Dental Emergencies

I JUST KNOCKED MY TOOTH OUT!

Teeth totally knocked out of their socket (avulsion) is a real dental emergency....

avulsed-tooth-cartoon-boxer

Firstly determine there are no other head injuries or bleeds as they would take priority. Neck injuries and loss of consciousness need expert medical care so please contact your first aider or medical practitioner or hospital for immediate assistance in this case.

The loss of a tooth is a secondary consideration.


If you or your child is conscious and otherwise well then determine what type of tooth it is. ie a baby tooth or adult tooth.

'Baby', 'first', 'milk' or 'deciduous' teeth

Young boy grimacing, showing off his first missing milk tooth

Most baby teeth are obviously lighter than the subsequent, relatively yellow adult teeth.  Under the age of 6, any lost tooth would more likely be a baby tooth. I personally do nothing about these baby teeth as re-implanting them just will not work. It is best, however, to contact a dentist as soon as possible to make sure that no other root fragments are left behind or indeed other teeth damaged.

avulsed-lost_baby_teethRelatively light looking baby teeth usually have smaller roots and some have none at all if they are soon to come out naturally.

DO NOT PLACE A BABY TOOTH BACK IN THE SOCKET! - It is a potential choking hazard!


Adult/ secondary or permanent teeth

avulsion-adult-incisor

The adult incisor is much larger approximately 1 inch or 2cms long and it more important to know what to do with these teeth.  If you are in doubt please call your dentist as soon as possible to confirm! Even take a 'selfie' to send to them for immediate clarification. They should be more than happy to get back to you as seeking timely treatment is extremely important for the survival of any adult tooth!

Do Not Wait for "Monday Morning"- It will be too late!

avulsed-first-aid-diagramKeep calm and act swiftly. The site around the mouth will probably be messy with blood and the lips may also be swollen.  DON'T PANIC and calm your child by reassuring them that all is not lost. Do not berate them no matter how silly the accident may have been. It will not help!

avulsed-freshFIND THE TOOTH.  Handle with care, only touching the crown of the tooth (the part that you see in the mouth).

avulsed_tooth1

If it is CLEAN - gently push the tooth back into the socket using light pressure and hold it there with a gauze/clean handkerchief or fingers. Contact a dentist ASAP.

If it is DIRTY - gently rinse with the patient's saliva or milk or saline solution DO NOT SCRUB THE TOOTH and DO NOT USE DISINFECTANT (by doing so you will remove the delicate cells on the surface that are critical for healing). Try to avoid tap water if possible but if you need to then rinse for 10 seconds under cold water. Again place the tooth in the socket as soon as possible and contact a dentist ASAP.

avulsed-tooth-tissue

Do not delay in replacing the tooth in the socket.

  • If you cannot place the tooth in the socket, then keep the tooth moist by placing in a sealable bag or container of milk. It does not matter if it is full-fat or skinny!
  • The patient could ideally hold the tooth in their mouth between the cheek and gum if old enough to sensibly do so, but bear in mind that this may pose the added risk of swallowing or choking!
  • Alternatively, you could get the patient to produce enough saliva into the sealable bag or container into which the tooth could be submersed.
  • There is no need to wrap the tooth in cotton wool, tissue paper or a cotton handkerchief.
  • Contact a dentist for immediate treatment. If they cannot attend for 24 hours call another dentist! Any dentist worth their salt will be happy to attend out of hours for an avulsed (knocked out) tooth!
  • They should reply with "how soon can you get to the surgery"!
  • If in doubt and you have your phone- just refer back to this page or take photos and email/ message them to a dentist.

If permanent teeth are knocked out, there is an excellent chance that they will survive if they are immediately placed back in the tooth socket and dental health advice is sought straight away.

Success depends on several factors...

  • The longer the time out of the mouth the higher the failure rate (try and place it immediately or at least see a dentist within a few hours). Every minute the tooth is out of the socket, the less chance it has of surviving.
  • Not touching or cleaning the root surface will also increase success.
  • Keeping the tooth moist and covered ideally with saliva, or milk or saline and as a last resort, plain water.
  • Seeing a dentist to stabilise the tooth ideally within a few hours (and at least within 24 hours, although long-term success will be greatly reduced).  They will be able to advise you as to the long-term prognosis for the tooth or teeth!

If in doubt - please take photos and email/ message them to a dentist. You could even Skype call these days whereby the dentist could advise and talk you through the above instructions!


So what happens next .....

Here is a case where a tooth nearly fully knocked out but the patient did not present to the dentist for over a week! (Courtesy of Cape Dental Care in Florida). The dentist managed to reposition and then temporarily "splint" the teeth for a few weeks. "Root canal" treatment (removing the dead nerve) was necessary but a good initial result was obtained.

avulsionsubluxation1text2          avulsion-subluxation-2-1280x850          avulsion-subluxation-3-1280x850          avulsionluxation-6-months-text

Your dentist will be able to advise you in your case if more work will be necessary and on the long term options and prognosis.


Teeth can also be severely damaged yet not get knocked out completely...

boy for a broken toothA severely fractured tooth should ideally be treated as soon as possible especially if you see a little pink halo like this...

fracture-pulp_exposureSimilarly, teeth that have been pushed forwards or backwards like this, need urgent dental treatment.

avulsion-luxation

If you have kids or play contact sports and have a good rapport with your dentist, why not ask him or her for their after hours emergency number! Please stress to them that it will ONLY be used in the case of dental emergencies like these, and they will be more likely to pass it on. However, DO NOT ring this number on a Friday afternoon with a just a "niggle" expecting to be seen straight away because you are going on holiday!

