Cominica: My First Teeth Whitening Experience

Dentist is the least place I’d go, I really hate go to a Dentist. I never look forward to a dental appointment, just being examined can make me feel stressed. I don’t know if I have a dental phobia or not, but I always thought a dental visit is really terrifying. I always avoid to go to Dentist and that makes my teeth turns discolored and damaged..

It makes me insecure to smile and sometimes I feel embarrassed if someone talk about how my teeth look, especially about the discoloration for sure. I still remember who they are lol

Sometimes I force my self to go when I can feel the pain but I always have trouble to sleep the night before, haha. This alsoe applies to my whitening experience at Jakarta Smile, I WAS SO SCARED..

I braved my self for the sake of whiter teeth so I’ll look good in my photoshoot next week.. 🙁

Jakarta Smile has many branches in Jakarta and I went to the one in Plaza Atrium, Senen. I was handled by Dr. Dinda, she treated me with patience and delicateness, because that was exactly what I need.

Sometimes the dentist could be reaaally cold and took my fear cheaply. I still remember some horrors I’ve gone through with intense fear and panic attack, I barely can move my jaw. Those with dental anxiety will know what it feels like T___T

People may think I was exaggerating but I think a good Dentist should be taken this kind of condition seriously and with extra kindness, lol.

I told Dr. Dinda about my feelings, concerns and fears. She help me to overcome my feelings, she even changed the way she treated me when my saliva flooding all over my mouth and disturbing the entire whitening process. Thanks Dr Dinda 😀

you may notice that I was sweating all over my face and body during the process, I was so anxious and afraid :/

I tried to relax and brave my self through the entire process and soooo happy with the result!

Here are some pictures of the BEFORE – AFTER,

Kindly watch the video below, it’s in Bahasa but you probably can grasp the process just by watching through the entire clip. See ya!

Source: http://www.cominica.net/2018/03/my-1st-teeth-whitening-experience.html

Smile Design Enhanced with Porcelain Veneers

Porcelain laminate veneers are among the most esthetic means of creating a more pleasing and beautiful smile

By Dr. Dean C. Vafiadis

Some facts you should know about Porcelain Veneers

  1. Since they require approximately 0.5 mm of tooth reduction, porcelain veneers are not considered a reversible form of treatment.
  2. Occasionally, the preparation of a porcelain laminate veneer does not necessitate the use of a local anesthetic. However, for those patients that are particularly sensitive or anxious, a local anesthetic is advisable.
  3. The laboratory time required for the fabrication of a porcelain laminate veneer is approximately one week, although this may vary.
  4. You can expect some sensitivity to hot and cold. This is normal and is due to the removal of a small portion of the tooth’s enamel covering. This sensitivity should disappear a few days after the placement of the veneers.
  5. The insertion or cementation of your laminate veneers can be accomplished once again with or without local anesthetic. This visit is usually longer in length. The laminates are placed with a light-sensitive resin hardened with the use of a white light, effectively bonding them to your teeth.
  6. Once placed, your laminate veneers are very strong and will resist most of the forces placed upon them by a normal diet. Porcelain is a glass and like glass it is strong, but brittle. Therefore, you should avoid anything that will tend to stress the laminate veneer. Opening pistachio nuts with your teeth, chewing on bones or candy apples is probably not a good idea. As with most things, common sense should prevail.

Maintenance of Your New Porcelain Veneers

The maintenance of your porcelain laminate veneers is relatively simple. Here are some recommendations:

  1. Brush and floss as you normally would to prevent dental problems. Porcelain veneers are one of the kindest restorations to gum tissues that we currently have in dentistry. Don’t be afraid of damaging your laminates by either flossing or brushing. Any non-abrasive fluoride toothpaste is acceptable. A good home care regimen will insure the esthetic success of your laminate restorations for years to come.
  2. If you are known to be a bruxer or clencher, i.e. you have a habit of grinding your teeth, please let your dentist know. He or she will fabricate a protective “occlusal” or bite guard for you to wear to minimize the stresses placed upon your teeth while you sleep.
  3. Approximately one week after the placement of your laminates you will be asked to return to the office for a treatment evaluation. This visit is extremely important. It gives your dentist the opportunity to evaluate the placement of the laminates, the gum tissue response and to answer any questions you might have regarding your new smile. Regular maintenance and dental check ups are recommended so that your veneers and oral health can be reviewed periodically.

 

Frequently Asked Questions About Veneers

What happens to my teeth after veneers, and will I ever get cavities?

The integrity of veneered teeth is only marginally compromised, and the veneer is bonded to the existing teeth. There is no higher incidence of decay provided the veneers are properly cared for as previously mentioned with regular flossing and brushing with toothpaste. In general, it is good dental advice to keep your sugar consumption low and confined to meal times to prevent decay.

How long will porcelain veneers last?

They can last from seven to twenty years. While the veneer itself is inert and non-living, the tooth or teeth to which they are attached and the surrounding gum tissues are living and may change. For example, gum line shrinkage may expose or reveal root surfaces. If a veneer comes off it can generally be rebonded. If it chips it can sometimes be rebonded or otherwise replaced.

If I have my upper teeth treated with porcelain veneers, will my lower teeth still be a different color, or more yellow?

This is certainly a factor that will be discussed during your evaluation and smile design so that everything matches and blends well. Most patients usually whiten the lower teeth with whitening (bleaching) procedures to ensure a good match.

Do porcelain veneers stain with normal things like tea, coffee and wine?

Porcelain veneers should never stain; however; if your teeth have a propensity to stain you should try to avoid or minimize the behaviors that lead to staining and look after them as recommended above with normal hygiene and maintenance procedures.

Does dental insurance cover porcelain veneers?

Some insurance companies will cover up to 50% of the fee they deem customary. However, it depends upon what your employer has contracted for with your insurance company rather than what your dentist is charging. Don’t forget your dentist also has to pay the dental technician who actually fabricates the veneers, a critical component in the fee.

Root canal treatment – How it is performed

Root canal treatment is carried out by your dentist over two or more appointments.

If the work is particularly complex, your dentist may refer you to a specialist in root canal treatment, known as an endodontist.

