Invisalign® has been around for a few years now and has proven to be a very effective solution for straightening teeth.

However, it does not take the place of all orthodontics by any means. There are many outcomes for optimal straightening of the teeth that can’t be accomplished with Invisalign®, in which case traditional orthodontics are the better option. Fortunately, for the great majority of people who once had orthodontics and it has relapsed, Invisalign® is an ideal procedure to get the teeth straight again. There are many situations where Invisalign® can get excellent results, even for someone who has not had orthodontics before.

In order to utilize Invisalign®, it is vital that the dentist has a full understanding of occlusion and the patient’s TMJ (joint of the jaw) health. Training in orthodontic movement and TMJ is ideal. The goal is not just straighter teeth, it is to get a healthy stable outcome for lasting results. Some outcomes with Inivisalign® can be less stable than they would be with traditional braces, which increases the need for fixed retention, such as wire bonding on the lower teeth or the use of retainers indefinitely.

Invisalign does allow business people to straighten their teeth and not have their image/business savvy interfered with because they can communicate well with Invisalign®, and most people can not even tell you have anything on your teeth. One of the big benefits we see from a dental standpoint is that you can straighten your teeth but still remove these things, brush and floss your teeth, and still keep them very healthy. With traditional braces you can not clean your teeth as well and it holds stuff against your gums. Many individuals with traditional braces end up with inflammation of the gums and discolored teeth from the pressure of the braces. Invisalign® has big advantages in that it uses the most modern Cad/Cam technology. This is where the dentist can view your individual case using a computer program that helps to guide how the movements in the teeth are made. An individual plan can be made that is tailored for optimal treatment for each patient.

What are some symptoms of a TMJ disorder?

Headaches:

There are many, many causes for headaches, but the majority of headaches are muscle related. We hear a lot of patients talking about their headaches caused by stress. In many cases, people get headaches because of stress because they are clenching and their bite is not in harmony with their joints. Certainly not in all of them, but that is a big part of it. And when their bite is in harmony with the jaw joints and the muscles are relaxed, they are less prone to get headaches.

Earaches:

Many people complain of earaches when it may be TMJ pain. The physician may tell them that there is nothing wrong with the ear. Often times its an inflammation in or around the jaw joint that is making it feel like an ear ache. A lot of jaw pain is transient. It is exasterbated or brought on by stress and once the stress is gone then a lot of the symptoms will subside. That doesn’t necessarily mean their bite is really great but it does mean they can adapt to it…except during times of stress…and if they get their bite and jaw in harmony then it takes a lot more stress to bring on those symptoms.

What is TMJ?

The Temporal Mandibular Joint is the joint where the jaw meets the skull. Within that joint is a thin disc that sits between the jaw and the skull. And a lot of the problems occur when the ligaments or muscles attached to that disc are damaged or not functioning properly and then the disc starts popping out of place. That’s when people hear the clicks and the pops and the grating noises. Often times our goal is to get the muscles relaxed so they will release their abnormal pressure on the disc so it can go into place and get the inflammation in the ligament space behind the disc and the joint healed. A major goal of our treatment is to get that back in place. In a few cases, it is necessary to do this surgically.

Temporary pain relief:

Something someone can do in the event that they have an acute muscle problem is to use ice packs: 20 minutes on one side and then 20 minutes on the other side…for the first day or two of the acute episode. And then change that over into using more moist heat after that and gently exercising their muscles…stretching, making sure they relax and don’t clench their teeth, get on a soft diet, and take mild anti inflammatory such as Advil.

A healthy TMJ requires finding the right solution:

In a comprehensive approach to dental care, making sure that you have a healthy TMJ has to be the starting point. You cannot restore a bite, restore a smile, or have anything that is going to function well long term for the patient, if the joints aren’t healthy. Fortunately, the majority of jaw pain is muscle pain that is often related to the bite. And if the bite is corrected and in harmony with where the muscles need to function, and the muscles can be calmed down and comforted. And a very small percentage of patients with jaw pain can actually be a problem within the jaw joint itself and many of these can be treated through splint and bite therapy but some of them have to be surgically corrected to get the comfort that’s needed. And all of that needs to be done prior to doing any major restorative work such as crowning teeth, changing bite, and other restorative work. So the foundation has to start with the joints that are healthy and comfortable and in good position. Then the bite can be constructed to be in harmony with that.

