

A dental bridge is the traditional way to replace a single missing tooth. A bridge requires that the two adjacent teeth be covered with crowns (you may know them as caps), and then a false tooth is suspended between them. This is a little less expensive than an implant.

Another option is to use a removable partial denture that clips onto your other teeth and has a false tooth on it. While less comfortable than either a bridge or an implant, it is a fraction of the cost of a bridge. A flipper partial is the simplest way to do this, and it can cost as little as a couple of hundred dollars.

Find a dentist who is willing to give you all your options and who will work with you to keep the costs down. I don’t know everything that went on in your visit with your dentist, but just from the information that I have it doesn’t appear that you should trust this dentist.
– Dr. Hall

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