Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

May 29, 2018

I went directly to the dental lab to make my partial


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Dr. Hall,
I had an upper partial made by a dental lab. I did not go through a dentist.

The last partial I got, nine years ago, my dentist used this lab. They did such a good job that I decided to go directly to them this time. But this time it’s not working out so well. I have a front tooth missing that was supposed to be replaced using this partial, however, the tooth won’t stay fastened to the metal. There was so much plastic backing that all the pressure was on my one bottom front tooth. He ground down a lot to make my bite touch but now there is not way of holding this tooth in place. Also the plate is too short and is sitting in the cavity where my old tooth was and it creates a rocking motion when I chew.

I have been back at least nine times and the last time he told me to go away and stop bothering him. I asked for my money back but he refused. What can I do to get my money back?
– Bill

Bill,
A very interesting question, and there are some interesting points to make in answering you.

I must say that I’m not following you as far as understanding the problems you are having with the bite and the one tooth in this removable partial denture. The rocking I understand, and that is a fundamental problem that in most cases is due to a distorted framework—a problem that could have originated with a distorted impression. Fixing this would require starting over again. The impression is supposed to be taken by the dentist, who is trained and experienced in creating an accurate model of your teeth that will enable the technician to fabricate an accurate metal framework. Technicians aren’t trained to do this step, which is one of the reasons it is illegal for them to do that.

So the answer to how to get your money back is fairly simple—just threaten to report the technician to the authorities. This seems mean because, while it was illegal for him to make this removable partial without involving a dentist, you were the one who asked him to do it, so you should share in that responsibility. But he is the one who knows the law better and so bears the bulk of the responsibility. So just go to him and tell him that if he doesn’t refund your money you’ll tattle to the state dental board and agree to be a witness in his prosecution. My guess is that this will work magic. And hopefully that may save some other patient from making the same mistake you did.
– 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.

May 3, 2018

Whose fault is it that this tooth broke off?

Filed under: Fractured teeth — Tags: , , , , — mesasmiles @ 9:41 am

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Dr. Hall,
I had a crown put on tooth #7 (right lateral incisor) about 40 years ago but no root canal. My dentist said I now need a root canal on that tooth due to decay under the crown. I’ve had no pain, abscess or any indication of infection. The dentist attempted a root canal through the back of the crown and after 2 hours he gave up and said the canal is calcified and he is unable to locate it. He put a temporary filling in the crown and said I will need an endodontic specialist to perform the root canal. Because I am not in pain, the endodontist booked me an appointment 4 weeks out. Well it’s been 2 weeks and now my crown (with some tooth inside) has broken off and I don’t know what to do. I’m elderly and can’t spend a fortune on this tooth issue when it probably should have been left alone in the first place. Should I just get an implant? Attempt a root canal? I doubt there is enough tooth left to put a new crown on even if the root canal is successful. I bought some DenTek at the drug store today and can reattach the crown myself. I would greatly appreciate your perspective on this.
Ruth

Ruth,
I’m going to start by trying to answer a question that you were too polite to ask: Whose fault is it that this tooth broke off?

Your dentist was drilling inside this tooth for two hours looking for the root canal and not finding it. It’s hard not to believe that doing so seriously weakened the tooth and is the reason it broke off. And having done that, he didn’t pass that information on to the endodontist or do anything in the meantime to strengthen the tooth. Hopefully he has learned a lesson from this, but meanwhile you are victimized here. It seems reasonable to me that he should accept some of the responsibility for the fix you are in.

With there being decay under the crown, the logical way to proceed here would seem to me to be to take the old crown off (it will have to be replaced anyway), get rid of the decay, and then finding the canal would be much easier. If the tooth really got infected, then the decay penetrated into the canal. But even if it didn’t, having the crown off greatly increases visibility and access.