How we address TMJ disorder:

The first thing we do is a true assessment with each of our patients to find out if the joints can be loaded without pain, which they should be, similar to the knee or any other joint in the body. We do measurements of range of motion, such as how far can they open and move their jaw from side to side, is it even, do they open without their jaw deviating from one side to another Deviation would indicate a problem within the joint in most cases. We also listen to the joints with a Doppler ultra sound to give us an indication of the health of the joint itself, It all starts with a good assessment. Once we’ve got the assessment its going to give us a good idea in most cases whether the problem is a muscle problem (which it is most of the time) or if it is in the joint. Each are handled/addressed a little differently. In a lot of cases it is wise to utilize a full arch splint where we can recreate an ideal bite that fullfils all the criteria for a good bite in harmony with the joints without doing anything to the teeth until we verify that we can get them comfortable and get the joints in a good place and everything is healthy…And then and only then, should you start on any restorative treatment.

The splints we use are often diagnostic as well as therapeutic. Many of the problems have occurred over long periods of time. While many of them resolve instantaneously, many others take an extended amount of treatment to get them healthy. A joint with abnormal pressure over an extended amount of time may have inflammation or a change within the joint itself that have to change back as you get a proper bite. This is one reason splint therapy sometimes takes some time: the joints themselves will heal and remodel and you want to wait until that remodeling has completed before you start restoring the bite. If you restore the bite where the joint is when it’s not completely healthy that bite is going to change as the joint heals.

For over 25 years dental implants have provided a natural looking solution for replacing missing teeth and for stabilizing or anchoring dentures. Before placing the dental implant into the jawbone, an analysis is taken to determine how the upper and lower jaw functions together. In addition, photographs, x-rays, and molds are taken of the teeth, smile, mouth, and jawbones.

Based on the analysis, we develop a plan that is in harmony with the patient’s goals and desired outcome. Most commonly, the patient’s goal is to replace their missing teeth, to use implants in place of their partial dentures, or for use with their dentures to create stability when chewing.

Some implants need time (four to six months) to fuse to the jawbone so that they will be strong enough to hold the crowns, bridges, or dentures. Implants usually require a surgical and restorative phase, but in some cases they can be used almost immediately after placement in the jawbone.

Typically, dental implants replace the roots of the missing teeth in the bone so that whatever attaches to it will be more stable. Individuals who have lost many of their teeth, if they have enough bone, have many options for stabilizing and making their dentures more functional with implants. Implants can also be used to build fixed bridges attached in part of the mouth, which is more like replacing teeth that the patient can really bite with. The advantages of putting in implants underneath the denture is, in addition to support, it stimulates the health of the bone and keeps it from resorbing as it does when it has a denture placed on top of it. One of the problems we have is that when the teeth are taken out, the bone begins to shrink down as it responds to the pressure of the dentures.

Over years of wearing dentures, the bone continues to shrink and eventually the dentures do not fit the mouth. Implants slow down this process dramatically by stimulating the bone to stay healthy and keep it from resorbing. The dentures will last longer because the underlying areas of the bone are healthier.

If you would like to learn more about implant dentistry to see if it is the best option for your goals for oral heath and beauty, please contact our office to schedule an evaluation.

We have become passionate about learning more about dentures over the past several years. Early in our dental practice we saw a new patient who was in her thirties and had dentures since she was sixteen years old. She had absolutely no bone left and could not wear her dentures. Back then we did everything that was known at the time to help her and this sent us on a quest as life-long students in dentistry. In today’s dentistry we have better answers, but at the time she was still unable to chew with her dentures. Our newest technology gives us options such as bone grafting, implants, and other stabilization. However, if a patient loses their teeth and simply puts plastic over the gums, they are going to be orally handicapped. For this reason, we do the best restoration that we can that is functional and aesthetic. This approach makes the patient look like they should look if they had their original teeth. That was a problem for most dentures in the past because, as the lower jaw shrinks, the neutral zone between the tongue and lip moves back. To keep your denture from having this constant movement of being pushed back and up, you couldn’t support that lower lip like you normally would. That’s why so many people with dentures look older-because they are not supporting the lips plus they wear them way to long and the jaw is over closed. As the jaw is over closed then you get the “Andy Gump” look where the chin almost meets the nose.

