Broken tooth

When a child falls or generally is rough-housing, sometimes, they fracture a tooth.
Ugh, why does it have to the be the front teeth, the ones everyone sees? Almost every Monday, we receive a call from a parent with a child or teenager that fell over the weekend and chipped, broke, or otherwise fractured a tooth. Teeth can sustain a lot of force, but a sharp hard force concentrated in one spot can cause a fracture or "broken tooth". Now, baby teeth often have multiple small chips on the edges or facets from "normal" wear and tear. Of course, a fracture in a permanent tooth can be cause for concern.

Fractures are classified as to location and basic level of severity with the Ellis classification system:

Class 1--Chips or fractures in the outer enamel layer only
Class 2--Fractures into the dentin layer
Class 3--Fractures into the pulp of the tooth
Class 4--Fractures onto the root often vertical fractures

What to do?


Well, sometimes baby teeth are handled differently than permanent teeth. In general, the principles are the same:

Class 1--Well, they may look bad, but are usually not sensitive. If it is very small, we often just smooth off the edge. It is very difficult to do a very thin filling on the edge of a tooth. You can, but it will chip off again in a heartbeat. If the chip is larger, you often have to do a composite filling (bonding). It's the same material we use for white fillings. It is "bonded" onto the tooth -sort of like gluing something onto a flat wall.

Class 2--Larger fractures. Very common and sometimes sensitive to cold water/air, -at least for a while. A composite restoration is indicated to cover the sensitive dentin and for looks. A very large fracture may eventually need a crown or porcelain facing, but in growing children a more conservative approach is often indicated till growth and orthodontic treatment is completed. Although it often looks pretty good, a composite can be difficult to match existing tooth structure with all the minor enamel inclusions and shadings. So, if you are looking at the photographs below and think, "wow, that's not too bad", you are correct, but most results are not this good. With most repairs, if you look really close, you can see where the tooth ends and the filling begins. That's why porcelain work is often indicated later on.



Class 3--Always needs attention as bacteria are entering into the pulp. In adults this often means a root canal will be needed. This is not often the case in young permanent teeth. The more vigorous pulps with a better blood supply can often recover quite well. If most of the crown of the tooth is missing, a root canal may be indicated just to create something to hold a crown.

Class 4--Not common, but difficult to treat, and often need removal. Dental heroics may be needed to save such a tooth. Treatment may include orthodontic extrusion, a root canal, post and core, and a crown--if you are lucky.


Once teeth are restored, there still may be problems later on due to the initial trauma. The tooth may abscess or have other problems.

Treatment is sometimes different for a baby tooth. Often parents want whatever it takes to "save" a baby tooth that is not of any real consequence other than appearance. We are much more likely to just remove a severely damaged baby tooth rather than do a "baby tooth root canal". The main objective is protecting the developing permanent tooth. Small fillings in front baby teeth are more difficult to retain without doing a crown. Having said this, we still try and "fix" fractured baby teeth if we can. The age of the patient can dictate what you are able to do (or not). A chip in the tooth of a two year old may be handled differently than that of a 5 year old. Behavioral considerations, the need for sedation, and how much root is left on the baby tooth will influence the ultimate decision.

There is more on the blog on trauma (and I know you want more info on this one):

Fractured teeth, Knocked out teeth, and other pediatric dental accidents

The Autistic Dental Patient

Patients presenting with Autism can be a challenge for dental professionals. We as Pediatric Dentists see patients with all kinds of special needs, developmental conditions and disabilities. Autism is a relatively common condition affecting children throughout the country.


These children need dental care just like every other child. Children with Autism usually present with a spectrum of disorders and often have difficulty communicating or interacting with others. Loud sounds, lights, smells and sometimes touching can overwhelm a patient with Autism. This presents a special challenge for dental treatment because pretty much anything about dentistry involves these things. Other than these sensitivities and the patient's reaction to them, the dental problems are pretty much like every other patient. Special attention to oral hygiene is helpful along with a measured approach to dental examinations and cleanings.


When fillings or other treatment is needed, sedative medications can often help patients more easily cope with the stimulus and stress of their environment during treatment. In a few cases where extensive procedures are required, general anesthesia might be considered. Each child is different. Treatment modalitites for one may differ for the next. As patients with autism may present reactions and symptoms in varying degrees, many can be treated in a similar manner to other children.


I see Autistic patients almost every day and they do quite well for most things. Sometimes just doing an exam can cause a loud commotion, but the kids are sweet and none the worse for it. Most parents are well versed in their child's condition and special needs. Although, like most parents, I think they are more stressed out by any dental appointment than their child.

