Brighton Dental San Diego | Review


Dental Health & Education P6

And if they had…say we see that patient again…they have no…maybe filling to do, or replace a worn out filling, we’d replace that. They are coming in 6 months and everything is fine I won’t take check up films for another 2 years. That’s kind of the way in my practice what I found it…Good patients can go 2 to 3 years. Carious patients, some kids…it’s every 6 months cause I know every 6 months there’s going to be decay. No matter what we tell the parents and how we counsel them, they just get decay every time they come in and if you don’t pick it up when it’s small in between the teeth, it will reach the pulp before…it can reach the pulp before you see it clinically. It will get that big and penetrate in and down, so the x rays are one of our most important diagnostic tools. And the check films don’t show anything in the front. But most of the time you get a feeling there’s decay between the teeth by…you can transluminantly light magnification. And if the person has a high carious rate, not only do we have to check the bitewing film we may take some anterior films to check for decay as well.

Student: Recently there’s been a lot of [inaudible] CT of your chest is equal to about a 100 standard x rays. If it is used too much, especially in children cause they are smaller, they got this cumulative effect.

I think it’s 19 full mouths of dental x rays equals one chest film.  It’s 19 times 21 films to equal one chest x ray. Dental x rays are…there is exposure radiation but it’s very small, particularly when you start comparing it to medical x rays, chest films, x ray of a broken leg or something like that. When you get into CTs and things like that it’s not even in the same room, not even the same chart.

Student: And they’ve come a long way. I mean, 20 years ago

The film is much more sensitive. Time has gone down from even when I first started practicing from D speed to E speed film. The film is much more sensitive so we’ve all tuned our machines down. Going digital is great. The problem with going digital for my office is slight $30,000.

Student: Is the quality of the film better with the digital?

Boy, you can open a can of…you can get people on it the both ways. The best thing about the digital is that is shows up big. Patients can see big. That’s the best thing about digital. It really doesn’t help…it’s not like we are going to diagnose much more but it’s sure going to help  the patient see what I’m talking about.

Student: Cause it’s going to show up on the computer screen?

[inaudible] put it on the monitor. That little decay now looks, you know, you’ll see that triangular decay “Oh, yeah, I need a filling.” Before I would hold up the films and “You see it right there.” So that’s the greatest thing about digital, it’s when you shoot the film that’s one the screen so you can see if you got the actual angle you want. If you don’t have the angle, you haven’t even taken the film out of the patient’s mouth, you can shoot it right at the angle you want. We’re going to get it. I’m very determined to get it, I just have to figure out where I’m going to get $30,000. That’s a lot of crowns!

Student: 5,000 dollar crowns!

Yeah, exactly. When you do the math then it’s like how do I pay for that? Do I have to increase my fees?

Student: You couldn’t have a central place in town that does it for all the dentists?

It’s not convenient enough. There is…I know one in Santa Barbara. They are set up for dental films but most x ray technicians don’t know how to take dental film. They are not trained to take dental films. It’s dental.

Student: That’s what I mean, just one dental kind of digital in town for everybody.

The problem is, I need a film and I need it now. I need to look at it if I’m going to do something. Then I may need to look at it again.

Student: And as a patient you don’t want to go there and then go to the dentist office.

It’s very inconvenient. It generally has got to be in the office. Digital x rays are here. They’re coming. Eventually all are going to go to them but…

Student: They’ll come down in price.

They haven’t yet because they know everybody’s going to go to them. And what’s interesting is that digital x ray manufacturers are driving the market. They are educating patients and kind of scaring patients that if your dentist is taking traditional films he is using way too much radiation which is hogwash. But now patients literally come in…we’ve had patients come in, look at the office and go “Do you have digital x rays?” “No” “I don’t want to come here.” That’s a poor reason to not select the dentist.

Student: How many implants do you recommend for a human being?

As many as he needs to replace the missing teeth. That’s a smart ass answer.

Student: So you’re going to do 32?

You could do…conceivably you could do 32 implants but that’s senseless.

Student: What you’re doing is you put in these posts in 2 or 4 places to cover all that?

Yeah, you could put, like, for a lower arch…you could do 4 to 6 implants and then you can build a myriad of prostheses that replace the lower missing teeth. It could be like a big bridge, it could be like a denture that’s bolted in place that is doctor removable but not patient removable, or it can be a denture type prosthesis that snaps over a machined bar. When I say machined bar, the bar is machined with a strict taper. And then the denture has the corresponding taper in it. And it’s a machined fit. When it’s in place, it’s solid, it doesn’t…put some [inaudible] through it, it doesn’t come out. Denture has metal substructure in it that fits on top of that metal bar so it’s solid. It may be a denture but it’s rock solid. It’s chews almost like natural teeth.

Student: Would you also put 4 implants in the top?