Preparation

Before having root canal treatment, your dentist may take a series of X-rays of the affected tooth. This allows them to build up a clear picture of the root canal and assess the extent of any damage.

Root canal treatment is usually carried out under local anaesthetic, a painkilling medication that numbs a specific area of the body.

In some cases where the tooth has died and is no longer sensitive, it may not be necessary to use a local anaesthetic.

Occasionally, teeth may be difficult to anaesthetise. On these occasions, your dentist can use special local anaesthetic techniques to ensure your treatment isn’t painful.

Removing the pulp

Your dentist will place a rubber sheet (dam) around the tooth to ensure it is dry during treatment. The dam also prevents you swallowing or breathing in any chemicals the dentist uses.

Your dentist will open your tooth through the crown – the flat part at the top – to access the soft tissue at the centre of the tooth (pulp). They’ll then remove any infected pulp that remains.

If you have a dental abscess, which is a pus-filled swelling, your dentist will be able to drain it at the same time.

Cleaning and filling the root canal

After the pulp has been removed, your dentist will clean and enlarge the root canal so it can be easily filled. The root canal is usually very narrow, which makes it difficult to fill.

Your dentist will use a series of small files to enlarge the canals and make them a regular shape so they can be filled.

This part of the treatment may take several hours to complete, and may need to be carried out over a number of visits.

Your front incisor and canine teeth (biting teeth) usually have a single root containing one root canal.

The premolars and back molar teeth (chewing teeth) have two or three roots, each containing either one or two root canals. The more roots a tooth has, the longer the treatment will take to complete.

If the treatment needs to be carried out over several sessions, your dentist may put a small amount of medication in the cleaned canal in between visits to kill any remaining bacteria. The tooth will then be sealed using a temporary filling.

If you have symptoms from the infection, such as a raised temperature or large swelling, you may be given antibiotics to help manage and prevent further infection.

Sealing and fixing the tooth

At your next visit, the temporary filling and medication within the tooth is removed and the root canal filling will be inserted. This, along with a filling, seals the tooth and prevents reinfection.

Root-filled teeth are more likely to break than healthy unrestored teeth, so your dentist may suggest placing a crown on the tooth to protect it.

In some cases a root-filled tooth may darken, particularly if it has died as a result of injury like a knock to the tooth.

There are several ways your dentist can treat discolouration, such as whitening the tooth using chemicals.

Crowns

A crown is a cap that completely covers a real tooth. It might be necessary to use a crown after root canal treatment to prevent the tooth fracturing.

Crowns can be made from:

  • metal or porcelain (or both)
  • a ceramic material
  • powdered glass

The size of your tooth will be reduced and the crown will be used to replace what’s removed. A mould of your tooth will be taken to ensure the crown is the right shape and size, and fits your tooth accurately.

When fitting the crown, cement will be used to glue the crown to the trimmed-down tooth.

If there’s only a small amount of tooth left after the root canal treatment, a post can be cemented in the root canal and used to help keep the crown in place.

Read more about what NHS dental fillings and crowns are made of.

Results

Root canal treatment is usually successful at saving the tooth and clearing the infection.

One review of a number of studies found 90% of root-treated teeth survived for 8-10 years.

The study also found having a crown fitted to the tooth after root canal treatment was the most important factor for improving tooth survival rates.

If you practise good oral hygiene, your treated tooth should survive for a long time.

The survival of your tooth depends on a number of factors, including:

  • how much of the natural tooth remains
  • how well you keep your teeth clean
  • the biting forces on the tooth

If an infection does return, however, the treatment can be repeated.

Alternatively, if treatment has already been carried out to a high standard and the infection remains, a small operation to remove the root tip (an apicoectomy) may be carried out to treat the infection.

Wisdom Teeth Pain Relief: How to Find Comfort

WISDOM TEETH

Definition

Wisdom teeth are the third and last molars on each side of the upper and lower jaws. They are also the final teeth to erupt; they usually appear when a person is in their late teens or early twenties.

Signs & Symptoms

Wisdom teeth that only partially emerge or come in crooked can also lead to painful crowding and disease. Because teeth removed before age 20 have less developed roots and fewer complications, the American Dental Association recommends that people between 16 and 19 have their wisdom teeth evaluated to see if they need to be removed.

Although you probably don’t remember teething as a baby, the arrival of your wisdom teeth can remind you of what toddlers suffer through: tender gums, aching teeth and pain. Beyond making you more sympathetic to a teething tot, wisdom teeth discomfort can also herald some potential problems in your dental health.

By understanding the cause of your sore gums and how wisdom teeth may play a part, you can find a method of wisdom teeth pain relief that reduces the aching sensation in the interim.

Wisdom Teeth 101

Wisdom teeth usually make their appearance between the ages of 17 and 21, though it’s possible for them to push through earlier or later. Referred to as your “third molars,” these four teeth begin to push through the skin like any other tooth, which can cause pain. However, wisdom teeth are much more likely to grow in at an incorrect angle – even sideways – causing impaction that can radiate this pain to the teeth in front of it. The American Dental Association (ADA) warns that wisdom teeth can also result in a host of following issues, such as infections and even cysts, so it’s important to talk to your dentist when your wisdom teeth do come in.

For most, wisdom teeth removal is a good option. Until then, however, you’ll need to confront the soreness naturally.

Wisdom Teeth Pain Relief

Sore Mouth Rinse

Rinsing your mouth can help you find wisdom teeth pain relief, so try this simple remedy: Mix a cup of warm water with a teaspoon of salt, and stir to dissolve. Swish this in your mouth for about 30 to 60 seconds before spitting it into your sink. You can repeat as necessary throughout the day.

Benzocaine

Numbing wisdom teeth is a simple way to dull the pain, particularly if the pain is disrupting your day and doesn’t seem to settle through other methods. Consider spreading a gel-based product such as Colgate® Orabase® 20% Benzocaine on your gums where wisdom teeth are protruding. You’ll get the best results if you use a cloth to dry the area before adding the gel. Apply as needed throughout the day.

