1) There is a cavity under this molar crown. 2) There is a cavity under this premolar crown. The root canal filling material (arrows 3, 4 and 10) does not extend to the end of the tooth root (arrows 5, 6 and 11). 7) & 8) Xray evidence of a root canal infection in the jaw that is causing this new patient pain even though root canal therapy was already (incompletely) performed. 9) A poor-fitting prefabricated post. The molar tooth will need to be extracted and replaced with a dental implant and new crown. The premolar tooth will need root canal retreatment, a new post, possible crown lengthening gum surgery and a new crown. Much of this problem could have been avoided with more careful initial dentistry.
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Dr. Jeffrey Dorfman's Blog
Archive for the ‘Dr. Dorfman Says’ Category
About three dental students or dentists per week contact The Center for Special Dentistry about studying or working with us. Over the years we occasionally offered a simple questionnaire to 106 dental students. We have created scatter plots below to show you their answers to seven seemingly “simple” questions. What do you think? Ask your classmates, professors and friends in private practice. We have found: 1) most student’s really don’t have any idea how to answer these questions, and 2) their answers frequently deviate significantly from reality. Schools should really provide students this knowledge but they typically don’t.
– Dr. Jeffrey Dorfman
Editorial credit to Jackie Willis, future dental school applicant, for creating the scatter plots.
It seems that many websites are valued based largely upon the amount of visitor traffic it receives. However, if two different websites have the same visitor traffic and conversion rates but one of these websites offers a product or service that costs one thousand times more than the other then shouldn’t these websites be valued differently? For example, in 2012 NYCdentist.com averaged 35,000 monthly unique visitors (muv) but dentistry has much greater economic value than, e.g. book sales at BN.com (the Barnes and Noble bookstore website). A new dental patient conversion can be worth 1,000 times more than the online sale of a book.
I haven’t found a metric to describe this difference in economic value of a website visitor and therefore propose one: $muv “monthly unique visitor dollars.” $muv measures the average economic value of the monthly unique visitor conversion ($) multiplied by the number of monthly unique visitors (muv). Muv is the standard value as determined by Google Analytics.
$muv may be important because it appears that many people involved in digital media mistakenly attribute website value based solely upon visitor traffic. They may therefore overlook a website that draws a mere 35,000 muv’s. However when factoring in, e.g. $ = 1000x, it really should be considered to have an $muv of 35,000,000! This could dramatically change the asset value of a lower traffic but much higher economic value per conversion website.
It might also be worth considering $muv per unit of time because sometimes a single conversion, e.g. someone seeking dental services, might lead to long term income rather than a single purchase. This might be expressed as $muv(t) where (t) specifies the time period considered to determine the average economic value of the conversion.
In 2010, global industry analysts forecasted the global toothpaste market to reach $12.6 billion in 2015 (“Toothpaste,” 2012). While there is an apparent trend toward improved personal hygiene, at least part of this growth can be attributed to biotechnological advances that expand on the function and benefits of traditional toothpaste. Consumers can now purchase toothpaste customized to their particular needs or preferences, such as enamel protection, whitening, and treatment of sensitivity. Different types of toothpastes include many different types of ingredients. It is helpful to understand what purposes the ingredients in your toothpaste serve. This article will educate you on common ingredients found in toothpaste.
When we eat and drink, bacteria in our mouth begins metabolizing the food sugar into acid. The debris leftover from the food gets stuck on and around our teeth. If left unbrushed and unflossed, this leftover debris becomes plaque, or a sticky mixture of food debris, mucus, and bacteria. Plaque removes minerals from the surface of the tooth and causes cavities. Left further untreated, plaque will harden into tartar and calculus at the base of the teeth. Bacteria will inflame the gums causing pockets to form, and plaque will continue to enter deeper at the base of the tooth. Gingivitis develops as gums become red, swollen, recede, and bleed easily. Left even further untreated, gingivitis can lead to a more serious condition called periodontitis, or inflammation of the ligaments and bone structure supporting the teeth. Loss of bone and support result in tooth loss. Therefore, it is vital to maintain your oral health by brushing your teeth with toothpaste, flossing, and visiting your dentist’s office for regular check-ups and cleanings. Read our article How to choose the toothpaste right for you for more information.