The top needs more implanted. [inaudible] You need more implants to…for a maxillary prosthesis. You need 6. Can’t be 4, got to have at least 6.

Student: Do insurance companies cover the cost of that?

Insurance companies will…it all depends on a plan. They cover the cost seldom…when they do cover the cost of the implants they will cover sometimes the crown that goes on the implant, they will cover the placement of the implant, some will cover the placement of the implant but won’t cover the crown on the implant. That’s more rare but they are coming round. The problem is, once again we get back to that expensive dental implants, what you run into is you’re over maximum. Most insurance companies your maximum is $1500 to $2000. So you get two dental implants done. Let’s say it’s $2000 a piece by the time you have all the diagnostic work up to the surgical guides made and general anesthetic that the oral surgeon uses. So you’ve got 4 grand into getting your dental implants in. That’s getting the dental implants in. Now you’re back at my door. You started at my door, I planned it all out for [inaudible] where the teeth are going to be, how long are they going to be, do we need the graft, do we not need the graft. That was all done. The implant’s got placed precisely with the surgical guide and then you’re back in my office and now it should be relatively easy for me to fabricate a great looking restoration. Because it was all planned from the restoration being there first so the implant didn’t get put where the bone is, it got put where the implant is and bone was put where it needed to be for the implant to be there. Because it’s very, very difficult to make a decent looking hygienic crown or restoration when the implant is placed way too far to the inside or way too high. So when you have a resolved bridge and the oral surgeon lays that tissue back, there is bone that I got to put in [inaudible] And then when your teeth need to be out here, well, back up the truck, the diagnosis of this case s not diagnosed properly from the get go. That stuff doesn’t happen anymore I believe because the placement of the implant is prosthetic driven. Prosthesis is figured out first then the support for that prosthesis is figured out and then the implants are placed in a position to do the support.

Student: During all this time when you started doing all that kind of treatment when you got your dentures and everything, you’ve been eating through a straw probably.

You want the truth? You’re right. That’s a difficult time. I call it…the patient’s in the limbo. Because they got implants in place they are healing, they are healing from surgery and they are trying to wear a denture that didn’t work to begin with and now we have it over a surgery site, for patient that’s difficult 2 to 3 months.

Student: Some people are going to get into that process and because their insurance is limited insurance they are going to have to take time to…

Sometimes you can do that but when you get into…when you’re doing the bigger cases, once it gets rolling because of the nature of the design, you have to go to the finish otherwise the patient is left completely in limbo without a prosthesis. But when it’s one or two teeth, you can have the implants placed so the bone stays there. Remember when you take that root out the bone starts to remodel. So the surgeon places the implant and that implant integrates. In the mandible it’s 98% of the time, in the maxillary it’s 96%, 97% which in dentistry there is nothing we do that is more predictable than that. There is nothing more predictable than osseointegration implants.

Student: do you accept Secure Horizon?

Do I accept Secure Horizon? You know, I couldn’t tell you. You’d have to call my office manager. I have no…I would say we accept all insurance plans. I don’t, I’m not signed on to plans that are PPOs or HMO plans. Secure Horizon has a whole host of different plans  so I think it would depend on the plan that you particularly have with Secure Horizon. Cause Secure Horizons plan…you have to go to a particular dentist. You are locked in to going to this dentist if this dentist “takes Secure Horizon”.

Student: Do you think as the correlation between oral health and overall health is more and more apparent to the powers to be that make these insurance decision. Will they catch up with…?

No. No because the powers to be in the insurance company [inaudible] concern is not your health. It’s their wealth. Precisely. They don’t care if you’re healthy other than they want you to be healthy so it doesn’t cost money. That’s a sticky wicket but they don’t necessarily want you to have every tooth in your head because if you’re able to chew some foods that’s fine enough for them.

Student: Oh, yeah. It’s much cheaper to just have your tooth just pulled out of your head. [inaudible]

They are protecting their bottom line to the point where…Delta Dental got involved with teachers. Teachers have…talk about benefits…they have insurance plans from [inaudible]. They have incentive plans that best if you kept your every 6 months appointments, your coverage went up to a 100%. So it started at 60% so if you’ve made every 6 months check, eventually you’ll have 100% coverage.

Student: They probably saved a lot that way.

Free Teeth Cleanings – Gum Disease Awareness Week

“Along with non-toxic dentistry, and helping fearful patients, the awareness and prevention of Gum Disease is a priority in our practice. We invite you to sign up for a free cleaning during our awareness week.” – Dr. Daniel Vinograd, DDS

To schedule your free cleaning in our San Diego office, call (619) 550-4904

free teeth cleanings

Latest Lecture On Biocompatible Dentistry

Topics Covered: Preventing gum disease with ozone, Biocompatible materials,  amalgam filling removal & the root-canal controversy.

