Bleaching

Q: My 13 year old daughter would like to whiten her teeth. Is she too young?

A: The whitening systems are very safe and reliable, but I think that unless there is a special problem, she is probably too young. My concerns are fairly simple. If the teeth are still erupting (growing out of the gums) then you will only whiten the part of the teeth that you can see. The part of the tooth that appears later will not be whitened. Also, the bleaching trays should not be used for an extended period of time on a younger child that is still growing. The 'trays' can prevent the teeth from shifting and growing properly.

Q: What is the best way to bleach my teeth, or how can I have whiter teeth for the holidays?

A: There are so many bleaching products on the market it is difficult to know where to begin. I will try to touch on the pluses and minuses of each system and I will be happy to answer any questions that you may have regarding your own bleaching experiences.

You can begin by buying a tooth whitening toothpaste, but I have never seen anyone get whiter teeth from using them. The whitening concentration is too low and doesn't spend enough time in contact with your teeth. It's also important to remember that it is possible to overbrush your teeth. If you scrub too hard and long, you are actually removing the white outer shell from your teeth and letting the yellow inner layer shine through.

I believe that 'TV" and 'drug store' bleaching kits can give you acceptable results. Unfortunately, there is no way of knowing if you have chosen a good or bad product, and they can be costly. Typically, these kits use an athletic type mouth guard to hold the bleaching medication against your teeth. The medication is of a weaker strength and the mouthguard fits too loosely to hold the bleaching solution against the teeth for very long.

Doing 'home bleaching' through your dentist can cost from $200-$300 per arch (upper or lower teeth). Although this is more costly than the other methods, the results can be pretty spectacular and can last indefinitely if you give yourself booster bleaches every month or so. Additionally, your dentist will be able to help you with any sensitivity or fit problems that you might encounter. Your dentist can provide the right bleaching system for you. The kits come in different strengths and can be worn during the day or at night. Generally you will get the results that you are looking for within 2-5 weeks.

There is a newer in-office version of the 'home bleach". A high concentration of bleaching paste is applied directly to your teeth and activated with a high intensity light. I think that there are probably times when this is a good option, but I am concerned that the cost is approximately twice as expensive as the 'home bleach'. Also, when you are done, you do not have any materials to take with you to use as a 'booster bleach'. As the color fades you must return to your dentist and redo the procedure. The advantage to this technique is that the results are much faster and it is not necessary to wear the bleaching trays for weeks.

Laser bleaching is the fastest of the bleaching methods but is by far the most expensive. It can cost $1000.00 per arch. There are also reports that it doesn't last as long as the 'home' bleaching methods. The equipment needed to do this type of bleaching is very costly to purchase and you will find that very few dental offices provide this service.

Keep in mind a couple of things when considering bleaching your teeth. First, only teeth whiten. Fillings and crowns will not change color. Your teeth will get lighter, but your 'dental work' will stay the same color. Second, different colors of teeth whiten at different rates - meaning that everyone gets different results. Your dentist, based on his or her past experience, should be able to give you a good idea of what to expect.

Lastly, don't ever confuse home bleaching with Clorox bleach. Clorox bleach in your mouth can kill you. The dental bleaches are safe, clinically tested peroxide formulas.


Braces

Q: My 5 year old grandchild's teeth aren't straight. My teeth have always been crooked and I am very sensitive about her teeth. When should I tell her parents to see an orthodontist? R.B. in Newark

A: Hopefully your grandchild's dentist is already aware of the problem and is just waiting for the right time to refer her to a specialist for proper treatment. But I can give you some general information. A number of years ago it was very common to wait for all the permanent teeth to come in before starting 'braces'. Most of these children were 12-13 years old. If the teeth were too crowded, a couple of teeth would be extracted to allow room to straighten the rest of the teeth. Today, I believe, that dentists have more tools in their orthodontic 'tool kit.' If a child has very crowded teeth when he or she is 7-8 years old, we can actually influence the growth of the jawbones to avoid doing extractions when the child is older. 5 years old is a little young, but if you believe that the child has a problem, it is better to be seen too early than too late.

Q: I am a 60 year old grandmother and my teeth have always been crooked. Am I too old for braces?

A: Many years ago I read an article entitled 'Granny Has Tinsel Teeth.' The general idea was that a grandmother had put her children and grandchildren through 'braces' and now it was her turn. She was in her 70's and was thrilled with the results. It is never too late to have beautiful, straight teeth. As long as your teeth and gums are healthy, your dentist or orthodontist can put braces on your teeth and move them into the correct position. It might take a little more time than when you were 12 years old (your bone was softer then), but you can still get great results.

My concern is that after your braces have been removed, what will the individual teeth look like. Will you have spaces between the teeth where the gums had previously receded? Are your teeth short, square, flat, or worn from years of chewing? And are the colors of your teeth what you want them to be? If your answer is yes to any of these questions, you should at least look into porcelain veneers.

