“My gums are receding! Help!!” … I get this a lot…”Are my teeth going to fall out? What can we do, Doc?”

People often complain that their gums are receding, but more often this is a problem of enamel having worn away from the tooth, exposing the softer underlying dentin. Sometimes both enamel wear and gum recession occur together.  Of course there is also actual gum recession due to loss of attachment to the tooth root usually accompanied by bone loss, but that is a discussion for another time.

What is buccal erosion or abrasion?  Often teeth get dished out or notched areas at the gum line. These are usually, but not always on the outer cheek or lip side of the tooth. They are sometimes, but not always sensitive to touch or temperature.

There are three main causes of this condition. Often a combination of the three causes have contributed to the problem over time. The first cause is abrasion. Abrasion is actual wear on the tooth surface caused by an overly abrasive toothpaste or aggressive brushing habits. The most common areas for this problem to occur are at the gum line in the corners of the mouth, both upper and lower and the front teeth.

The second cause is acid erosion. This can be from citric or carbolic acids in fruit and soft drinks or other acidic foods. It can also be from regurgitated stomach acids, a condition known as acid reflux. Many people suffer from mild acid reflux and don’t even realize it. This type of erosion can occur almost anywhere on the teeth, including the cusp tips and inside surfaces if acid reflux is the cause.

The third cause is called abfraction. Abfraction is the flaking away of the thinner enamel at the gum line that occurs from heavy stress on the teeth caused by bruxing (grinding) or clenching the jaws. This type of problem will usually show up more in the molar areas on the outer gum line surfaces of the teeth.

It is important to identify the causes of the problem and not just to fix the  dished out or sensitive areas with bonding. This is of course the first step, but it is also important to try to remove the cause of the problem. In the case of abrasion, a careful study of tooth brushing patterns, toothpastes used and toothbrush hardness will help eliminate overly abrasive habits.

Acid reflux is a more complex problem and a referral to a physician can be helpful in identifying and treating this condition. Treatment for bruxism or tooth grinding and clenching can range anywhere from simple occlusal guards (often called night guards) to complex restorative and even surgical intervention. This is because the problem can be caused by both psychological and physical factors and can range from mild tooth damage to severe jaw joint problems. Almost all treatments for this condition will involve an occlusal guard at some point, however, so this is a good starting point when this condition has been identified since it is very easy to make and non-invasive. It requires only a simple impression with no tooth preparation.



The health threat from mercury poisoning has long been an issue in
dentistry due to the inclusion of mercury in silver amalgam fillings.
For many years there was little that could be done about it, because
there were no viable alternative filling materials available. In more
recent years, however, the bonded composite resins have continuously
been improved and strengthened to the point where they are today a very
viable option to the use of dental amalgam fillings, even in the back
chewing teeth.

If you have new cavities or old silver fillings that are in need of
replacement, ask your dentist about tooth colored fillings. These bonded
composite resins can be done in one visit like the old amalgam fillings,
or in the case of more extensive tooth structure damage, in two visits
as an inlay or onlay made in the laboratory.

Amalgams vs Composites

When considering what you want for your teeth, consider the following
points:

* Amalgams cost less generally, but also look cheaper. Amalgams darken
with age and end up as black fillings. Composites are tooth colored and
the newer generations hold their color very well.

* Amalgams contain mercury, which is a very toxic heavy metal. The
degree to which mercury is released from amalgam fillings has long been
in dispute, but there is no question that it is released and absorbed
into the system. It can not easily be removed from the body once
absorbed, so it has a cummulative affect. There is some occurance of
allergy to dental composite resins, but this is quite rare and usually
self limiting as well.

* In order to place an amalgam filling, quite a bit more tooth structure
must be removed, beyond the actual decay in the case of small new
cavities, than with the bonded composites.

* Amalgam tends to expand with age, pushing outward on the tooth from
within the cavity preparation. This leads to many teeth cracking and
breaking off parts of the teeth. When properly handled, composite resins
tend to hold the tooth together because of the bonding.

* Amalgam restorations are weakest at the margin between filling and
tooth where they are thinnest. It is here that they chip and wear and
begin to allow re-decay underneath. Composites are actually strongest at
the bond junction between tooth and filling. There tends to be much less
re-decay at this junction than with traditional amalgam.

* Amalgam conducts heat readily leading to many teeth having post-
operative sensitivity. With properly placed composite resins, we
experience much less post-operative sensitivity than in the past.

It is important that you develop a good raport with your dentist and
discuss with them the materials planned for use in your teeth. Research
your options and ask your dentist about your findings.

Bonding in dentistry technically means attaching a material
substance to the tooth structure through a chemical bond.
Typically it is used by many people to describe three
different processes: recontouring front teeth to fill
unsightly gaps, repairing chipped corners or edges on front
teeth or putting a veneer of composite resin over the whold
surface of a tooth to change its color or contour.

Bonding is actually used in many ways in cosmetic dentistry
today:

1. Repair or fill abraded and sensitive areas of teeth at
the gum line
2. Fill cavities or chipped and broken areas of front
teeth
3. Minor reshaping or recontouring teeth to provide more
natural contours and contacts between teeth
4. Filling cavities in back teeth with composite resins
in place of silver amalgam
5. Sometimes resurfacing the whole face of a tooth (best
accomplished by bonding a porcelain veneer rather than
composite resin)
6. The sealants used to “seal” and protect the grooves in
children’s teeth are bonded flowable composite resins
7. Bonded cements are used now to chemically bond crowns
and bridges to their anchor teeth.

If properly applied, bonded restorations preserve more tooth
structure than traditional fillings because deeper drilling
is not required just to “retain” the material as with older
methods. Bonded restorations are strongest at the place
where tooth and bonding meet, so these restorations do not
tend to chip and pull away from tooth structure and leak at
the margins as the older materials did.

Since there is ofte less drilling required and less marginal
leakage, bonded restorations are typically less afterwards
than the older methods and often can be done during the
appointment without anesthetic.

These restorations are much better looking than the older
materials. Composite resins come in many shades to better
match tooth color. Due to the bonding and expansion
properties of composites, there seem to be fewer cracked and
broken teeth with these restorations.

Tooth bonding itself is a one visit procedure, though the
bonding can be associated with restorations that have been
made in a laboratory. If the area of tooth to be restored is
small, the materials used usually require only one visit.
Larger areas require the two visit procedures. If done in
two visits, there will be a temporary restoration (usually
also a composite resin) placed with a sedative temporary
cement.

Before bonding, any decay or old filling material present is
removed. Then the tooth surface to be bonded is slightly
roughened and treated with a mild etchant to provide maximum
bond strength. Then the bonding materials are placed in a
layered sequence and “cured” with a high intensity light
after each layer. Then the restoration is shaped and
polished to a smooth finish and proper contour and fit with
adjacent and opposing teeth. Sometimes the tooth and bonding
are then treated again and “sealed” with a clear sealer
layer of bonding material.

It is very important to maintain the bonded restorations
just like teeth by carefully brushing and flossing using a
non-abrasive toothpaste. If many of the biting surfaces of
teeth have been restored or there is a history of grinding
or clenching of the teeth, then the dentist may recommend a
plastic guard, called “occlusal guard” or “night guard”
since many people wear them at night. This guard protects
the jaw joints and teeth as well as the restorations.