Meanwhile, to answer the question you actually asked, if the tooth is down to a stump then yes, it may be difficult to put a crown on it and you could lose the tooth and need an implant. However, if your bite isn’t particularly stressful, the right kind of dental post in the tooth could enable it to hold a crown, even if there isn’t much of the tooth left. But after the fiasco you’ve been through, I’m doubtful that your current family dentist has enough expertise to pull that off. The placement of the post or posts would need to be done in such a way as to brace the restoration against rotational forces, and that can be tricky. Posts are round and lateral incisors are kind of round in cross section, and it doesn’t take much twisting force to loosen a crown and post in this situation.
– 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.

April 21, 2018

Water relieves the pain in my tooth


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Dr. Hall,
It’s been ten years since I got my two fillings. One fell out but doesn’t hurt. The other one is still in but is causing severe pain. It doesn’t bother any to bite on it, but it hurts most of the time. The only thing that relieves the pain is water and only for a few seconds. Any advice?
– Brandon from Oregon

Brandon,
I wish I had better news for you, Brandon, but your tooth, the one with the filling, is showing classic signs of a dying pulp and you’re going to need a root canal treatment on it. I’d get the other filling replaced before it’s too late.

Here’s what’s going on. There has been some decay get into the tooth, probably getting under the filling. That decay has grown until it has infected the pulp. As the infected pulp tissue dies, it can go into a state where it is called a gangrenous pulp. In that state, it gives off gasses that increase the pressure inside the tooth and cause a toothache. When you cool the tooth with water, it causes the gas to shrink somewhat and eases the pain.

This is a classic situation. When a patient reports that cold water or ice water is the only thing that relieves their toothache, you can be 100% guaranteed that they’re suffering from a gangrenous pulp in a tooth that has almost died. Relief can be obtained by simply creating an opening into the tooth to relieve the pressure, but then it needs to be followed up with a root canal treatment to fully remove all of the infected tissue inside the tooth and seal it against further problems.

It’s a similar situation when a tooth is sensitive to heat—it’s a nearly dead tooth.

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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.

April 13, 2018

My wisdom tooth is touching the nerve. Will it cause nerve damage to take it out?


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Hi Dr. Hall,

I am most grateful I came across this website. I have read the posts and I can’t say how much appreciation I have to see your honest and direct feedback and opinions.
I would be very very grateful if you could shed some light with your experience in my situation:
1. I have an impacted lower left wisdom tooth, I did an x-ray and the doctor (surgeon specialist) said it is close to the nerve and he recommended me to take a CT scan, which I did.
2. CT scan came back and he told me the tooth is touching the nerve (how much I don’t know), but I asked him what is the probability of damaging the nerve? He said 10% chance to damage the nerve, but after reading your blog about the risk of nerve damage, it seems like with a tooth touching the nerve – chances of damaging the nerve should me much higher? please would very very much appreciate your thoughts on this.
I am turning 30 years old this year.
One more piece of information – the impacted wisdom tooth is lying horizontal and food gets stuck there most of the time when I eat.
– Dennis

Dennis,
You referenced my earlier blog post on what are the real chances of nerve damage from wisdom tooth removal. The main point there is that the surgeon is more likely to exaggerate the chances of nerve damage rather than minimize it. I would take the 10% chance of nerve damage that he has quoted you as a fair estimate. And I would add to that that the damage would most likely be temporary. The most likely type of damage would be compression or bruising of the nerve, and not severing the nerve. I’m not saying that permanent damage isn’t possible but that it isn’t likely.

The use of CT scans is decreasing the chances of damage to the nerve because the surgeon can now tell, in advance, exactly where the nerve is in three dimensions. When I was doing this, if the nerve appeared superimposed over the tooth, I didn’t know whether it was in front, behind, touching, 1 millimeter away, or anything like that. So I had to be very cautious and allow for multiple possibilities.

Your surgeon just has to avoid any pressure in the direction of the nerve and, in sectioning your tooth prior to removal, has to stay away from the nerve. Then, post-operatively, you need to be aware that there will be swelling that could press against the nerve. If you notice any prolonged tingling or numbness after the novocain has worn off, advise the surgeon, and he will likely prescribe a steroid to hold down the swelling and minimize that pressure against the nerve.

– 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.

