Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

August 3, 2016

So does flossing really help?


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So the Drudge Report yesterday linked an article from the British newspaper The Guardian about flossing. The link said, “Smile! Now experts decide flossing makes no difference.” The article in The Guardian is titled “Everyone recommends flossing – but there’s hardly any proof it works.” I’m not going to give the article any respect by linking to it–if you want to read it you’ll have to Google it.

But I can sum up the article in one word–ridiculous.

There is strong evidence through multiple scientific studies that flossing helps prevent both gum disease and interproximal tooth decay. In my dental practice, I could tell whether or not a patient was flossing simply by examining their gums. In fact, the science is so carefully calibrated that dentists can predict how long it would take a patient with inflamed gums to bring the inflammation under control with daily flossing. Two weeks of regular, daily flossing would do the job. In my practice that timing worked every time.

And rarely do regular flossers get interproximal tooth decay.

But if you go back and re-read the article, it’s fairly easy to detect the slant in the writing. Notice that the article doesn’t say there is no proof. It is titled there is “hardly any proof.” Think that through. That means there is proof.

Further along in the article it says: “A major review last year concluded: ‘The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal.'” Notice again the wording, which admits that there are studies that demonstrate the benefits of plaque removal, but it’s not a majority of studies, or rather, it’s not a majority of the studies that were available to the person that made this comment.

Let me play this same word game with the benefits of showering. I could say something like this: “The vast majority of studies published in American medical journals fail to demonstrate that showering prevents body odor.”

Well, you may respond, the vast majority of studies in American medical journals don’t even deal with the subject of showering.

Oh, you’re so smart.

And this article in The Guardian is so stupid.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

July 12, 2016

She’s reluctant to do the second half of her full-mouth reconstruction


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Dear Dr. Hall,
I have taken great comfort in the information you provide and the honest, intelligent, accessible manner in which you provide it.

I am 37 years old and had my entire lower arch redone with crowns and veneers over a year ago. My dentist is a cosmetic dentist listed on your website. She recommended a full smile makeover for my worn teeth. After years of clenching and grinding (I didn’t wear a nightguard until recent years), I was having a lot of sensitivity on my molars and my dentist said that I had a collapsed bite.

I know that my dentist did a good job, but the whole process was very hard for me emotionally. I never wanted “perfect” teeth and I do miss some of the quirkiness of my originals. Even though I went for a “darker” shade (m2 instead of m1), I still feel they are a bit white for me. Also, I have had a bit of gum inflammation, which I never had before. My dentist is having me treat this with baking soda and peroxide and may eventually do some procedure she thinks will help.

My dilemma is now that I am torn about doing the top teeth. My dentist is pushing for it. And indeed my top teeth are very worn, darker in color and contrast with the bottoms. However, my gums are very healthy on top and I have no pain at all in the teeth. I know that I cannot whiten the tips because I did Zoom whitening years ago and now I think my teeth are too worn and it may cause sensitivity.

I am agonizing over this decision and would be very grateful for any advice you might have.

My dentist seems to feel that my teeth will be better off if she completes the whole mouth, but I am so hesitant to go through such a big procedure when I not in pain anymore. The esthetic discrepancy does bother me a little, but maybe not enough to get this major work done.

Thank you for any words you have for me!!

Best,
Anna from Connecticut

Anna,
It’s hard for me to give a definitive answer as to what you should do without seeing your case and knowing everything that is going on dentally. But I’ll see if I can be of some help with some guiding principles.

There are points to be made in favor of both options–doing something and not doing anything.

First, I am not in favor of half-mouth dental reconstructions. I don’t know what the crowns on your lower teeth are made of, but most ceramics are somewhat abrasive to natural teeth. Some of the newer ceramics are very kind to natural dentition, but most of them will wear natural dentition more than they would otherwise wear, which can lead to sensitivity and other problems. You may want to ask your dentist about this, if this is an issue in your case.

The original problem was excessive wear of the teeth. I’m sure that wasn’t confined to the lower teeth–they both must have worn equally. And now your upper teeth are continuing to wear down. So it appears to me that your original problem is now half solved, and you need to finish the treatment.

Having said that, crowning and veneering all the teeth is a very aggressive step, and if you aren’t completely sold on the benefits, my inclination would be to leave well enough alone.

On the issue of the “quirkiness” of your natural teeth, a masterful smile makeover will include some “quirkiness.” If you discussed that with your dentist, I’m sure she could take care of that so that it wouldn’t be an issue. Knowing that is your preference, I think that most ceramists would love the opportunity to put some quirky features into your smile. My ceramist wanted to do that, but the barrier to doing that is that there are some obsessive patients who fuss over anything that they perceive as an imperfection in the smile makeover. I would want the smile to look natural–they would want all the teeth to be “perfect.” I would try to persuade them to have some imperfections in the teeth, but in the end the patients would get what they wanted.