For a Free Consultation with Dr. Vinograd, Call (619) 382-3884.

How To Brush


Dental Health & Education P5

Student: So what do you recommend when the person eats something?

If you can rinse with water, rinse with water. Once again, it’s that frequency and duration of the exposure. So if you’re going to have pineapple juice, have your pine apple juice.

Student: How about raw pineapple?

Same thing. It gets very acidic, very acidic. And it’s got sugar source.

Student: They are in season right now so we’re eating a lot.

Eat it and be done with it. So it’s one exposure. You know, if you have a slice now and you have a slice later, it’s all those exposures is what’s added. Because…what you were talking about the acidity of the drink…the decay doesn’t happen until the critical pH is reached. The pH gets lower and becomes more acidic. So if you have an acidic drink, it takes less acid produced by plaque to reach that critical level of the enamel being dissolved or eaten by the acid.

Student: [inaudible]

For kids? Yeah. With kids we use topical fluoride and fluoride toothpaste and sealants, dental sealants. If we can get to a tooth as it erupts and we see its dental anatomy… deep fissures and pits, that’s going to be the tooth that’s likely to get decayed. If we can get that tooth isolated and it means keeping saliva off of it long enough. With the little kid moving around and their tongues darting everywhere that’s a challenge and sometimes you’d love to put sealants on those teeth and you try to put sealants on those teeth but if you put anything into child’s mouth, they start salivating and that’s the last thing you want to do because I want to etch the tooth. I’m going to etch the surface and I’m do going to clean those grooves and then I’m going to flow in a composite, it’s kind of a more liquid composite than we use to fill your teeth and then cure it. So it fills in those pits and grooves and fissures and seals out the decay. I think the last little study I saw cross my desk, it was like 80% reduction in occlusal pit fissure decay. They can fall off, they can wear out, they can chip off. They need to be replaced with time because they wear off. They are not high, obviously, because you can’t add a big thickness to the tooth because now their teeth are not going to come together. They have to be added in a manner in which they are not going to be chewed against, otherwise they get chipped off. But they wear off and need to be touched up and replace with time but they do a great job of sealing that decay on the chewing surface.

Student: They only do that where there’s a problem with the tooth and not on all the teeth?

Well, you do know the teeth that you suspect are going to be a problem. I’d love to do it on all of kids’ teeth when come in. Unfortunately, realty hits me in the face. Insurance company only pays for sealants till a certain age so a lot of times the second molars that I’d love to seal, the insurance won’t cover it. It’s the natural tendency of the patient if he hears the insurance doesn’t cover it, it doesn’t need to be done. And that’s a whole another lecture on itself.

Student: [inaudible] with the fluoride toothpaste and the water, there’s something recent about there’s only too much the fluoride effect.

It can be. There can be. We had to get together as a dental community and stop the physicians from writing prescriptions for fluoride drops because they were giving fluoride drops at 1 point per million, the ideal supplement. But our water in the valley…it depends on the well and the water companies won’t to give you the straight answer the reports that I saw it was reported from .3 parts per million to .6 parts per million. Let’s say average of that, half part per million fluoride in the national ground water. Well if you supplement, give a full supplement to a child or infant, and the parents are brushing their teeth as well… the child, they don’t spit out all the toothpaste, they are getting fluoride from the water…they are getting fluoride too much fluoride.

Student: [inaudible]

Now they are adding fluoride to the water where necessary to maintain the optimal fluoride level. There was a state law passed that said [inaudible] of a certain size that had control had to fluoride the water. There was a big battle, the anti-fluoride came in.

Student: The optimal level is what?

It’s .1 part per million.

Student: Naturally we get .3 to .6?

Yeah, so they’ll add enough to get to .1. They won’t add .1. So depending on the well and all their equipment monitors maintain so that water supply come out of that well is at .1 part per million.

Student: So only natural ones have less that .1? But others have up to .6?

They will always lower them than normal but almost half of normal.

Student: You said they add up to .1 but you said naturally we already have up to .6.

I’m sorry. So, 1 part per million. I’m getting my decimals and that’s where I’m…1 part per million. We have .3 to .6 in the water. They are adding enough to get to that 1 point. In…I think it’s Texas, parts of Colorado and parts of Mexico, they have ground water that’s at 18 parts per million fluoride.

Student: They have a lot of teeth too.

Student: Do they do something to get it reduced?

No. They don’t. They have…they get kind of [inaudible] ugly fluoride teeth but they get no decay. But the interesting thing is those communities have been studied from hell to high water to find out if fluoride none, nothing, none. There is not one scientific study in these areas with the high fluoride that says increased rate of bone cancer or anything like that. So, fluoride is safe.

