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All on Four

Dr. Paulo Malo, a dentist in Portugal, in cooperation with Nobel Biocare, has developed what he calls the “All-on-Four” technique for dental implants.

The problem he is trying to address is restoring the mouths of patients who have lost all their teeth and don’t have much bone left to retain dental implants. Often these patients require extensive bone grafting procedures, which is time consuming and expensive.

Dr. Malo found that if he placed all the implants in the anterior of the jaw, where there is usually better bone density, and if those implants were highly angled, they could provide stable support for a complete denture.

The radiograph on the left and diagram on the right illustrate this technique.

all on four dental implants - x-ray view

Radiograph of All-on-Four dental implants

Here is a panographic x-ray of the four angled implants that have been placed.
You can see above that the implants are highly angled. But notice that the exposed tips of the dental implants, the part sticking out of the bone, are all pointed upward and are relatively parallel.

An illustration of placing All-on-Four dental implants

Placing a denture over All-on-Four dental implants

On the right you can see that when the denture is screwed on, the screws are all placed normally, because the angulation all occurs under the surface of the tissue.

But this technique isn’t without its critics. One renowned implant dentist in Phoenix who has pioneered other techniques, after thoroughly studying the All-on-Four technique, is concerned about its risks. If one of the implants fails, the entire mouth has to be re-done, and he feels that this is an unacceptable level of risk. Some leading implant dentists have been reporting higher rates of failure with this technique. Still others feel that there is no increased risk. The result is that some accomplished implant dentists will work with the All-on-Four technique, others refuse to do so. We advise you, before you have your dentist use this technique for you, that you be sure your dentist is highly experienced and willing to stand behind his or her work.

Click here to ask Dr. Hall a question.

Click here for referral to an expert cosmetic dentist.

Dentistry Study

for Infinity Dental Web content writers from David Hall

This page indexes the information on mynewsmile.com that you need to know in order to write our dental websites. Study it carefully. You may want to take notes. You need to know all of this very thoroughly to be able to write content for our websites. And so that there is no misunderstanding, this is considered “schooling” that helps you prepare for writing, and not paid time. So our expectation is that you study this on your own time. But the better you master it, the better you will write, which will translate into better pay. We want this investment of time you make to be a show of good faith on your part that you intend to do this and stick with it, because we want writers that we’ll be able to rely on over the long term. Plus, I make a sizeable investment in time in your training, and we want that investment to pay off.

After you read through this material, there is also a 20-page content writers manual we have you study, and a two-hour video to watch, and a quiz on those materials. Those materials focus on marketing strategies. You will learn that marketing a dentist is very different from most other kinds of marketing. One of our strengths as a company is our understanding of that, and it will be important for you to learn the fundamentals of that strategy. The manual also explains on-page search engine optimization.

This reading material, however, is actually only the beginning of your training. After you begin getting paid for your writing, for your first couple of projects, I will spend many hours instructing you further on the clinical aspects of your writing as well as the marketing. We want that investment that we make in you to pay off, and it will only do so if you continue with us over the long term. The system appears to work well, and most of our team of dental writers have been with us for a number of years.

When you take the test, we ask you that you not refer back to this website, but rather to answer only from your memory. This is important, because only then will you and I know if you have yet mastered the material. The test is challenging, and you will likely miss 20 to 30% or more of the questions. But as long as you have made a genuine and careful attempt to learn the material, I will walk you through all the questions you miss. For those questions, I will either suggest pages for you to review and then have you re-answer those questions, or I will simply give you the correct answer and explain why. But if you refer back to the website during the test, you will appear to be more ready than you really are, and you run the risk of bombing on your first project and exposing your lack of preparation.

The test is short answer, which helps me evaluate not only if you have the “right” answer, but if you’re giving the right reasoning that demonstrates whether or not you understand the material. If the comprehension seems to come quickly for you, go ahead and move quickly through the material. If you are uneasy about that, take your time going over it. We’re more interested in quality of preparation than in speed.