If the only problem you need to fix is the color, I would do whitening. You mentioned that you worry that you would have too much sensitivity, that you had Zoom whitening before and are reluctant to do that now. However, there are a number of other options for whitening the teeth besides Zoom. Zoom, because of the light, is more harsh than other options. Kör whitening is gentle yet very effective. There is also Nite White or Day White, Boost, Opalescence, and other systems, all of which are also more gentle than Zoom.

On the issue of gum inflammation around the lower teeth–I’m assuming that is around the crowns. That is a factor that should be taken into consideration. You could be having a sensitivity reaction to the ceramic in the crowns or it could be something else. I would try to pin that down before doing the uppers. One excellent option could be doing porcelain onlays on the upper teeth rather than full crowns. Onlays stop short of the gumline so that gum inflammation shouldn’t be an issue. If not porcelain onlays, then porcelain crowns that only go very slightly into the gingival sulcus or even stop at the gingival margin. There should be a way to avoid this on the upper.

And then, about the overall result. I had a number of patients who were hesitant about moving forward with smile makeovers and had some misgivings about the procedure before starting. But once it was done and they saw themselves in the mirror with their beautiful smile and felt that great sense of confidence to where they couldn’t stop smiling, I don’t believe anyone would have ever given a second’s consideration to going back to the way they were. It was always a positive, life-changing experience. You mention that the esthetics of your smile bothers you some now. I would fix that.

I hope this is helpful.

Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

October 12, 2015

Should porcelain veneers have a hump at the gumline?

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Dr. Hall,
I am in the process of having two front teeth veneers replaced. I started out with these teeth having bonding. Then I had that replaced with veneers, but they felt bulky. They looked fine but it was hard to close my mouth. So then my new dentist did bonding, but the job came out horrible. So my dentist told me she could help me have a more comfortable smile and still look good by doing a new set of porcelain veneers, so she has prepped my teeth for new veneers.

My question is, is it necessary that the front teeth hump out for veneers or is it possible to have a smoother surface at the top? Most of the veneers I have seen seem to be humpy but I did see a nice transition on the durathins. Right now I am in temporaries and they look ok but have that hump at the top I am referring to. Please, I would be happy to hear any of your thoughts.
– Yolanda from Virginia

 
Yolanda,
You don’t sound to me like you have a lot of confidence in your dentist, and, from what you say, I’m not having a lot of confidence in her either. If you have to tell her not to make a “hump” up near the gumline, you’re in trouble. The first step in getting beautiful cosmetic dentistry is having an artist for a dentist, and I’m not getting the feeling from you that you have that. Maybe you do. Hopefully you do. But if she’s the one who did the horrible bonding, that doesn’t bode well for your veneers.

To answer your question, no, there absolutely should not be a “hump” near the gumline. Not only can that look bad, but it creates an area that tends to attract plaque and will cause gum inflammation. But your dentist should know that.

And the question is not whether or not you should have bonding, or conventional porcelain veneers, or DURAthins. All of those will produce a beautiful result for you in the hands of the right dentist.

But with you already in the hands of this dentist, what do you do now? I would make sure you get a try-in so you get a good look at these porcelain veneers before they are bonded on. Don’t let her pressure you into bonding them on unless you can see clearly how they look IN YOUR MOUTH and you like them. If you don’t like them and your dentist says, “Oh, they’ll look better once they’re bonded on,” don’t let her do it. Every excellent cosmetic dentist will insist that you love the result before bonding on veneers permanently because everything about them can be fixed before they’re bonded, but once they’re bonded, you’re stuck.

And if she ends up not ever getting it right, you can switch and have a more artistic cosmetic dentist take over. But I’d give her the chance to get it right first.

I hope it goes well.
– Dr Hall

Do you have a comment? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

August 29, 2015

This dentist wants to do gum surgery, while admitting she doesn’t understand the problem