TADs, Temporary Anchorage Devices in Orthodontics

In orthodontics we move teeth with basic mechanics. When you push on something (a tooth), you have to pull on something else. You "brace" yourself against a stronger object. When you are moving teeth, the thing you brace against is called the anchor-you know, like an anchor on a boat. Most of the time, anchorage is achieved by placing one force against a small tooth that you are trying to move, against another large tooth (or several teeth tied together, the "anchor"). The small tooth moves a whole lot more than the anchor. There are several instances in orthodontics where this anchorage is an elusive thing to acheive. TAD means Temporary Anchorage Device. These are basically very small screws inserted into bone. The TAD does not move, the tooth then can be moved against this fixed point. TADs are removed when they are no longer needed.


Wait, a screw? in bone? Ouch! doesn't that hurt? Well, --no. We even tried this on each other before using it on patients. Topical anesthetic does great for placement. Here is one of our docs with a TAD in place:

National Museum of Dentistry Facebook Contest

The National Museum of Dentistry announces a two-month Facebook challenge to raise awareness of the museum and its mission to improve oral health nationwide. Help the National Museum of Dentistry reach 5,000 Facebook fans by June 1 —and you could win a tooth-rific dream tour…

Now through June 1, 2010, all National Museum of Dentistry fans on Facebook are automatically entered for a private tour package that features:

An exclusive curator-led tour of the museum for six people, including a rare chance to get up close and personal with George Washington’s choppers
A peek into the museum vault, where some of the most curious dental treasures are stored
A swag bag from the Museum Shop
And to cap it all off, smile kits for each of your guests, including toothbrushes, toothpaste and floss.
Help to share the power of a healthy smile. Make sure your friends “Become a Fan” of the National Museum of Dentistry. Go to www.smile-experience.org for details.

Brace yourself. One winner will be selected from a random drawing of fans on June 4, 2010. Tour package must be redeemed by December 31, 2010

Dentists Who Go Green Grow Green for Earth Day 2010

On April 22, that’s just a few days away, tree huggers and vegans will celebrate the 40th annual Earth Day. Even dentists have hopped on the clean green machine. From the Emerald Coast to Greenland, your colleagues are practicing eco-friendly dentistry. Some have designed office interiors with air filtration systems, natural lighting, bamboo flooring, and latex-free paint. Extreme green dentists hire architects to design offices that minimize electricity usage and recycle rainwater for landscape irrigation.

Don’t be envious or jaded, just get on board. For the average Dr. Joe, going green doesn’t have to involve redecorating or rebuilding. And contrary to a popular frog’s beliefs, it IS easy being green. Here are just a few ways to celebrate Earth Day this year:

Your Front Office

Online Registration Forms – instead of printed paperwork
Web Marketing – instead of phone book ads
Texted Recall Reminders – instead of postcards
Recycled Paper & Biodegradable Office Products
Recycling Program in the Office – call your city for details
Your Back Office

Digital X-rays – instead of conventional films
Composite Fillings – instead of amalgams
Safe Mercury Removal Procedures – see mercuryfreenow.com
The Facility

Recycled or Bio-Friendly Building Materials
Reusable Instruments & Supplies (when possible)
Lush Landscaping & Rainwater Irrigation System
Windows for Natural Light
Furniture with Eco-Resins
HVAC with Zone Controls
Energy Saving Appliances
Mercury-Free Lighting

Fact: The first LEED-certified dental office as Mint Dental Works in Portland. LEED® is the Leadership in Energy and Environmental Design program, which is part of the US Green Building Council.
Why Go Green?

Well, you are a human, aren’t you? Do you want your great-great grandchildren to have to wear a respirator 24/7? Other than that, green is good to get you more green. Let me explain. The hot trend in marketing today is giving – investing in people and community is what Generation G is all about. Consider that Miley Cyrus traded her mother’s Porsche in for a Prius, and you’ll see my point.

What better community could you support than the global community? Seriously, just like the Halloween Candy Buy Back can boost your marketing campaign in October, six months later, a Green Dentistry campaign centered around Earth Day has the potential to make a splash with local media.

Find out what your city is doing for Earth Day and get on board
Find out what local schools are doing for Earth Day and offer to help
Sponsor a community clean-up day in a high-visibility area and wear T-shirts with your practice’s name in big bold print on the back
Send out an e-newsletter advertising that any patient who wears green the week of Earth Day will get a special gift – and give away bedding plants or pet rocks
Create a “How to Save Your Smile and the Earth” article that reviews the green things your office does, and submit the article to local newspapers and blogs
Get creative this Earth Day and make a mint in the process.

An interesting read… The Wellness Factor.