When you are writing content, you may certainly refer back to mynewsmile.com for help with writing and answering questions. However, you may not copy any content. Google severely penalizes copied content, and so every page for each site that you create must be written from scratch with unique wording. If we ever discover that you are copying content, even just paraphrasing other writing, we will not give you any more projects.

And when you do begin to write for us, remember that the focus of the mynewsmile.com website is very different from the focus of our clients’ websites. Mynewsmile.com is brutally honest and not politically correct, and so would be inappropriate for a dentist’s practice website. For example, it is blunt in its statement that only a few dentists are good at cosmetic dentistry. We would not want to be that blunt on a client’s website. Your reading here is to provide background information so that you understand the dentistry. When you actually begin to write, we have another website that is dedicated to helping train content writers, and one of the features of that website is a list of sample pages on all of the search terms that we typically target. Pattern your writing after those pages, not after mynewsmile.com, and it will be easier to stay out of trouble.

Start by reading all these main menu items:

Now go back through for more detail:

Bone Grafting

When teeth are missing, your body resorbs the bone that used to support those teeth. If you later want to replace those teeth with dental implants, you may need to have bone grafting performed.

For the patient, bone grafting can be expensive. But if you try to short-cut here, you will probably end up with dental implants that aren’t adequately supported and thus fail.

There are various sources that can be used for bone grafting. A popular source is the patient’s own hip. The hip is an excellent source of ample bone, easily accessible, and when it is used there are no issues with compatibility or communicable diseases being transferred from one patient to another. Many patients are uncomfortable with using cadaver bone or other sources.

The bone graft needs time to heal and to be knit together with your native jaw bone. Once it has healed, the dental implants can be placed. After implant placement, there is additional healing time usually required before the dental implant root forms can be reliably used to support teeth.

When there is general bone atrophy because of a patient missing all their natural teeth for a period of time, bone grafting is almost always needed. One attempt to avoid this extra step is to use the All on Four dental implants technique. While some dentists use this technique, it is a matter of some controversy in the profession. Some studies seem to indicate that there is a higher risk of failure with the All on Four technique, but dentists that use the technique deny that this is the case.
Click here to ask Dr. Hall a question.

This content was written by Dr. David Hall.

Dental Fear

Treating Anxious Dental Patients Like Me

by David A. Hall, DDS
This was printed in Dental Economics, February 2003

Does local anesthetic block pain? In the textbooks, yes. We read how local anesthetic prevents depolarization of the nerve membrane. With the local anesthetic acting on the nerve, it’s impossible for the nerve to transmit pain impulses. Theoretically. It doesn’t take too long in private practice to realize that there must be other factors at work, because we’ve all faced patients that are difficult or impossible to get completely numb. I know. I’m one of these patients.

My story of dental-chair trauma begins, as most of these stories do, in my childhood. I had a dentist who didn’t use local anesthetic. I tell people I think my fingernail-prints are still in his chair. Pain city! When we moved and got another dentist who used novocaine, I thought it was wonderful. Who invented this stuff? It was great!

I went on with basically comfortable dental experiences, but with some lingering bad memories. Then, when I was in college, I had an uncomfortable incident that brought back some of those memories. I was long overdue for dental care and I decided I needed to get caught up. I refused the dentist’s offer of nitrous oxide, so he gave me a shot of novocaine. The problem was the novocaine didn’t completely numb the area where the dentist was working. Being kind of a stoic, I didn’t let the dentist know I wasn’t numb. I just “toughed it out”.

In my thirties, I decided to finally get the braces that my family couldn’t afford when I was a youngster. I went to a dentist friend to have four premolars extracted. For some reason, I was feeling particularly anxious about this. I knew my bone was dense and the teeth had long, spindly roots. I was afraid the teeth might break off when he attempted to extract them … and they did!

My palms were sweaty, and it wasn’t long before the lidocaine wore off. The dentist gave me more. In about five minutes, it wore off again. He gave me still more. This went on and on – and I never was completely numb! It was a harrowing experience, yet I didn’t want to say anything to my friend because he was being so good about it and only trying to help me. But I was exhausted from the pain and stress, and I’ve had trouble getting numb ever since. Local anesthetic alone won’t do it!

