Some of the most basic treatments are often never discussed in dentistry, such as the simple occlusal (or biting surface) restoration. In the images below, the dark staining in the occlusal (biting surface) grooves are clearly visible. Within this stain, there are perforations in the enamel allowing bacteria and the byproducts of bacterial activity to damage the inner dentin tooth structure. Once the dentin has been affected by decay, the tooth now requires repair in the form of a restoration.
















The grooves of the tooth were "opened" with the necessary preparation to access the underlying decay. The decay was exacavated with a sharp carbide bur and then restored with Filtek resin (3M ESPE). A simple restoration like this can often be completed in less than 20 minutes. Timely treatment of decay such as this can save a patient money by not allowng the decay to progress to the point of becoming symptomatic and needing more extensive treatment, not to mention saving valable tooth structure!

This wondreful patient was tired of wearing a removable upper partial denture to replace a missing front tooth and decided a fixed option would be the right fit for her. She was also unhappy with the bonding and rotation of the adjacent front teeth. 





A simple, single unit implant supported crown was placed to replace the missing fron tooth and the adjacent teeth were restored with the same ceramic as used for the implant restoration. A simple procedure with dramatic results!




Following a sports injury, this patient was left without a lower central incisor. Initially, the patient was using a removable prosthetic (partial denture) to replce this missing tooth. After wearing the appliance for a few years, the patient decided a fixed option was in order.

An implant fixture was placed with excellent inital stability. A temporary crown was fabricated so the patient no longer required the use of the denture. Once integration of the implant was complete, the patient was ready for the final prosthetic.
 







A scanpost was placed atop the implant fixture and a Cerec digital image was obtained. The Cerec software was used to create an Emax custom abutment as well as an Emax custom crown.








































In the above images, the custom abutment has been delivered and torqued to 35Ncm. The access hole has been sealed with teflon.



















The final crown was cemented and minor tissue recontouring completed with a Waterlase to sculpt the tissues into an esthetic emergence profile. With some additional restorative work (i.e. repair of the fractured canine and a full coverage crown for the adjacet central), the esthetics of this case would be complete.

What happens to a tooth once it has a cavity and subsequent restoration to repair this defect?

The life cycle of a tooth that has received a restoration is very predictable and has been well documented over the years.



The first area of decay for a tooth is usually the biting surface or proximal surface (i.e. between adjacent teeth). The initial restoration is small and usually free of sensitivity. As time goes by, the filling and surrounding tooth wear (from abrasion, acid erosion, thermal flexure, etc) and the filling fails. Moisture begins to penetrate the margins and recurrent decay develops. Most often, the restoration is not replaced in a timely manner because there are no symptoms with this process and the patient does not feel the treatment is necessary.

Once the patient decides they are ready for treatment, the old restoration is removed and a larger one placed to accomodate the damaged areas of the tooth. This means the width has increased, the depth has increased, the risk of sensitivity has increased (and the proximal surfaces are usually involved).

As the size of the resoration increases, so does the risk of fracture. Once recurrent decay develops around a filling of this stage, a fracture is inevitable. The fracture usually encompasses a large portion of the tooth and may encroach on the pulp tissue (nerve supply) of the tooth. 

Further recurrent decay will develop with time and, when left untreated, will lead to even further fracture and risk for root canal therapy. As this point the only restorative option for the tooth will be a crown. 

No restoration is permanent. Eventually the crown will require replacement. If the treatment has been delayed and even more tooth structure is lost, then the tooth may no longer be restorable and require extraction. 

This doesn't sound very good, does it?! There are ways to prevent the progression from simple filling to extraction. The single most important thing is routine hygiene maintenance to keep restoration margins free of long-standing plaque and calculus debris. Routine radiographic and visual assessment of the restorations is necessary to detect failing restorations. Timely replacement of restorations can dramatically reduce the increase in size from one restoration to the next. 

Choosing the right filling material can also improve the life-span of a restored tooth. Once the filling size has progressed to greater than 1/2 the intercuspal width or a cusp requires replacement, then a CEREC onlay, 3/4 crown or crown are the most durable and long-lasting options. They will reduce the risk of fracture dramatically! 

If a tooth gets to the stage where root canal therapy, periodontal surgery and a new crown are required, one has to consider the long-term prognosis for the tooth. In some cases the prognosis will be good. In others, the prognosis may be guarded at best. At this point, replacement of the tooth with an implant-supported crown may be the best option. Implant treatment most closely resembles the original tooth and has an excellent pronosis - if cared for, they may last a lifetime.

One of the great many misconceptions people have about tooth decay is that it is an inherited trait. Many patients will often state, 'my Mom/Dad had bad teeth so I have bad teeth'. This is untrue. There are some genetic traits associated with teeth such as congenitally missing teeth, growth pattern of the jaw bones (Angles Class I, II and III), amelogenesis imperfecta to name a few.

Tooth decay is not inherited. It is 100% the result of the bacterial effects on our teeth. It is an infectious and contagious disease. In fact, it is the second most common disease in North America - second only to the common cold.

When we are born, we lack the bacterial flora in our mouths that are responsible for tooth decay. These bacteria are acquired following exposure; i.e. we become infected! This is most often caused by Mom or Dad sharing spoons with children. The longer we can delay exposure to these bacteria in young children, the lower the risk of developing tooth decay. Think about this before sharing utensils, food and cups with your children!