Veneers can help improve the size, shape, and color of the teeth. They are thin layers of porcelain that bond to the outer edges of the teeth. Because they rely on the underlying strength of the tooth structure, veneers are not the right solution for all patients.

Veneers are not always the solution.

When a patient seeks out help for worn teeth, far too often the decision is to simply use veneers to lengthen the teeth back out. The problem with simply adding veneers onto the teeth is that it is important to find out why the teeth were shortened in the first place. Simply lengthening the teeth back to where they were may only treat the effect because it does not solve the underlying cause of why the teeth wore down in the first place. This sets the patient up to potentially wear down or break their veneers, just as they did with the teeth the first time. Often it is necessary to reposition the teeth or deal with another problem the patient may be having, such as grinding their teeth at night. If they have veneers placed, they may want to use a night guard to protect the teeth from damage as a result of grinding.

Addressing the Underlying Problem.

Before deciding to use veneers, we carefully examine the underlying problem. We determine whether the problem is skeletal, just the teeth, or the bone that supports the teeth itself in order to truly solve the problem. We also provide you with the options that are available because veneers are a big investment and they are not really reversible. So if the patient has problems with them, they just have to keep replacing them. We make sure that the patient’s gums are in the proper place and that they are not showing too much gums when they smile because their teeth have worn, erupted down and brought the gums with them. We also ensure that the gums are even to assist with a beautiful smile because putting veneers on them does not solve that problem if the gums are not addressed.

If the front teeth are tilted back and in, that is an abnormal relationship that leads to wear and if veneers are put on those type of teeth, the same wear will happen over again only now they will have to pay for the veneers over and over again.

Far too many times veneers are the answer that is given because the patient requests them or the dentist does not properly assess the entire situation. For example, sometimes veneers are put on when the answer really needed to be repositioning of the teeth prior to restoration. If the teeth are properly positioned, that makes room to ensure that the veneers are the appropriate size for the patient. If the teeth are restored in an abnormal position that has taken place because of wear the teeth, the veneers can not be the right width to length ratio for that patients smile…and may not be in the right place in that patient’s smile.

There are negative effects to getting veneers before restoring teeth. The patient may feel discomfort, such as jaw pain. In most cases, there will simply be a problem of maintenance. The patient may break off, chip, or wear down the veneers just like they did with their natural teeth.

A lasting Solution

If the teeth are restored correctly in the proper place, the patient can look forward to increased longevity, increased comfort, and a very beautiful smile as a result. Simply making teeth bigger with veneers often times does not solve the core problem and does not give the patient the best smile that is possible. Although it may offer improvement, it will not give the final result that could have been accomplished. Far too many people get veneers and feel semi-happy with them because it is an improvement over where they were, but they are so far from where they could have been for the final outcome.

Many people don’t realize that dental insurance can be quite a bit different than medical insurance and part of that difference is with the limited coverage provided by many dental insurance plans. Often times the patient’s coverage does not include protection against aspects of the disease process, which is important for follow up treatment.

Limited Coverage

Insurance companies are in business to make money. Therefore everything has to be set up on actuarial basis so that they can charge enough and yet not have to pay out too much. What that means to the patient is that if you rely on your insurance alone for what they will cover or pay for, then there is always the potential that you are deteriorating in your overall oral health. There are procedures that are not covered by insurance that are necessary to remain healthy. Insurance plans have limitations on all preventative procedures and some people require more than the average in order to stay healthy. If you only do what the insurance will pay for, yet you require more, then that means your health is going to suffer over a period of a few years.