Student: [inaudible]

Yes, mottling. Mottling or fluorosis mottling. It gets speckling. You get white opacities on teeth and when it gets very severe it gets really yellow and ugly. Yeah, gets really yellow and ugly. Again, kind of a whiteish speckling appearance to the enamel. Those people don’t get decay but their teeth don’t look pristine. But you don’t get that till you get up…it gets around 8 or 9 parts.

Student: In speech class in college in 1956 they gave a talk against fluoride. Controversial ever since even then.

Yes, it’s been controversial ever since it came out. And it…from the personal perspective I don’t like the government telling us what to do.  You can make a, you can make a not a scary junk…fluoride prescription. It’s prescription drug. [inaudible] So where does it stop?

Student: [inaudible] fluoride toothpaste because they don’t swallow….so they are already adding it to the water.

The reason they do that is because if you swallow all your toothpaste you’d be getting over, you’d be getting too much fluoride. That’s why… you have to be careful with children. One thing I don’t like about the flavored toothpaste is that kids love that flavored toothpaste and they’ll brush their teeth and swallow it. And so if they’re getting fluoride drops they’re going to get fluorosis. They have too much fluoride. With young children you have to monitor their tooth brushing and how much toothpaste…pea sized amount is all they get. And ideally I’d like to have them spit out toothpaste. Most of them little kids don’t know how to spit. They just swallow it.  So with those kids, they get no fluoride supplements. They don’t need to be supplemented. They are getting enough fluoride from the fluoride toothpaste. [inaudible] of fluoride toothpaste is 1 part per million fluoride. There is prescription fluoride toothpaste called, one of the brands is PreviDent and it’s 5000. I mean toothpaste is 1000 and this is 5000 parts per million.

Student: But the only negative side effect of fluoride discovered is the speckled teeth, mottled teeth. If your children swallow toothpaste you don’t have to worry about heart disease or cancer or? Not that I want small children to be walking around with mottled teeth but

No cancer or anything like that. They studied these communities that have way more fluoride than is put into groundwater and everybody that is anti-fluoride has looked for data to say look it’s causing bone cancer, it’s causing this…There was just nothing.

Student: Years ago they thought that fluoride would [inaudible]

Yes, you get fluorohydroxyapatite rather than Calcium Hydroxyapatite and that’s a topic we can jump into…are there any questions on any of this?

Student: People who were against fluoridated water they said it’s not natural fluoride, it’s a chemical fluoride made from something else, I forgot what it was and that it was different than…

Fluoride ion is a fluoride ion is a fluoride ion.

Student: What about the radiation exposure and dental x rays and how often…?

The general consensus is, full mouth set of dental x-rays is 21 films. Traditional films, not digital x ray. Soon we’ll going digital…

Student: What’s the difference in exposure digital versus…

About a half. So there is a significant reduction with the digital dentistry.  But significant from almost insignificant. Full mouth set of x rays, the radiation exposure that you get from 21 dental films is the equivalent of living in Denver for a year versus living at sea level. Because you are a mile closer to the sun.

Student: How would you need to repeat that amount if [inaudible]

What you’re asking if I understand you, correct me if I’m wrong, what is the criteria by which we based how frequently we take dental x rays. It depends on, essentially, on what the experience has been, the carious experience of that patient has been and what is the periodontal status of that patient. If they are stable and have a very low decay rate, once every 2 or 3 years [inaudible] that films.  If they’ve got full mouth of decay, you’re going to take full mouth set of x rays cause you’re looking for abscesses, and everything else. But once you have that full mouth set of x rays, if you complete the dentistry and restore the mouth, then probably about every year on that patient, that high risk patient until they prove to you that they are not getting decay anymore. Because interproximal decay can get quite large and quite deep before you see it. Once it gets quite large and quite deep, it can get to a point where now you’re going to be doing a root canal and a crown versus if I had taken a film a year ago I would be doing  smaller filling. 4 check up films or bitewing films, they don’t show the end to the root of the teeth. There is no dental diagnose of anything really relative to bone other than the boning height. Now if there’s been bone loss, you can’t even see that on bitewing x ray. So you can’t follow if it’s getting worse, if you are getting a bone end crater. So in some cases the [inaudible] won’t even show the bone level because we’ve got bone loss already on that patient is off the x ray. Bitewings are check films basically to look for decay between the teeth and to kind of see what the bone level is around those teeth. And that’s about all it shows. You can miss a dental abscess, you can miss odontogenic cariuses, you can miss a lot of things with bitewings. If you did a full mouth x rays you would see. Teeth will abscess painlessly. You have a pea sided hole in the bone, and with all the host reaction to it with no pain. It’s amazing. Kids in particular, little children, they have abscessed teeth, draining sinus tracts and no pain. So I get a new patient in and if they’ve seen that they’ve had a high dental carious rate in the past, they’ve had a lot of dental work. They’ve had a lot of dental work done in the past and they haven’ had a full mouth set of x rays in the last 2 years, I’ll recommend they have a full mouth set of x rays.

