This is certainly so with cavities in teeth – they hardly ever go away, if we just wait, even though we might at times be tempted to believe that.

Fortunately most parents of small children are eager to handle any cavities they discover in their children’s teeth. But these teeth are often so small and cavities can not be easily discovered by the naked eye, especially if they develop between teeth – and flossing the teeth of a four-year old is not an easy task.

An additional factor in baby teeth is that cavities can develop rather quickly and virtually undetectable under the enamel. Only when this fragile outer shell collapses do they become obvious.

This might then look like this baby molar…

Decayed Primary Tooth: A cavity in a baby molar will look like this only if it is advanced. At this stage it has probably invaded the nerve (pulp) chamber and is in need of a laser pulpotomy.

If this is a tooth that would fall out very soon it could be removed to save the child from any possible tooth ache, but if this tooth is still needed to keep the space open for the permanent tooth to grow into, it need to be saved. Extracting the tooth and then using a spacer to maintain the opening for the new tooth would probably the more costly and way more inconvenient solution.

If we are in the fortunate situation that the majority of the pulp and nerve are still savable, a pulpotomy can be performed (see the graphical explanation).

The following sequence of images shows how this procedure is performed.

1. Decay has been cleaned out with a slow electric drill. There is bleeding from the gums as well as the nerve, which is exposed.

2. The tooth is sealed from the side with a "matrix" to prevent any blood or saliva creeping into the cavity during the following steps.

3. Laser energy is used to remove the nerve tissue from the pulp chamber (Waterlase at 2.25 W).

4. The laser is angled to completely remove nerve tissue from all the recesses of the chamber, to avoid future re-infection.

5. The openings into the canal are now visible with healthy and untraumatized nerve tissue left intact. Mild bleeding is very normal and indicates healthy tissue.

6. A mild 2-3% hydrogen peroxide solution is used to gently disinfect the chamber and stop bleeding before placing the MTA.

7. MTA (Mineral Trioxide Aggregate), a highly biocompatible cement is used to plug the openings to the canals. Very light pressure with a small cotton pellet is used to compact and dry it to avoid trauma to the nerve.

8. After making sure that there is no bleeding seeping through the MTA, this is now covered with a base of glass-ionomer cement.

9. After the Glass-ionomer sets in 5 minutes, traces of MTA and cement lining the side walls and the margins are removed with a dry, slow bur. A self-etching bonding agent is applied with a micro-brush and dried after 30 seconds.

10. The cavity is now restored with a bonded composite using proper bonding principles.

11. The final filling completed and polished. This tooth will survive for a few years until it is replaced with a permanent premolar.

Tooth ache usually means that the nerves in the center of the tooth – the pulp – are being attacked by an infection. This is mostly caused by a cavity that remained too long untreated so that it penetrated the enamel, the underlying dentin and is now approaching the pulp.

The following illustrations show the progression and treatment of this condition.

Nerve dying: A cavity arising in a tooth, if not addressed in time, will eventually approach the nerve (pulp) and cause an infection. At some point the infection will irreversibly damage the nerve and cause it to die. Usual symptoms characterizing this stage are pain, pain to hot drinks and throbbing.

1. The necrosis (death) within the nerve chamber will spread to other parts of the root canals. Soon the whole tissue within the nerve chamber and the canals will die and degenerate into pus or a gangrenous mass.

2. The toxic tissue within the canals now spreads out through the small opening at the end of the roots into the bone. A localized bone infection sets in also known as apical periodontitis or local osteomyelitis. The bone at the tip of the roots dissolves away. Symptoms at this stage include throbbing pain and extreme tenderness to touch. Sometimes the tooth feels as if it is longer. This is due to mounting pressure from the pus beneath it that pushes the tooth outwards.

3. Root canal therapy is initiated. An access hole is made and the chamber is drilled out.

4. Special files are used to clean out the canals and widen them. Disinfecting solutions are used to loosen the dead tissue and kill germs. The canals are widened at least four-fold in diameter to make sure all the dead tissue lining the toxic walls, its recesses and irregularities are removed.

5. A laser is used with a special flexible tip to irradiate the canals and further disinfect its walls.

6. After it is disinfected and dried, the canals are filled with a paste that seals the empty space and prevents bacteria from growing.