Evora Plus™: The First Probiotic Mints for Complete Oral Care

Fresh breath. White teeth. Balanced oral health.

Evora Plus™ mints for adults and EvoraKids™ chews for children add good bacteria and a low level of hydrogen peroxide to the oral environment for fresher breath, a healthier mouth, and whiter teeth. Twenty-five years of research went into the making of this innovative product, developed by Jeffrey Hillman, DMD, PhD.

The company’s website states: “Within 30 days of using EvoraPlus twice daily, the natural healthy oral balance of good bacteria will be greatly restored and you will begin to notice a whiter, brighter smile and long-lasting fresh breath.”

How it Works

For some time, scientists have known that probiotics promote good digestive health. Yogurt, a food rich with probiotic power, is often recommended for patients with stomach aches and digestion issues. The same philosophy backs the effectiveness of Evora.

Good oral bacteria “crowd out” bad bacteria to promote a positive balance in the mouth. In addition, by reducing bad bacteria, Evora mints reduce potential for foul breath caused by bad bacteria. Good bacteria actually bond to teeth and gums, and even below the gum line for lasting results. This is unlike traditional mouthwashes that kill all bacteria in the mouth, not just the bad bacteria.

As for teeth whitening, Evora’s by product is a small amount of hydrogen peroxide, which is known to naturally brighten tooth enamel without causing sensitivity or irritation to oral tissues.

Each Evora mint has one calorie, and patients are instructed to use two mints each day for best results. Today, Evora is sold at these retail stores: Albertson’s, A&P, Kerr Drug, Walgreen’s, Sweetbay, Heartland, and Pathmark. Online, consumers can purchase Evora through ActiveForever.com, CVS.com, Drugstore.com, ProHealth.com, Quick2You.com, Swansonvitamins.com, Target.com, and Walgreens.com.

Visit Evora online at http://www.evoraplus.com/.

A guide to toothache and how to deal with it

What is toothache?
Toothache is a painful condition in your jaw and facial area. It usually occurs when a nerve in the tooth root is inflamed or irritated. It could also occur because of tooth decay, infection or even tooth loss.
Types of toothache
Everybody doesn’t experience the same kind of toothache, and very often a toothache can be a sign of a much deeper condition. The severity of the toothache may also vary, in terms of the sensitivity of the tooth and the pain intensity. No matter what type of toothache you suffer from, you should get it evaluated by a dentist.

Sharp tooth pain or sensitivity
When your teeth become extremely sensitive to cold, causing a sharp pain when you eat or drink very cold items, it could be due to loss of tooth enamel. This deterioration of tooth enamel occurs because of excessive brushing, as a natural part of the aging process, recession of the gums or the deterioration of a tooth cavity. If your teeth are overly sensitive to heat, this could be because of dental cavities, abscesses or a severely decayed tooth.

Chronic toothache
A consistently aching tooth can be the result of nerve damage. The nerves of the tooth may get damaged because of severe dental decay or because of excessive grinding of the teeth. It could also occur because of any kind of injury or trauma to the tooth.

Excruciating pain
Intense, agonizing pain, including a throbbing sensation, is most often because of an abscess or dental infection. Very often, when the pain is this intense, there is also a noticeable swelling in the face.

Pain while eating
If you experience pain while eating, it could be either due to a crack in the tooth or dental decay.

Pain the in back of the jaw
If the pain is mainly concentrated in the back of the jaw, it could be due to impacted back molars. People, who have a habit of grinding their teeth or TMD can also experience jaw pain.

Serious health issues
A little known fact is that a toothache can often be a symptom of serious underlying health problems. Studies have shown that a pain on the left side of the jaw can be the first sign of a heart attack. Your toothache can also be a sign of sinus infection. Inflammation of the jaw, and pain while eating can be one of the earliest symptoms of a maxillofacial condition called temporomandibular joint disorder (TMD).

Symptoms of toothache
The symptoms of toothache can manifest themselves suddenly, and can range from simple discomfort in your tooth to high intensity pain. At one end, you could have a mild irritation, while on the other, you may experience intense pain in your jaw, head and ear. The pain may worsen when you eat or drink, especially if what you are consuming is very hot or cold. Toothache can quickly spread to the entire jaw area, making it tender and sensitive. You may notice that the pain worsens when you lie down, because of the increased pressure on the tooth.

