Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

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.

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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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.

September 9, 2017

Swelling after a tooth extraction


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Dr. Hall
The tooth right beside my lower left wisdom tooth was extracted last Wednesday. There was swelling already on my jaw before the extraction. After extraction, the dentist prescribed amoxicillin for the infection. After 3 days, the swelling has worsened and pain killers are no longer helpful. The swelling below my jaw hardened and is larger than half of a golf ball.
– Jem from the Philippines

Jem,
It sounds like your infection is getting worse, even with the antibiotics. You need to report this to your dentist and he or she should switch antibiotics. I don’t think your dentist has done anything wrong here—amoxicillin is a good first choice for an infection from a tooth. But there are many infections that won’t respond to amoxicillin, sometimes because the bacterial strain has developed amoxicillin resistance.

These infections in the jaw can become quite serious, so I wouldn’t mess around with this but work with your dentist to find an antibiotic that will get this infection under control.
– 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.

August 15, 2017

Is this allergies or a perforated sinus?


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Dr. Hall,
I had a right molar extraction six months ago, and think I have a perforated sinus; molar area is very tender can’t eat on right side, if I do I get throbbing in all my top teeth, I can smile the after taste of my food, sinus headaches, my nose feels like water went into it in a bad way, burning my nose and I have some leaking out of my right nostril. All this time I just thought it was allergies, but when I drink or eat someone with a lot of liquid, it goes up my nose causing burning and draining in my right mistral. I was thinking that yes by now the perforation should be closed. It’s such a discomfort. I do have allergies and get sinus infection but this is very different?
Can this still be fixed?
– Cynthia

Cynthia,
I really doubt that this could be a sinus perforation, after all this time. Surely the socket has healed over by now. I’m not saying it’s impossible, but it seems highly unlikely to me. The liquid getting into your nose could be through the back of your mouth where there is a passageway from your windpipe up to your nose.

I would check you for a garden variety sinus infection–or it could be allergies as you have suspected. As we have said, the roots of your upper back teeth can be very close to the sinus wall, so any pressure in the sinus may manifest itself as pain in the teeth.

I would have it checked, and, since I think it is more likely that it is just a sinus problem, I would go to an ear, nose, and throat physician (otorhinolaryngologist). One thing you could do at home: close your mouth and try to blow through your mouth, puffing out your cheeks. If you can do that and hold the air in your mouth, there is no perforation. If there’s a perforation, air will bubble up through your nose.
– 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.

August 4, 2017

Preventing Dry Socket


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Dry socket is a potential complication of tooth extraction, and studies have shown that it occurs after anywhere from 15% to 30% of the time after the extraction of an impacted mandibular third molar (wisdom tooth). However, in my practice, I went the final ten years of my practice doing hundreds of extractions of mandibular third molars, including many full bony impactions, without a single incidence of dry socket. Let me tell you how I did it.

As I began my practice, I had a special interest in oral surgery. In dental school I had won the award as the outstanding oral surgery student of my graduating class. I considered specializing in oral surgery, but decided I really wanted to be a general dentist. I did decide, however, to try to tackle difficult extractions, gradually increasing in difficulty until I didn’t refer any of them to oral surgeons unless the patient was over 40. With these extractions, I had a normal incidence of dry socket in my patients.

One day, when I had two patients return to me with dry socket, I realized that in the case of both of these patients I had used a great deal of force in extracting the teeth. This gave me the idea that forceful compression of the mandibular bone was a precipitating factor for dry socket. From then on, if I couldn’t get a lower wisdom tooth out with moderate elevator force, I would section the tooth and/or remove bone until I could. I was very pleased that this dramatically decreased my incidence of dry socket. Over the next seven years I had only two dry sockets in my patients. This was up until around 1991 or ’92.

Then I read a study in a journal where the researchers had tried placing a square of Gelfoam soaked in a suspension of clindamycin antibiotic into the socket after the extraction and suturing the tissue over it. They did this on one side of each patient, and left the other side untreated. For every patient that developed dry socket after the extractions, it never occurred on the side that was treated with clindamycin. I am unable to find what journal that was in, but I was able to find an online reference to that study on the website of a Dr. Ted Rothstein.

I found the study very persuasive, so I applied this practice routinely for every impacted lower third molar that I extracted, and for the next ten years, extracting all sorts of impacted lower wisdom teeth, didn’t have a single incidence of dry socket. And I did not shy away from any difficult extractions. I did partial and full bony impactions including horizontal impactions, disto-angular impactions, whatever.