Cloves and Clove Oil

As an old wives’ remedy, Mayo Clinic suggests using cloves or clove oil as a way to appease toothaches and wisdom teeth pain naturally. The best part? There’s a good chance you already have cloves in your kitchen cabinet. Take a whole clove (don’t crush or cut it) and place it in your mouth, directly on the spot causing the most irritation. Keep the clove in your mouth until you experience a numbing sensation. You can also use clove oil: Simply dab some on a cotton ball or swab and brush it gently over your sore gums.

Ibuprofen

Of course, an over-the-counter pain reliever can definitely help you get rid of that throbbing sensation so you can concentrate on your day. Just be sure to always read package directions, especially where dosages are concerned.

Although you can find relief at home when your wisdom teeth start to make their appearance, it’s important to remember most pain-relieving measures are a temporary fix. You’ll still need to make an appointment with your doctor to determine if your wisdom teeth should stay in your mouth or be removed by an oral surgeon. Whether you can just grin and bare it or your dentist recommends removal, it takes a pro’s opinion to help you understand how to best deal with your third molars

Care and Maintenance of Dental Veneers

If you’ve gotten dental veneers, or if you’ve done the research, you would know that these small porcelain dental works are actually more expensive than you think they are. In fact, they can really put a dent on your bank account. So if you do not want your investment to go to waste, it’s always a good idea for you to take close care and maintenance of your veneers.

Listed below are ways that you can stretch the years out of your dental veneers:

  1. Avoid hard foods.

Porcelain is a naturally brittle mineral which explains its fragility. However, once the porcelain veneer has already been attached to the tooth, the strength of the dental work increases exponentially making it less prone to breakage and chipping. But that does not mean that you can be complacent with your dental veneers. If your natural teeth can break and chip by biting into very hard objects like unpopped popcorn kernels, then your veneers are just as susceptible. If you really want to be nitty gritty about taking care of your porcelain veneers, you can even try cutting up dense foods and fruits into bite sized pieces instead of biting into them.

  1. Take care of your gum health.

While you might not see the connection between your gums and your veneers, the state of your gums will have a huge influence on the cosmetic appearance of your dental veneers. The ends of your veneers are tucked in just slightly underneath the gum line, or the junction where the gums meet the teeth. When you have gingivitis or any type of gum disease, there is a tendency for your gums to recede. This will cause your gum line to move forward. When that happens, the ends, or the apex, of the veneers will then be exposed, making for a more conspicuous dental work and defeating the entire aesthetic purpose of getting veneers.

  1. Avoid foods and drinks which stain.

Unless you want to again spend for teeth whitening procedures, it’s better than you keep your enamels from prolonged contact with substances which are known to stain teeth. Porcelain veneers are actually not susceptible to staining. However, your teeth are. So as your teeth begin to turn into a yellowish color, your porcelain veneered tooth will stay as white as ever. The uneven in the color of your teeth will only point out that you had work done.

Treated Complication

How Long Do Dental Implants Last

With proper care, dental implants should last a lifetime but, if they are not brushed and flossed regularly, peri-implantitis can occur. This is a condition similar to periodontitis (bone and gum recession) and a chronic case can lead to loss of soft tissue and bone and, quite possibly, the loss of the implants. It is very important that dental implants are correctly maintained.

Looking After Dental Implants

Looking after your implants is a simple procedure. A single tooth implant only requires regular brushing and flossing. The hygienist may recommend a special implant cleaning brush or Piksters to enable you to clean effectively between the teeth.

Multiple teeth implants and full arch implants require the brushing and flossing as above and, in addition, the use of a waterpik high-presure water system twice a day to clean around the implant prosthesis. This must be done as the acrylic used on this will accumulate plaque, calculus and stains which must be removed, and the prosthesis may need to be removed every few years for a thorough clean and debridement by a dental specialist.

The JAKARTA SMILE Dentistry Philosophy

In addition to regular dental hygiene appointments, patients need to have a brief follow up appointment six month to one year after their final restoration is placed. This appointment is important to remember as it allows us to clean and review the implant as well as take an x-ray to monitor its long term health and stability.

We provide comprehensive follow up care because we believe this is essential to the success of the procedure. This includes post-surgical checks, implant integration checks and, even after your final restorations are placed, we will spend the time to teach you how to care for your new teeth.

Poor Implant Maintenance & Complications

Unfortunately we are seeing more and more patients suffering complications from poorly executed dental implants, sometimes due to inexperienced or overseas dentists. The substandard dental work and use of implants that are not approved by the International Dental Implant Association, can result in considerable pain, infection and failure after only a short time. For this reason it is critical that you ensure to have your implants properly placed in the first instance and follow up with the correct care and maintenance. We never compromise on follow up care because we, as well as you, want you to love your teeth for a lifetime!

If you suffer from any conditions below, or in need of repairing your existing implant, please contact us on +62 (021) 29054478 or email thejakartasmile@gmail.com

Brushing Baby’s Teeth

Your baby’s primary teeth may be only a temporary tool for chomping, to be replaced during the early school years by his permanent pearls. But it’s no less important to take good care of them now and to establish the habits that will lead him toward a lifetime of dental health. Decayed or lost baby teeth can interfere with good nutrition and speech development, and by not holding a proper place for permanent teeth, they can make the permanent ones come in crooked.

WHEN SHOULD I START BRUSHING MY BABY’S TEETH?

Tooth brushing can begin as soon as baby’s first tooth pokes through the gums. Use a clean, damp washcloth, a gauze pad, or a finger brush to gently wipe clean the first teeth and the front of the tongue, after meals and at bedtime. Toothbrushes — moistened with water and no more than a rice-grain size smear of fluoride toothpaste — can also be used, but they should be very soft and with no more than three rows of bristles (a pediatric dentist or your pharmacist can help you find the finger brushes and a proper baby toothbrush). Toss any toothbrushes that have become rough at the edges (or that are more than two to four months old, because nasty mouth bacteria can begin to build up).

SHOULD I BRUSH MY BABY’S GUMS?