Dental Health & Education P4

There has been cases, fortunately I haven’t been involved in them, but I’ve seen the crash and burns and all of the talks. In the implant study club we have when these crash and burns come out it’s okay, we all have to learn from this. Here’s where the implant is replaced, here’s what the patient was promised. You’re going to get a tooth coming out of your gum that looks like a natural tooth. That’s anything but the case. The implant is placed pointed in the wrong direction and they literally when cervical integrated the only way to get him out is they had to be cut out. You can’t pull them out. They literally go in and do the osteotomy and cut the implant out. Now you got a big bone defect and that’s got to be grafted back.

Student: You have these posts I guess…

Yeah, 3/16 bolt.

Student: And then you have the prosthetic. How does that join together?

The top of the implant it has…generally has an internal taper, and it’s threaded at the bottom so things screw into it. I can screw thing into the top of the implant.

Student: These screws are a little stub. Then you put the crown on the sub, just like had a restoration crown [inaudible].

I didn’t bring any slides or pictures.

Student: I have two of them.

Student: Does your brochure say anything?

OK; so, this is threaded. This is the implant. And this is the bone out here. And the gums comes in. I can make a part that fits this and has a screw that goes in and I screw it. I screw this onto the implant. This is threaded in here.

Student: It’s like screwing a nut over a bolt.

Exactly. So this part is custom fabricated and it can be…this can become a bar, it can become a button for a crown, it can become a gold dome with ball on top of it where the denture’s going to snap onto. We have a implant and we call this the abutment. And the abutment screws down into implant. Each implant manufacturer and there’s a host of them, has their own connection and right now there is a big fight between companies who has the best connection. Because this seal is important and the stability is important. All these internal, basically machine, characteristics of the top of the, the inside of the top of the implant is…there is a big marketing push between implant  companies who’s got the best. We have a abutment that screws into the implant and that abutment comes through the gum tissue. We can put a crown on that abutment or it can become a part of a bar that goes from implant to implant all the way around and then you make a denture that gets over the bat and it engages the bar.

Student: I have one dentist that [inaudible] implants in the front and I have 1 dentist who put in the implants, the other dentist put in the abutments and the crowns and she was so mad the first time cause it was 2 different types of implants. And I actually got new veneers on top of that because I had other problems. But what she put on didn’t actually look so hot. [inaudible] that antibiotic that turns your teeth [inaudible]…

You had tetracycline stained teeth?

Student: Yeah. So I had slightly grey teeth and then this one was really grey because it was [inaudible]. SO when she put the crowns. Here we got a grey kind of blueish tone, right? And then we ended up with the yellowish tone here.

You looked like you had two crowns.

Student: What goes [inaudible] they say the tooth is dead. [inaudible] brown or something?

Yes, they’ll sometimes turn dead. They turn brown because when that pulp gets traumatized, it bleeds and pulp is a unique space. It’s just like your cranial space. If it swells it has no area to swell into. So it died of…it chokes itself off. We can detach the cranium and let the brain swell and put the cranium back but we can’t cut the top of the tooth off and let the pulp swell and then put it back in again. You get trauma to tooth, you get the swelling internally and bleeding and then the breakdown of the hemoglobin called hemosiderin and that stains the teeth. It becomes…if it gets into the tooth, it stains the tooth dark.

Student: [inaudible] stay there?

Yeah, the attachment…a tooth can be [inaudible] and you can replace that tooth…

Student: Prosthetic tooth not a living tooth.

Right. the natural tooth can be [inaudible], put back in and the periodontal ligament will regenerate. So the periodontal ligament that holds the tooth to the bone lives on but the pulp inside the tooth is what dies. Once the tooth is formed, the pulp is worthless. Except for the dentists cause it keeps us busy. But it does nothing. You don’t need it.

Student: Once that occurs the only way you can do anything is to put veneer to make it look like the other teeth?

If you do a root canal, you can do a root canal and generally the pulp dies you’re going to end up with the root canal at some point in time because you’re going to see the abscess on the filum, you’re going to get dental pain. So you do a root canal. Now that the inside of the tooth is opened up and you can use [inaudible] solution, seal the [inaudible] inside that pulp chamber, the top part of the tooth and it will bleach the tooth internally. And you can get that in the [inaudible] now and get the tooth back to its natural color. So you can internally bleach the tooth. There’s been reports in the literature however, that internal bleaching of teeth will sometimes result in root reabsorbing. I think what happens is some of the bleach travels down the root canal filling material and outside the canals of the tooth, and then your body reacts to this hydrogen peroxide by reabsorbing the tooth and replacing it with bone. So when you take an x-ray of the tooth, there is the root but it’s not root shaped. It’s got C shaped [inaudible] filled with bone. Or just eat…that tooth’s going to go.