The first insurance that came around somewhere in the late fifties/early sixties had annual maximums around $1000 – $1500. The great majority of insurance plans that we see today still have the same maximums. So it doesn’t go very far anymore. Basic inflation suggests that maximums should be increased to $5 – 6,000. For this reason, dental insurance just doesn’t seem to go very far-you fix a couple of teeth and the maximum is reached. Patients often times need more than what is covered in their dental insurance plan. Insurance is certainly beneficial.

Those who only go to the dentist because they have insurance and a 3^rd party is going to pay for it may not value their oral health highly enough to put money out of their own pocket for it. So they are going to do the minimum…and if you do the minimum that insurance will cover, that is usually not enough for many people and their health will deteriorate. For example, dental insurance does not always address problems that need treatment, such as worn dentation. Many insurance companies will not pay for any of the newer procedures that are available in dentistry, and some of the dental insurance companies are still downgrading certain procedures such as the teeth colored restoration on back teeth. They say they won’t pay for that-they will only pay for silver filling because it is cheaper. Some insurance companies have a clause in the plan that offers “the cheapest alternative benefit”. There are also all sorts of limitation on pre-existing conditions.

One of the biggest issues we run across is the patient thinks the insurance company is paying 100% of 80%. Actually that percentage is determined by whatever fee the insurance company dictates that they think a specific procedure is worth, at an average for the particular area the patient is in.

Treatment dictated by insurance coverage.

Another important issue with insurance is if a dentist does sign up with some plans that try to control the maximum payment that they will make on certain procedures, then in order to make a profit those dentists are forced into a clinic situation where they have to use multiple chairs and see as many people as possible and the patient finds themselves in a chair waiting, and waiting, and waiting for the dentist to get done with the previous procedure so that they can get on with yours and somebody else’s treatment at the same time. I just found that to be a method of treatment that does not predispose to the highest quality results for the patient. One thing that really suffers in this system is the communication process-the patient doesn’t get enough information to make an informed choice about what kind of treatment they are getting. They are not being educated when the dental professional chooses the quickest way to get started drilling on the tooth in order to get the restoration done that the insurance will cover, because they may not be getting paid enough to spend the time to educate and set goals in the treatment plan for the patient. Insurance driven dentistry is also doing a lot of full coverage crowns that don’t need to be done and it would be preferable to do a conservative type restoration that covers part of the tooth instead of the whole tooth. These procedures are being done because they are covered by insurance. It would take more time to explain to the patients the benefits of the conservative restoration and that it costs more and it is easier to just offer the full coverage crowns to execute the procedure and collect the insurance payment. Many times the patient doesn’t even realize that they have other options available to them.

The patient should have the opportunity to get involved like they should. Because our job really is to educate the patient to the point where they can make choices based upon what’s important in their life- instead of dictating treatment-because there are so many options today and some of it, quite frankly, is elective. The patient needs to determine whether it is important to them or not to spend that money at that particular time in their life. It changes for people sometimes based on what is going on in their life.

Dental insurance is set up on averages.

These restrictions implemented by insurance companies can sometimes create hostility between the patient and the dentist because they look at their plan and think the dentist is charging too much. However, the insurance companies don’t know how much it cost for the dentist to run their practice and to use the best laboratories, materials, and etc. Insurance-driven dentistry can lead to mediocrity of dental care. While this type of dentistry is acceptable for individuals with exceptional oral health, in a curve of oral health there will be those who need extra dental care to prevent or manage poor dental health. The insurance companies are designed for those who can get away with average to little dental care. They can not afford to make their plans to consider those on the other end of the oral health curve because that would not be profitable. People should be ready to spend the time and sometimes their own money to maintain good oral health, in spite of what the insurance companies will or will not cover.

Health-Driven Dentistry

I often ask patients, if I see something in your mouth that is not correct and needs some attention that’s not covered by insurance do you want me just to ignore it? Obviously we can’t do that-I’m going to have to do something about it. The question is, do you want to be healthy or do you want to rely on your insurance company to take care of you. You should be careful if you are relying on the insurance company alone, because your health may not be their primary concern and if you rely on other people to take care of you they can become your tailors and create problems for you in your life-in this case your oral health.