Porcelain veneers are porcelain facings that can make even the darkest and twisted teeth look white and straight. There are limits to even porcelain veneers and a combination of veneers and orthodontics is sometimes the ideal treatment plan. Your dentist can help you with your decisions, but don't be sensitive about what your friends might think. You might be surprised that the most common feeling among your friends and family is going to be jealousy.


Crowns

Q: I am the embodiment of the old song "All I Want For Christmas Is My Two Front Teeth". Since a 3rd grade accident, I've had damaged incisors. Because of limited finances, I had to wait until my service in the U.S. Marines for them to be fixed properly. While my front teeth are 'suitable', they are cosmetically 'off'. It is a point of embarrassment and low self esteem after 30 years. My HMO is like many others and difficult to work with on this. Are there local dental schools that you would recommend to do the work? Also, could you suggest companies that would finance dental procedures? D.H. in North Wilmington

A: You sure pack a lot of information and questions into a short letter. Let me start by saying, even without seeing you, you can probably have anything you want.

I am going to try to change your mind and your direction. First, don't expect your dental insurance to pay to fix the problem. They will simply help pay for your least expensive option. Your dental insurance is only a dental help plan, not a dental insurance plan. Your employer wants you to have a dental benefit. So he goes to an insurance company with only a certain amount of money available, and then asks what can he get for it. He negotiates and ends up with your plan. Your dental insurance company isn't going to stay in business long if he pays more for your teeth than he gets from your employer. Obviously, the more money that you pay for your dental plan, the better the plan will be.

If you want the job done right, you need to pick your dentist. You can't let your insurance company pick the lowest bidder for you. Insurance companies can make more money when they find dentists that are willing to lower their fees. These dentists are then put on insurance company lists and are sent more patients. The dentists still want to make more money, so they use less expensive materials and labs. By 'cutting corners' they can reduce their expenses. Remember new equipment, good staff, and continuing education are expensive and can be the first victims of a tight budget.

Regarding the dental school option, unfortunately, Delaware does not have a dental school to send you to. In Philadelphia there are two schools, University of Pennsylvania and Temple dental schools. At both of these schools you will get very reasonable costs and the students are well supervised. There are also dental residents at Christiana Care's Wilmington Hospital, but the waiting list is very long. My concern with both the dental schools and the residency program is not the quality of care that you will get. I am sure that your new crowns will be technically correct. But, there is a good possibility that the student or resident will be doing his second, third, or fourth front teeth crowns on you, and their choice of dental labs is usually very limited.

Lastly, if you decide to pick your dentist, how can you afford this expensive work? The number of third party payment plans seems to grow every month. My office, for example, has a plan now that charges about 10% interest and the payments can be spread out over 5 years. Good luck, you have many choices to make, but in the end you will have a great smile.


Discoloration

Q: I had my front teeth 'bonded' almost 5 years ago. They have chipped and been fixed a couple of times and they are getting darker. Can anything be done to make them look better? J.L. - Hockessin

A: If your intent is to salvage your present bondings, the answer is probably not. When 'bonding' materials begin to fail or reach the end of their useful life, they need to be replaced.

'Bonding' is the name given to cosmetic fillings placed, generally, on front teeth. Bondings are usually made of a ceramic, composite material and can be used to change the color or shape of your teeth.

Although some bondings last longer than 5 years, it's not unusual to see them start to stain by 5 years. If you're a heavy coffee or tea drinker or a smoker, the staining can be worse. Also, the more composite or bonding material that was added to the teeth originally, the greater the chance of chipping.

The good news is that if you've been bushing and flossing well you probably have minimal, if any, decay. The old bondings can be stripped off like old paint off a wall and new ones can be designed and placed. The new composites and bonding adhesives that will be used to replace the old bondings are definitely prettier and stronger than they were 5 years ago.

Q: My teeth have dark tetracycline stains. I have always wanted white teeth. Do you have any suggestions? G.Y. in West Chester

A: Tetracycline is a common antibiotic used to treat many kinds of infections. If tetracycline is taken as your are forming, the medicine becomes part of the tooth and the tooth will have varying intensities of colored bands. A common color scheme is a dull grey-blue banding. Healthcare providers now know not to give children tetracycline, except under unusual conditions.

Whitening 'tetracycline stained teeth' is a job for an experienced dentist. The darker your staining, the more difficult it will be to make the teeth look 'naturally' white. If you had a black wall in your bedroom, you can imagine how many coats of white paint would be necessary to cover it.

Any time you begin a cosmetic procedure you should strongly consider bleaching your teeth first. Bleaching tetracycline teeth has a low success rate, but I have found that if you are diligent and can stick with it for a few months, you can get very good results.