The “inside-the-box” thinking on the causes of dry socket is pretty rudimentary. The blood clot is missing, therefore the patient must have sucked it out! So therefore, don’t suck through a straw and that will reduce the incidence of dry socket. Similarly, if you smoke after the extraction you will suck it out. There are no clinical studies that give any credence to these simplistic theories. I don’t believe them and didn’t pass them on to my patients.

– 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.

August 1, 2017

Why do I feel pressure in my nose after getting my wisdom teeth out?


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Hi Dr. Hall,

About 10 days ago I had all 4 wisdom teeth extracted (all bony impactions). 3 days ago I had my recheck where the surgeon explained how to flush the sockets and said all was going well. He told me the upper sockets would not need to be flushed, but a day later I started tasting a salty taste from each of the extraction sites, predominantly from where the upper left molar had been extracted. I decided to flush the area and when I did a yellow discharge came out. When flushing directly into the socket, I sometimes feel a pressure on the left side of my nose (I assume this is the sinus). Is this a sinus perforation? Does this sound like a serious situation/infection? Is there anything I should be doing to speed up the healing process? After the 6 day mark my pain has been slowly subsiding and has been increasingly mild and has not flared up much with the discharge.
– Kayla D.

Kayla,
Nothing you’ve told me sounds abnormal. The key here is that, while it seems that the healing is happening slowly, it is getting better steadily. Some bacteria are bound to settle in the sockets, but it appears that your body is handling that.

As you read in the post about a perforated sinus, the roots of upper molars can be very close to the sinus. This is why you are feeling pressure in the area of your nose as you flush this socket. If there were a perforation, the solution would be actually coming out your nose as you flushed into the socket. Since it’s not, that membrane is intact and doesn’t need any extra attention.

What to do? Just be careful and flush, if you must, very gently, so that you don’t rupture the sinus membrane. You also want to leave the blood clot in the socket because that will end up forming a framework for the formation of new bone as the extraction site heals, so you don’t want to flush that out either.
– 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 31, 2017

Sinus infection after extraction


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Hi Dr. Hall;
I really like your clear advice. I had an upper molar on the right removed two weeks ago, and my dentist showed me on the X-rays where the root went into the sinus. (It was an old root canal tooth that was redone two years ago by an endodontist due to infection at the root tip. It was finally so consistently painful that I had it removed). When he removed the tooth my dentist told me there was infection in the root that went into the sinus. He cleaned the sockets and filled the holes with bone graft and used stitches – which have now been removed. He put me on a course of clindamyacin antibiotics 150mg for a week. In this time I have been extremely careful to not blow my nose, rinse gently, and brush gently with a soft tooth brush when I got the okay from my dentist. All was going really well. I’ve been off the antibiotics for a week and this morning I started having sinus drainage on that side, pressure and some pain in my face and gum. I took an oral decongestant, but it hasn’t made any difference in the pressure sensation. Do you think I should call my dentist and ask for more or different antibiotics? Are these kinds of sensations normal in the healing process of a tooth extraction with the root in the sinus? I’m concerned that if there is still infection in the sinus from the tooth, that it might affect the bone graft.
Thanks for your help.
– Nicole L.

Nicole,
It sounds like your dentist did everything right, and I appreciate the clear explanation you have given of your history.
The roots of upper molars can lie very close to the maxillary sinus. Sometimes the only thing separating them from the sinus is a thin membrane which would naturally be ruptured during a tooth extraction, causing a sinus perforation. When this happens, the appropriate treatment is to surgically close the perforation. This can be done with a surgical gelatin sponge material called gelfoam, or with bone grafting material as your dentist did, followed by suturing over the opening. Then you need to be gentle with it for a period of time to allow the body to heal over the opening. You did all that. Antibiotics would be called for if there is any infection present, and clindamycin is an excellent choice in this situation.

You do need to get back to your dentist to see why you are having this relapse of the infection. It could be that you just need to get back onto the clindamycin for a longer period of time, or you may need to switch antibiotics.

It is possible that some bone fragment got pushed up into your sinus and will need to be surgically removed in order for this to completely heal. If you take the antibiotics and it gets completely better and you continue the antibiotics for several days after that, and the infection returns again, I would have your dentist refer you to an otorhinolaryngologist (ear, nose, and throat specialist) for an x-ray to see if there is anything like that going on here.

– 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.

