These are all complaints I get regularly. The jaw joints are a very complex mechanism and there are many factors involved with what is know as TMJ Dysfunction, TMJ Syndrome or just TMJD. The cartilage disk in the joint can become worn and the ligaments holding it become stretched, leading to various problems which in early stages can elicit the kinds of complaints I mentioned here as well as others.

So what is a nightguard? A nightguard (or more accurately an occlusal guard) is a plastic appliance made from an impression taken by a dentist that is worn over the teeth to protect the teeth from grinding action. This grinding (or sometimes clenching) is often done while a person is asleep, hence the term nightguard. However, it does not have to be worn only at night. It can be worn any time. You would not want to wear it while around other people or while eating, however.

The grinding of the teeth, known as bruxing, causes excess pressure on the teeth and jaw joints and can be responsible for the abnormal wear of teeth and the joint cartilage. When you sleep, the nerves responsible for controlling the amount of pressure you put on your teeth when you close your jaws are inactive, so you can put up to ten times more pressure on your teeth asleep and not even know it.

Pressures on the joints cause abnormal wear of the cartilage disc between the jaw bone and the skull. The ligaments holding this disc in proper position can also get stretched. The wear of the disc itself and stretching of the ligaments causes the disc to lose proper shape and position resulting in clicking or popping noises in the joint, and eventually pain. If these problems become severe enough, a simple preventive measure like a nightguard will not solve the problem and it may require crowns, bridges and even surgery to correct the problem. There are also alternative healing modalities that are centered around realigning muscle and joint function, but again, these measures would need to be applied before significant anatomical changes have taken place.

Pressures on the teeth cause abnormal wear on the teeth themselves, as well as stress to the nerves within the teeth. When the teeth wear, it can be either at the point of contact between opposing teeth or where the enamel is thinnest at the gum line. This wear at the gum line from grinding pressure is the result of microscopic “bending” of the teeth and is known as abfraction. This is one of the causes for the dished out sensitive areas that can appear at the gum line of teeth in various parts of the mouth. The wear at the point of contact is usually less serious, but can result in the need for bonded fillings, or sometimes crowns if a fracture develops in the tooth.

The stress to the nerves within the teeth leads to “aching” teeth and eventually to the need for crowns, root canals (removal of the nerve) or even extraction if accompanied by severe damage to tooth structure.

Nightguards are preventive appliances and can help to mitigate minor symptoms related to early problems from grinding or clenching habits. They are not, however, a treatment solution for the problem and if grinding or clenching persist or have cause significant symptoms already, treatment solutions should be discussed with your dentist.

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.



This discussion is by no means an exhaustive comparison of in-office bleaching products or procedures available. I will, however, try to give you some comparitive information about some commonly used products so that you will be able to understand your dentist’s explanation of the system he has chosen to use.

I am going to talk about eight different in-office bleaching systems. I will compare each product with regard to the bleaching agent used, use of an accelerator light, average cost to the dentist for that light if so used, whether an at-home system is recommended as follow up, and the average time the treatments take.

NuPro (R) White Gold/Illumine (TM)

NuPro (R) White Gold/Illumine (TM) is produced by Dentsply International. There is no required light activation for this system and hence, no cost to the dentist for a light. The use of at-home bleaching system as a follow up is considered optional (to be determined by discussion with your dentist). The treatment takes a little over an hour total. The specific applications of bleaching agent is done in 3 fifteen minute applications. It uses a 35% hydrogen peroxide agent with a pH of about 6-8.

Niveous (TM) and Opalescence (R) Extra Boost (TM)

There are two products that consider an accelerator light optional. These are Niveous (TM) by Shofu and Opalescence (R) Extra Boost (TM) by Ultradent Inc. Both of these can be accelerated with a dental curing light if desired. Dental curing lights have other functions in the dental office and will already be owned by the dentist, so no extra cost is required by the dentist for a light. At-home bleaching follow up is considered optional for both products. Niveous (TM) requires two applications of a 25% hydrogen peroxide gel with a pH of about 7 for 15 minutes each. Total time in the chair of about 1 hour. Opalescence (R) requires three applications of 15 minutes and uses a 38% hydrogen peroxide gel with a pH of about 7.

BriteSmile (R) and Zoom (R)

BriteSmile (R) and Zoom (R) are both made by Discuss Dental Inc. BriteSmile (R) requires either a gas plasma or LED (light emiting diode) accelerator light. The lights are owned by BriteSmile Inc. (who’s bleaching systems were bought by Discuss Dental Inc.) and not by the dentist. Dentists are charged on a per patient basis. At-home bleaching follow up is considered optional. A 15% hygrogen peroxide gel with a pH of about 6.5 is applied in two 20 minute applications with a total chair time of about 1 hour.