Below is a table list of common ingredients and their specific purpose
Fluoride is a naturally occurring mineral and active ingredient in toothpaste that is proven to prevent tooth decay (Higham, 2011). Fluoride protects the teeth by stopping or even reversing the tooth decay process and by strengthening the enamel. Eating sugar and refined carbohydrates would normally remove the minerals from teeth. Fluoride helps to remineralize the tooth surface. Following the remineralization, fluoridated hydroxyapatite and fluorapatite embed in the tooth surfaces, strengthening the tooth enamel, and preventing cavities (Higham, 2011). A study in the Journal of the American Dental Association finds that even the highest fluoride toothpaste does not appear to prevent enamel erosion (Rios D. et al., 2008). Therefore, patients with highly acidic diets or who are at high risk for enamel erosion or cavities should take other preventative measures with the help of a dentist than just seeking out the local fluoride toothpaste.
Sodium fluoride, stannous fluoride, or sodium monofluorophosphate are ingredients classified as a drug by the FDA, and are considered unsafe to ingest in large amounts, in which dental fluorosis may occur. Fluorosis is an abnormal condition in the appearance of the tooth’s enamel. “It can result when children consume higher-than-recommended amounts of fluoride during the teeth forming years, age 8 and younger” (“Community water fluoridation,” 2012). A 2012 study about Topical Fluoride says, “there is overwhelming evidence that reports not only the significance and importance of the use of fluoride as a caries-preventive agent, but also how safe fluoride application is when used appropriately, particularly in higher risk individuals and populations” (Miller et al, 2012). Therefore, it is not only important to prevent cavities and remineralize the enamel with fluoride, but it is also important to follow the safety directions on fluoride toothpaste to prevent fluorosis.
Many U.S. states provide community water fluoridation as a way of preventing tooth decay. The Center for Disease Control and Prevention (CDC) has recognized water fluoridation as safe, healthy, and one of ten of the United States’ greatest public health achievements (“Ten great public,” 1999). The CDC also recognizes that ‘almost all water contains some naturally occurring fluoride, but usually at levels too low to prevent tooth decay’ (“Community water fluoridation,” 2012). Results from a study involving U.S. children show how water fluoridation has played a dominant role in the decline and prevention of dental caries (Brunelle & Carlos, 1990). It is recommended to use fluoride toothpaste in addition to drinking fluoridated water as it offers more cavity prevention.
Toothpaste manufacturers often use abrasive ingredients in their product for the removal of debris, plaque and stains that accumulate on surfaces of teeth. Common abrasive include calcium phosphates, alumina, calcium carbonate, and silica. Toothpaste should be abrasive enough to remove plaque or stains and to polish teeth; however, they must not be abrasive enough to damage tooth enamel. Factors such as aggressively brushing teeth, teeth grinding, acidic diets and toothpastes with high abrasivity may grind down the enamel over time, which could lead to sensitivity, gum recession and damaged enamel. Damaged tooth enamel also causes yellowing as the thinned enamel reveals the yellowish dentin layer below. Strong whitening toothpastes use abrasion to remove external stains as opposed to changing tooth color. In vitro studies find that whitening toothpastes appear to be more abrasive to dentin (Schemehorn, Moore & Putt, 2011). A scale for measuring abrasiveness is called the Relative Dentin Abrasivity (RDA) scale. The RDA scale ranges from 0 to 250 with the low number being least abrasive and the high number being most abrasive.
Surfactants or Detergents
Detergents or surfactants produce foam to help clean out the fatty films and food debris. Sodium lauryl sulfate (SLS) is a common toothpaste detergent which provides foam, helps to clean teeth, has anti-bacterial properties and can disintegrate plaque. However, detergents can dry the inside of the mouth, which may directly cause irritation of oral membranes and canker sores (Herlofson & Barkvoll, 1996). A published article in the International Journal of Dental Hygiene found data that suggests while detergents may have the potential to cause soft tissue damage, the saliva in the mouth could possibly neutralize such effects (Moore, C., Addy, M., Moran, J., 2008). There is a substitutive ingredient which does not evoke gum irritation called Sodium N-Lauryl sarcosinate, a milder detergent than sodium lauryl sulfate. Certain toothpastes such as Tom’s of Maine are SLS free and can include a gentle ingredient called glycyrrhizin for natural low foam. SLS-free toothpaste is a common recommendation for people who frequently get canker sores.