Student: [inaudible] put a veneer over that? What would you do?

Over darkened tooth? Dark front tooth .Well, if it’s a single tooth. It’s difficult to put a veneer over a single tooth, a single veneer, because it’s going to show. Particular if you are talking about the lumineer style of veneers, the no prep veneers. If you don’t prep the teeth, and you add a thickness to the tooth, the teeth grow forward. So if you do a single veneer and you do the no prep veneer, that tooth is going to…the 2 front teeth were like this, you add thickness, now this tooth is going to be stuck out front. So you have to prep the tooth. So that veneer replaces what you’ve reduced and you end out [inaudible]. Or what you’ll do to get by sometimes is 4 veneers. If you do 2 veneers it still kind of gets that funny 2 front teeth look and 4 veneers. And everybody sees them as fake. 6 veneers only. It connects when they smile and they have 6 horse teeth coming at you.

Student: [inaudible] cut back on the tooth, physical width of the tooth or the depth and put it on…

Yes, you can. That’s the prep veneer.  That’s what we do. Actually, I’ll reduce half to ¾ of the millimeter of the tooth. And that half to ¾ millimeter tooth structure is replaced with ceramics. And that ceramics, if the underlying tooth structure is stained or discolored, the ceramics is translucent and it’s going to show through. So you have to use opaque cement to get that opaque bonding resin to hide that discoloration if it’s [inaudible] through the tooth. So it becomes…it’s not easy to just simply hide a tetracycline defect. Because if you want to do veneers then you want to make them look good then the tetracycline stain shows right through because it’s translucent. So the tetracycline veneers are opaque. They look a lot like porcelain fused metal crown. They have an opaque layer. The first layer of porcelain is opaque. And then they bond porcelain over top of that. Once you put that opaque layer over tooth, you don’t get any [inaudible] effect of light going up the tooth, up the tooth. So you get that dark edge appearing at the gum line. Because once you put the crown over the tooth, the root goes dark. Because no light is transilluminating up the root and lighting up the gum and underneath. You’d have a tooth, put  crown on it, all of a sudden it goes dark above it cause not much light is transilluminated up the tooth. When you start having a high difficult staining and you’re using opaque material, life likeness of it begins to diminish. Still it looks a lot better because the patient doesn’t have tetracycline stains but they are little more opaquey than a natural tooth. And when I say opaquey that’s kind of my terminology for…you get that…it doesn’t look like you can see through the tooth.

Student: [inaudible] They grind down my tooth and put a crown on it. And they did that [inaudible] made it opaque but it sure looks a whole lot better than the grey tooth.

Those esthetic changes…we have to tell the patient…you know they’ll bring in a smile, A Susan Sarandon’s smile, “I want that smile” I can sometimes come close to getting a shape of that smile but the translucency, the opalescent effect, if I’m hiding tetracycline stains, it’s out the window. It can’t be done. Because otherwise if you put an opalescent, translucent ceramic and bond it to the tooth, what’s underneath, the color shows through. layer. The vitality, the life likeness of it .

Student: What’s happening in tooth prevention of cavities? [inaudible] coating on children’s teeth.

Still [inaudible] yes. Prevention of tooth decay still boils down to one: developing good hygiene habits and two: good diet, good dietary habits. High sugar diets they just…kind of on the side that I’m seeing in my practice a lot lately is the sport drinks, the Gatorade drinks. The high school players that are playing high school sports and they are sucking on these Gatorades over a period of time and decay happens because of the number of exposures to the sugar. If you’re going to have one soda, be horrible and drink one soda, if you drink it down in one gulp, it’s one exposure but if you make that soda last all day, you might as well drink a whole bunch of sodas. It’s the number of exposures. It’s not necessarily the amount. All you have to do is feed that with sugar and converts that sugar, it uses the sugar as a food source and it’s byproduct of that food source is acid and that’s what eats the hole in the tooth. The bacteria don’t really eat the tooth. It’s the acid they produce that eats the hole in the tooth.

Student: It’s not the acidity of the drink itself?

No, that plays a role. That plays a role. It is the combination of two. My son did an experiment. He took a track of teeth. He put them in various sodas and we measured with my micrometer very careful to see if any of the tooth will erode away. Some of them etched quite dramatically, just like I would etch it to put on a veneer. Diet Coke turned the tooth and the root as brown as that shoe in 7 days. Regular Coke did not do it but Diet Coke did. The difference was amazing. Pineapple juice, that tooth was etched. The acid had eaten layer of the enamel off, it actually changed dimension a little bit.

