Regular dental exams and cleanings are extremely important for children in order to maintain their dental health. In our office, a routine cleaning visit consists of a thorough oral and dental exam. This includes a screening for oral cancer, an assessment of the gums and oral mucosa, a check for any growth abnormalities, visually checking for cavities in the teeth, and an orthodontic evaluation. Bitewing x-rays are taken of the back teeth in order to detect cavities in their early stages. Many times, if a cavity gets large enough to be seen visually, it could be already deep enough to be in the nerve which would greatly increase the cost to repair. The teeth are gently polished to remove plaque and then the teeth are bathed with a high concentration of pleasant-tasting fluoride. We have many flavors to choose from to satisfy event the pickiest of tastebuds. We recommend the routine check-up and cleaning to be every 6 months. Cavities tend to grow much quicker in children than adults, so an ounce of prevention is so much better than the pound of cure.
Your child’s first trip to the dentist is a very special time in their life. Just like the first haircut, it can be fraught with fright. In the days before, it is best prepare them with positive comments. Statements like – “It will be a lot of fun”, or “They will shine your teeth so you have a pretty smile” go a much longer way than -“Oh, it won’t hurt”. In our office, we go out of our way to make that first visit a special occasion. We don’t force anything on them, but we positively reinforce good behavior each time they try something new. We have TVs in the ceiling that can play cartoons. That goes a long way to soothing any uneasiness. Then, to cap off the visit, there is a trip to the treasure chest filled with toys. And hopefully, there will be a picture taken to display in the “No Cavities Club”. Having a good experience during the first trip to the dentist can be tantamount in having good behavior in future visits.
In my last blog, I discussed in-office bleaching. The other method for lightening teeth is done at home. There are over the counter products and ones that are professionally available at your dentist’s office. The over the counter products seem to work OK for teenagers and young adults, however, with older adults, the professional variety works much better. My speculation is that the stains have been there much longer and are more resistant to the bleaching process.
In our office, we make a custom tray, essentially an ultra-thin, clear mouthpiece to hold the bleach in the mouth. The bleach that we use is slightly viscous and sticky so it doesn’t run all over the mouth during use. I instruct my patients to sleep with the mouthpiece in all night. The process can take anywhere from 2-6 weeks, but the bleaching solution is not near as harsh as the in-office variety and is much kinder and gentler. This greatly reduces the incidence of sensitivity. Studies have shown that after six months, the results between in-office and at-home bleaching is exactly the same. And other studies have shown that patient satisfaction hovers around 96% positive for at home and less than 50% for in-office.
There are two main methods for bleaching teeth: in office or at-home. In an office setting, a rubber-like substance is painted on the gums and then light cured. An extremely strong solution of hydrogen peroxide, usually 35%, is applied to the front teeth surfaces. The solution is left on the teeth for long enough to leach into the enamel and oxidizing the stains. This usually takes about 15 minutes. Some dentists employ the use of lights to accelerate the process. The lights can cause overheating of the dental pulp which contains the nerve and can greatly increase the sensitivity to temperatures. Studies have shown that the use of lights or “lasers” makes no difference in the final results. If there is an increased lightening right after the appointment with the use of lights, it has been shown that that is due to dehydration of the tooth surface and the color will return once the teeth have rehydrated. There are some desensitizing that the dentist can apply afterwards. These contain potassium nitrate. There are also toothpastes that are specially made for sensitive teeth that can help make an in-office bleaching procedure much easier to tolerate.
When bleaching one’s teeth, it must be kept in mind that the bleaching process will not effect the color of dental restorations such as tooth-colored fillings, bonding, or porcelain laminate veneers or crowns. It will not harm porcelain, but scanning electron microscope studies have shown some some minor pitting in composite (tooth-colored) restorations. Hypocalcified and fluorosed areas have stark white splotches. When initially bleaching the teeth, these areas tend to stand out dramatically, however, as time goes on, the surrounding tooth structure will begin to lighten, thus allowing the hypocalcification to blend in better. Teeth bleaching will not remove these splotchy areas, just make them less noticeable. Many people have grey stains in their teeth. These stains can be very resistant to the bleaching process. The products that cause the grey color do not appear to oxidize as well. On the other hand, yellow stains are very amenable to bleaching and will lighten very well. The nice thing about the grey stain is that it is not as noticeable from a conversational distance as the yellow, so the teeth can still have a light, appealing appearance even with some residual grey.