7. After the paste sets, and commonly in a separate session, the top section of the root canal material is removed, and a space is prepared to accurately accept a fiberglass post. This is bonded inside this space with a resin cement, which also fills the void in the tooth and reconstructs the core for the future restoration. This is called "post and core buildup".

8. The top part of the tooth is now prepared and shaped to accept a porcelain crown or onlay. An impression is taken and the tooth temporized.

9. In the final session, the tooth-colored porcelain is bonded to the tooth. It is important to understand that the tooth is now essentially bonded from the post all the way up to the top restoration, acting as a single unit, as close to an original tooth as one can get. Therefore the stability and function of the tooth is reinforced.

But looking at it a bit closer this perspective does not quite hold true. Although the outer shell seems to be hard as an inanimate object the tooth is a living part of the body. Fact is that the inner parts of the tooth contains living tissue that needs to be nourished to stay healthy. Once the root canal procedure is performed, removing nerve and blood vessels and filling the now empty cavity with an inanimate substance, the tooth indeed becomes an object that is no longer connected to body fluids that make it a functioning part of the body. It has become a dead object that is no longer renewed and protected by the body’s defenses. Bacteria entering through the tiniest cracks might cause persistent infections because there are no blood vessels any longer that would bring white blood cells to fight that infection.

Therefore a root canal should be only a very last resort and every effort should be made to save the inner living part of the tooth – the root canal.

The direct cap procedure is such an effort. The following illustrations by Dr. Sarkissian demonstrate this procedure.

1. HEALTHY TOOTH: A healthy tooth is covered by a shell of enamel, the hardest substance in the body. It is a complex organ comprised of all three embryological layers.

2. CAVITY FORMATION – EARLY STAGE: A cavity starts when bacteria in plaque produce acids which eat away at the surface of the enamel.

3. CAVITY FORMATION – DENTINE INVASION: As the cavity penetrates the softer dentine, it spreads like a wave and infects the microscopic tubes of this live tissue.

4. CAVITY FORMATION – DEEP DECAY: Very soon it approaches the nerve chamber, or the pulp, causing an inflammation which at this stage is reversible. This is when one feels mild pain or heightened sensitivity to sweets and cold.

5. DRILLING OUT GROSS DECAY: Treatment is initiated by removing the outer layers of decay with a slow drill.

6. LASER EXCAVATION AND DECONTAMINATION: The deep layers of decay are removed with the Waterlase® at lower settings, to avoid trauma to the nerve. There is no mechanical insult to the nerve, such as vibration, smearing or heat, which is the case when using drills. The infected dentine is thus removed completely, resulting many times in an exposure of the pulp.

7. EXPOSED PULP: If the nerve (pulp) is still healthy, it may bleed slightly. At this stage the exposure is treated like a wound. It is gently irrigated with hydrogen peroxide, followed with an isotonic homeopathic remedy.

8. DIRECT CAP: The exposure is gently covered with MTA, a cement well known for its biocompatibility and ability to preserve vitality of tissues with which it comes into contact.

9. CORE BUILDUP: The remaining cavity is then lined with a self-priming bonding agent without disturbing the MTA. After drying, the whole dentine surface is built up with a core of a flowable composite or compomer.

10. FINAL RESTORATION: The tooth is restored with an esthetic, tooth-colored bonded restoration, preferably an indirect porcelain inlay or onlay. The biomimetic principle is followed, which means that each part of the tooth that was restored, functionally mimics the biological tissue it is replacing.

Metals are good conductors of electricity and it does not take too much imagination to suspect that when they are placed in our bodies, they will create electrical currents that may not only cause the release of toxic corrosion products, but also interfere with the body’s subtle energy fields.

Since many dissimilar metals, such as silver amalgam and gold are used as fillings in our teeth, and are present in a moist environment, a battery effect is produced. This electrical activity is measured as “galvanic currents” between different fillings, or between fillings and body tissue. Electricity may cause corrosion of the less noble metal component, releasing harmful metal ions, or it may have neurological effects as it travels though our bodies.