April 4, 2018

A botched sinus perforation


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Hello Dr. Hall-
I had my right rear molar extracted because it felt sore when chewing and didn’t hit much on teeth below. The molar, I found out later, was in the sinus. Anyways, after the extraction, the dentist put a plasma plug into the socket and sewed that and something neon yellow into the tooth socket.

While recovering, about an hour after the extraction, I was feeling a lot of sensitivity in the right canine tooth. After carefully drinking a green smoothie, I noticed some of that liquid was in my nose with some blood. I went home to take it easy and did almost nothing and didn’t talk because certain words made me feel like air was going into the socket.

I called the dentist and went back. They did the exam and then they cut some of the tissue, scraped some bone and filled the area with collagen and sewed it in, this time with non dissolvable stitches and said come back in three weeks. I have been only drinking fluids, not bending, not looking down, just on bed rest eating healthy meals. Today is six days after surgery, and the packing has dissolved and most of my symptoms are back and my sinuses or ears are both aching. Yesterday the ear pain came and went. I am not talking because it feels sensitive speaking certain letters.

Do you think I should give this dull throb time to heal itself and keep taking it easy? Is this sounding like dry socket and a perforation? If I found food I drink in my nose – does this define a perforation? The dentist didn’t speak clear English so I am not sure what I have. I have been in so much pain from swelling and bruising. I took all 5 days of antibiotics and the sinus pills but the pressure and pain in my ears makes me think this is all causing a sinus infection? I also noted oral thrush as I have been taking antibiotics for a month. What should I do? I have no insurance. Is it definitely a sinus perforation if I saw my smoothy in my nose? Is it dry socket? Shall I give it a few more days? Yesterday I placed a small sterile gauze ball over the area. It was too uncomfortable and when I removed it, it had a bad odor. Thank you for this blog and for your help! What shall I do?
– Vanessa from California

Vanessa,
It certainly doesn’t sound to me like you are in good hands. I would find someplace to go for a second opinion.

With the pain and delayed healing, and you mention swelling, it sounds to me like, on top of the sinus perforation, you have an uncontrolled infection. If that is the case, you need a dentist who understands infection and knows how to pick the right antibiotic. I would tend to check with an oral surgeon, with that being the case. It also could be that you have a root tip or a bone fragment that went up into the sinus and that is what is causing the infection and complicating the healing.

And these sinus perforation repairs should not be falling out after a couple of days. I don’t understand that—if they sewed it closed, why is it coming out? Yes, when you have fluids or air passing between your mouth and your nose, that is a sinus perforation. Again, hopefully a dentist with a better command of the situation can get this fixed properly for you.
– 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.

March 16, 2018

Ordering Implant Parts Online


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Dear Dr. Hall
I have full upper dental implants, the kind that are removable, the kind that snap in with four posts. I need the locator male retention caps, but my dentist charges me $25 for one! Not one set—one single little piece of silicone or nylon (I’m not actually sure what they are made of). I can’t afford to pay that much anymore. I have seen them online for $20 for a set of four, but I cannot order them because I’m not a dentist. Is there anywhere I can buy them without being a licensed professional?
– Sue from Las Vegas

Sue,
While I understand why your dentist may feel that he or she needs this markup because of high office overhead, this is such a small item in the dental office operation scheme of things, you would think they could make some allowances. Anyway, I have a couple of ideas for you.

The first is to call around, explain your situation to various dental offices, and I’ll bet you could find someone who would order them for you at cost. Dental offices tend to be populated by friendly, kind people, and I would think you could find a sympathetic dental assistant who would order these for you. The dentist doesn’t actually have to be personally involved at all. The staff usually does all the ordering.

But I actually believe you can order these without being a dentist. If you go to ebay rather than an established dental supply house, I am finding dental implant locator caps available there from overseas sellers and they are not requiring any documentation of your being a dentist or dental professional. The caveat here is that you need to know exactly what you want and how to pop them into your denture. There are various strengths of these caps—soft ones and firm ones that give different amounts of resistance. And they’re about $20 a set or more, depending on whether or not you get some other things with the caps.