About 10 years later, I developed a crack in a tooth and it required endo. The endodontist didn’t even have nitrous oxide available in her office. I decided I was going to psych myself up and get numb – I knew it was all in my head! But try as I might to relax, I just couldn’t. The endodontist couldn’t get me numb. “Give me an intrapulpal injection!” I pleaded. She complied. Whoa – was that an out-of-body experience! My tooth was finally 90 % numb, and we got through it; but, it took a heavy emotional toll on me.

So ask me if local anesthetic works! For me, it only works if combined with some type of anti-anxiety medication. Nitrous oxide does fine – with the nitrous running, I can get numb! Or, if I take some Valium and Demerol, I’ll get numb. But I won’t get numb with just a local anesthetic.

I’m unusual in that even though I had serious dental anxieties, I pursued a career in dentistry. There are many patients like me who have serious anxiety problems when it comes to dentistry. We don’t know how many for sure. Studies and experience indicate that at least 20 percent of patients have trouble getting numb with just local anesthetic. It’s probably more than that because this figure is based on people who show up in the dental office. So, if we, as dentists, intend to serve all types of patients, we need to know how to identify and treat the portion of the population that has so much trouble in our dental chairs.

Your first challenge is to identify the anxious patient. This is not a simple proposition. Often, they will not tell you. Some – especially men – don’t want to admit it. Others may just be stoic, noncomplaining types like me who want to try to tough it out, and may not even fully understand their anxiety. You can cut through both of these obstacles to quality treatment for these individuals by simply asking how “novocaine” works for them.

I sit every new patient down in my private office – in a nonthreatening, nonclinical situation – before I do my comprehensive oral evaluation. “I want to get to know you,” I will tell them. After asking why they’re in my office (i.e., their “chief complaint”), I immediately delve into anxiety-related questions. “So,” I’ll begin, “what have your previous dental experiences been like? Any traumatic experiences? I like to know these things.” Some of them will spill it out right there: “Oh, I had this terrible dentist when I was a kid!” they may say. “He ate children for lunch! I’m sure of it!” Other patients might give me a perfunctory “no” for an answer. Even if they reveal no previous traumatic dental experiences, I still need to know more.

My second question is the key: “When you’ve had dental work done, I suppose you’ve had novocaine?” I wait for an acknowledgement and then go on. I use the word “novocaine” because that communicates my meaning to the vast majority of people. “So, does novocaine work for you? Are you numb and comfortable after the injection?” If the patient indicates directly and without hesitation that novocaine has worked fine, then I’m satisfied and I move on to other questions and a review of that person’s medical history. If there is any hedging, hesitation, or qualification in the response, I pursue it. Often, patients will tell me that novocaine works fine for them, but then there is a hesitation. If I pause to let the patient talk, then he or she may reveal the problem. “Sometimes, it takes a little extra novocaine,” the patient may confess.

Any patient who qualifies the answer to the question, “Does novocaine work fine for you – are you numb and comfortable every time?” is an anxious patient and you need to address that anxiety to properly treat this person.

However, some anxious patients may slip through this detection system. A history of irregular care may tip you off, such as patients who come in only for pain or lost fillings. Or, you may not discover their problem until you actually begin treating them. For example, the local anesthetic is wearing off much more quickly than it should. If you’re alert and understand the pain-anxiety-more pain-more anxiety vicious cycle, you’ll be able to identify it and treat the patient successfully.

Treating the anxious patient

Treatment of anxious patients needs to be custom-tailored to the level of anxiety of each particular patient. Different patients require different levels of care in order to get them comfortable.

