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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!
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!
The Canadian Dental Association (CDA) in coordination with the American Dental Associtaion (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) have changed their protocol for antiobiotic prophylactic coverage for patients who have received total joint replacement. Patients who have received a total joint replacment (including pins and other retentive elements) are NO Longer Required to take prophylactic antbiotics prior to dental appointments.
An evidence-based review of literature has shown the risk of complications from taking a prophylactic antiobiotic is greater than the chance the antiobiotic coverage will prevent infection localized to the joint. The prophylactic use of antibiotics results in unnecessary use of antiobiotics increasing the risk for the production of antiobic-resistant strains of bacteria.
For more information, please refer to:
Basinview Dental Centre is on Facebook! On our page you will find daily and/ or weekly updated dental information about the practice, oral health tips, dental humor, treatment before and after photos and information about general dentistry.
For those of you who have already 'liked' us,
Thank you and enjoy the page!
Dr. Luke Haslam
Many of you may or may not already be aware of the recent changes made to the MSI dental coverage for children. As of May 30, 2013, children will be covered for basic dental services up to the end of the month of their 14th birthday. This is a significant improvement over the previous age of 10!
Coverage for children has remain unchanged; i.e. children up to 14 will be covered for examination, 2 bitewing radiographs and one preventitive service per year. Children with a history of cavities (and subsequent fillings) will be covered for fluoride treatments twice per year. Restorative services are covered as per usual. Emergency treatments are often covered when accompanied by an explanation of the emergency service provided by the dentist.
Any children covered by another insurance provider(s) must have all claims submitted to the primary insurance provider(s) before being submitted to MSI. Any remainer may then be submitted to MSI. They will cover the co-pay portion of any services which they would normally cover. Parents will be responsible for balances on non-insured treatments only.
There are some services that will not be covered by MSI such as Panorex radiographs, extractions for orthodontic purposes, space maintainers (unless the total household income is below the specified criteria), etc. Often, the services covered by MSI are insufficient to completely provide children with the appropriate level of preventative care they require.
Despite the system's shortcomings, this is a siginificant improvement! This will increase the access to care for children into the teen years.
If you have any questions or concerns, please feel free to contact us at Basinview Dental Centre and we will be happy to explain the details of this program further.
Dr. Luke Haslam
This patient presented with a tooth that had fractured at the gumline and was hoping to have the tooth restored. Unfortunately, due to the extent of the fracture and the underlying caries (Cavity) that was the source of the fracture, the tooth was nonrestorable and required extraction.
The coronal portion of the tooth had fractured to the level of crestal bone. The patient had minimal discomfort due to a previous endodontic treatment completed on the tooth. Catastrophic failure of a restoration/ tooth such as this is often easily prevented by properly restoring the tooth with an appropriate full coverage restoration (i.e. crown).
A full thickness flap was raised to access the remaining tooth structure followed by a minor osteotomy. The remaining fragments of root structure were extracted and the site was closed with 4-0 chromic sutures. Once the site has healed, the patient plans to replace the missing tooth (and other missing teeth) with a removable partial denture.