Some people may perceive this as a “metallic taste” in the mouth or a spark of electricity when they have metal utensils or aluminum foil touch their metal fillings. It may also cause fatigue, sleep disturbances, irritability, skin lesions, etc.

It is easy to measure the battery effect. We do that regularly on our patients. A regular voltmeter will typically measure values of 20 to 300 millivolts between a mercury filling and the body. Mercury fillings hiding under or placed adjacent to gold crowns is of major concern because the electricity generated is much more profound.

Mercury released through galvanic corrosion enters the bone and gums surrounding these teeth in concentrations 20-100 times normal values. Other components of amalgams, such as tin and copper, also are released as salts which have a highly toxic effect on the body.

As we age, or in some cases following certain aggravating conditions, the vertical relationship between the jaws is diminished, and an “overclosed bite” results. The “columns” are shortened and worn down. As an analogy, the “roof” of the mouth is lowered. In the space inside the mouth, or the “room” that is now smaller, the tongue has less room to fit and function, and the airway, our life channel, is diminished in size and volume.

“Bite opening”, a simple layman’s term to describe the orthopaedic gain in vertical space between the upper and lower jaws,  is a method to restore the vertical relationship between upper and lower jaws to the original, or to a dimension that the body physiologically was meant to have, or once had.

What are oral and dental signs of an overclosed bite?

Many people who have an over-closed bite have:

1. worn-down teeth, man times so extreme that the teeth are flattened and have no enamel covering. There may also be other signs such as small craters caused by erosion on the chewing surfaces of the back teeth.
2. Fracturing of fillings, ceramics, or outright teeth, especially if they are root canalled.
3. thinner lips, as these get pushed together and collapse inwards, (just like in the elderly) when the vertical is reduced.

Can a history of orthodontics (braces) cause an overclosed bite?

According to our experience within our patient pool, most of those who have had braces with 4 sound premolars extracted also have over-closed bites, which is not only erosion-caused, but also due to an abnormal constriction of the size of the jaw and the inward tilting of the teeth.

Many dentists and orthodontists who have a deeper understanding of the way the jaws and jaw-joints works, frequently open the vertical in order to avoid relapse, or to prevent fracturing of tooth restorations.

What are other TMJ symptoms of loss in vertical?

The vertical collapse ultimately reflects in the jaw-joint. As the teeth wear down, the joints gets pushed back and jammed into their socket in the skull, and the delicate tissue behind the joint space, as well as the disc between the cartilage faces are damaged. Clicking, jaw tension and headaches ensue, which are common signs of Jaw-joint dysfunction (TMD).
How does one identify a loss in vertical at first glance?

If the lower incisors are worn down and crowded, facets appear and the dentin shows through, that indicates that at least 2 mm of vertical has been lost.

How is vertical bite opening achieved?

This is achieved in two phases:

• PHASE I: One option is to add some temporary material (composite) to lower teeth at a pre-determined opening, as dictated by the jaw-joint and neuromuscular function.
  Another option, especially in patients who have TMJ symptoms, is to have them wear a splint on the teeth to train the jaw to function in the new position for a few months. This allows for healing of the jaw joint.
  Phase I is an interim phase that is fully reversible and lasts 3 months.
• PHASE II: If the new jaw position is drastically different and the teeth are crowded or angled incorrectly, braces are placed to have the teeth move to a new position in space as dictated by the jaw.
  If many teeth have failing fillings or crowns, or are worn down, they are restored with porcelain crowns, overlays or onlays to the new dimension dictated by the jaw.

What are other benefits of restoring the vertical?

• Improved jaw-joint health
• less headaches
• less clenching and grinding
• stable tooth relationship
• more conservative tooth drilling for crowns and onlays (which are built with proper tooth anatomy thanks to the increased clearance between teeth)
• better lip support, reduction of wrinkles around the corners of the mouth, larger airway
• increased scope of jaw movement (range of motion)
• improved esthetic profile

The known history of dental implants begins more than 1300 years ago with this ancient Mayans artifact.

A 1930s archaeological dig led by Dr. Wilson Popenoe in Honduras turned up the ancient dental inlays. Similar discoveries were made when excavating ancient Egyptian artifacts. It was decades after these archaeological discoveries before the modern world caught up with the Mayans’ dental technology.