Triclosan is an antimicrobial agent, which is effective in reducing plaque bacteria and gingivitis when combined with a retentive agent. It is also anti-fungal, anti-viral and compatible with other agents in toothpaste as it is non-ionic. Many household products such as soaps and hygiene products contain triclosan as well.
Interestingly, a 2004 controversial study from Virginia Tech found that soaps containing triclosan can combine with chlorine in tap water to form chloroform (Vikesland, 2004). According to The United States Environmental Protection Agency (as cited in Vikesland, 2004), chloroform is classified as a probable human carcinogen, or cancer-causing agent targeting the liver, kidney, and central nervous system. There is a great deal of concern over the small amounts of dioxins created because it is a high risk to one’s health. Because triclosan is an ingredient in soaps and toothpaste, there was health concern on whether triclosan in toothpaste was combining with chlorinated tap water to produce potentially harming effects.
The American Dental Association published a response to these concerns stating that the Virginia Tech study, as designed and conducted, is not relevant to toothpaste. The study showed that the amount of chloroform generated was less than amounts often present in chlorinated drinking waters. According to an American Dental Association archive, Dr. Vikesland, study’s lead author announced, “It is highly premature to presume that there is a problem associated with the use of triclosan-containing toothpastes. In order for the reactions that we studied to occur, you would need excess amounts of chlorine–which usually doesn’t occur when you are brushing your teeth, which is a little bit of tap water, a lot of toothpaste and saliva.” (Berthold, 2005).
Sweeteners, Thickeners, and Humectants
Toothpaste includes sweeteners such as saccharin or sorbitol to improve the taste. Most toothpaste sweeteners are artificial and contribute little to no cavity formation. Coloring agents and artificial dyes are used to make toothpaste more colorful and aesthetically pleasing to the eye. Thickeners such as xantham gum, cellulose gum, and carrageenan help to create the texture and thickness of toothpaste. Thickeners help to stabilize all the chemicals together in the toothpaste tube. Humectants prevent water loss by attracting and holding water molecules within toothpaste. Glycerin, sorbitol, xylitol and water are common humectants. Xylitol is a humectant and natural sugar that fights tooth decay and gum disease instead of enhancing it as most sugars do. A study in the Journal of Oral Science found that the combination of fluoride with xylitol is more effective than either ingredient alone (Sano et al, 2007).
Beware of Diethylene Glycol
Diethylene Glycol (DEG), an ingredient used in antifreeze, is a toxic and lethal sweet-tasting substance that should not be found in U.S. toothpaste. After diethylene glycol was found in Chinese-made toothpaste sold in the Dominican Republic and Panama in 2007, the U.S. Food and Drug Administration (FDA) made preventative measures to test and sample all Chinese-made toothpaste entering the U.S. (as cited in CNN report, 2007). Diethylene Glycol, or diglycol, was known to be used as a substitute for the more so expensive ingredient glycerin in toothpaste. Although there were no U.S. reports of poisonings from toothpaste containing diethylene glycol, the FDA took precautions and warned populations about potential risks from chronic exposure, unintentional swallowing or ingestion of toothpaste containing DEG (“FDA,” 2007).
In 2007, FDA inspected and tested toothpastes labeled “Made in China,” which FDA found to contain about 3 percent DEG (“FDA,” 2007). The DEG containing toothpastes did not have diethylene glycol labeled in its ingredients. Furthermore, counterfeit toothpaste falsely packaged as “Colgate” had been found in several dollar-type discount stores in New York, New Jersey, Pennsylvania, and Maryland (Klimerman, 2007). These counterfeit products were typically sold at low-cost, bargain retail outlets. As a precaution, FDA urged American consumers to immediately stop using Chinese-made toothpaste products and either throw them away or return them to the place of purchase (“FDA,” 2007).