Before bleaching one’s teeth, they should have a thorough dental examination by their dentist. One would not want to place bleach over cavities. The bleaching process many times will cause the teeth to be sensitive, so placing bleach into a cavity could increase the sensitivity. Bleaching is also not recommended for children under 16 because their pulp chamber in the center of the teeth where the nerves reside are very large which could make for extremely sensitive teeth. The peroxide ion has been shown to give off oxygen free radicals which have been shown to cause tissue damage. That is something I would not want to take a chance with in a growing child. Other issues include the possibility of gum irritation. The bleaching solutions, especially at the higher concentrations, can be somewhat caustic, and can injure the gums. Most of the time, it is just a temporary reddening and discomfort. This can be reduced by cutting the bleaching time or by switching to a weaker concentration of the bleaching solution. Both sensitivity and gum irritation tend to go away when the bleaching is stopped.
Vital teeth bleaching is performed by placing a peroxide based solution on the tooth surface. Even though tooth enamel is extremely hard, it is somewhat porous which allows the bleaching solution to leach into the tooth. The solution can be either hydrogen peroxide or carbamide peroxide. Carbamide peroxide will turn into hydrogen peroxide when it comes in contact with water. Once the peroxide ion has permeated into the body of the enamel and dentin, it will oxidize the stains that are residing inside the tooth structure thus, effectively lightening the tooth color. Studies have not shown any harm done to the enamel. The peroxide ion has been shown to give of oxygen free radicals which has been implicated as being possibly carcinogenic. No study has shown this to be a problem with short term use of the solutions. However, I personally feel that one should use caution when selecting a “whitening” toothpaste to make certain that they do not contain peroxides. Since toothpastes are used daily for not only years, but decades, I don’t think that it is a good idea to find out after the fact that there was some harm being done.
Bleaching of vital teeth has been a great thing for cosmetic dentistry. Teeth can be lightened considerably with out having to do any invasive drilling or bonding of tooth-colored materials onto the teeth. The cost is significantly cheaper than all other cosmetic dental procedures. Discolorations in teeth can come from many sources. Intrinsic stains (ones that are actually incorporated into the tooth structure itself), include antibiotics (especially tetracycline), fluorosis, and enamel hyperplasia. Aging will also naturally yellow the teeth. Foods such as tea, coffee, red wine, and colas and tobacco products will also discolor teeth. Extrinsic stains, stains that reside on the surface of the teeth, are caused by bacterial plaque accumulations soaking up pigmented food and drink. Extrinsic stains can be removed by a professional cleaning or by using a “whitening” toothpaste that has extra abrasives in it. Since intrinsic stains reside within the tooth enamel, they must be removed by chemicals that have the ability to soak into the tooth structure itself.
A dental rubber dam is an extremely useful adjunct to dental treatment. It is an extremely thin sheet of latex rubber usually cut into six inch squares. A latex-free variety is also available for those who are allergic to latex. A rubber dam is used to isolate a patient’s mouth from the various instruments and chemicals that a dentist uses in the mouth. For teeth bleaching, the chemicals that are used are very caustic and would not bode well floating around in someone’s mouth. There are “paint on” dental dams available for bleaching which are more convenient to use for bleaching procedures. Rubber dams are are extremely important for endodontic (root canal) procedures. A sodium hypochlorite solution (the same chemical found in household bleach) is used to flush out the inside of root canals. It is certainly a good idea to keep that confined to the inside of a tooth. The rubber dam also keeps the thin, sharp files from going down the patient’s throat (or worse yet, their lungs). A rubber dam is also very helpful in children’s dentistry. Placing a rubber dam over a tooth on a fearful child can make them feel isolated from the dental treatment being done and can help calm them down.
Brushing one’s teeth is an extremely important part of one’s daily oral hygiene. Coupled with flossing, it removes the plaque that causes cavities and gum disease. There have been a variety of methods for toothbrushing that have been recommended. The main question is usually “Do I brush side to side or up and down?” Either way, if done properly, can be fine. If one wishes to go up and down, it is best to start above (on the upper) or below (on the lower) the gum line and roll the toothbrush head across the surface of the teeth. I will tell patients who wish to use that technique to brush your teeth in the direction that the teeth grow. When going side to side, the bristles should be angled at a 45 degree angle to the surface of the teeth, and then, the handle should be vibrated side to side. With either method, vigorous scrubbing must be avoided. Dental plaque is not very difficult to remove and only requires a gentle hand on the brush. Too much pressure can cause the gums and tooth enamel to be eroded away causing permanent damage.