Zoom (R) requires a mercury metal halide light with a cost of about $1,500. At-home bleaching is recommended as a follow up. It comes in a few strengths (16-25%) with a pH of about 7.5. It is applied in three 20 minute applications with a total chair time of about 90 minutes.

LumaCool (TM)

LumaCool (TM) is made by LumaLite Inc. It requires the use of a xenon halogen accelerator light, which runs from $2500-$4000. At-home bleaching is recommended as a follow up. It uses a 35% hygdrogen peroxide gel with a pH of about 6. Each bleachig session consists of three 8 minute applications with a total chair time of a little less than an hour.

Beyond (TM) Power

Beyond (TM) Power is produced by Beyond (TM) Dental and Health. It should not be confused with a similarly named over-the-counter product, Beyond (TM). Beyond (TM) Power requires a halogen accelerator light running an average of a few thousand dollars. At-home bleaching follow up is considered optional. It uses a 35% hydrogen peroxide gel with a pH of about 5.5 which is applied in three 10 minute applications with a total chair time of less than an hour.

LaserSmile (TM)

The final product I want to discuss here is LaserSmile (TM) by Biolase Technology Inc. This product requires the use of a diode laser, which costs the dentist approximately $20,000. However, the diode laser will be used for other dental procedures as well, so a dentist will not likely use this system unless he is already using a diode laser in his practice for other procedures. At-home follow up is considered optional. LaserSmile (TM) uses a 37% hydrogen peroxide gel with a pH of about 7. Each session consists of two applications of the bleaching agent: the first for 16 minutes and the second for 8 minutes. However, the laser light is applied only for a total of about 4 minutes during these applications. The session is about an hour.

In the above discussions, where at-home bleaching follow ups were mentioned, the final decision whether to use a follow up product is something to be worked out with the dentist based on his or her recommendation and based on the whitening goal desired as well as the original condition of the teeth being bleached.

If your discoloration problem is primarily from extrinsic staining, you can often get very good results using toothpastes that advertise themselves as “whitening toothpastes”. This method is only for extrinsic staining and is not part of this discussion on actual bleaching procedures.

In-Office Bleaching

The first type of delivery system for tooth bleaching is the in-office procedure performed by a dental professional. These procedures use the highest concentration of bleaching agent and it is generally going to be a hydrogen peroxide agent, which tends to be stronger than carbamide peroxide. Carbamide peroxide breaks down into hydrogen peroxide when activated. When high concentrations of hydrogen peroxide (9-40%) are used, the gum tissues must be protected by isolation with a dental rubber dam and the agent applied carefully and monitored.

These procedures are much faster than other methods, but also correspondingly more costly. The cost can range from $500 – $700. Many of these systems are used with an activating light of some kind. There is controversy in the profession about the effectiveness of this light activation and some studies seem to show no significant difference between light activation and no light.

Professionally Dispensed At-Home Bleaching Kits

The second type of delivery systems for bleaching the teeth is custom tray fitting with professionally dispensed bleaching products. An impression is taken of the teeth in the dental office, a custom tray is produced from this impression and the patient takes the tray and bleaching material home to wear the bleach filled trays from 1/2 hour to 1 hour per day, depending on the product used.

These products rely on the less strong, but safer agents using carbamide peroxide. As mentioned, the carbamide peroxide breaks down into hydrogen peroxide having about 1/3 the strength of hydrogen peroxide. A 15% carbamide peroxide solution is equivalent to about a 5% hydrogen peroxide solution. It usually will take a couple of weeks of consistent use to get the desired whiteness of the teeth with these sytems. The cost is usually only about $150 – $300.

Over-The-Counter Bleaching Kits

The third category of bleaching sytems are the over-the-counter store bought whitening kits. These systems have the lowest concentrations of bleaching agent which is usually applied with a general sized tray, some kind of strip, or painted onto the teeth with applicators. This results in considerably less acurate dispensing of material to the teeth. This can result in burning and discomfort to the gums, and uneven whitening results overall. There is also a tendency for these systems to only be able to whiten some of the front teeth as opposed to the full arch whitening possible with custom fit trays. These sytems typically cost from $20 – $100.

Realistic Expectations

It should be noted that whichever type of bleaching system one chooses, no amount of bleaching can achieve a whiter shade than a person’s own natural optimum whiteness. If bleaching is carried out beyond professional instructions, the enamel can lose its luster and be left with a chalky appearance which weakens the surface. If proper directions are followed this danger is very minimal, so follow the directions.