It is very interesting to learn about the scientific research behind the ingredients in health products such as toothpaste. Rarely do we think about the risks and dangers of using toothpaste other than the benefits of using it to combat cavities and stains. However, it is helpful for us to continue educating ourselves about new information, new products, new ingredients, and new technology. The more consumers are able to learn what they use, the better their decisions will be upon purchasing products. When in doubt, always ask your local NYC dentist, Dr. Jeffrey Dorfman.
Toothpaste, also called dentifrice, is essential to proper oral hygiene and is used for many reasons: to protect and build the enamel against acidic and sugary foods; to clean out all leftover food debris; and to prevent tooth decay and cavities. Part of the apparent growth toward improved personal hygiene can be attributed to biotechnological advances that expand on the function and benefits of traditional toothpaste. Patients can now purchase toothpaste customized to their particular needs or preferences, such as enamel protection, whitening, relieving dry mouth and treatment of sensitivity. This multi-functionality of toothpaste now offers us more targeted control of our oral care regimes at home. This article will educate and guide you in how to choose the right toothpaste for your specific needs. Read our article What is in your Toothpaste for more information.
After every meal, molecules of debris and biofilm get caught on and between the teeth. Biofilm is a thin film of bacteria, also known as plaque, which builds up in the mouth and attacks the teeth and gums. Our mouth already has bacteria which digests and metabolizes sugars in food we consume to form lactic acid. This acid dissolves minerals from the tooth enamel in a process called demineralization. Tooth decay and cavities form when the acid breaks down dental enamel. Demineralized enamel also leaves you more sensitive to hot/cold foods, pressure and pain compared to normal enamel. Not brushing your teeth will allow the debris and biofilm to accumulate on tooth surfaces, which will lead to serious inflammation and infection of the gums, bones, and ligaments supporting the teeth.
The purpose of traditional toothpaste is to clean the enamel, remove food particles, stain, and bacteria. Effective toothpaste with the right ingredients should be used to prevent the demineralization process or strengthen and restore the enamel’s mineral with the process of remineralization. While the precise chemical makeup of different toothpastes may vary, most are composed of the same basic elements: fluoride to protect teeth from cavities; abrasives that remove particles and stain and also polish the teeth; humectants that provide the paste-like consistency and retain moisture; detergents that generate foaming action during brushing; thickeners that contribute to the integrity of the paste; preservatives that help prevent the growth of unwanted microorganisms during storage; flavoring agents, sweeteners, and coloring agents. For more information on toothpaste ingredients, see our article, What’s In Your Toothpaste? – (to be published soon).
The U.S. Food and Drug Administration (FDA) requires the manufacturer to show a Risk Evaluation and Mitigation Strategy (REMS) to ensure safe use of toothpaste and to ensure the benefits of the medication outweigh the risks. The FDA insists that manufacturers of fluoride-containing toothpaste meet certain requirements for the product’s active ingredients, product indications, claims and other qualifications.
Furthermore, a product like toothpaste can be considered both a cosmetic and a drug according to the FDA. Different laws and regulations apply to drugs and cosmetics. When a product has two intended uses like fluoride toothpaste which also whitens teeth, such products must comply with the requirements for both cosmetics and drugs. Firms sometimes violate the law by marketing a cosmetic with a drug claim or by marketing a drug as if it were a cosmetic, without adhering to requirements for drugs.
The American Dental Association (ADA) conducts extensive and thorough laboratory tests on toothpastes to ensure safety and effectiveness. The ADA determines the product’s fluoride content, how it is released and its effectiveness on tooth enamel. Some toothpaste will have an ADA seal, which means the selected toothpaste has been tested on and has met the ADA criteria for safety and effectiveness.
Choose Your Toothpaste:
1) To Fight Cavities
Many research studies confirm and continue to reinforce that fluoride toothpaste is more effective compared to non-fluoride toothpaste. Fluoride protects the teeth by strengthening the enamel and can remineralize caries like enamel lesions (Arnold, 2006). Common fluoride compounds in toothpastes include sodium fluoride and sodium monofluorophosphate. Studies have shown that toothpaste should have a fluoride concentration of at least 1000 ppm (parts per million) or above to be considered effective in reducing caries and preventing tooth decay (Twetman et al, 2003). Fluorosis is an abnormal condition characterized in children and is caused by excessive intake of fluoride. In children under 6 years, the decision of what fluoride levels of toothpaste to use should be discussed with your dentist (Walsh et al, 2010).