Basic level of care

Let’s call the first category of patients the ones who only require a basic level of comfort. This is the level of care for the majority of your patients – those who report no history of dental trauma or problems with local anesthetic. With these people, you need to address basic comfort issues to keep from turning them into anxious patients. Here are the principles used to treat patients in this category:

  1. Trust – Trust helps prevent anxiety. If patients trust you, it will help keep them comfortable. There are two elements to trust: 1) skill and 2) caring. If patients feel that you care and that you have the necessary skill to properly treat them, they will put their trust in you and trust dispels anxiety.
  2. Sensitivity – You must show sensitivity to the patient’s needs. This concept overlaps the concept of caring, but I address it separately because certain behaviors need to be addressed. By sensitivity, I mean that you begin your doctor-patient relationship by meeting the patient in a nonthreatening environment, such as your private office. I also mean that you don’t dictate treatment to your patients, but give them options and let them choose their own care. I also mean that you respond to the patient in the operatory. You listen. You also provide the level of information that the patient wants. Some patients want to know everything about what you’re doing, while others want you to just tell them when it’s over.

You pause in your treatment when your patients need to pause. You put up with their idiosyncrasies. You recognize that many people feel very threatened when you enter their oral cavity. You understand that a sense of powerlessness intensifies anxiety. All of these attitudes and behaviors on your part exhibit sensitivity and help dispel anxiety. This is the level of care you need to give everyone.

But if a person has had trouble with dental treatment before, my experience is that you need to go beyond these basic comfort issues. Let me remind you that I speak from the dual perspective of a clinician and an anxious dental patient. I believe that you need to treat the patient’s anxiety pharmacologically to ensure that he or she will have a comfortable experience.

Yes, you can try to manage these patients with psychology. You may even be able to say that the psychology probably will work. But you need to understand the interplay of pain and anxiety. Pain causes anxiety. Anxiety intensifies pain and complicates its management. Also, anxiety is an antagonist to local anesthetic. The presence of anxiety can cause a local anesthetic to either wear off quickly or to not completely block the pain. Finally, when it comes to pain and anxiety, negative experiences are far more powerful and long-lasting than positive ones. If you’ve had five good dental experiences and one bad one, and you go to sit down in the chair, which one is going to come to your mind? The bad one – we all know that. So, if you create an experience with less than total pain control, you will be feeding into this negative pain-anxiety cycle.

Now, if you have that aura about you that you can use psychological techniques alone and all your patients are comfortable, then I’d say to just keep doing what you’re doing. This article, I guess, isn’t for you. But if you lack that aura, then my suggestion is to err on the side of controlling the anxiety more aggressively rather than less.

The mildly anxious

Let’s call the second category of patients the mildly anxious. These are the people that have had occasional trouble with dental care – an incident where they wouldn’t get numb, a dentist who slapped them when they were a child, something like that. I have found that nitrous oxide works well for these people – and they’re the majority of the anxious patients. Sometimes you need to even politely insist that the patient use nitrous oxide. They don’t understand that they need it in order to be numb. I explain to them that the nitrous oxide strengthens the novocaine, and since novocaine alone doesn’t work for them, we need to up the strength with nitrous oxide. It won’t impair their ability to drive or work after the appointment, and I make the cost of the nitrous low enough so that money isn’t an obstacle and so that they don’t think I’m pressing the nitrous in order to increase my revenue. And by polite insistence, of course I don’t mean that you force them. You can’t do that. But you earnestly urge them, for their own sake, to let you give them what you believe they need in order to be comfortable.

What do you do for the patient who fools you? You don’t identify their anxiety until you’re in the middle of the appointment? With these people, you need to stop, explain what is happening and how you believe nitrous oxide will help them. Then you induce the nitrous oxide and give more local anesthetic. Whatever it is about the effect of the anxiety on the potency of the local anesthetic, I have found that you need to treat the anxiety and then re-administer the local for the local to have full effect.