Good luck.

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.

March 7, 2018

Can a root canal treatment be re-done a second time?


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Dr. Hall,
I have a tooth with a root canal that has been redone once, nine years ago. the tooth is bothering me again. Can the root canal be redone more than once?
– Jodie from Ohio

Jodie,
A root canal treatment can be re-done twice, three times, whatever, but that’s not the question. The question is whether or not that makes sense as a treatment.

Root canal treatment is one of the less predictable treatments in dentistry. It is accepted that even when the dentist has done everything right, there could be a failure rate of 5-15%, maybe more if the dentist is less skilled at this procedure. Let me explain the reason for this.

The living tissue inside your tooth is the pulp. There is a pulp chamber up in the crown of the tooth and a pulp canal that conducts the blood supply and the nerve to this pulp chamber. When the pulp becomes infected, the chamber and the canal have to be cleaned out and sealed against any bacteria re-entering the tooth. The problem is that the pulp canal can have branches and twists and turns inside the tooth that can, in some situations, make it difficult or even impossible to full clean out and seal. For example, in a molar, the standard number is three canals—one for each of the three roots. But often there is a small, difficult-to-find fourth canal. Furthermore, sometimes some of the canals can split off into branches at right angles. The dentist has tiny, highly flexible files that he or she inserts into the tooth and cleans out the infected tissue. There is no way this file can be manipulated to enter a side branch that comes off at a right angle.

Now these anomalies occur in a small minority of teeth, so the large majority of root canal treatments are successful. If a root canal treatment fails, re-treatment can remedy the situation, but only in somewhere around 50 to 75% of the cases. But if that re-treatment was done by a dentist skilled in root canal treatment and didn’t work, there’s a pretty slim chance that it will work if tried again.

There is another option, and that is root canal surgery. The dentist, most likely a root canal specialist, will make an opening in the bone and cut off the root tip of the infected tooth, and probably do a small filling at the end of the tooth to help ensure that it is sealed. This is called an apicoectomy and retrofill. If a root canal re-treatment has failed, this is usually the next best option and will be successful again in somewhere around 50 to 75% of the cases. Furthermore, some roots of some teeth are not surgically accessible or are in locations that would make surgery very risky, such as near the nerve that goes to the lower jaw and lip.

Another option is extraction. This isn’t the first choice, for sure, but some teeth are simply not savable.

– 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.

February 19, 2018

Another Sinus Perforation – Did My Dentist Treat it Right?


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Hello Dr Hall,

First off I would like to thank you for sharing your time and knowledge. Today I had 12 teeth extracted. Upon removal of an upper molar, my sinus was perforated. The dentist put a compound in to increase blood clotting. Immediately I was able to breath quite easily through the perforation. Will a perforation allowing air through easily heal properly? I was prescribed a 10-day antibiotic to help prevent infection. I am also not currently experiencing any real pain or discomfort. Kinda strange while normal at rest breathing I feel the air in my mouth. I am currently using gauze to apply pressure although I have no bleeding. Any information you can offer will be greatly appreciated. Thank you for your time.

– Robert L.

Robert,
I don’t want to paint myself as the country’s greatest expert on sinus perforations, though I’m getting a lot of questions on this. I had only had this happen to my patients a couple as I was practicing, and I followed the procedure I was taught. I packed the socket with gelfoam – a resorbable sponge that assisted in the retention of the blood clot and its conversion into replacement bone, and then I pulled some of the tissue around the tooth I had extracted – this tissue becomes loose when the tooth is gone and it was easy to pull that over the extraction site to close it over. Then I advised each patient not to blow their noses for a few days. Both cases healed in a few days and without complications. Bone grafting materials are now readily accessible to oral surgeons, and they can be used to accelerate the healing of bone – which is the goal here – to re-create a layer of bone between the teeth socket and the sinus.