Various shade guides are dispensed with these kits for analysing your beginning tooth color and your progress towards a lighter shade. There are many factors affecting the outcome of bleaching procedures and it is important to have a realistic expectation when trying to achieve a lighter (whiter) tooth color. Usually, from two to five or six steps on a shade guide is realistic. Your dentist can give you a good idea what you can expect given the condition of your teeth.

What I often do with my patients is to show them a shade guide representation of their current tooth color next to the shade they might realistically hope to achieve. Then I will suggest that instead of using the paper shade guide that comes with most kits, I ask them to bleach first the upper teeth and use their own lower teeth to measure their progress. Then when they have reached their desired goal, they can bleach the lowers to match the uppers.

More and more, people are demanding whiter teeth. They are no longer willing to accept the slow discoloration of their teeth over time. As a result, a major industry has grown up around “tooth whitening”. I want to bring some clarity into the cloud of information (and misinformation) concerning “tooth whitening” and the procedures and products used to achieve whiter smiles. This is going to be a series of posts addressing this subject.

Today we will start with some definitions and explanations. In subsequent posts I will discuss the pros and cons of the different methods and materials employed and then, finally, discuss some of the major brands of tooth whitening systems out there currently. Let’s get started.

The Factors Affecting Tooth Color

Tooth color is an enormously complex subject composed of many factors including hue, saturation, transluscency, stains and age to name a few. However, for our purposes here, the thicker the enamel, the whiter the appearance of the teeth. Some people start out with thick opaque enamel and, hence, whiter looking teeth. In general, the original color of teeth ranges from the yellow-brown caste to the grey-green caste. As teeth age, the enamel tends to wear and become thinner and more transluscent. This allows the yellow-brown color of the underlying dentin to show through more. Also, aging is accompanied by slight cracking and imperfections in the surface of the enamel allowing deeper penetration of stains.

Types of Stains

Stains are classified as either intrinsic (internal) or extrinsic (external or surface). Intrinsic staining can be a result of age, trauma (either accute or chronic), exposure minerals (as in Tetracycline) during formation or fluoride in too large doses. Often there is a combination of all these factors, different for each individual.

Extrinsic stains affect the surface of the tooth enamel coming from foods, dark colored beverages (wine and juices), tobacco and other sources that penetrate surface imperfections over time with the wear and trauma of chewing and/or tooth grinding.

Whitening vs Bleaching

Although the term “tooth whitening” is commonly used for all types of whitening systems, there are actually two distinct types of procedures involved. The FDA classifies the use of a peroxide containing agent to produce a whiter intrinsic shade as “bleaching”. “Whitening” on the other hand is the process of removing as much of the extrinsic or surface stain on teeth through the use of toothpastes, toothbrush floss and other cleaning agents such as the pumice used by the hygienist.

In the next installment, we will talk about the three types of whitening systems commonly available: In-office systems, At-home systems and Over-the-counter systems.

A root canal preserves your natural tooth, but removes the decay within
its structure and any infection within the root. Dental implants are a
more complex dental surgery procedure that involves the extraction of
your diseased tooth and its replacement with a prosthesis or
“artificial tooth”. Our goal as dental professionals is always to
preserve as many of your natural teeth as possible. Root canal
treatments preserve 17 million teeth a year. However, due to the
increasing predictability and reliability of dental implants, this
alternative can be a very good option when the prognosis of a tooth
restored with root canal is still questionable.

Despite the “fear factor” the term root canal often creates, root
canals are actually a simple and relatively pain free procedure. In a
root canal the source of your tooth pain, infected or inflammed nerve
tissue, is removed. The tooth is cleaned and filled with a
biocompatible material, then sealed with a crown. The procedure is
relatively painless with modern dental anesthetics. Implants require
surgically extracting the tooth and a separate surgery later to insert
an artificial tooth root into the jaw bone. After sufficient time to
properly attach to the bone, the replacement crown is affixed to the
implant.

There are many factors to evaluate before deciding the course of
treatment. The integrity and amount of remaining tooth structure as
well as the amount and quality of surrounding bone will profoundly
affect the long term prognosis of a tooth restored by root canal
treatment. The bone also affects the possibility of anchoring an
implant. Also, some people with certain medical conditions should avoid
dental surgery whenever possible and for them root canal therapy may be
the best option.