Severely traumatized patients

The third category is made up of patients who have had very traumatic experiences in the dental chair or repeated failures to get numb. These people may not get numb even with the use of nitrous oxide, and you will need to go to orally administered sedatives such as Valium or Halcion. Both are great drugs. Valium has a much longer half-life, which, in my mind, makes it a great drug for surgery. The person will still feel the effects of Valium the next day, which will help them rest. But there is a lot of confusion and contradiction in the published information about Valium. Many textbooks suggest an oral dose of 5-to-10 mg. for anxiety. While that dose is completely inadequate for many patients presenting with high levels of anxiety, there is an implication that much more than that would be an overdose. On the other hand, there is actually no safe dose limit established for Valium. Some people have swallowed whole bottles of Valium pills in attempts to commit suicide and failed. In some instances, even though they took a number of pills, they didn’t even require resuscitative measures. So, what is the upper limit for a safe dose? I can’t tell you. It would be a good idea for our experts to clarify this issue with hard scientific data, not just professional bias.

But Valium is an older drug which, these days, has frequently been replaced with Halcion for oral sedation for dentistry. With a shorter half-life, Halcion is more convenient. It has harder safety data than Valium because there have been some adverse incidents reported with its use.

Patients who become physically sick

There is a fourth category of patient that is beyond the reach of moderate doses of anti-anxiety drugs. These are the people who may become physically sick even thinking about dental care. These patients will need to receive conscious sedation (or general anesthesia in severe cases). In times past, conscious sedation was administered with intravenous drugs. More recently, it has become common for dentists to achieve conscious sedation with orally administered drugs. The American Dental Association has recognized and sanctioned this practice, and has published guidelines of educational standards, monitoring, and emergency preparedness for dentists who wish to use these techniques.

Regardless of whether or not it is required by your state board regulations, I feel that you need that higher level of education in physiology and pharmacology and anesthesiology to safely administer oral conscious sedation. There are organizations that will teach you these things. If you’re interested, seek out a reputable course and get the training you need to effectively provide this service. You’ll become a credit to your profession and a servant of a segment of the population that really needs these services.

My opinion is that there are a large number of people who are not coming in for dental care who would come if we were more proficient at treating their anxiety – up to and including the use of conscious sedation by appropriately qualified and conscientious practitioners. Minimally, however, we should all be willing to be trained in the use of nitrous oxide, as well as in providing modest doses of anti-anxiety medication where indicated. Our patients need it!

Patient Anxiety Categories

  1. Those who require a basic level of comfort. These patients have no history of dental trauma.
  2. Those who are mildly anxious. These are the people that have had occasional trouble with dental care.
  3. Those who have had very traumatic experiences in the dental chair. These people may not get numb even with the use of nitrous oxide, and you will need to go to orally-administered sedatives.
  4. Those who become physically sick even thinking about dental care. These patients will need to receive conscious sedation or general anesthesia.

Dr. David Hall.

Your child’s first dental appointment

Many times parents worry about preparing their child for their first dental appointment. But experience shows an interesting pattern. Sometimes the preparation backfires by making the child worried or anxious about the visit. Often, the children who do the best seem to be the ones with the least preparation.

When you think about it, this pattern seems to make sense. If parents aren’t worried about the visit and treat it as routine, then the children are also likely not to worry about it.

Most general dentists who like seeing children in their practices recommend first seeing children when their baby teeth have all erupted, or are close to being complete. This usually occurs around age two or three. That’s what I did when I was practicing. And if you take your child in for a routine exam at this time, you are well on the way to helping that child develop a healthy attitude toward dental care. This visit can be fun for your child. We would “count his or her teeth”—do a quick check in the mouth, tooth by tooth. If they are willing to accept it, we would do a light cleaning. This helps the child develop a positive attitude toward dental care.

If you wait until your child has a dental problem, this first visit could end up being very traumatic for them, and could adversely affect their attitude toward dental care for the rest of their life.

Depending on your child’s age and the personal style of your dentist, your child may sit on our lap or in a chair near you. Some dentists prefer to have you wait in the waiting room for your child. In any case, a big concern during the first visit will be to help your child establish a relationship with the dentist and the staff.

Usually around age four is when your child will be old enough to cooperate in the taking of x-rays. I never recommended fluoride treatment for children until the permanent teeth came in—the benefits are transitory, and the children are too likely to swallow the fluoride, which isn’t healthy.