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that’s why when you put someone that has porcelain fused to metal crowns that has old style porcelain in them particularly, and you put them in front of a camera, all will say “That’s a crown.” You can’t miss it. It’s not the same shade. The term is [inaudible] It looks one color under one set of light and looks different color under another set of light. So when we take our shades, we take our shades take close to the windows with as much sunlight as possible so that shade looks best in natural light. If you go under fluorescent light or under camera light and the shade’s off. Doesn’t match. You see that bounce back color and that’s why they don’t exactly look alive or real. The best we try with porcelain fused to metal crowns, they can look pretty good but they never look quite as natural as a natural tooth. Or all ceramic, good all ceramic crown. All ceramic crown has no metal substructure. It gains its strength from being bonded to the tooth. The porcelain on the crown gains its strength from being bonded to the metal subcrown. Cause porcelain is very brittle, it’s weak. It’s like a ceramic tile. You can take that ceramic tile when it’s not bonded and you hit it and it’ll shatter. But now that it’s on the floor bonded to the substrate of the floor, that ceramic tile is very strong. It gains its strength by being bonded to the sublayer of the floor through that cement. Well, it is the same concept with bonding porcelain to the tooth or porcelain veneers we bond to the front of the teeth. The porcelain if you had it, if I gave you porcelain veneer and asked you to handle it, if you weren’t careful when you grip it between your fingers you could snap it.

Student: What’s the difference between porcelain and ceramic?

Same thing. I’m sorry. These are interchangeable. Ceramics is porcelain. They are very weak. You bond it on the tooth and they last for years. Because they gain their strength from the underlying tooth structures strength. These Cerec crowns are all ceramic. And they gain their strength by being bonded on the tooth. We have another porcelain that we can use with Cerec technology. It’s called EMAX. It’s lithium disilicate ceramic and the difference with the lithium disilicate ceramics is it’s inherently very strong. It doesn’t necessarily have to be bonded to the tooth. Labs would say we can make you an all ceramic crown and you can cement with conventional cement. Conventional cement that you cement the crown down with really is not a cement, it’s a space filler. It’s a space filler. And it fills the gap between the tooth and the restoration. It really doesn’t adhere to the tooth all that well, it really doesn’t adhere to the crown all that well. It’s a space filler. It’s in the gap. When you bond something you got ceramic, and the bonding resin actually chemically and mechanically bonds to the ceramic, chemically and mechanically bonds to the tooth. So it’s a…the idea is one cohesive unit. And that’s [inaudible] dentistry in a nutshell. And that’s how we can put those porcelain [inaudible]. They bond onto the tooth, otherwise they have no strength. So, ceramic allows us to do porcelain veneers, it allows us to do single crowns, and it even allows us to do bridges. I haven’t jumped on the bridge band wagon yet because I’m one of those guys…I want to some longitudinal data. You give me some data that shows that these long span all ceramic bridges, cause ceramic is brittle. Little old lady, weak bite, okay that’s probably going to be my first all ceramic bridge that I’ll do.

Student: [inaudible]