We can not blame our parents for tooth decay. Proper hygiene practices and diet can easily keep cavity causing bacteria in check and prevent decay!

Here are a some interesting dental myths:

1. My kids took all the Calcium from my teeth while I was pregnant and caused my teeth to decay.

Teeth are formed when we are children. They have a organic mineral matrix that once formed remains completely unchanged for our entire lives. Erosion, abrasion and attrition of the exterior surface of the tooth causes wear, but in no way can pregnancy remove Calcium from our teeth!

2. I inherited my bad teeth from my parents.

There are some dental traits that are genetic; e.g. congenitally missing teeth, genetic disorders like amelogenesis imperfecta, etc. Tooth decay is in no way genetic. It is caused by the metabolites produced by bacteria as they process sugars in our diet. We are not even born with cavity causing bacteria in our mouths, but rather acquire them once exposed (usually when sharing a spoon with our parents as babies). Every individual's teeth are as unique as finger-prints. Unfortunately, we can't blame our parents for this one!

3. Cavities in baby teeth are no big deal because they will just fall out anyway.

Baby teeth are the primary dentition and are just as important as our adult dentition. They are the only way for us to properly chew when we are children. They provide the space required for the eruption of the adult teeth when our jaws have grown to a sufficient size to accommodate them. If we do not treat baby teeth in a timely manner, children may experience pain that may reduce nutritional intake and affect growth and development. Early loss of baby teeth often leads to malpositioned adult teeth and costly orthodontic treatments!

Some fun dental facts:

1. Cavities are the second most common disease in North America - second only to the common cold!

2. Emergency dental treatments cost on average 10 x more than routine preventative dental care.

3. Someone dies of oral cancer every hour.

As of April 1, 2014, the Childrens Oral Health Program (MSI) will be increasing the age of eligible coverage to under 15. This means that children will have basic dental coverage until the end of the day on their 15th birthday. 

It is important to note that this program is far from comprehensive and is designed to provide only basic coverage for dental treatment. The program will cover one examination, 2 bitewing radiographs and ONLY ONE PREVENTATIVE SERVICE per year. As usual, basic restorations (or fillings) are covered.

The problem with the program is that these coverages are generally far less than what the average individual requires to maintain their oral health; especially for teenagers! Changes in hormones and the continued eruption of the adult dentition in these years places teens at a high risk for dental problems. Crowding of teeth during eruption, poor oral hygiene techniques/ practices and diet are a few other additional risk factors. To reduce risk, most individuals will require at a minimum, TWO PREVENTATIVE SERVICES per year. 

Many parents have been falsely informed and believe that this program is comprehensive meaning that all services will be covered. The purpose of examination is to not only identify dental problems (such as tooth decay), but to establish the patient's RISK. Each treatment plan is based on the individual's needs to reduce risk. Because the program is basic, it rarely covers the pateint's needs - this means there may be treatment required that is not covered by the program. 

For more information on this program, please feel free to contact Dr. Luke Haslam and staff at Basinview Dental Centre or the Quickcard Nova Scotia Chilren's Oral Health Care Program.


 

When looking at this image, there are a few obvious problems:

The dark dark discoloration of the tooth is due to marginal leakage and subsequent recurrent decay beneath the old filling. There is a significant wear facet on the buccal cusp extending distally indicative of malocclusion and possibly parafunction (clenching/ grinding). There is a craze line in the enamel running from the buccal cusp tip distally through the isthmus, beneath the old restoration and ending on the lingual cusp. The proximal surfaces are overbulked with old amalgam giving the tooth poor contour and making hygiene difficult.

The patient was advised of the poor condition of this tooth but decided not to proceed with any treatment until there was a problem with the tooth. A discussion ensued that involved the malocclusion, occlusal wear, recurrent decay and risk of fracture. A full coverage restoration would be ideal to optimize occlusion, strength and gingival health. The patient indicated that he was not interested in treatment because the tooth has never given him problems.

A mere 4 months after our discussion regarding this tooth, the patient returned with a fractured filling. There was some discomfort when biting and the appearance of the tooth was highly suspicious for fracture.

The tooth was anesthetized and isolated with rubber dam for comprehensive assessment: the mesial portion of the amalgam was fractured and missing; there was a large gap in the cavosurface margin, the remaining filling material was mobile and the buccal cusp moved with light pressure.


The restoration was removed to reveal the source of the problem - a clear vertical fracture completely dividing the buccal and lingual segments of the tooth. Unfortunately, this type of fracture can not be repaired and the only course of treatment was immediate extraction of the tooth. 

Timely care and maintenace of existing restorations are a crucial component of comprehensive dental care. As old fillings, crowns, etc. wear down, they dramatically increase the risk of fracture to the remaining tooth structure. Also, our bite will change with time such that even regular bite forces can lead to trauma to our teeth. 

Don't let this situation happen to you. Waiting until there is a problem can often be too late and very costly - as in this case where the tooth was nonrestorable. A replacement for this tooth will cost the patient more than three times what the initial treatment proposal was. Being proactive with oral health care is the best way to save time, money and maintain your natural, healthy smile.

Contact Dr. Luke Haslam at Basinview Dental Centre to schedule your consultation today!