This content was written by Dr. David Hall.
Click here to ask Dr. Hall a question.

Cosmetic Dentistry Mistakes / Horror Stories

Unfortunately, I have a large file full of stories I’ve received from patients who have been the victims of cosmetic dentistry mistakes. While many who email me just need reassurance that they are receiving good care, there are many unfortunate cases like some of these in which the dentist, who may be a nice person and very knowledgeable in general dentistry, does not appear to know the subject of cosmetic dentistry very well, and the dentist ends up “practicing” cosmetic dentistry on the patient. In many cases, these unfortunate patients now have no legal recourse after their cosmetic dentistry mistake, because the dental care they received met the legal standard of care—the typical level of care for general dentists—even though it was far short of the standard of care for expert cosmetic dentistry.

And by giving these examples of dentists who gave less-than-expert cosmetic dentistry care, by no means do I intend to imply that dentistry as a profession in the United States is in bad hands. The level of general dental care and expertise in the United States is very high. But there is clearly a problem with patients being able to get excellent cosmetic dental care from general dentists.

So look through this list, and then check the larger list on my blog under the category of cosmetic dentistry mistakes.

—Dr. Hall

Read the amazing article from the June 29, 2004 Wall Street Journal, “New Business for Dentists: Fixing Botched Cosmetic Work.”
Read about the difference between a general dentist and a cosmetic dentist.

And keep in mind that these emails are only a sampling of this type of complaint that I receive. I have received hundreds of emails that are similar to these, in which the patient has sought treatment from a dentist who claimed to understand cosmetic dentistry but didn’t. Click here if you have had a problem with your cosmetic dentistry that you’d like to ask Dr. Hall about.

Lynn in Minnesota says her dentist is trained in cosmetic dentistry, but her porcelain veneers look gray. Dr. Hall explains that expert cosmetic dentists know how to use opaquers to block out the underlying color of dark teeth.

Stephen in Ontario said that his wife recently got three new fillings. She wanted white fillings, and the dentist obliged, but now she has terrible pain in all three teeth. Dr. Hall explains that the dentist was probably not fully trained in placing white fillings on back teeth, but did them anyway to try to please his patient.

Cindy in New Jersey had six porcelain veneers placed. Several months later, one of them cracked. The dentist replaced the cracked veneer, but the replacement veneer is much thicker and whiter than the other five. Dr. Hall helps her get a refund and a referral to an expert cosmetic dentist who gives her a beautiful smile.

Karen in Ohio had bonding done, but the bonding looked like putty and now has come off. Dr. Hall explains color depth and opaquing.

Michelle in Georgia says she wants her bonding replaced but her dentist says that the new bonding will be amber colored and she should have caps instead. Dr. Hall tells her how dental bonding, in the hands of an expert cosmetic dentist, can look beautiful and can be as white as she wants.

Tom in London, England went to a dentist for a new smile, but his porcelain veneers have begun to yellow after only two months. Dr. Hall questions if the “porcelain veneers” are really made of porcelain.

Stacy in Missouri asked her dentist to give her the whitest veneers possible. But the veneers she got are actually darker than her own bleached teeth. Dr. Hall tells her that general dentists often don’t know the full spectrum of colors that are available in cosmetic dentistry materials and that there is no limit to how white she can have her veneers.

Lee Ann in Tennessee has six porcelain veneers. One had to be replaced because it chipped, and the new one is more opaque than the others. Dr. Hall urges her to go to a genuine cosmetic dentist who understands color and opacity and can give her an accurate color match.

A.R. in California has had upper veneers for seven months, and they are starting to get a yellow tinge. Dr. Hall tells A.R. that properly done porcelain veneers, that are really made out of porcelain, are very color-stable.

Gonzalo in Alabama had one tooth bonded, and now he wants to bleach his teeth. Dr. Hall tells him that his bonded tooth will not bleach and that he should have bleached first and bonded after that.

Sharla in Iowa wants porcelain veneers, but her dentist says they won’t last and that she should have one front tooth pulled and then a bridge. Dr. Hall congratulates her on not wanting her front tooth extracted and urges her to go to a fully trained cosmetic dentist who can give her a beautiful smile.