They’ve made the studies, Cerec’s study. They’ve got all the studies and they’ve got their longitudinal data. But, once again, I’m always weary when company has their own data. Of course it’s going to show what they want it to show. I’d like to see, you know, University of Louisiana, Louisiana Tech, UCLA, UCSF, you know, do these studies and show…give me a 5 year data on how well these things last before I start putting them into my patients’ mouth. Just because ceramics are weak and when you have a bridge, you got a crown here and a crown here, and you’ve got the false teeth in the middle, and the bite force falling between so that ceramic flexes. Ceramics don’t flex, they break. And so, therein lies the rub. Of course their data says if you use it over this given distance, you know, it’s safe, it will work, we’ve got longitudinal data. Average bridge, I gate to tell you, and it’s insurance company data, it says 7 years. And that struck me when I got that one. The average bridge only lasts 7 years. Because that’s a significant investment for the patient and if they have to redo it in 7 years that’s another significant investment. That’s changed my outlook on my next topic. That’s implants, dental implants. I love implants. I love doing the implant dentistry. Literally savior for patients that are missing teeth, particularly denture patients. Denture patients are dental cripples. Really are dental cripples. I can make a set of dentures for patients that have no teeth that look great, that you would be hard pressed to know they are dentures. I don’t… you can make a denture with all the picket fence looking and it looks fake. A good lab technician and a good quality tooth that’s setting the teeth to look natural, you can make a denture look very natural. They can talk and speak but it becomes everybody knows when you give them a piece of steak that they got dentures. It’s like somebody that has two false limbs, two false legs, you put them in a suit and tie and ask them to stand there, they’d look great. You ask them to run a 100 yard dash, and it’s painfully apparent they have two false legs. And it’s no different with dentures. Dentures are  a prosthetic replacement for teeth. We’ve kind of done patients disservice by calling them your teeth. Here’s your teeth. They’re not your teeth. They are your prosthetic appliance. And the lowers particularly don’t function very well. And that’s where implant dentistry got us biggest [inaudible]. Implant is a titanium alloy. Used to be pure titanium but titanium alloys were better. You can pick it as a screw or as a [inaudible] but it’s a titanium fixture that’s surgically implanted in the bone. And I used…Dr [?] and Dr [?] practically as my own surgeons to do this for me and I’ll send the patient over and they prepare the osteotomy, the hole in the bone, and they place the implant and then…it used to be we had to wait 6 months. Now it’s got to be…it’s 8 to 10 weeks. That’s how fast your bone thinks titanium is bone. It grows right to it. Everything else we put in your body there’s always intercellular layer between the material and whatever tissue you are putting it in. Titanium…the bone cells grow right to the titanium. Without any intermediary between it. You get fibroblast and odontoblast right on the titanium with nothing in between it. It becomes osteo and [inaudible] coining the term osteointergration. Implant is osteointegrated. It’s integrated into the bone. Now I’ve got a fixture in bone that comes up to gum bone level that I can then screw anything into that I need. It can be a bar that patient’s denture rests on. Now instead of the denture resting on the tissue, and hurting and being picked, it can rest on this bar that’s custom fabricated very complexly and has attachments so that the denture is a fixture. So now when they chew the denture is just like solid teeth. And they can take it out and clean it and put it back in. You can also do restorations that are individual, individual teeth on implants that look just like they’re coming out. You don’t need the flange, you don’t need the pink gum. And that all depends on how much bone absorption has occurred, how long has patient been without teeth. When you lose a root, the bone that’s around that root, the stimulus for it being there is the root. Once that root is gone, it starts melting away. It starts reabsorbing and remodeling. And that becomes a problem if we want to put an implant in, the bone volume has to be big enough. It has to be wide enough and tall enough to be able to put an implant in that’s big enough to withstand the chewing forces. My surgeons now got toward where they can graft bone about anywhere. We used to say you’re not a candidate for implants. Now you almost can’t say you’re not a candidate for implants but you may have to have some reconstructive surgery first before they can put the implants in. So if there’s enough bone we can put the implants in. It allows us to attach teeth, attach dentures. In the simple form we just put two implants in and kind of a ball and socket arrangement where the denture slips down onto that ball and it retains it in place. So the denture is still borne by the tissue but it is not flopping around loose. It’s at least held over the ridge.

Student: [inaudible]

Generally right around where your canines would be. Right around canines.

Student: So you put in two posts?

Yeah. I put in two posts. That’s a minimum. Then if you can go to four, you can just about, depending on how long they are, you can just about restore the whole lower arch with 4 implants. 4 long implants now. It used to be we wanted to have 6. We wanted to have all these number of implants. Turning out we don’t need that many implants. They are that strong, they are that osteointegrated. There is a formula for the length and the A-P spread that you have to go by. But the concept is four on the floor. 4 implants that you can restore the whole lower arch. The nice thing about that is you can make a prosthesis that is relatively cost effective. I hate to say it but if there is a downside to implants, it’s the cost. It’s the fees [inaudible].

Student: Which is? What kind of money?

What kind of money? I don’t know exactly what the oral surgeons charge per implant to place them. It depends a lot on what type of surgery do you have to do to place the implant. But I’m going to say, maybe I’m going to get myself in trouble and I’m on tape. I’m going to say roughly $1700 for the first implant. One thousand seven hundred dollars. Then you have a work up however so…you have diagnostic work up, you’ll probably have cone beam scan so that we can make from that cone beam scan which is basically a 3D image, 3D x-ray on a computer.  Then we can look where all the anatomy is and we can then plan, we can actually pick an implant out of inventory and fit it into bone just the way we want it, just where we want it. Then we can plan where we want the teeth, then we can put the implant underneath that tooth just to the precise location. And then from that hit a button and off to Germany it goes. And they fabricate the surgical guide that when put into patient’s mouth dictates and guides the surgeon to place the implant precisely to that location, precisely to that depth. And what that does, it gets the implant where I want it. In the early implant dentistry, the surgeon always put the implant where the bone was. However that’s not necessarily where the tooth needed to be and that was a problem. Now it’s come around to where the prosthetics where the teeth need to be dictates where the implant is placed. And if the implants… there’s no bone where that implant’s got to go, then we graft bone to get it there cause that works predictably rather than having ugly looking prostheses that’s impossible to clean because the implant is way too high or way too towards the roof of the mouth. Because in the upper arch the ridge shrinks back and up. And when it shrinks back and up you still the front teeth where they need to be but if the bone is way back here, you put the implant here, how do I get a tooth out there? That also dictates the type of prosthesis that we are going to fabricate. And all that has worked out diagnostically hopefully beforehand so that you know you’ve essentially fabricated prosthesis on models beforehand so that you know when the surgeon places the implants in that location, all is well.

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