We recommend cleaning baby’s gums after feedings, which helps fight bacterial growth and promotes good oral health, long before baby’s first teeth start to appear. Rather than cleaning baby’s gums with a toothbrush, try a soft, damp cloth, or even a soft rubber or silicone finger brush, both gentle options with a nubby texture babies tend to love.

CAN BABIES USE FLUORIDE TOOTHPASTE?

The American Academy of Pediatric Dentistry (AAPD) recommends using cavity-preventing fluoride toothpaste starting with baby’s very first tooth, rather than waiting until age 2 as was previously recommended. Use a rice-grain-sized smear of toothpaste for your baby or toddler, graduating to a pea-sized dollop by age three. And don’t worry if your baby swallows some of the toothpaste (as she almost certainly will)—in such a small quantity, it won’t cause any damage to the teeth. Starting in the second year, you can teach your toddler to spit after brushing.

TEACHING BABY TO BRUSH

Your older baby or toddler will probably want to try his hand at brushing himself; let him give it a go (if he has the dexterity and doesn’t just get frustrated), but be sure to follow up with a more thorough cleaning of your own, using a finger brush or gauze pad, before bed. To encourage his interest in dental care, try a fun brush with a favorite character and bright color. And let him watch Mommy and Daddy take good care of their own teeth, so he learns that it’s a habit to keep for life.

WHAT TO DO IF YOUR BABY HATES TOOTH-BRUSHING TIME

Unfortunately, not every baby loves having her teeth cleaned—and when baby is teething and her gums are sore and tender, she might be especially resistant. Here’s what to try if tooth-brushing time becomes a struggle:

Go easy: Baby’s gums are sensitive (even when she’s not teething), so if she really doesn’t seem to like the brush, try a soft washcloth and a gentle touch.

Sing a song: For some babies, a little distraction is all it takes to make tooth-brushing palatable. Sing a favorite tune while cleaning baby’s teeth, or make up silly versions of standards (maybe “Old McDonald had a brush,” or “Mary had a little tooth”). Your little one may reward you with a tiny-toothed smile.

Show her how it’s done: Seeing mom or dad brushing—and enjoying it—helps make a game out of tooth-brushing time. “Mom goes first…now your turn!”

Let her play: Your baby will probably be curious about the toothbrush or finger brush. Encourage her interest by allowing her to hold the brush and examine it at her own pace. She may even end up putting the brush in her mouth, all on her own.

Focus on implant home care before, during, and after restoration

by Susan Wingrove, RDH

Good oral hygiene must take place before, during, and after placement of dental implants to ensure the health of the implant. Patients are concerned about what kind of maintenance their implants will require. Do they brush and floss their implants like regular teeth? Does food get underneath the fixed implant bridge or prosthesis? Patients look to their hygienists to address these concerns and help them with an individualized home-care routine.

The tissue surrounding the implant should appear pink, firm, and keratinized with no signs of infection. The peri-implant soft tissues (permucosal seal) that separates the connective tissues surrounding the implant from the outside environment should be keratinized tissue (see Figure 1). The absence of keratinized tissue has been documented to be more susceptible to pathogenic bacteria thus leaving the implant vulnerable to peri-implant disease. The success of the implant depends directly on the health of this seal, and the hygienist’s goal is to educate the patient on how to obtain keratinized tissue and maintain a healthy permucosal seal.

Figure 1: Keratinized tissue surrounding the implant. Courtesy of Dr. Robert Horowitz

Figure 1: Keratinized tissue surrounding the implant. Courtesy of Dr. Robert Horowitz

This reinforces the point that home-care must begin immediately and, if possible, before the implant is placed to maintain a healthy field and for optimal healing.

Once the implant is exposed to the environment, loaded (occlusal forces) and restored (see Figures 2a, 3b) a salivary pellicle is formed followed by bacteria with the formation of biofilm., The elimination of 85% of plaque/biofilm on a daily basis is critical to the overall health of the implant.4

Hygienists can prepare patients by providing home-care recommendations based on the individual treatment case. This begins with post-surgical home-care guidelines to ensure the patient feels comfortable and confident until they return for routine implant maintenance.3 (see Table 1). Always verify recommended guidelines with the implant surgeon’s recommendations.

Figures 2a, b: Placement of an implant. Courtesy of Keystone Dental

Figures 2a, b: Placement of an implant. Courtesy of Keystone Dental

Knowledge of the implant titanium surface is necessary to fully understand what oral hygiene recommendations and products to present to patients. After 1990, a definite switch from smooth titanium alloy surface to a rougher implant surface transpired, which has proven to accelerate osseointegration. The addition of surface coatings to create roughness with plasma spraying, grit blasting, and etching has also proven to raise the bone-to-implant contact and accelerate osseointegration.

To help the patient protect their implant(s), their investment, patients need to be aware of the following key points on choosing safe home-care products. First the product (for example, toothpaste or gel) needs to be low-abrasive to not scratch the surface of any exposed surfaces of the implant (exposed threads, for example). Avoid dentifrice with stannous fluoride, sodium fluoride (APF >3.0), baking soda, stain removers, and smoker’s toothpaste.

Companies are researching low–abrasive dentifrices that are effective yet safe for implants, natural teeth, and completely edentulous implant patients (Colgate, Procter & Gamble, and Rowpar among others). Ramberg et al. reported that Colgate Total in a double-blind, randomized, parallel-group clinical (in vivo) trial with 59 participants concluded that brushing with Colgate Total twice daily reduces bleeding on probing adjacent to implant sites in a three- and six-month period with proven results of reducing plaque bacteria to help prevent peri-implant disease.

Secondly, products should not irritate the permucosal seal, or corrode and/or etch the titanium.10-11 A high fluoride concentrate of > 3.0 sodium fluoride, combined with a low PH, will remove the oxide layer on implants and can make the titanium surface anti-corrosive. Once this layer is removed, the implant is prone to corrosion. Stannous fluoride can cause etching, roughness on implants, and their esthetic restorations.

Figures 3a, b, c: Interproximal brushes. Courtesy of Hager Worldwide

Figures 3a, b, c: Interproximal brushes. Courtesy of Hager Worldwide

What toothbrushes and interdental products are best to use with implants?