Matthew in Pennsylvania had his front two teeth bonded. On one tooth, in several places, there is some discoloration in the bonding. Dr. Hall tells him that his dentist may be doing the best that can be done under the circumstances.

Barbara’s daughter in New Jersey had uneven color on her two front teeth. Her dentist recommended bleaching, but the blotchy color hasn’t gotten any better. Dr. Hall tells her that bleaching was the wrong treatment for this case and to consult a fully trained cosmetic dentist for this situation.

Chris in Oregon is having 11 crowns done on her top teeth. After the first appointment, the lab technician said they were going to do porcelain to metal crowns, but Chris wants Empress crowns. Dr. Hall expresses some grave reservations about how this case is proceeding and recommends that she switch dentists.

Silvia in California had a porcelain veneer and a porcelain crown done on her two front teeth. While they looked okay in the office, and she signed a paper in the office that they looked fine, when she goes into outside light, they look different in color. Dr. Hall explains the concept of color metamerism that her general dentist maybe doesn’t understand.

Tracy in New Jersey had porcelain veneers done 22 months ago, and all the porcelain veneers have fallen off. The dentist made a whole new set, and one of the new ones has now fallen off, and all the teeth hurt terribly.

Marie from Wisconsin has had porcelain veneers for six years. The last time she got her teeth cleaned, the hygienist used the prophy jet salt-water spray to clean them. Since then the veneers have become more yellow. Could the spray have damaged the veneers?

Lesley in Texas had Lumineers and crowns placed. Now one of them is turning dark, and she is terribly self-conscious. The advertising makes it seem that it is easy to place Lumineers, but this case shows how going to the wrong dentist can become a terrible mistake.

Mark in Michigan had four porcelain veneers, then had six more done. The new porcelain veneers don’t match the old ones.

Click here to read about the difference between a general dentist and a cosmetic dentist.

Click here to read Dr. Hall’s blog post about how to ask for a refund from your dentist.

By Dr. David Hall

Deep Cleaning

Dental Insurance Doesn’t Like to Cover Deep Cleanings

But don’t let that dissuade you, if you need this service.

It is needed for treatment of certain types of gum disease.

In gum disease, you get deposits of tartar or calculus on the root of the tooth. This calculus is made up of bacteria that are embedded in mineral deposits. It is highly irritating to your gums, and is associated with the deepening of pockets in your gum and the destruction of the bony support of your teeth.

Deep cleaning involvesdeep cleaning going into these pockets with instruments and cleaning out the calculus. When you have gum disease, it’s important that these pockets be cleaned out thoroughly.

For financial reasons, dental insurance doesn’t like to pay for this higher level service. They also often deny claims when these cleanings are done more often than every six months. In doing this they are putting their own financial interests above the health of the patient. The truly unfortunate thing about this practice is that their policy implies that these services aren’t needed, which causes some patients to question their dentist. But the truth is that it is the truly ethical dentists who genuinely care about their patients who are performing these services.

It is very easy for dentists to place a low priority on treating gum disease. When they do that, they won’t have to hassle with the insurance companies. They can also hire a dental hygienist with a lower level of skills, which may save them money. And the deleterious effects of ignoring the progression of gum disease may not be felt for decades.

But with gum disease, it is strongly recommended that an initial deep cleaning be done using novocain, and it may take as many as four appointments to complete. After the initial deep cleaning is done, maintenance periodontal cleanings should be done every three or four months, depending on the severity of the gum disease and the response seen in the patient’s mouth. In some cases, they should be even be done every two months. These maintenance cleanings, besides being more frequent, require a higher level of skill and take longer than ordinary cleanings, so they are more expensive.

I remember a discussion I had on the phone with a representative from a dental insurance company when they had denied a claim for the maintenance cleaning for one of my patients. They had a policy that they would pay for those maintenance cleanings only for one year after the deep cleaning, in spite of the fact that gum disease never really goes away and the maintenance needs are perpetual. But they wanted to save some money. He would not budge, so finally I told him that what we would do then was re-do the initial deep cleaning each year so that we could fit the patient into their policy. With that he changed and agreed to cover the maintenance cleaning.