If bleaching doesn't give you your desired result you may want to look into porcelain veneers or full crowns. Porcelain veneers are porcelain facings that are bonded to the front of your teeth. The veneers are particularly good if the staining on your teeth is lighter and your teeth have no previous fillings. You might lean toward crowns if the teeth are badly stained (the bleaching was unsuccessful) or there are numerous large fillings. Your choice of treatment will depend on the condition of your teeth, the experience of your dentist, and the quality of the dental lab that is being used. Whatever your choice of treatment you can have teeth as beautiful as you can imagine.


Implants

Q: My 16 year old son had his top front tooth knocked out playing ice hockey. We read your column and we are thinking of replacing it with an implant. T.R. in Centerville

A: At 16 years old an implant should not be your first choice. An implant is a metal root that replaces a missing tooth. Once the implant has been secured (integrated) into the bone, a new tooth can be attached to it. While I don't know your son, it is a good bet that he is not finished growing. An implant should not be placed in a growing mouth.

The target age for implants in girls is approximately 17-18 years old. The target age for boys is a couple of years older. Another reason to delay the placement of the implant is that normal teeth are all a little loose. When they get hit they can 'bend' a little instead of breaking. Implant supported teeth are very strong, but are more likely to break with a hard impact, like a hockey puck.

There are a number of good temporary tooth replacements, both fixed and removable, that your dentist can help you with until your son is old enough for an implant.

Q: I would like to get implants to replace my missing teeth, but I am afraid of the surgery. Do you have any suggestions? N.G. in Greenville

A: An implant is a metal root that is placed in your jawbone to replace missing teeth. The teeth (or crowns) that are placed on the implants are very strong and can look like your original teeth. You will never get any decay and anything more than mild gum disease is unlikely. When properly planned and placed, the implants are 95% successful at 30 years. If you have had teeth extracted, then you should have no problem with the minimal discomfort you will have from the placement of your implants.

Although there are some exceptions, the placement of implants is a fairly common procedure that can be done with mild sedation or just local anesthesia (or a shot). If the surgery is going to be long or painful, your surgeon should tell you ahead of time, and it is rare that you should have any surprises. I hope that you overcome your fear, because the implants are a wonderful procedure and I believe that you will be very happy that you chose them.


Veneers

Q: I am trying to decide whether to have orthodontics and whiten my teeth or to have porcelain veneers placed to improve my smile. Do you have any suggestions?

A: Whenever possible, having your teeth straightened (orthodontics) and then whitened is your best option. Sometimes the teeth can be finished with a little bit of cosmetic contouring (or spot sanding).

When dentists study smiles we don't look at just how white and straight your teeth are. We look at the shape of your face and the shape and size of your lips and smile. We want your gum line to be symmetrical and the proper height. Showing too much gum when you smile can be very distracting. We want your teeth to be a cosmetically pleasing length, but if the teeth are the wrong length you can have speech problems or the porcelain veneers are more likely to chip or break. It is important to analyze your bite or the way your teeth come together. Sometimes the 'bite' (or occlusion) needs to be modified to make the veneers last longer.

In nature there are certain shapes that are more pleasing to look at. Over the years your teeth can show signs of age. You can have crowding, shifting, chips, and badly worn areas. As your teeth get shorter and more worn they loose their a graceful and youthful length and curves. Short, fat teeth, no matter how straight and white they are, still look short and fat.

There are many ways to decide which type of treatment is best for you. Models of your teeth can be made and either orthodontics or porcelain veneers can be done on the models and you can view the result. Temporary veneers can be placed over your own teeth or computer imaging can alter the shape of your teeth in a photo.

Q: I am 47 years old and about a year and a half ago I had porcelain veneers placed on my six top front teeth. I liked the veneers when they were put on but since that time two have chipped and one has fallen off. I read a newspaper article that said porcelain veneers last forever. I am very disappointed. Why have my veneers done so badly?

A: I am sorry that your veneers have not gone well, so let's try to figure out what went wrong. Porcelain veneers are cosmetic porcelain facings that are bonded to the front of your teeth. They replace missing parts of the teeth or are used to make teeth whiter or prettier.

There are many areas of possible failure, but your problem is probably related to your bite (or occlusion). Your upper and lower teeth come together and slide around in a very particular manner. If the veneers interfere with your normal bite or your normal 'path of occlusion' you will break the veneers or develop jaw pain problems (TMJ) or both.

I have always believed that dentistry is a combination of engineering and arts and crafts. Nowhere is this truer than with porcelain veneers. I have seen short, ugly veneers seem to stay on forever and I have seen beautiful veneers begin to chip within a couple of weeks.

It is not easy to find a dentist that can put all the pieces of the porcelain veneer puzzle together for you. I have seen porcelain veneers placed by a dentist with a very good understanding of occlusion, but the veneers were not pretty. The wrong porcelain was used, the gum line was uneven, and the color made the teeth look like white Chiclets.