Several studies have been conducted regarding what type of toothbrush is most effective for implants. The results show no significant difference between sonic, electric, or manual toothbrushes. The main focus needs to be on adaptation to the prosthesis and the patient’s dexterity. Instruct the patient to brush the implant(s) twice daily to remove bacterial plaque with a low-abrasive dentifrice. A soft toothbrush should be used; options include a manual brush, electric, or sonic brush (examples include Oral-B Triumph, Sonicare, and Waterpik Sensonic Plus), Sulcabrush, or end-tuft brush.

Figures 4a, b: Examples of implant floss. Courtesy of Hager Worldwide and Sunstar Americas

Figures 4a, b: Examples of implant floss. Courtesy of Hager Worldwide and Sunstar Americas

Nylon coated interdental brushes/ proxabrushes are also an excellent alternative to clean especially tight and hard-to-reach areas around implants and prostheses. Nylon only interdental brushes (no metal wire) are necessary to prevent scratching the implant or prosthesis. The interproximal brushes such as I-Prox P or I-Prox Plus work extremely well and can be dipped in non-alcohol antimicrobial rinse or gel. It is extremely important to brush under, around, and in the peri-implant crevice circumferentially (see Figures 3a-c).

Floss

There are many types of floss on the market, and generally it is highly recommended to use unwaxed tape or implant-specific floss in order to protect the tissue surrounding the implant. Alternatively for a bar-retained prostheses, full fixed retained prostheses, or wider interproximal spaces, a floss threader or a specialized floss that has a built-in threader is necessary (see Figures 4a, b).

Figure 5a: Insert floss on mesial and distal. Courtesy of Dr. Peter Fritz

Figure 5a: Insert floss on mesial and distal. Courtesy of Dr. Peter Fritz

To floss the implant, use dental tape and insert the floss in contacts on both sides of the implant. Wrap in a circle and crisscross in front, switch hands, and move in a shoe-shine motion into the peri-implant crevice, which is highly susceptible to inflammation/peri-implant disease due to biofilm (see Figures 5a, b).

In addition, antimicrobial mouth rinses may be recommended, especially if inflammation is present or if the patient has dexterity problems, and difficult-to-reach areas. If the patient is prone to inflammation, the use of an antimicrobial rinse, in conjunction with a rubber tip stimulator, may be recommended to inactivate bacteria substantive.

Figure 5b: Crisscross floss and move in shoe-shine manner. Courtesy of Dr. Peter Fritz

Figure 5b: Crisscross floss and move in shoe-shine manner. Courtesy of Dr. Peter Fritz

Oral irrigators/Water Flossers

It is highly recommended for patients to use oral irrigators for the reduction of plaque/biofilm, inflammation, and hard-to-reach emergence profiles around implants (see Figure 6a). Instruct the patient to use a nonmetal tip one to two times daily, and, if inflammation is present, add a diluted non-alcohol antimicrobial rinse (chlorine dioxide or chlorhexidine gluconate).

Studies using oral irrigators with implants for oral hygiene reveal that Waterpik Water Flosser is the only oral irrigator to date to be proven safe and effective with dental implants. A study was conducted to compare rinsing with 0.12% CHX to using a Waterpik oral irrigator with 0.06% CHX. The irrigation group using the soft rubber tip (PikPocket Tip, see Figure 6b) at lower pressure was 87% more effective in reducing bleeding and three times more effective in reducing gingivitis than the rinsing group.
Another study of oral irrigation and floss revealed that the Waterpik Water Flosser with the standard tip with three bristle filaments (Plaque Seeker Tip, see opening page) used at medium pressure around implants was 81% more effective in bleeding reduction compared to 33% using floss.16 These specialized tips are very effective for implants and to deliver anti-microbial rinse around difficult-to-reach prostheses (All-on-4, full-fixed prosthesis, for example) in a prevention of peri-implant disease.

Figures 6a, b, c: From left to right, Waterpik Ultra Water Flosser, Waterpik PikPocket Tip, and Waterpik Traveler Water Flosser

Figures 6a, b, c: From left to right, Waterpik Ultra Water Flosser, Waterpik PikPocket Tip, and Waterpik Traveler Water Flosser

Water irrigation in conjunction with diluted non-antimicrobial rinse has proven to be extremely helpful for full-fixed and removable prostheses to remove daily biofilm and prevent inflammation if used on a daily basis. Waterpik makes a compact Traveler Water Flosser unit, which is my personal favorite to recommend ensuring patients continue their home-care routine at home and away (see Figure 6c).

Stimulators

Stimulators are coming back into vogue with implants and regenerative procedures. Remember healthy keratinized tissue is the key to a healthy permucosal seal surrounding the implant. Stimulators are the ticket to achieve this, particularly in full-fixed, supra-structure implants, as well as implants that retain over-dentures (bar-retained implants). Examples of stimulators are rubber tip stimulators producted by multiple manufacturers and Soft Picks by Sunstar Americas (see Figures 7a, b).

Figures 7a, b: Examples of stimulators. Courtesy of Dr. John Remien & Sunstar Americas

Figures 7a, b: Examples of stimulators. Courtesy of Dr. John Remien & Sunstar Americas

Instruct the patient to place the tip of the rubber-tip stimulator so it lays flat against the gum tissue, not poking in the tissue, with pressure roll to massage and stimulate the tissue. The tissue will blanch or change to a lighter color when the correct pressure is applied.

A generalized home-care routine for implants is listed in Table 2 to be modified to individualize the patient’s home-care routine. For an All-on-4 full-fixed case, add the use of a water irrigator unit twice daily with a non-alcohol antimicrobial mouth rinse in 1:10 dilution to the home-care guidelines.

For removable prosthesis, the patient should use the guidelines in Table 3. Note that a specific denture cleaner may be recommended for the overdenture. Plaque and bacteria can also accumulate on the inside of the overdenture, causing wear to the attachments and oral–systemic health complications for the patient. Educate the patient on how to do a visual check for attachments (O-rings, locator caps, and clips) and the importance of these attachments for retention. If attachments are worn or missing they will need to be replaced. O-rings and locator caps should be replaced once a year and clips as needed.