What I was taught was to eliminate that air passageway between the mouth and the nose so that the perforation would heal. Now you’re telling me that you have a hole in that perforation that hasn’t really been closed. Will it heal? I’m guessing that eventually it will, but I’m not entirely sure, and it could take quite a long time. But meanwhile you have a situation susceptible to infection and every time air goes through the hole it’s going to want to open that hole a little more–not how I was taught and it seems to me a recipe for very slow healing. Plus what do you do when you’re eating peas and they get up into your nose? :-). I know some kids who would love that, but that can’t be how this is supposed to work.

What to do? I would ask for a referral to an oral surgeon to close this. The future health of your mouth including the ability to plant implants to replace the teeth requires a good thick foundation of bone to work with here and that will be enhanced by proper healing of this sinus perforation.

Dr. Hall

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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.

February 14, 2018

Days of pain after a root canal treatment


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Dear Dr Hall,

I found your page on post root canal pain the be very reassuring, thank you.

I was hoping that you might be able to advise on my particular case.

I had quite a traumatic root canal (my first ever) done over 3 sessions in October 17. It remained painful so I didn’t get it crowned as I wanted to wait . The discomfort persisted and I was referred to an endodontist who after reviewing X-rays suggested that a canal might have been missed. Based on that I decided to have it redone.

During the procedure no missing canals were found. I could feel discomfort close to the bone where it felt raw and exposed, the root canal was completed and I was advised I would be in discomfort for a few days.

I am now on day 4 of immense discomfort and I intend to ring up for some advice tomorrow. I feel worried that things haven’t worked and I’ll have to have the tooth removed.

How long should it take to calm down do you think before I jump to conclusions and assume something nasty is happening in there? This has been a worry for 5 months now, I just don’t know what to do and I don’t want anybody else fiddling with my tooth anymore.

Your advice would be greatly appreciated.

Regards,
Michelle from the UK

Michelle,
The key in evaluating your tooth and whether or not the root canal treatment is successful or not isn’t how long you are in discomfort, but the direction the discomfort is going. Is it getting better, albeit slowly? If so, I’d be optimistic.

The fact that your endodontist predicted that this would hurt for a few days adds to my optimism here. If the treatment weren’t working, you could be having some increased swelling. I take it that isn’t happening in your case.

The root canal failure at the hands of your general dentist apparently wasn’t the result of a missed canal, but may have been an inadequate seal at the end of the root.

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.

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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.

January 24, 2018

The filling in my root canal tooth came out

Filed under: Root canals — Tags: , , , , — mesasmiles @ 6:10 pm

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Dr. Hall,
So it might sound a little crazy, but I had a root canal done a few years ago. Since then I haven’t been to the dentist, and can’t currently go due to financial problems and no health insurance. Since it’s been so long the cap or synthetic tooth, has fallen out and is now revealing a metal rod. The rod seems to be moving back and forth. What would be my best option? Can I remove the metal rod myself? Should I just leave it till it falls off or till I can get to a dentist?
Heather from Pennsylvania

Heather,
You really need to go to a dentist for a simple replacement of the temporary filling material. And knowing that your finances are strained, you may be able to talk some compassionate dentist into doing this very cheaply or even for nothing at all. Goodness, a dental assistant could do this for you—just get some Cavit and plug it into the hole. Otherwise, you’re going to lose this tooth. Cavit is a simple temporary filling material that comes out of the tube as a paste but when placed in a moist environment like your mouth it hardens. Since it requires no mixing or tray of tools, it can be placed in a few seconds.

When a tooth has a root canal treatment, the root canal filling material then needs to be protected against the oral fluids. Otherwise, saliva will seep down and loosen that root canal filling, which allows the tooth to become re-infected. This causes failure of the root canal treatment. The tooth would then need a new root canal filling in order to save it. So the dentist will put in a temporary filling and then plan when to finish the treatment of the tooth, probably protecting it with a crown.

When I was in practice, knowing that some patients could get into your situation and not come back for the crown, I would fill the tooth with a bonded core material, often using a metal post. If they didn’t get back right away, this would hold up for several years. Maybe something like that has been done in your situation. If the metal post is still present, hopefully there is still time to save the root canal treatment, but the hole needs to be sealed.
– 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.

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