Your dentist, on the other hand, seems to have a good understanding of esthetics, but your beautiful teeth have interfered with your bite and you have seen the results. What can you do?

The veneers need to be redone and they may need to be shorter or your bite needs to be changed enough to allow longer front teeth. The problems should have been discovered and corrected when you had your temporary veneers. The temporary veneers are the plastic trial veneers that protect the teeth after they have been prepared. They also let the patient get a good look and feel of the real thing. This is when you fix the problems.

The last concern I have is the anticipated life span of your veneers. I read the same article in the paper that you did that said veneers last forever. That dentist should have been ashamed of himself. An anticipated life span should be 10-20 years depending on many factors. For almost all of my patients this means that the veneers will need to be redone once or twice in their lifetime.

Q: I have read a number of your articles about porcelain veneers with great interest. I have had badly stained teeth since I was a child and I would love to have straight, white teeth. Could you tell me about the process? How long does it take? How many visits are involved? G.T. in Centreville

A: For those of you that do not know, porcelain veneers are cosmetic porcelain facings that bond to the front of your teeth. They can be used to replace old, dark fillings or restore the original youthful shape to worn or chipped teeth. They can also give "instant orthodontics" to crooked teeth or whiten discolored teeth.

All dentists have different training and experience so I will limit this discussion to the process with which I am most familiar.

In your case, with highly stained teeth, the dentist might suggest that you first spend a few weeks bleaching your teeth. The porcelain veneers can cover even dark stains, but it is easier, prettier, and more natural looking if we can lighten your existing teeth a little first.

After bleaching, the more tools and technology that can be brought to bear, the more predictable your final results. It is possible to take digital photos of your smile and let you pick the shape of your new teeth from a book. A computer-imaging program is used to combine your photo and tooth choices to let you get a glimpse of your new look.

When the imaging is complete models should be taken of your teeth and mounted on a jaw (or chewing) simulator. These models should be sent to the ceramicist (lab technician) that will eventually make your porcelain veneers. He will create your new teeth in wax on the models. This gives the dentist a chance to check the final look and search for any potential problems.

You are finally ready to have your veneers made. The good news is that you and your dentist already know what they are going to look like and all your preparations have turned up any potential problems. You have two visits left. Visit #1 is my favorite. You are 'numbed up' (or anesthetized) and your teeth are prepared. When you leave the office your temporary veneers will look just like the permanent veneers will look. The new look is exciting and fun to see. Over the next couple of days, if there are any changes you want to make, they can be changed on the temporary veneers and the changes passed on to your permanent veneers so you will get exactly what you were dreaming of.

The last visit (#2) is for seating your new veneers. If all the preparation has gone smoothly this should be a smooth, easy visit with no surprises.

Many years ago I used to simply talk with my patients, find out what they wanted and just make the veneers. The last visit was always the most stressful because I hoped that my vision was also their vision. Fortunately, we have more refined techniques in place so that you can get just what you want.

Q: In the past year I had some porcelain veneers placed on my front teeth. One of the teeth has been giving me problems ever since. Please tell your readers that porcelain veneers can cause problems and that they should look into them carefully before having the procedure done. H.R. in Hockessin

A: Thank you for your sound advice. Any cosmetic procedure that you have done should be looked into thoroughly before proceeding. Porcelain veneers are porcelain facings that are bonded to the front of your natural teeth to give you a beautiful, white smile. These veneers have a wonderful and long history and I have seen dull, lifeless grins turn into gorgeous, bright smiles. Unfortunately, not all teeth are good candidates for veneers and not every procedure works perfectly. It's possible that your bad tooth only needs a root canal and you will feel completely better.

I want you to know that porcelain veneers are a terrific procedure and I am sure that your dentist can solve this problem and make you feel better. For the rest of you that are considering cosmetic porcelain veneers, it's important that you and your dentist discuss the benefits and risks before you start.

Q: I am getting married in four months and I want my teeth to be straight and white. Can I have a beautiful smile in that short a time?

A: The short answer is yes. Without knowing the specifics of your smile I am going to make lots of assumptions. You can forget braces. You simple don't have enough time left. It is always a good idea to begin almost any cosmetic procedure by first whitening your teeth with a bleaching system approved by your dentist. After you have your teeth as white as they can be, you need 'instant braces' or porcelain veneers. The veneers or 'facings' are bonded to your natural teeth and will make them look straight and white in about two weeks.

Now that you have your easy answer, let me tell you what you should really do. Take a deep breath and wait until after the wedding to go to the orthodontist and get your teeth straightened. Although I think that porcelain veneers are terrific, I also believe that the less work that you have done to your teeth the better. While braces can last forever, porcelain veneers will need to be replaced every 10-15 years.

If you know that orthodontics will never be an option for you, then please hurry and get your porcelain veneers done, but patience could be your best choice.