Hygiene tip: Note the color and attachment type (O-ring, locator or clip) and record in the patient’s chart (see figure 8).

Figure 8: Note the color and attachment. Courtesy of Salvin Dental Specialties

Figure 8: Note the color and attachment. Courtesy of Salvin Dental Specialties

For implants with peri-implant disease, mucositis, and/or implantitis, follow the home-care guidelines, but add antimicrobial therapy. Use Soft Picks, interdental, end-tuft or Sulcabrushes dipped in non-alcohol antimicrobial rinse or CHX gel (compounded by compound pharmacies). “Soak” or apply the antimicrobial to the infected area twice daily and continue with this protocol until three to six week re-evaluation.

This article gives the latest home-care products available currently; however, the technology and implantology is constantly changing. Research and evaluate home-care products that are safe with clinical research done on implants. Patients rely on their dental professionals for recommendations on what products to use and to present them with a safe daily home-care routine. RDH

SUSAN WINGROVE, RDH, is an international speaker and practicing dental hygienist who does regeneration research for Regena Therapeutics, and instrument design for Paradise Dental Technologies, Inc. She is the co-designer of the Wingrove Titanium Implant Set, ACE probes, and Queen of Hearts instruments. She is a member of the Academy of Osseointegration, American Dental Hygienists’ Association, International Federation of Dental Hygiene, and The Implant Consortium. She is an published author on implant dentistry, including textbook for Wiley-Blackwell publishers; Peri-Implant Therapy for the Dental Hygienist: Clinical guide to Maintenance and Disease Complications. She is the founder and CEO of Wingrove Dynamics.

References

1. Greenstein G, Cavallaro J. The clinical significance of keratinized gingiva around dental implants. Compend Contin Edu Dent. 2011; 32:24-31.
2. Subramani K., Jung R.E. Molenberg A. & Hammerle, C.H. Biofilm on dental implants: a review of the literature. Int J of Oral Maxillo Implants 2009; 24:616-626.
3. Wingrove, S. Peri-Implant Therapy for the Dental Hygienist: Clinical Guide to Maintenance and Disease Complications. Wiley-Blackwell 8:2013.
4. Kracher CM, Smith WS Oral health maintenance dental implants. 2010; Mar-Apr, 79(2):27-35
5. Carlsson L, Rostlund T, Albrektsson B, et al. Removal torques for polished and rough titanium implants. Int J Oral Maxillofac Implants. 1988; 3(1):21-24.
6. Gotfredsen K, Berglundh T, Lindhe J. Anchorage of titanium implants with different surface characteristics: an experimental study in rabbits. Clin Implant Dent Relat Res. 2000; 2(3):120-128.
7. Ivanoff CJ, Hallgren C, Widmark G, et al. Histologic evaluation of the bone integration of TiO (2) blasted and turned titanium micro implants in humans. Clin Oral Implants Res. 2001; 12(2):128-134.
8.Ramberg P., Lindhe J, Botticelli D, et al. J Clin Dent 2009;20:103-107
9. Yukna R. Optimizing clinical success with implants: maintenance and care. Compend Contin Educ Dent. 1993; 15:S554-S561.
10. Nakagawa M et al. Effect of Fluoride concentration and PH on corrosion behavior of titanium for dental use. J Dent Res 1999:78(9): 1568-1572
11. Matono Y et al. Corrosion behavior of pure titanium and titanium alloys in various concentrations of Acidulated Phosphate Fluoride (APF) solutions. Dent Mater J. 2006 Mar; 25 (1):104-112.
12. Esoposito M, Worthington HV, Thomsen P, Coulthard P. Interventions for replacing missing teeth: maintaining health around dental implants. Cochrane Database Syst Rev 2004;3:CD003069
13. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Clin Dent. 2013; 24(2):37-42.
14. Gorur A, Lyle DM, Schaudinn C, Costerton JW. Biofilm removal with a dental water jet. Compend Contin Educ Dent. 2009; 30(spec no 1):1-6.
15. Felo A, Shibly O, Ciancio SC, et al. Effects of subgingival Chlorhexidine irrigation on peri-implant maintenance. Am J Dent. 1997; 10(2):107-110.
16. Magnuson B et al. Water Flosser vs. Floss: Comparing reduction in bleeding around implants. J Dent Res 92(Spec Iss A):#3761, 2013
17. Staubli P, Bagley D. Attachments and implants reference manual, 8th ed. San Meteo, CA: Strong Design, 2007.

Dental Plaque

Dental plaque is a biofilm or mass of bacteria that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. It is commonly found between the teeth, on the front of teeth, behind teeth, on chewing surfaces, along the gumline, or below the gumline cervical margins.

Progression and build-up of dental plaque can give rise to tooth decay – the localised destruction of the tissues of the tooth by acid produced from the bacterial degradation of fermentable sugar – and periodontal problems such as gingivitis and periodontitis, hence it is important to disrupt the mass of bacteria and remove it. Plaque control and removal can be achieved with correct daily or twice-daily tooth brushing and use of interdental aids such as dental floss and interdental brushes.

Oral hygiene is important as dental biofilms may become acidic causing demineralization of the teeth (also known as dental caries) or harden into dental calculus (also known as tartar). Calculus cannot be removed through tooth brushing or with interdental aids, but only through professional cleaning called scaling.

GINGIVITIS (GUM DISEASE)

Gingivitis (“inflammation of the gum tissue”) is a non-destructive disease that occurs around the teeth. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that is attached to tooth surfaces, termed plaque-induced gingivitis.

Gingivitis is reversible with good oral hygiene; however, without treatment, gingivitis can progress to periodontitis, in which the inflammation of the gums results in tissue destruction and bone resorption around the teeth. Periodontitis can ultimately lead to tooth loss.

The symptoms of gingivitis are somewhat non-specific and manifest in the gum tissue as the classic signs of inflammation:

  • Swollen gums
  • Bright red or purple gums
  • Gums that are tender or painful to the touch
  • Bleeding gums or bleeding after brushing and/or flossing
  • Bad breath (halitosis)

Additionally, the gums may appear shiny when the gum tissue becomes swollen and stretched over the inflamed underlying connective tissue. The accumulation may also emit an unpleasant odor. When the gingiva are swollen, the epithelial lining of the gingival crevice becomes ulcerated and the gums will bleed more easily with even gentle brushing, and especially when flossing.