Generally, you will notice:

Sensitivity to hot or cold foods and drinks.
Bleeding in the gums or around the tooth.
Swelling of the tissue around the tooth.
Swelling of the jaw.
Pain while eating.
Causes of toothache
Dental caries.
Tooth cavities.
Tiny tooth fracture.
Exposed root of the tooth – this can happen when the gums recede, exposing the root.
Sensitivity – this can also be caused by gum recession, which leaves the sensitive areas of the teeth exposed.
Dental treatment – sometimes after a dental treatment, the tooth pulp may become irritated, leading to pain.
A periodontal abscess in the gum.
Acute ulcerative gingivitis, which causes ulcers on the gums.
Sinusitis, which can lead to pain in the upper jaw.
Inflamed gums around a tooth that a just beginning to emerge, like a wisdom tooth.
Temporomandibular joint injury – this is the joint that connects the jaw to the skull.
Teething – when babies and children begin to sprout new teeth, this can cause toothache.
Diagnosis of toothache...isn't it obvious?
Even if the toothache you are suffering from is mild, you must get it checked by a dentist immediately. Very often, pain in a tooth has got nothing to do with that tooth. The pain could easily be in another tooth, or in some cases, the other jaw. Your dentist will conduct an examination of your teeth, and look for signs of any damage to the tooth or inflammation. He may also look for sensitivity to heat. If your dentist suspects dental decay, jaw bone injuries, or minute fractures in your teeth, he will take an X-ray before he can confirm these conditions.

Treatment for toothache
Fortunately, these days a toothache cure doesn’t have to involve the extraction of the tooth. Depending on the cause of your toothache, your dentist will use different methods to treat it:

Tooth decay
Dental decay resulting from poor dental hygiene practices and a faulty diet can lead to toothache. Treatment will involve removing the decayed portion of the tooth, and replacing it with a composite or amalgam filling. When a number of tooth surfaces are decayed, fillings may not be sufficient to treat the problem, and your dentist may suggest dental crowns as a solution.

Loose filling
If an earlier filling breaks or becomes loose, your dentist will remove the filling, clean out any decay that has been formed, and replace it with a new filling.

Pulpitis
When your tooth pulp becomes infected, your dentist may suggest root canal treatment. This procedure can be performed by your dentist or an endodontist. He will remove the decayed pulp and fill the empty space with a paste. Then he will cover the tooth with a dental crown.

Gum recession
Receding of the gums away from the teeth can be reversed using a gum graft procedure. Your dentist will either graft tissue that has been removed from the palate, use synthetic gum tissue, or a sliding graft in which the root is covered by gum tissue from the neighboring areas.

Loss of enamel
Tooth enamel can be lost either due to an improper diet or aggressive brushing. Desensitizers can treat the sensitivity and sharp pain that results from the loss of tooth enamel.

Tooth sensitivity
Your dentist may apply desensitizers, which require frequent reapplication to treat sensitivity. He may also prescribe desensitizers to be used at home.

Abrasion
Your teeth can be exposed to all kinds of wear and tear in the form of minute chips and cracks, irregular teeth and loss of enamel. If there are uneven surfaces, your dentist may fill these with composite fillings. When there is extreme wear and tear, he may suggest dental crowns or veneers.

Infections
Infections can result in abscesses, and these are caused by dental decay or injury. Your dentist may prescribe a course of antibiotics and painkillers, and will suggest root canal treatment after the pain has subsided. The tooth that has become weak can be restored with a dental crown.

Teeth grinding
People who are in the habit of grinding teeth can experience tooth pain as a result of minute fractures, or even a shift in the position of the teeth. Your dentist may prescribe mouth guards to use while sleeping to protect your teeth.

Tooth fracture
Fractures in the tooth can result from abrasion, trauma or as a result of teeth grinding. A dentist will treat a fracture using a protective covering, like a dental veneer or crown.

Wisdom teeth
Impacted wisdom teeth (back molars that don’t surface) can result in crowding of the teeth, and can shift the other teeth. Your dentist may have to perform oral surgery, and remove the impacted wisdom teeth.

If these methods don’t help ease the pain, the tooth may have to be extracted. In cases where the tooth has become wedged between the jaw and another tooth, tooth extraction may be required.

First aid for toothache
To handle the pain while you wait to see the dentist, take paracetamol or ibuprofen. However, if you have a history of liver or kidney problems or peptic ulcers, or suffer from asthma, ibuprofen is not recommended for you. Also, avoid very hot and cold foods and drinks, because they worsen the problem.

Prevention is better than cure...
Toothache can easily be prevented by maintaining good dental hygiene practices.

Cut down the amount of sugar in your diet. Excessively sweet foods and drinks should be consumed only occasionally.
Follow a twice-a-day brushing routine, using a fluoride-containing toothpaste. Remember to brush your gums and tongue.
Use dental floss to clean between your teeth, and a mouthwash to rinse your mouth.
Avoid smoking
Get your teeth check regularly, and have them cleaned at least once a year by a dental hygienist.