We try to help patients set goals for their health. We do not focus on insurance when going through the process of determining how healthy the patient wants to be, how pretty they want their smile to be, and what is most important to them? Sometimes, when money is the driving factor, we look at how can we get them to a basic healthy state and then help them maintain that. We also look at how the insurance can best be used to help support that. However, it is not the driving factor. We don’t decide that we are going to clean your teeth every six months because that is all the insurance will pay for, when you may actually need periodontal cleanings every three months to stay healthy. If the insurance company will only pay for silver fillings on the back teeth, and we don’t think putting silver fillings back there is the best restoration method, then we are not going to put them in. It may cost a little more for those patients who want to stay healthy, but there are certain things that I in good conscious can’t do, just because the insurance company would pay for it.

There are a lot of different insurance plans out there, and they have preferred providers. Individuals will call the practice to ask if I am on their insurance plan. The answer is: we will help process their insurance to help them get the maximum amount out of it but we can’t sign up for those plans where insurance companies gain more control of the patient’s treatment because a third party who is doing something for profit is certainly not going to agree to do what is best for the patient if it means their going to lose money.

One-Patient-At-A-Time Dentistry

We treat one patient at a time. We want to spend the time goal setting and examining where they are, how they got there, and where they want to go. Instead of just treating an immediate problem, we want to find out what caused that problem to occur and what can we do to prevent it in the future. And insurance is set up for procedures, how many procedures can you do. This process becomes more about numbers and less about the individual’s needs. Removing insurance as the main focus, allows us to spend time with patients who are truly concerned about their oral health.

Preferred Provider List

Our practice is not on a preferred provider list. Many times when patients come in and we are not on their preferred provider list- they still get reimbursed the same amount from their insurance company. In some cases the insurance company is set up where they penalize the patient for going to an out of network dentist but the majority of the time we find that if someone is getting significant treatment of any kind, when they hit the plan maximum, that is all it is going to pay no matter what.

Effects of minimum care for teeth

We have seen all kinds of patients who had previous dentistry done that was dictated by only what insurance would cover. One tooth here and one tooth there…instead of a comprehensive plan considering all the final goals to treat your entire oral health. There will be restorations on different types of materials, crowns done at different times, different colorations, without consideration to the entire mouth wearing down. That needs to be addressed before putting in individual crowns. Insurance driven dentistry, forces you to ignore some of the major issues going on in the mouth (i.e. taking care of TMJ before starting restorative treatment). Periodontal disease is another treatment that can not be effectively addressed by only regular 6 month teeth cleaning.

Long term the patient will save more money by addressing all the issues early. And the insurance company may not allow a reimbursement for certain treatment of bite problems or TMJ problems. But if you ignore these, in some cases it can turn out to be a major investment later on to restore your teeth as they have worn to much or sometimes needs surgical intervention, such as for TMJ, that could have been avoided. So it is not only more expensive but it is a deterioration of your health that can occur…and years of discomfort.

There has been a lot of progress made in the area of filling materials for teeth for small areas of decay. Previously, silver imogen was the major choice for dentists. One downside of these silver fillings is that they are held in mechanically so the dentist has to undercut the preparation to get it to lock in to the tooth, resulting in the removal of good tooth structure to get it to mechanically lock in to the tooth. Because they did have to make a larger opening to put in a silver filling, dentists were many times reluctant to fill the smaller cavities, waiting until the cavities were bigger to put in bigger fillings. The bigger a silver filling gets, the more discrepancy there is in the coefficient of expansion. This means the metallic filling will expand and contract more than the tooth structure it is in when making contact with hot and cold foods. When this happens over an extended period of time, often times the teeth will crack or the margin between the filling and tooth will break down, causing leakage. The biggest problem found with baby boomers who received these big silver fillings when they were young, is most of them needed crowns as they grew older. So now there is a push to perform less invasive dentistry and the composite resins have come a long way from previous generations. The composite tooth color restorations wear more like tooth structure now and they bond to the tooth so the dentist doesn’t need to rely on undercuts. This allows us to remove just the decayed area itself and bond the filling into the tooth, preserving more structural integrity to the tooth.