If you notice any signs and symptoms of gingivitis, schedule an appointment with your dentist. The sooner you seek care, the better your chances of reversing damage from gingivitis and preventing its progression to periodontitis.

The dental diet: 10 nutrition strategies for healthy teeth

Dental health is more important than most people realize. And nutrition plays a big role in this. Want to know what to eat to keep your teeth and gums strong? Chew on this.

Our teeth may be small. But they, and our gums, are a lot more important to our health than many of us realize.
Without teeth, we can’t chew. Imagine that. No more crunchy raw vegetables and fruits! No more nuts! No more peanut brittle! (Um… did I just say that?)

And here’s an interesting fact: People with 25 or more teeth tend to eat more nutritiously. (Apart from peanut brittle, that is.)

Not sure how many teeth you have? Go ahead, do a quick count.

We need healthy teeth and gums to eat nutritious foods. And we need to eat nutritious foods for healthy teeth.
As children, our diet influences how our teeth develop. And once we’re grown, with all teeth in place, what we eat plays a role in maintaining dental health.

Dental distress

If we don’t take care of our teeth and gums, we risk tooth decay, gum disease, and even bone loss.

Meanwhile, the state of our teeth and gums can often signal systemic problems, including cardiovascular disease, celiac disease, diabetes, sinus infection, rheumatoid arthritis, irritable bowel disease, gastroesophageal reflux, alcoholism, and more. In fact, your dentist can sometimes diagnose these conditions before your doctor!

If our eyes are a window to the soul, our teeth and gums are a window to our bodies.

Cavities

A cavity is a hole in the tooth’s enamel. Up to 90% of school children and the majority of adults have at least one cavity.

If you want inspiration to brush and floss, seek out some Google images of severe untreated cavities. Not a pretty sight.

Cavities result from the build-up of plaque – a sticky slimy substance composed mostly of bacteria. In breaking down sugar and carbohydrates, bacteria create acids, and these acids can eat away at the teeth.

Cavities hurt when they get bigger and touch nerves. An untreated cavity can become a tooth abscess.
So if you find a cavity, get treatment fast.

Periodontal disease

About half of American adults over the age of thirty have some form of periodontal, or gum disease.

Gingivitis, or inflammation of the gum tissue, is an early stage problem. With proper care, you can reverse it. But if you don’t, eventually the inflammation will lead to “pockets,” or little spaces between the teeth and gums.

Bacteria love to colonize these pockets, which can lead to periodontitis: the permanent destruction of the tissues that connect teeth to bone in the mouth. Not good.

Symptoms of periodontitis include swollen or discolored gums, tender gums, bleeding gums, receding gums, change in tooth sensation when eating, loose teeth, tooth loss, and bad breath.

And as if that weren’t bad enough, when gums are inflamed and broken, harmful bacteria can enter the bloodstream more easily, leading to other chronic health problems.

Periodontal disease is a risk factor for coronary artery disease. Why? We don’t really know for sure, but apparently gum disease doesn’t just signal inflammation; it also increases inflammation. And inflammation contributes to coronary artery disease.

Interestingly, the same bacteria that colonize our gums have also been found in arterial-wall plaque.

Periodontal disease can be treated with a procedure called root surface debridement. Root surface debridement, which is every bit as much fun as it sounds, involves tools that resemble torture implements, local anesthetic, hours wedged into a dental chair, and a huge bill.

Note: This procedure doesn’t guarantee a successful outcome.

Nutrient deficiencies & oral health

Mucosal cells in our mouths turn over within three to seven days. So nutrient shortfalls or excesses will show up in mouth tissue before they show up anywhere else.

Periodontal disease is associated with lower blood levels of vitamins and minerals. And getting enough of specific nutrients can be important to successful treatment.

What do you need for healthy teeth and gums, and why? Here’s a handy chart.

Protein
Tooth structure, mucosal/connective tissue development, and immune function.

Calcium
Tooth structure; may enhance enamel remineralization.

Phosphorus
Tooth structure.

Zinc
Mucosal/connective tissues and immune function.

Antioxidants
Mucosal/connective tissues and immune function.

Folate
Mucosal/connective tissues and immune function; low levels are associated with periodontal disease.

Iron
Mucosal/connective tissues and immune function.

Vitamin A
Mucosal/connective tissues and immune function. But be aware that getting too much from supplements may result in gum problems.

Vitamin C
Collagen maturation and to maintain the integrity of the periodontal ligament; mucosal/connective tissues and immune function.

Omega-3 fats
Mucosal/connective tissues and immune function; modulates the inflammatory response.

Vitamin D
Mucosal/connective tissues, immune function; may enhance enamel remineralization.

B vitamins
Epithelial cell turnover.

What to eat or avoid

A list of nutrients is all very well, but when you’re standing in the grocery aisle, you still need to know what actual food to buy.

Luckily, you don’t have to do anything special:

Eat a mostly whole foods diet with lots of lean protein and fresh vegetables

Avoid most processed foods, especially those that are high in simple sugars.

Take your fish oil.

Want to go for bonus marks? Here are a few foods, nutrients, and/or supplements that may play a specific role in oral health.

Probiotics

Probiotics may help to decrease gingivitis and plaque; bacteria in fermented foods might suppress the growth of pathogens in the oral cavity. One study showed that consuming fermented dairy was associated with less periodontal diseases. Probiotics from any source could be helpful in a similar way.

Cranberries

Cranberries and other plant foods rich in anthocyanins (such as blueberries, red cabbage, eggplant peel, black rice, and raspberries) may prevent the attachment and colonization of pathogens on host tissues (including teeth).
Some studies even show that cranberry extract-infused mouthwash improves dental health! Sure, we all knew about blueberries’ superpowers, but who knew that the humble bog berry could give you healthy teeth?