Colgate Total carries the seal of approval from the ADA as it incorporates fluoride to prevent cavities and strengthen enamel. In addition, Colgate Total has another anti-biotic ingredient triclosan, which helps to kill the bacteria that cause plaque and gum disease. This toothpaste incorporates a copolymer to keep the fluoride and triclosan actively protecting teeth and gums for up to 12 hours between brushings. Colgate Total has been certified by independent dental associations in 29 other countries (“Colgate total,” 2012).
Tooth sensitivity occurs with when there is open exposure of the ‘dentin’, or the softer part of your tooth that is layered under the enamel. Dentin has fluid-filled tubules of nerve endings. When fluid moves, the nerve endings react in response, which causes the distinctive sharp pain. Blowing air, eating or drinking hot, cold or sweet things can cause this fluid to move (Brännström, 1966). Common causes of wearing the enamel away and gradually exposing the dentin include brushing your teeth too vigorously or frequently, gum disease, teeth grinding or clenching, receding gums, and eating or drinking highly acidic foods or drinks which erode the enamel (Addy, 2002).
Using a sensitivity toothpaste like Sensodyne Pronamel toothpaste treats and protects against sensitivity. “The potassium ions in Sensodyne toothpaste builds a protective barrier that blocks the pain caused by pain stimuli,” (“Minimizing the risk,” 2012). This toothpaste will relieve the sensitivity and help protect against the effects of acid erosion. Sensodyne Pronamel is formulated to re-harden acid-softened tooth enamel while also preventing cavities. Two active ingredients are potassium nitrate, which aids against teeth sensitivity, and sodium fluoride, which aids against cavity formation.
Desensitizing toothpastes normally take some time to reduce sensitivity. However, a recently new oral product called Colgate Sensitive Pro-Relief Desensitizing Paste has Pro-Argin technology which claims to provide instant sensitivity relief after one application. The Pro-Argin Technology effectively plugs and seals open dentin tubules when polished into teeth with a rotary cup. This desensitizing paste can only be administered by professionals trained in performing dental prophylaxis (“Colgate sensitive pro-relief,” 2012). Since our technological world is rapidly advancing, it is only a matter of time until this new technology can occur in toothpaste.
Patients continue to increase their demand for products that whiten teeth. As time passes, teeth may become discolored and stained from various causes such as drinking alcohol or coffee, eating certain foods, and smoking tobacco. Specific peroxide-based bleaching pastes and gels are used to improve intrinsic tooth color or remove and prevent extrinsic tooth stain. Whitening toothpaste may commonly include special abrasives that gently polish the teeth and sodium tripolyphosphate to help break down or dissolve stains. However, some whitening toothpastes may be highly potent with abrasive agents, which can harm the enamel if used too often. When choosing whitening toothpaste, you want to consider active ingredients, effectiveness and safety.
Whitening toothpaste does not change the natural color of teeth or reverse discoloration. It merely whitens the teeth slightly by removing surface stains. It is highly recommended to seek whitening treatment in a dental office rather than use toothpaste products. Nevertheless, ADA sealed toothpastes such as Crest’s Pro-Health Whitening Toothpaste is safe and effective in helping to whiten teeth by removing surface stains, when used as directed (“ADA seal product report,” 2013). In addition, it is effective in helping to prevent and reduce tooth decay, gingivitis, and plaque above the gumline, bad breath, and relieves sensitivity.
New research shows the chemical blue covarine can make teeth appear whiter immediately after treatment. Blue covarine adheres to the surface of the teeth to create an optical illusion making teeth appear less yellow. In addition, “silica based whitening toothpaste containing blue covarine did not have an undue degree of abrasivity to enamel or dentine compared to other relevant commercially available products and is an efficacious source of fluoride” (Joiner, 2009). Technological breakthroughs have advanced toothpaste so that the optical properties of the tooth color are modified rather than having the enamel at risk of being abraded.