If you have lost several teeth, dental implants can present a very
attractive alternative to dentures, or even be used in conjuntion with
full or partial dentures to provide a much more secure anchor to hold
the dentures in place.

The most common type of dental implant used today is called a root form
implant. These are post-like devices usually made of titanium alloy
that are placed in the bone to serve as artificial tooth roots to which
the dentist can then securely attach a crown or bridgework or an anchor
for a denture.

Every situation is different and if you are experiencing tooth pain or
have recently broken, cracked or otherwise damaged teeth seek the
advice of a dental professional to discuss the right restoration option
for you.

When a patient’s teeth have flaws or have become damaged, porcelain
veneers or crowns, also referred to as caps are used to restore the
teeth for a more brilliant smile. Crowns are used to fit over and cover
damaged or flawed teeth. Porcelain veneers are a covering for a tooth
that is custom made to restore the front of the tooth. The covering is
thin and blends with the natural color of the other teeth so it can’t be
easily seen.

Problems that Porcelain Veneers and Crowns Can Address

If you have excessive damage to your teeth because of tooth decay, these
two products can help. Teeth that are stained permanently or are
discolored for a variety of reasons will benefit from cosmetic dentistry
that involves veneers or caps. If your teeth have become brittle after
having root canal or have become fractured for any reason, porcelain
veneers and crowns can address these issues as well.

In the past, crowns were the way that we addressed these problems.
Today, porcelain veneers have become a popular way to make teeth whiter
and brighter and can cover a wide range of conditions. Your dentist will
have to examine your teeth and tell you which of the two methods are
better suited to your needs.

Situations that Influence One or the Other

Your dentist will take a number of factors into account when deciding
whether your teeth would best be served with either porcelain veneers or
traditional crowns. The condition of your gums, what type of bite or
occlusion you have as well as the amount of damage the teeth have
suffered are all taken into our consideration when determining the best
method to restore your teeth. Porcelain veneers rely on intact enamel
for their bond strength and sometimes there won’t be enough quality
enamel for veneers, but with modern crowns made of porcelain, it is
difficult to distinguish whether they are porcelain veneers or caps.

Pros and Cons

When porcelain veneers are applied, very little of the tooth enamel has
to be removed, while when applying crowns, a larger portion of the tooth
is removed for the cap to be able to fit over the damaged tooth.
Porcelain veneers only cover the sides and front, while a crown will
cover the entire tooth and is the preferred method when damage to the
teeth is severe.

Cost is another consideration for the patient. Porcelain veneers, since
they only cover the visible side of the tooth are usually considered to
be cosmetic in nature and may not be covered by insurance, even though
the procedure for veneers and crowns are nearly identical and the costs
usually very close.

You and your dentist can discuss the pros and cons of each of these
products to find the one that will best suit your pocketbook and your
needs. As a dentist, I know that all dental professionals are more than
happy to take the time to discuss the proper procedures that will have
you smiling again, but it is up to you to ask the right questions that
will elicit the information you need to make your decision.

Not only is this condition a cosmetic concern but it can also affect the
good health of your teeth and gums. The end results of this condition
can be gum irritation, sensitivity to the surface of the root, bone
loss, root caries or even loss of one or more teeth.

Many advances have been made as to techniques and materials used to
improve not only the appearance of your teeth and smile, but the comfort
level of the surgery involved as well which can be a major concern for
many patients.

Receding Gums: One Cause of the Appearance of Long Teeth

When our gums have receded because of periodontal disease, the teeth
have the appearance of being much longer than the norm. And though it is
not attractive, this is not always the main concern of those of us in
the field of dentistry. Receding gums expose the surface of the root
which can cause sensitivity. Root caries and accumulation of plaque and
calculus (calcified plaque) can result when your condition is not
addressed. When the condition is allowed to worsen it can cause bone
loss and loose teeth. In many cases, your condition can be addressed
surgically by using a small transplant of tissue from the roof of the
mouth or the gums.

Papilla Regeneration

This small section of the gum is often overlooked until black triangles
or holes appear between your teeth. This often indicates that the tissue
between your teeth has been lost. Major advances have been made, but it
is still the toughest surgery we as dentists must perform.

Connective Tissue Skin Graft

For receding gums that have advanced to more than just one or two teeth,
covering root surfaces that are overexposed is not much of a challenge
for today’s cosmetic dentist practitioner. After the underlying
periodontal disease has been controlled and the bone is healthy, tissue
from the palate can be grafted and placed so that the area of recession
is covered. In six months time, a complete recovery can be enjoyed along
with the return of your gum tissue to normal levels. Your teeth look
like they once did before periodontal disease advanced.