It was only in 1907 that a new and accurate method of casting gold inlays was announced by Dr. William H. Taggart. This technique was called the disappearing wax technique. He patented this technique but lost his patents when it was discovered that Dr. Philbrook of Denison, Iowa had written an article concerning gold inlay castings 25 years earlier. A copy of this article was found in the dental library of the University of Iowa.

• A 2007 study conducted by researchers at Johns Hopkins University and published by the New England Journal of Medicine concluded that Human Papilloma Virus (HPV) nowadays is strongly associated with oral cancer among people even without traditional risk factors of tobacco and alcohol abuse.

Any dental office with attention to the holistic nature of dental treatment will  now offer an important adjunctive screening test, the Vizilite, to catch oral cancer as early as possible.

An annual ViziLite Plus exam, after a conventional visual examination, represents an integral part of comprehensive oral-cancer screenings. The screenings help dentists detect oral cancer in its early stages, as well as precancerous tissue. Detection promotes early intervention and prolongs life expectancy.

In the past, oral cancer predominately struck men, adults over 40, African Americans, smokers and heavy alcohol drinkers. The new cancer-screening procedure “ViziLite® Plus with TBlue630″ is simple, quick,  non-invasive, pain-free and effective. We found that ‘Humana Dental’ will cover the screening once a year beginning April 1, 2008, and we are sure that other insurance companies will or may have already started to follow.

Enamel has growth rings just like trees. The growth pattern may be interrupted at any phase during the embryonic phase of tooth formation, such as an intense episode of malnutrition, emotional stress or disease, giving rise to changes in these growth rings.

Sometimes these can be so pronounced that we see them as ring-like defects around baby or adult teeth, depending on when the growth retardation occurred in early life. These defects are sometimes called “enamel hypoplasia”, and are more prone to decay.

Depending upon which teeth they are found on and which part of the tooth they are located on, we can extrapolate to the time period, within a few months, in which that interruption happened in pre-partum or post-partum life.

Depending on other accompanying symptoms or irritations, it can be combined, if taken at least half an hour apart, with

• Belladonna (in case of throbbing pain or flushed face),
• Ruta (in case of jaw soreness, sore ligaments or soreteeth due to a heavy bite), and
  
• Pyrogenium (in case of infection, fever, sepsis).

In general, the more intense the symptoms, the more frequent the dosage. Increase the potency, however, only as the symptoms become more deep-seated on the psychological or emotional character of the person.

1. the inner pulp,
2. the middle dentin layer. and
3. the outermost enamel cover.

Each of these layers provides it’s own specific properties to the tooth as a whole.

The pulp contains the blood vessels, nerves, and lymph channels. Even though the tooth appears to be hard as a rock, it is still living material. The  pulp layers supplies the tooth with “live” and enables it to respond to injury. Around the pulp is the middle ‘dentin layer’.

The biggest part of the tooth’s mass is dentin. This layer is highly organic and contains a large amount of collagen through which it provides the tooth with flexibility and compliance. In other words, it allows the tooth to be hard and still bend without breaking. This layer of dentin is also directly attached to the nerves. This is the reason that when it becomes exposed we experience tooth sensitivity.

The outermost part of the tooth is the enamel layer. It is the hard shiny coating. Enamel is the hardest substance in the human body. Through it, the tooth gains its strength and rigidity. It also covers the dentin layer to prevent its rapid aging due to the harsh environment in the oral cavity. Without the enamel, the tooth would be floppy and we would not be able to bite firm fruits and vegetables like apples and carrots. The optimal combination of the dentin and enamel layers provides the teeth with the perfect blend of stiffness, strength, and resilience.

The main challenge of a population that is getting older and wants to keep more of its natural teeth are age related changes in tooth structure. Through the natural aging process the original enamel thickness gets smaller over time. A loss of strength, color changes and even cracking are some of the adverse effects caused by these changes. This knowledge, combined with access to high-performance modern dental materials, allows modern dentistry to correct these changes. With the correct treatment it is now ensured that we can keep our teeth strong, attractive and free of sensitivity. These modern treatments, if started early enough are typically very conservative, safe and, best of all, pain-free.