Xerostomia is the medical term for having a dry mouth due to lack of saliva. Having a dry mouth is an uncomfortable and unhealthy condition that should be treated and improved. Xerostomia increases the risk for tooth decay, gum disease, and bad breath since the lack of saliva leaves the mouth unprotected. It is very common among adults and is generally caused by, but not limited to: side effects of medications, allergies, sleep apnea, snoring, radiation therapy and chemotherapy. Dry mouth persists by dehydrating the body with smoking, ingesting caffeine or alcohol. Age and menopause also decrease how much saliva we produce. Treatment of xerostomia relies on the diagnosis so it is best to seek the advice of your dentist and a multidisciplinary team of doctors.
Research does show how the use of toothpaste and mouthwash based on triclosan, fluoride, gingival revitalizers and mineral salts improves the symptoms of patients who suffer from dry mouth (Lopez-Jornet, 2011). Toothpastes such as Biotene Dry Mouth may improve dry mouth, but it certainly does not cure xerostomia completely. This toothpaste contains patented Salivary LP3 enzyme system that supplements the mouth’s salivary defenses. Using a bio-active enzyme system to replace salivary enzymes helps reduce tissue irritation. In addition, Biotene Dry Mouth contains a gentle formula not to irritate the gums, fluoride to fight cavities, and it reduces bacteria associated with bad breath (“Biotene dry mouth,” 2013).
Halitosis is when unpleasant odors are released from breathing. Oral malodor may be one of the top three reasons why patients seek dental visits, following after concerns over dental caries and periodontal disease (Loesche & Kazor, 2002). Bad breath can result from poor dental health habits and may also be a sign of other health problems such as yeast infection, dry mouth, diabetes, or pneumonia. If you do not follow oral regimens daily, bacterial will grow between your teeth, on your tongue and around your gums from eating. Persistent bad breath may be a warning sign of gum disease and it is important to make a visit to your local Periodontist, a dentist who specializes in treating gum conditions.
Studies have consistently shown that toothpastes containing zinc ions help to reduce volatile sulfur compounds (VSCs) and oral malodor (Burnett et al, 2011). Stannous-containing toothpastes show statistically significant reduction of bad breath (Feng, 2010). Of course, understanding the cause of your bad breath and making changes to medications or habits will help to relieve halitosis. Crest Pro-Health Toothpaste is formulated toothpaste containing stabilized stannous fluoride, which kills bacteria associated with plaque and gingivitis.
When it comes to choosing toothpaste, it can be a bit overwhelming. Now that you understand and are educated about some research studies involving toothpastes, it will relieve some stress in picking your desired toothpaste. The more technology advances and the more we research, the more we will continue to discover and improve toothpaste ingredients. Nonetheless, it is always best to consult with your dentist about what the best toothpaste might be for you, considering your specific dental needs. When choosing toothpaste, look for the ADA seal and always remember to floss daily!
Comparison photos in two different patients showing teeth that exhibit signs of Bulimia Anorexia (top picture) from those that are healthy (bottom picture).
A temporary crown-form, or lab-fabricated temporary crown, of the appropriate shade, size and color is tried into the space to be closed. The orthodontist will then bond an orthodontic bracket to the temporary crown and attach it to the orthodontic wire using standard elastics.
This technique may be used until the space is closed with fixed teeth braces. The mesio-distal diameter of the temporary crown can be reduced as the space is closed as the teeth move.
These photos show how to repair a loose crown on top of a dental implant. In the x-ray (not shown here) the bone around the implant appeared to be healthy and the implant abutment appeared to be in the exact middle of the crown. This helped to identify where to start drilling through the porcelain crown with a round diamond bur. Next, a sharp-edged steel bur was used to cut through the metal of the crown below the porcelain. This cutting was performed carefully so as not to damage the second stage implant abutment while looking for the access hole to the second stage screw. An implant screwdriver was fit through the opening. If necessary the metal of the crown can be smoothed to allow more room for the screwdriver. One must choose a screwdriver that fits the brand of implant under the crown. A torque driver was then connected to the implant screwdriver and the implant company’s recommended torque applied. Blue wax was then placed over the screw and composite resin dental bonding of the appropriate shade was placed in the occlusal opening.
1dentist, LLC is in discussion with Liberty Enterprises, Inc. and its President Gerald (Jerry) Musano about relocating its corporate office.