—Dr. David Hall.
Click here to ask Dr. Hall a question.

Dental Floss

Flossing is a critical part of keeping your teeth clean. A toothbrush will clean the smooth surfaces of your teeth very well, and will also reach into the crevices under your gumline.

smooth surface
At the left the picture shows the area that a toothbrush cleans well. These smooth surfaces do not get cavities very often, because most people clean this part of their teeth pretty well and pretty regularly.
floss between teeth
However, the place where the teeth touch together, the interproximal zone, is a frequent place for tooth decay. You need dental floss to clean this area at all.The interproximal area is also the prime spot for developing gum disease

One of the things that can make flossing difficult is if the floss shreds. It will shred if you have rough dental work that involves the contact point, or if the teeth are too close together. For this reason, waxed floss has become popular. The wax helps it glide through the contact point more easily and also strengthens it to resist shredding.

This content was written by Dr. David Hall.
Click here to ask Dr. Hall a question.

Read Dr. Hall’s blog posts about tooth decay and gum disease.

Denture Reline

When you have complete dentures, they should fit snugly when they are new. However, your jawbone, when you have no teeth, will continue to shrink over time and the dentures will become loose. This is why every few years you will need to have a denture reline.

There are adverse health effects of a loose denture. If they go for too long without proper care, the soft tissue begins to overgrow in folds under the denture and around the rim. There are cases where surgery may be required to to remove this excess tissue. Sometimes, however, the tissue overgrowth can be healed easily with tissue conditioner treatments from your dentist.

There are various types of denture relines available. They can be done in the office or sent to a dental laboratory. They can be either hard or soft. The advantage of the in-office treatment is that you don’t have to be without your teeth for the day or two that would be required of laboratory processing. In-office reline materials have improved somewhat over recent years. Light-cured materials have been developed that are more durable and longer-lasting than the old chemical-cure materials.

And soft denture relines are more comfortable than hard ones, though they are more expensive and less durable. Click the link to read our page on that subject, to learn more about their pros and cons.

A home denture reline kit

A home kit

There are also home denture reline kits available. We recommend them only for temporary fixes, because, as mentioned above, if this procedure isn’t done properly, it can cause difficult-to-treat soft tissue problems. If money is an issue, we would advise you to shop around to various dental offices. This procedure is fairly straightforward and within the abilities of every dentist, and you are better off in the hands of a cheap dentist than trying to do it yourself.

This content was written by Dr. David Hall.
Click here to ask Dr. Hall a question.

Crowns and Bridges

This page indexes information on this website about crowns for broken-down teeth, as well as bridges and other treatments for replacing missing teeth.

A crown (some people call it a “cap”) is used to restore a tooth that would otherwise be in danger of breaking. It covers and protects the entire tooth. Click here for information about crowns for front teeth. Click here for a general discussion of all types of crowns including porcelain crowns, whether for front teeth or back teeth. We have a separate page about the new CEREC crown that can be fitted in one appointment instead of two. For general information about dental crowns, click here.

A dental bridge is used when there is a tooth missing. It usually involves putting a crown on each tooth on either side of the missing tooth, and then a false tooth or teeth is suspended between the crowns.

An Encore® bridge is a special kind of bridge that is popular with some cosmetic dentists. It is made entirely of tooth-colored materials.

A Maryland bridge is like an Encore® bridge but with a metal framework instead of a tooth-colored framework. This causes some esthetic problems.

A dental implant is a tooth replacement that is surgically placed in the jawbone, and then a crown is placed over the implant. For replacing a front tooth, we recommend a cosmetic dental implant done by an expert cosmetic dentist.

A removable appliance may also be used to replace a missing tooth.

A dental crown

A dental crown

Read about metal allergy.

This content was written by Dr. David Hall. Click here to ask Dr. Hall a question.