How to Treat Tooth Decay, a Cavity, Below the Gum.

This patient had a very large cavity underneath an old dental crown.  #1 – following crown removal this tooth had decay (cavity) below the gum. Gum inflammation can be seen. The soft tooth structure is the remaining cavity. Photo #2 – an Endodontist then performed root canal. Photo #3 – the root canal was reshaped into an oval to prevent rotation of the cast post & core. A gingivectomy was performed at this time to remove this excess gum tissue before taking an impression for the cast post & core. Photo #4 – the cast post & core with a Kaitlyn Loop with a long piece of dental floss tied and knotted through it. The Kaitlyn Loop will help prevent accidental swallowing of the post & core if it is dropped in the back of the mouth. Photo #5 – the cast post and core is cemented in the tooth. The interocclusal clearance is checked. Photo #6 – a Periodontist then performed crown lengthening periodontal surgery.  A marginal incision was made on buccal side and a 4 mm submarginal incision was made on the lingual side. A distal wedge was removed. Interproximal soft tissue was removed and then 1-2 mm of osseus reduction was performed on the mesial, distal, and lingual sides of the tooth. 4-0 chromic gut sutures were next used. A provisional cap was cemented with temporary crown cement and then periodontal packing was placed around the tooth and temp.

Dentists and doctors are increasingly reliant upon the internet in general and search engines in particular.  The power that search engines exert upon private practice has reached an alarming level.  Free speech exists for an anonymous “patient” to criticize a doctor online while search engines employ censorship without explanation.  Many doctors don’t know that they are breaking the law in many states by offering discounts on coupon websites.  It is time for a national discourse on internet dentistry and medicine.

Censorship is a timely topic as evidenced by the recent SOPA-inspired Google and Wikipedia blackout.

In America, great power incurs great responsibility.  On the internet, Google yields great power.  Some would argue it is a monopoly deserving the fate that befell Microsoft in the prior decade in the U.S. and Europe.  Google should therefore avoid corporate policy that puts it at risk for government intervention.

“Democracy… Is two wolves and a lamb voting on what to have for lunch. Liberty… Is a well-armed lamb contesting the vote.”

– Benjamin Franklin

Google is not Coke.  Coke’s secret formula has no impact on millions of American businesses; Google’s secret algorithm does.  The “review” sites like Yelp or the bottom-dwelling, Doctoroogle, are not any better.  Yelp’s algorithm only displays “reviews” if the “reviewer” has written many other “reviews” and has many Yelp friends.  This tends to censor (“filter”) reviews from older, busier and probably wealthier consumers whose opinions may matter most in certain market segments like luxury items.

I suggest the following definitions:

Censorship – the illegal delisting of a website without proper notification and without access to an impartial review board.

Suspension – the legal delisting of a website with proper notification and with access to an impartial review board.

Search engines like Google should properly:

1) send notification to a website that it deems worthy of delisting and provide contact information for an impartial review board.

2) create an impartial review board where the delisted website owner may adjudicate the delisting without disclosing it’s algorithm.

“Review” sites need to be held accountable for how “reviews” are shown online.  Bad “reviews” should not be disproportionately displayed in order to force a doctor to become an advertiser.  I understand the issue of Free Speech on the internet but extortion is extortion.  Doctors have rights too.

Removable Dental Braces Before and After Photos.

This patient underwent orthodontic treatment for twelve months with an Orthodontist.  At the end of treatment the front teeth were reshaped by a Cosmetic Dentist to create symmetrical teeth shape and size.  People should consider straightening their teeth with dental braces before beginning cosmetic dentistry.

Your mother was right.  Sugar is bad for your teeth.  Like it or not, that fact doesn’t change the older you get.  We’ve seen many adult patients who are relatively cavity-free for years suddenly develop new cavities.   The reason?  Most likely, it’s because they’ve been eating more sugar.  Chocolate, candy, cakes, soda and ice cream are not the only culprits.  Sugar also comes from foods we consider good for us, like fresh fruit, juices or honey.  Complex carbohydrates like potatoes, pasta and bread become the simplest form of sugar – glucose – once you digest them, and they also can wreak havoc on your teeth.