June 9, 2017

Tooth roots left behind

Filed under: Extractions — Tags: , , , , , — mesasmiles @ 4:40 pm

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This is a follow-up from Mozna from a post I answered yesterday: Will taking out this tooth root risk nerve damage? Mozna sent an x-ray with this comment:

Dr Hall

I have included a link to the x-ray. The surgery I need is for my bottom left tooth number 35. You will be able to see from the X-ray that I have roots left behind on both the left and right side of my mouth however the surgeon will only be extracting the root on the left side. Is it a good idea to do this extraction if it’s sitting on a root?

Many thanks,
Mozna

Mozna,
So this is a lower premolar, as I suspected, and we are talking about the risk of damage to the mental nerve, because of proximity to the mental foramen.

What I said yesterday stands, as far as the risk of damaging this nerve. This is a matter of good surgical technique. I do not believe that a skilled, careful surgeon would have any problem avoiding damage to this nerve.

Now about whether or not this root should be removed. Here is the x-ray you sent:
tooth roots left behind

Yes, I see that we are talking about a very sizeable part of the tooth. It looks like the entire root on the left side (which is our right) was left behind. On the right side, the tooth fragment is maybe 2/3 of the root.

In my opinion, you are getting good advice here. On the right side, the bone has healed around the remaining part of the root and there is no pathology. On the left side, however, the amount of root remaining is so large that the bone was not able to heal over the tooth, leaving a bony defect which could eventually threaten the teeth on either side.

I’m sorry that you were so poorly served by your original dentist. It seems like you are in good hands now, though.

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.

June 8, 2017

Will taking out this tooth root risk nerve damage?


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Dr. Hall,
I had to have braces and got 4 extractions done however my dentist left a root in and whenever I asked him about this he said it would fall out itself. I proceeded to get braces with him. However later on I decided to have a second opinion. Long story short they tried to remove the root but couldn’t and now I have to get general anesthesia and I am told the root is sitting on a nerve after having X-ray done. I am beyond petrified for this procedure, my surgeon said there are risks involved and I could have numbness. I fear any facial paralysis.
Thanks,
Mozna

Mozna,
I would have been helpful to have known which tooth we’re talking about here. It sounds like it would be a lower premolar. I’m going to make some assumptions here to try to be helpful to the general audience. If I’m off a little concerning your situation, hopefully I’ll be helpful to others.

First of all, on leaving the root in. As you can now see, your first dentist was incorrect. Tooth roots that are left in do not fall out on their own. The bone heals around them and they remain in place, buried in the bone. Now they don’t always have to be removed. If it is just a small root tip, say, in the case of a wisdom tooth extraction, there could be significant risk in going after that root tip, while the chances of it causing any trouble down the road are very small.

In your case, however, if this is a lower premolar and you’re getting braces, that space that is left by the extraction will need to be closed, and the root could get in the way of that. I’m fuzzy about whether or not you had these braces yet or not. If you haven’t, the root probably needs to be removed. If you have already had the braces and are pleased with the results, I’m not sure why the root would need to be taken out. Are you having some kind of trouble?

I’m also noticing that you are using the term “root” and not “root tip,” seeming to indicate that this is a pretty sizeable chunk of the tooth that is left. But if it is large it would have gotten in the way of moving your teeth with the braces. So I’m not sure what your condition is or how to advise you here.

But now let’s go to the surgeon and the risks of having this tooth root removed. Unfortunately, the courts and lawyers have created a climate where dentists are very afraid of lawsuits. To protect themselves, they will exaggerate the possibility of risks. When I was practicing, I resisted this tendency, because I didn’t want to cause unnecessary anxiety in my patients. So while I tried to give an accurate assessment of the risks that could be involved in various surgeries, I didn’t exaggerate them as many dentists do. I don’t ever remember telling a patient there could be a risk of nerve damage for any extraction other than a lower wisdom tooth. The roots of lower premolars are often near what is called the mental foramen, which is where the mental nerve comes out of the bone. This nerve goes to the lower lip and chin. Severing this nerve would cause a loss of sensation in the lip and the chin. “Paralysis” is too strong a word here, in my opinion, because that implies a loss of movement, which would not occur–only a loss of sensation. And it is very easy for the surgeon to see this foramen on an x-ray, and very easy to find it surgically. With good surgical technique, there should be no difficulty for the surgeon to avoid damage to this nerve.

Hopefully, this eases your anxieties.

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.

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