Body fat & oral health

Adipose tissue

In obesity, excess adipose (fat) tissue often gets deposited in places where it shouldn’t be, such as the liver. Dental health is no exception.
Obesity is correlated with adipose tissue being deposited as a lipoma (essentially, a tumour-like mass made of fat) into in the oral cavity, such as inside the lips or cheek (buccal mucosa), on the tongue, or into the salivary glands (sialipoma).

Inflammation

It’s clear that controlling inflammation is important for oral health, and obesity is correlated with inflammation. This is why obesity is the second biggest risk factor for inflammation in the mouth. The only thing that’s worse for your oral health than being overfat is smoking.

Why? Because high blood sugar, AGEs, changes in salivary pH, and pro-inflammatory compounds all tend to be present in those who are over-fat. Meanwhile, mucosal cells may also be more permeable (due to nutrient deficiencies or imbalances).

The result? An increase in oxidants – those nasty free radicals that can damage our body’s cells.

Additionally, body fat cells release inflammatory compounds.

One common inflammatory marker associated with periodontal inflammation in folks with more body fat is orosomucoid. Meanwhile, orosomucoid is also a marker for malnutrition. Should that be a surprise? Maybe not, when you consider that many people become over-fat on a nutrient-poor diet.

People who are over-fat are also at greater risk for diabetes, and diabetes, in turn, is associated with poor oral health. This is probably due to elevated blood sugar and its associated effects.

Relationship between obesity and periodontitis

Relationship between obesity and periodontitis. Source: Boesing F, et al. The interface between obesity and periodontitis with emphasis on oxidative stress and inflammatory response. Obesity Rev 2009;10:290-297.

Disordered eating & oral health

Healthy eating patterns can improve oral health, changing the pH of the mouth’s environment.
Meanwhile, the purging and malnutrition associated with disordered eating can seriously compromise oral health. Problems include enamel loss, lesions, dysfunctional salivation, swelling, and sensitivity.

Aging & oral health

Our risk of periodontal disease goes up as we age. But the longer we maintain good oral health, the better our quality of life will be.

It’s not clear what exactly causes oral disease with age. Theories include wear and tear on teeth/gums, medication use, financial changes (leading to less preventive treatment), other chronic diseases associated with oral health, and/or immunological changes.

What is clear is that taking good care of our teeth and gums at every age is important.

Sugars & oral health

Eat more sugar, get more cavities, right? Wrong.
Are you surprised?

In fact, one study showed no relationship between eating highly sugared breakfast cereals and developing cavities!
Maybe the kids added a Listerine chaser.

But here’s a more probable explanation: It turns out that the sheer amount of sugar we eat may be less harmful to dental health than the frequency of consumption.

That’s why sugared sodas and energy drinks are so dangerous.

Sipping sugar-containing beverages provides repeated hits of sugar on the teeth. Most sugary beverages are highly acidic, which promotes demineralization. Our mouth gets a double-whammy.

Whether frequency or amount of sugar intake is key, one thing is for sure: A diet built around refined and processed carbohydrate foods can lead to tooth decay and gingival inflammation.

How much is too much – and what kind?

Added sugars appear worse for teeth than naturally occurring sugars.

The World Health Organization suggests that no more than 10% of total energy intake should come from added sugars. So, if you ate 2000 calories per day, that would be 200 calories of added sugars, or 50 grams.

(The WHO also suggests no more than four separate added-sugar foods each day. Based on these liberal recommendations, I have to wonder if the authors of the WHO report hold shares in Willy Wonka’s Chocolate Factory.)

Other sweeteners

Artificial sweeteners like sucralose (Splenda) and aspartame (Equal) don’t seem to promote periodontal disease or cavities.

Sugar alcohols, such as xylitol or erythritol, don’t seem to influence oral health. Actually, chewing gum containing the sugar alcohol xylitol after meals may even decrease your risk of forming cavities.

As for stevia, it doesn’t appear to have negative effects on oral health. But more research is needed here.

Recommendations

Get your oral hygiene on. Seriously. Are you flossing yet? Are you brushing at least twice per day? If not, start.

  • Brush your teeth, not only with fluoride-based toothpaste, but also baking soda-based toothpaste. The baking soda will raise the pH in your mouth, making it more alkaline and therefore decreasing risk of cavities.
  • Avoid smoking. Smoking can wreak havoc on gum and tooth health.
  • Drink green tea. Drinking green tea improves the health of your teeth and gums, as it decreases inflammation, makes your mouth more alkaline, inhibits the growth of cavity-causing bacteria, prevents tooth loss, may slow progression of oral cancer, and freshens breath by killing odor-causing bacteria. Wow! All this, and it can help you to lose fat, too.
  • Chew xylitol gum after meals. Xylitol increases saliva production and prevents the bacteria in your mouth from producing the acids that cause cavities. But don’t go overboard, because even if sugar alcohols won’t harm your teeth, they can cause gas and bloating.
  • Eat mostly whole, nutrient-dense foods that provide plenty of calcium, phosphorus, magnesium, vitamin K (especially K2) and vitamin D. Foods like leafy green vegetables, nuts, seeds, hard aged cheeses, plain yogurt, meats, natto, beans, mushrooms, fish, eggs, and organ meats all work here. Oh, and make sure you get some sunlight.
  • Eat some raw, crunchy fruits and vegetables every day. Raw veggies clean your teeth to a degree (apples, carrots, bell peppers, etc). Eating an apple as dessert after lunch will help to remove material that has adhered to the surface of your teeth. Plus, apples contain naturally occurring xylitol.
  • Limit added sugars from both foods and beverages. This includes soda, fruit juice, energy drinks, candies, etc. Energy drinks are particularly damaging as they combine a high sugar load with an incredibly acidic pH. If your diet is built around energy bars and energy drinks, you probably won’t have any teeth remaining on your 45th birthday.
  • Maintain a lean/healthy body composition. Excess body fat can promote poor systemic health, including poor oral health.
  • Increase the amount of arginine in your diet. Eat more spinach, lentils, nuts, eggs, whole grains, meat, seafood, and soy.
  • Get regular exercise. Exercise seems to protect against periodontal disease.