Far be it from us to suggest that you avoid sugar or starch completely.  Rather, consider adopting a few new habits when you indulge.  Mom may have always told you to eat slowly, but when consuming sugar or complex carbs, it’s actually better to eat more in a shorter time.  (Sorry, Mom.)  So, if you’re inclined to savor sweets until they literally melt in your mouth or snack on crackers throughout the day, don’t.  The longer these foods stay in your mouth, the greater the potential for cavities.

Once you’ve gotten your sugar or starch fix, remember to clean your teeth.  While flossing and brushing are the gold standard, they’re not always practical.  If you’re on the go or don’t have a toothbrush, floss or mouthwash handy, no worries.  Simply drink a mouthful of water.  And, if you’re partial to fruit juices, water will also clean the citric acid they leave behind on your teeth.  Water isn’t just a convenient way to clean your teeth, it’s also essential for daily nutrition (the recommended average for adults is 50 ounces per day), so you’re getting a double benefit.

By making these simple changes, you can enjoy your favorite sweets and carbs while reducing your potential for cavities.  Mom will be so happy.

–Mary Di Landro

Canker sores (Recurrent Aphthous Stomatitis, RAS or Recurrent Aphthous Ulcers, RAU) are idiopathic (canker sore causes are unknown) oral lesions that occur in approximately 10 -15% of the population. Most people who get canker sores find they recur several times a year. They typically appear as a white oval on the cheeks, lips, palate and tongue that lasts for about seven days. Ten percent of people who get canker sores will get major canker sores. Major canker sores (aka Sutton Ulcers or Periadenitis Mucosa Necrotica Recurrens) can reach up to a half inch in size and last for one or more months; they typically affect immunosuppressed people. Major canker sores can leave permanent scars. All canker sores can be extremely painful, highly disproportionate to their size. The pain from canker sores can prevent people from eating and/or drinking; this can lead to malnutrition and dehydration. Many people therefore seek help with canker sore relief. Unlike Herpes, canker sores are not contagious.

Physical trauma to the inner lining of the mouth (e.g. cheek biting, pizza burn), stress, diet or an allergic reaction to a food, toothpaste or mouthwash may cause a canker sore to occur. Vitamin B12 & folate deficiency, gluten sensitivity, allergy to sodium lauryl sulfate in toothpaste and smoking cessation are all liked to the development of canker sores. Men develop canker sores less frequently than women. Some medical conditions like Crohn’s disease, ulcerative colitis and celiac disease result in a higher incidence of canker sores. It also appears more frequently in people who have HIV/AIDS, neutropenia, reactive arthritis and those undergoing cancer chemotherapy who develop Oral Mucositis. Susceptibility to canker sores appears to be genetic.

Treatment for canker sores include: analgesics, anesthetics, antiseptics, anti-inflammatory agents, steroids, fumaric acid esters, sucralfate, tetracycline suspension and silver nitrate. The two most common anesthetic gels applied to canker sores are Benzocaine and Lidocaine. Another approach would be to use topical Benzydamine Hydrochloride (Amlexanox) which is an anti-inflammatory, anti-allergic medication. It was reformulated as a 5% topical oral paste that will adhere to oral mucosa and approved by the FDA for the treatment of canker sores. This will relieve pain and accelerate ulcer healing.

Other canker sore remedies use a protective barrier, such as topical Hyaluronic Acid or Cyanoacrylate adhesives. Topical Hyaluronic Acid is made up of 0.2 % Hyaluron Gel. It acts as a protective barrier that functions to help in local tissue hydration. It also serves as an anti-oxidant.

Antimicrobials that will reduce the duration of the ulcer. Some antimicrobials used are Chlorhexidine, Triclosan, Tetracycline, and Penicillin G. All of these are used to reduce ulcer pain and hasten healing time. Chlorhexidine comes in a 0.2% mouth rinse or 1% gel and is used to increase the number of ulcer- free days. Triclosan is an anti-inflammatory agent, as well as an antimicrobial and is used to reduce the number of canker sores, relieve pain, and shorten duration. There is some concern, however, about the use of Triclosan. Tetracycline has an anti-inflammatory effect that works in the ulcerative phase. Penicillin G can be used four times a day for 4 days and will reduce the healing time, pain and size of the ulcer.