Dr. Hall,

My front teeth developed little ‘holes’ on the surface when I was a teenager and in my 20’s. I initially had some of them bonded. That was in the 80’s. This bonding yellowed with time. So my dentist suggested crowns and veneers. My 2 front upper teeth have veneers. The 2 teeth next to the front teeth on both sides have crowns. These were done in 2003.I had no problems with this until about 3 years ago. Suddenly the gums around these teeth became inflamed. I am now 49 years old. My dentist isn’t sure what is going on. We have tried an all natural antibacterial liquid (I forget the name) with no luck. I get my teeth cleaned faithfully every 6 months. Flossing every day doesn’t help resolve this. This inflammation improves at times and gets worse at times, but it never goes away completely. I do have other crowns in my mouth. On my bottom teeth on both sides I have 2 crowns and a bridge. I also have 2 other caps in molars on my upper teeth. There is also inflammation around those but not nearly as bad. The gums around the remainder of my natural teeth are just fine.
Could these changes be because I am in peri-menopause?
I find it odd that it took 10 years for this to occur. Also, my dentist suggested trimming back the gum tissue. She won’t guarantee that this will fix the problem. I think she wants to do it for cosmetic reasons. Or she may know there is a structural/mechanical problem with the fit of the crowns but doesn’t want to admit it. I don’t want to go through this gum procedure if it’s just a bandaid and the problem will return. So far all this inflammation has not caused full on gingivitis or bone damage (so they say). The gums sometimes get friable and look almost ulcerated. Also, on a side note a few months ago I developed lichen planus on the checks of my mouth (not in the front). This is very frustrating. Sometimes my gums are sore. Sometimes they look just terrible and you can see the red border around my front teeth. It seems my teeth have separated between 2nd and 3rd tooth on both sides counting from the front teeth.
Should I have this procedure? It’s only on the front teeth. What about the inflammation on the other crowns in the back? This is what makes me think it’s systemic. Again this is just around the crowns and veneers.
Any thoughts, suggestions?
Thanks for your time!
Donna from Philadelphia

Donna,

You have a very interesting question here.
When you have gum inflammation around teeth with crowns, there are about five possibilities that come to mind.

  • One is that the cement wasn’t fully cleaned out from around the crowns.
  • Another is that there is some problem with the fit of the crowns.
  • A third is that the crowns go too deeply under the gumline.
    For all three of these situations, the reaction would have been immediate–not delayed ten years.
  • Another possibility is to have some kind of allergic reaction to the material in the crowns. This would happen with porcelain fused to metal crowns where a cheap metal was used containing nickel or some base metal. Usually the metal sensitivity reaction is immediate, but it doesn’t have to be. But veneers should be all porcelain with no metal in them, and you are having the same reaction around the teeth with the veneers, so that seems highly unlikely.
  • The fifth possibility is simple gum disease, aggravated by some things that are going on with your general health. That’s not to say that the causes are simple, but that the disease is a common one and there are some straightforward things to do to address it.

Unfortunately, there are a lot of dentists who simply don’t pay that much attention to the health of the gums, and I am concerned that your dentist is saying that she doesn’t understand what is going on here.
I would recommend a second opinion for you. I don’t think this should be that mysterious–maybe to your dentist, but not to a dentist with strong knowledge about the gums. I would absolutely not let her do this gum surgery on you. I’m not impressed with her aggressive treatment for your yellowed bonding ten years ago. You’re a little suspicious that there might be some structural problem with the crowns that she doesn’t want to admit. That’s possible–there could be some irregularities in the fit of these crowns and veneers that aggravates the gum disease. Your being peri-menopause is probably a contributing factor, also. Hormone imbalances can exacerbate gum inflammation. You mentioned lichen planus. That condition is exacerbated by stress just as gum disease is. It’s possible that a good, thorough deep scaling of your teeth could take care of this, but I feel you need a dentist with more expertise.
Think about what your dentist is telling you–she doesn’t understand why this is happening and yet she wants to do gum surgery to address it. One of the most fundamental principles of health care is that you first diagnose, then you treat. Don’t let anyone attempt any kind of serious treatment here like gum surgery without first having a good diagnosis.
As I think over what you have told me, it’s a little puzzling why your dentist hasn’t referred you to a gum specialist (periodontist). You’re in Philadelphia. There have to be a number of gum specialists you could go see. Maybe she doesn’t want another dentist to see her work. Anyway, since she hasn’t referred you, just self-refer. Just find a periodontist with good reviews. If you have any doubts about who to pick, call a couple of well-respected general dentists and ask what periodontists they refer to. Don’t ask your dentist for a name because of this suspicion we have that she may be trying to hide something. But you do want the periodontist to contact your dentist after you’ve made the appointment and get records that will help him or her assess what is going on.
And then get back to me, if you would, on what they find out. I’d be interested to know what is discovered about your condition.

Dr. Hall

Read more about fixing a discolored tooth from a root canal treatment.

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

July 21, 2011

Cement left around my new crown

Filed under: Dental crowns — Tags: , , , — mesasmiles @ 2:40 pm

Dr. Hall
Is it common for a dentist to leave cement in a mouth that had a crown? My gums were hurting from the temporary crown. After the permanent crown was put on he said in a few weeks my gums would heal. They didn’t. I finally took tweezers and anything else I could find and pulled out a piece of cement under my gums. NOW my gums are healing. I felt instant relief after extacting this piece of cement. A 7 week ordeal.
– Mona from Texas

Mona,
This is a “no-no”, for a dentist to leave cement around a crown, and it will cause gum inflammation until it is removed.