If you are unhappy with your smile and have brought your periodontal
condition under control, talk with your dentist about cosmetic surgical
procedures that can be done to improve the look of your smile. Our
profession has come a long way in recent years with different methods to
improve the look of your smile and at the same time address the overall
health of your teeth and gums. Find a good cosmetic dentist in your area
to give you a thorough exam and a treatment plan that will be beneficial
to you and your teeth.

When visiting the dentist, find out exactly how much it will cost. Sit
down with the office manager or the person in charge of insurance and
billing to find out what each procedure will cost. Before you sign for
treatment to begin, check with your dental insurance plan to see what
costs are covered and how much they will pay for your entire treatment
plan. Once you agree to a treatment plan, and allow your dentist to
complete treatment you are liable to pay no matter what your insurance
does not cover.

Payment Options

There are some dentists that will agree to a payment plan that will
allow you to pay off your dental bill in installments. If in your case
your treatment exceeds the yearly limit and treatment is necessary to
keep your teeth in good shape, sit down with the dental team that
handles payments and come up with a plan that will enable you to pay off
your bill at a monthly price that is acceptable both to you and the
dentist. There are also third party credit solutions available that are
specifically geared to help people with dental costs. Your dentist can
often help you find these. You can also go online to find a bank that is
willing to lend you the money. Care Credit is one such company that
extends credit for those in need of medical or dental care whether they
have insurance or not. There are a variety of plans that can be looked
into to find out which plans are best for your needs and your dentist’s
requirements.

If your dental treatment is considered a medical necessity then you have
the right to appeal to the medical part of your insurance plan to pay
for treatment above and beyond what your dental insurance will cover.
This will only work if your dental treatment is truly a medical
necessity.

The Bottom Line

When going to the dentist and offered a treatment plan, be sure that you
have the coverage before you start. If not, discuss the treatment
priorities. Sometimes certain procedures can wait for the next insurance
coverage period. If you are in no pain or if delayed treatment will not
cause further treatment to be needed, you can often wait until your next
year’s limit comes around. Though no dentist will advise you to wait,
you are the only one who knows what your entire situation is and what
you can reasonably afford. The dentist will have your oral health in
mind so don’t be afraid to sit down with him or her and the staff. Your
dentist has your best interests at heart and will work with you in any
way they can in order for you to get the proper treatment you need and
to make sure that your insurance benefits are maximized.

Some children act out and can put themselves and the medical or dental
staff at risk, so many doctors and dentists refuse to treat them. We as
dentists can take special classes in order to learn how to treat your
children with developmental disabilities and challenges gently and
effectively.

General Anesthesia

One option that we can utilize is to perform the dental procedures while
your child is under general anesthesia. This ensures that a child that
is prone to violence in an unfamiliar setting is completely safe to
themselves and to others that are around him. A child that has a violent
tantrum in the dental office runs the risk of breaking equipment and
potentially harming himself or a member of the staff.

General anesthesia is recommended for those children that not only are
unable to cooperate but are unable to comprehend the procedure at hand
as well. Children that are in this category should be examined every one
to three years whether there is any indication of dental problems or
not.

Before beginning the exam under anesthesia, you should be made aware of
the risks involved for your children and a consent form needs to be
signed. All medical information pertaining to your child should be made
available to the dental team. Post operative care should also be
explained to you and what you should expect when your child awakens.

Schooling

The medical and dental needs have long been ignored for those children
with developmental disabilities and challenges because of the difficulty
involved in treating them. More dentists along with their staff are
taking classes to learn more about specific conditions and how to
address the special needs of these young patients. We in the dental
profession have the opportunity to become well versed in problems that
may arise and the solutions we can apply will be able to better meet the
needs of children with developmental disabilities. Keeping the child and
the members of our team safe, not letting the child become too
frightened are all being addressed in continuing education for medical
and dental professionals alike in order to further our knowledge and
abilities to work with these very special children.

Everyone deserves the best care that is available and with the new
education programs targeted for medical and dental professionals,
children with special needs can be routinely treated so that more
serious problems do not occur because of lack of early treatment. Not
every dentist or doctor is suited for this delicate but work, but those
that feel they can take on the challenge will find many resources that
will allow them to properly treat and handle children that have
developmental disabilities or challenges. In the end, they will find
that the work with these children is rewarding and worth the extra time
and effort taken in order to give them treatment they need.

If you are a parent of a child with special needs, ask your dentist if
they are equipped to handle those needs or for a referral to someone who
does handle those needs.