Steroids and Immunomodulation can also be used in the canker sore healing process as well. Steroids come in mouth rinses (Betamethasone Valearate), ointment, and creams (Triamcinolone Acetonide). Immunomodulation treats canker sores by affecting the immune system. A few immunomodulators are Thalidomide, Colchicine, Pentoxifylline, Levamisole, Dapsone, and Cimetidine. The immunostimulant, Thalidomide, is especially useful in HIV positive patients with RAS. Some adverse drug reactions include teratogenic, rashes and peripheral neuropathy. Levamisole will reduce the pain and frequency of ulcers and also promotes healing.

Other medications used to treat canker sores are: Adalimumab, Alefacept, Cyclophosphamide, Cyclosporine, Dapsone, Efalizumab, Etanercept, Infliximab, Interferon, Methotrexate, and Penoxifylline. Herbal remedies include: Licorice Root, Sage, Echinacea, Chamomile and Myrrh. Magic Mouthwash provides a limited benefit. Hydrogen peroxide, salt water rinse, Milk of Magnesia and liquid antihistamines can be used as mouth rinses. Silver Nitrate Sticks cause a chemical burn when applied to the oral mucosa.

Physical therapy may be employed to manage the ulcer: surgical removal, laser ablation, chemical cautery, and low dense ultrasound. Laser therapy reduces canker sore pain and may reduce the frequency of recurrence. Cryotherapy (freezing the canker sore) does not work.

The canker sore treatment we use in our office involves a medication that induces a chemical burn (chemical cautery) on the canker sore. The exposed nerve endings of the canker sore are covered in a callus that forms in response to the burn. This burn will last about seven days but during that time nearly all of the pain associated with the canker sore will be gone.  This aphthous ulcer medication is currently available as an in-office treatment, or by prescription, only after diagnosis in our office.  The procedure itself takes a few minutes and is not painful.

Many people are confused by common pathology seen on the lips or just inside the mouth.  This picture is offered as a simple comparison.

Photo comparsion: Herpes, Canker Sore, Chapped Lips and Angular Cheilitis.

Norvasc side effects include swollen gums and bleeding gums.  Norvasc is from a group of medications known as calcium channel blockers that frequently cause gingival hyperplasia (gum overgrowth).  Gingivitis and other symptoms of periodontal disease may be seen in patients taking Norvasc but they may not necessarily require treatment if they maintain meticulous oral hygiene.  All people taking calcium channel blockers should be seen regularly by a Periodontist.

Dr. Leonard I. Linkow, DDS, DMSc*

I was just in the middle of deep involvement with writing my eighteenth book on implant dentistry- this time on the greatest implant ever created- the tripodal mandibular subperiosteal implant which I introduced to the profession in 1984.

It is now 5:00AM in the morning and I am sitting at my desk to begin this letter to you with many disturbing figures, not because they have the potential to shock or intimidate but mainly because they will resonate throughout my introduction on just about everything that I have to say to you.

Let me introduce myself: my name is Leonard I. Linkow. As a leading pioneer in implant dentistry and considered by many the world over as father of Implantology. I have treated more than 100,000 patients using more than 101,700 implants in my 50+ years of practice.

I had seventeen books published in implant dentistry where I considered nine of them bibles of implant dentistry.

And I want it to be known that I never received one penny of the royalties from any of the books sold but instead had the publishers receive the same to use the proceeds to pay for the translators to translate the volumes into various languages.

So why I am now writing another book if I receive no returns? Because there is a great need to illuminate the negative approach of the dental profession regarding subperiosteal implants and their tremendous need for the millions of edentulous patients who desperately need them.

Now let’s get into the facts and figures of subperiosteal implants.

However, first let me mention a few other implants that proceeded the mandibular tripodal subperiosteal implant.

In 1964 I introduced the very first self-tapping screw type implant which I called the vent plant. Prior to this every screw implant had to first have the osteotomy performed with a bone tap before the implant could be inserted.

In 1967 I introduced the immediate loaded one piece blade/plate form implant. Both of these implant designs became extremely popular and have certainly passed the test of time.

In 1984, after designing and redesigning the original subperiosteal implant since 1952 I introduced to the profession what I consider today the greatest and most needed implant of the world.