I wouldn’t assume that you got all the cement but would make an appointment with the dentist, explain what happened, and say you want it checked carefully for any residual cement. If cement is left in there long-term, it can contribute to irreversible gum disease.
– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

May 13, 2011

Gum inflammation after porcelain veneers – a big red flag.

Dr. Hall,
I got 8 veneers in December of 2010. My gums continued to be tender and slightly inflamed for several weeks and I asked my dentist if this was normal. He looked at my gums and told me I just wasn’t flossing my teeth with good enough technique, and that was why my gums were inflamed.

Then at the beginning of March, I noticed a fistula above tooth #10 so I contacted my dentist immediately. He took x-rays at that time and told me I have a root canal and needed it treated ASAP. He brought another dentist into his office to do the root canal treatment, so I assumed that the dentist was an endodontist. The root canal treatment took 4 hours and my gums remained inflamed for 3 weeks (fistula still there). When I went back to the dentist with my concern, he then told me I needed an apicoectomy. At this point I asked if the dentist who had performed the failed root canal treatment was an endodontist, and when I found out it was a general dentist I decided to seek out a second opinion from someone else.

I went to Dr. —– (a dentist on the mynewsmile.com referral list), who has referred me to an endodontist who is “the best.” Dr. —– told me that most likely the area will heal on its own and there is no need for an apicoectomy. He said my gums were inflamed because there was cement on the veneers that was causing my gums to stay chronically inflamed! After Dr. —– scraped that cement off, it has only been a few days and already my gums are less tender than they’ve been in months.

Now I’m really concerned that some major mistakes were made with my veneers because the dentist did no wax-up and was not able to address any of my concerns with the esthetic look of the veneers after the procedure. (One tooth appears chipped, and the dentist told me it was “just the anatomy of the tooth.” Another tooth feels like it is cracked. And I’m not completely sure if the teeth are all completely vertical because they look slightly slanted or off-centered. They definitely look better than my teeth looked before getting the veneers, but I can’t say that look perfect or absolutely stunning. They just look like normal teeth.)

Basically, I want my money back for what he did to my teeth! It sounds like he was negligent in leaving concrete on the veneers, which caused my gums to remain inflamed. And then he did NOTHING when I told him that my gums were red, sore, and inflamed until it was too late. And then he was negligent again by bringing a general dentist into his practice to perform a root canal. According to Dr. —–, the x-rays show that the dentist did an “overfill” on the root of tooth #10 and this was why he was wanting to do an apicoectomy. Is there anything I can do to get my money back for these chipped, cracked veneers which caused me to have a root canal?
Jamie from Southern California

Jamie,
You have quite the interesting story. You’re a good example for people looking for smile makeovers – showing the need for an expert cosmetic dentist. I wish I had money to run ads on TV warning about that.

When you told me your dentist’s answer to your gum inflammation was that you should floss more, I knew you were in trouble. For anyone doing porcelain veneers, this is a huge red flag and is a big indication that the dentist did something wrong. One of the criteria I use to evaluate the cosmetic dentistry of dentists I list on this website is the health of the gums in the “after” photographs – they should be at least as healthy afterwards as they were before, if the work is done right.

Here’s the deal for your case. To get any satisfaction, you’re going to have to be willing to make the dentist worry that you’ll be trouble for him. I’m sorry to have to put it that way, but I’m basing this on the way he has treated each of your complaints so far – dismissive, not truthful. He needs to worry that this could turn into a peer review case, or could get to the dental board, or could result in a malpractice action. And if you can get him worried about this, that is what will motivate him to refund your money.

And then you need to realize that your esthetic complaints won’t go very far. Since cosmetic dentistry isn’t a legally recognized specialty, the standard of care for esthetic work is the level of quality that would be expected of an average dentist, which is pretty low.

But you do have two areas of common negligence – the cement left behind, which caused gingivitis, and the root canal overfill. Both of these caused pain and suffering, and have threatened the health of your teeth. So you need to let him know that you are aware of these problems, and also let him know that you have another dentist to back you up on these claims. If you were to bring an action against this dentist, having another dentist willing to testify to the negligence is necessary. I wouldn’t reveal the name at this point, but I would let him know that you have that “arrow in your quiver.” And the fact that a general dentist did the root canal is not of itself a problem. Many general dentists do great work with root canal treatments, especially on front teeth, which are pretty easy. But there does seem to be an issue of competence with the dentist taking four hours to do a root canal that should have taken half an hour.

So I would tell this dentist that you have been to an expert cosmetic dentist, a dentist of international prominence, who told you that he had been negligent, but that you want to make it easy for him, so all you’re asking for at this point is a refund.

I hope this is helpful.

I’d be interested to know how this turns out. Please write back and let me know your next step and what your dentist says.

Links:
Click here for a referral to a cosmetic dentist.
Click here to ask the dentist a question.

 

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

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