Because we are taking care of decay at an earlier stage and using filling that bond to the tooth that have a coefficient of expansion that is more similar to the tooth structure, there are fewer cracked teeth caused by the restoration, the fillings are smaller so they last longer, and cosmetically they blend to look more like part of the teeth.

When fillings get to be a certain size, regardless of the material, you are exceeding the limits of that material for it to be an effective restorative product. In this case, porcelain restorations can be shaped and cast to fit in or on the tooth and bond to the tooth. This solution can be effective for teeth that need full coverage to protect where they have been cracked or broken. Often times now we don’t have to do a full crown when we can do different shaped restorations that bond to the teeth and maintain more structural integrity to the tooth.

Bleaching and whitening is a popular service in dentistry. When done correctly, bleaching has evolved to be safe, effective, and to not damage the teeth. We caution patients about using some over-the-counter whitening products. While many are safe, most are not as strong as what we use at our office and some contain high levels of acid. Short term this will make the teeth whiter because it removes some of the minerals and reflects more light, but it is actually damaging to the teeth over long-term use. Some of these products also make the teeth more sensitive. We are careful to use products that cause less sensitivity and bleaching teeth is a routine service.

Patients who are considering restorations to their front teeth, whether composite fillings or crowns, should consider bleaching before the restorative work because bleaching can not be done afterwards.

A large number of people do not have room for wisdom teeth. This may be the result of an evolutionary change because our diet has changed over thousands of years and we don’t eat as many greens and nuts and our jaws are not as big as they used to be. We are seeing more and more people in the past few generations did not even form some of their wisdom teeth. Those who do have wisdom teeth and don’t have room for them will get impacted teeth. When a tooth becomes impacted it can do damage to the tooth in front of it. Depending on how it’s sitting in the jaw bone(or what happens in most cases) the wisdom tooth will come part way out of the jaw and then the gum tissue surrounding the enamel covered crown of the tooth can’t adhere to the enamel and a pocket forms. Food can get trapped in the pocket and cause an infection caused periocornitis. This infection causes swelling and pus from around the wisdom tooth that will come and go but become more frequent and severe over time. Quite often it is necessary to remove those wisdom teeth and, in many cases, it is a surgical procedure to extract the tooth.

In our office, we provide IV sedation so that the patient isn’t aware of the treatment while it is going on, and will recover better than with just using a local anesthetic. Taking out wisdom teeth is sometimes an elective thing but it is usually best to do it when the patient is younger before the bone becomes dense. Early extraction also gives less likelihood of the wisdom teeth causing damage to the other teeth, caused by the patient’s bite or resorption of the tooth in front of it. If extraction of wisdom teeth is ignored and it is growing into the molar in front of it, the patient may get almost like decay but its resorption similar to the resorption you get when permanent teeth come under the baby teeth and resorp the roots. Sometimes if you ignore it, you will end up losing multiple teeth: the wisdom tooth and the one in front of it, and then the one above it because it doesn’t have a tooth to function against. For these reasons, extraction of wisdom teeth is an important thing to evaluate at an early stage.

A large segment of the population does not seek proper dental care because of fear. Today there are several options that make dentistry much more comfortable. For years nitrous oxide has been available, which is an analgesic gas that raises the pain threshold and alleviates anxiety. This is a good solution for many patients and the gas is out of the system within just a few minutes of breathing oxygen afterwards, so a designated driver is not necessary after treatment.

Some individuals are reluctant to even just have their teeth cleaned because of fear. For these individuals we have oral medication that can be taken 45 minutes to an hour before their appointment that will alleviate their anxiety. The medication is strong enough to really do an effective job so these patients will need a designated driver after treatment.

If we are going to be doing significant dentistry on an individual who is not comfortable sitting for an extended amount of time or has an extreme fear, IV sedation is available. This is a safe method of sedating the patient so that they will not have an unpleasant memory of the treatment. They will not be unconscious, as with general anesthesia, so there are not extreme dangers associated with this sedation. Patients can still respond and inform us if something is bothering them so that we can respond accordingly.