If it is such a great implant then why doesn’t the academia teach them to their students and use them in the universities? Simply stating, the academia, unfortunately know absolutely nothing about subperiosteal implants. If they also avoided inserting the endosseous blade/plate form implants it further shows you what they don’t know.

I will make this statement once more—there is absolutely no implant design that is on the market today to come close to the uniqueness of design and constant need for the mandibular tripodal subperiosteal implant nor its long time success in the most severely atrophied jaws.

Another reason for the academia’s dilemma of ignorance is because the few blade companies that existed could not feed the universities freely as did the screw companies and thus research on those uniquely designed endosseous blade implants were neglected.

Even more of a disgraceful scenario by the academia and the rest of the dental profession was the fact that subperiosteal implants were not “shelf implants” like screws and blades and thus could not be sold at random. Instead, they had to be designed and cast individually so their implant companies could not benefit by marketing them. Thus, very few doctors ventured out to do subperiosteal implants, especially the tunnel visioned Academia.

There is no one in the entire world who has done as many subperiosteal implants as I have done and I can say this with absolutely no reservations that when the surgery, prosthetic procedures, the occlusion and design of the implant framework as well as the removable over denture is done correctly there will not be seen any bone resorption beneath the entire metal framework for as long as thirty or forty years. These results can be obtained as long as the procedure was done over severely resorbed mandibles, even in cases of mandibular nerve dehiscence.

Elderly patients who over the years due to periodontal conditions had lost most of their teeth leaving them very little bone to insert blades or screw type implants successfully.

There exist millions of these poor people who have been toothless for years and desperately need to once again become a part of our society.

Subperiosteal implants are the answer.

I have often shown a 52 year post operative clinical and radiological tripodal subperiosteal implant with no bone resorption. How many cases of screws can pass the test of time as well?

I am willing to challenge anyone on the true value of tripodal subperiosteal implants and I will continue to accuse the tunnel visioned and stubborn academia for their lack of understanding the true significance of these implants.

I have absolutely no fear in my aggressive remarks as I have been retired for the past ten years and have no monetary interest or money invested in these magnificent implant designs.

I have finally come to a simple design for totally edentulous maxillae where no other types of implants can be inserted. Using only the anterior nasal spine, the canine eminences and the palatal side of the alveolar crest is all that is needed for a long standing subperiosteal maxillary implant.

All of the bone mentioned consists of dense cortical bone that is as hard as the bone used for mandibular subperiosteal implant.

To view hundreds of these magnificent implants just click on your computer to “Linkow library.org”.

*Dr. Leonard Linkow was born in Brooklyn, New York on February 25, 1926. He placed his first dental implant in 1952, four months after he graduated from dental school. By 1992, Dr. Linkow had placed over 19,000 dental implants and stopped counting. He retired from private practice in 2002 leaving a body of work that included 12 books and 36 patents. Many implant dentists around the world refer to Dr. Leonard Linkow as the father of modern implant dentistry.

Four classic textbooks written by Dr. Leonard Linkow may be read for free elsewhere on this website at NYCdentist.com/Linkow.

Editor’s note:  A few weeks ago I asked Dr. Linkow to summarize all of his knowledge and experience in dental implantology into a few pages.  The result, transcribed above unedited, appeared via US mail on two typewritten pages. Contact me if your dental school or dental implant study club is interested in hearing Dr. Linkow in person.  One may discover that the “latest” innovations in implant dentistry were invented by Dr. Linkow forty years ago!  Feel free to post your comments below.
–Dr. Jeffrey Dorfman, Jan 29, 2012

“Democracy… Is two wolves and a lamb voting on what to have for lunch. Liberty… Is a well-armed lamb contesting the vote.”

– Benjamin Franklin

Diabetes is positively correlated with Periodontal Disease (Gum Disease). Some anaerobic periodontal pathogens (gum disease-causing germs) like: Spirochetes, Porphyromonas Gingivalis and Actinobacillus Actinomycetemcomitans are positively correlated with periodontal disease.

Oral Microbiology cultures should be obtained in Diabetic patients who have Periodontal Disease. The elimination of the periodontal pathogens via periodontal therapy, with our without oral antibiotics indicated by a culture, should be the goal. The elimination of the periodontal pathogens should be confirmed by a follow-up culture. This should be the standard of care for the treatment of people who have both DIabetes and Gum Disease.