I HAVE A SWELLING - WHAT CAN I DO?

Do not under-estimate infections in the mouth!

Swelling from dental causes can be dramatic and in severe cases even require hospitalisation.abscess-submandibular-hospital

Please immediately contact your nearest dentist doctor or hospital especially if your swelling is causing difficulty in swallowing or breathing or if you are developing a fever!


Swelling and pain often go hand in hand and is usually a sign of inflammation or infection. The most common causes are...

Tooth abscesses...abscess-caries

infected gums around wisdom teeth...wisdom-teeth-pericoronitis

and gum abscesses...abscess-gingival

abscess-facial-swelling

abscess-diagram

In dental abscesses, the infection is caused by bacteria rapidly growing and expanding within the hard tissues below the tooth. This "acute" stage creates severe pain, often becoming increasingly intense until the pressure is relieved by extracting the tooth or performing root canal treatment. (Contact your dentist!)

Most swellings are usually localised to an area around an offending tooth but occasionally the infection can spread to the soft tissues, proving extremely distressing for all concerned...abscess-facial-swelling-girl

                  abscess-facialswelling-kid

Swellings like this require immediate treatment with antibiotics and active medical intervention (usually involving extraction of the offending tooth under General Anaesthetic and drainage of the infection).

DO NOT DELAY- CONTACT YOUR DENTIST, DOCTOR OR HOSPITAL IMMEDIATELY!


Swellings can also appear without pain (known as "chronic" abscesses). The following photos show some abscesses which may be typical findings at routine dental check-ups where the patient had either been blissfully unaware there is a problem or did, indeed notice something wrong but did not attend, as it was not painful!

They commonly appear in baby teeth as they have very thin enamel on them! (Please have a look in your child's mouth if they say or report there is something wrong - they might not be trying to get out of going to school!)

swelling-sinus-decid-molar

abscess-intra-oral-decid

or adult teeth...swelling-sinus-21

Again these need treating by your dental professional so if you have a non-painful swelling like this, please get your dentist to check it out before it does become a more serious issue!

WHAT CAN I DO FOR TOOTHACHE?
Pain relief options....
toothache2

Toothache has many forms but the most common severe conditions include "PULPITIS" where the nerve inside the tooth is irritated by either a cavity, an old filling or decay and becomes sensitive to hot or cold drinks or foods. The second is PERIODONTITIS, where the tooth has also become tender to touch and pain is more spontaneous, coming on without warning. This often leads on to abscess formation with associated swelling (see the previous question).

Some people would take the tooth out themselves if they could!

toothache-pliers

The occasional niggle is not unusual especially if you have an ageing dentition or one that is heavily restored. However, if pain persists, I suggest you contact your dental professional for more specific advice. In the meantime, you can try several things to alleviate your symptoms...

1. Avoiding any stimulus that brings the pain on (heat, cold, sweet, pressure etc.) is a good start.

2. Applying an external compress. Fill a food storage bag with ice, cover it with a thin cloth and apply it directly to the tooth or the cheek area just outside the tooth or use an ice pack instead of a bag, but be sure to cover it with a towel. You can try the same with a heat pack or hot water bottle -not too hot though!

toothache-cold-compress

3. Taking OTC ("over the counter") medication. If the previous measures do not work then I suggest the use of analgesics (painkillers) are probably the most effective way to relieve the pain.

There are so many medications available it would be counter productive to explain the pros and cons of everyone here. I advise my patients to consider the following regime...

Take the recommended doses for their age (written on the container) of any painkiller that you can purchase over the counter at your chemist/pharmacy/drugstore whilst you are waiting for definitive treatment to be carried out. If it has worked to relieve a headache previously, it will probably also work for dental pain. The most common and readily available medications are:

Ibuprofen(Brand names include Nurofen, Actiprofen, Advil, Anadin & Brufen).

Paracetamol (Acetaminophen or APAP in the USA). (Brand names include Panadol, Calpol & Tylenol).

toothache-otc-painkiller_

The synergistic or combined effect of taking both medications at the same time has also been shown to be of great benefit for relief of moderate to severe pain and these preparations are also readily available. (Brand names include Maxigesic and Nuromol).

Warning: Do not place an aspirin tablet next to the tooth. This is likely to give you a nasty burn in your mouth. Please swallow the tablet as directed on the container. 

Please be aware that whilst drug companies provide a fantastic product that benefits millions of people daily, they are in it to make money! Drug companies have successfully convinced consumers to pay up to five times more than they have to (according to Choice, based on prices at supermarkets, chemists and online in April 2014) for the generic ingredient of ibuprofen or paracetamol.  So, if you are faced with two Brand Names, one saying it is good for targeting back pain and the other to target tension headaches or toothache then just look at the ingredients! If they contain the same active ingredient then they will have the same effect. Confirm the contents with the chemist and maybe choose the cheaper, non-branded one!

There are also many other combination painkiller preparations containing codeine and caffeine (e.g. Panadol Extra, Nurofen Plus, Panafen Plus, Prodeine, Panadeine Aspalgin, Disprin Forte and more). As you can see it is can be tricky to pick the most appropriate medication to suit your particular situation so please ask your chemist or pharmacist for advice.  This is especially important if you have allergies, existing medical conditions or are taking other medications.  Please note, supermarket assistants are not qualified to advise you of these interactions!


Typical scenario....

Patients often ring for an appointment when they have had toothache for a while (often set off by hot or cold drinks) and it is becoming more intense or not subsiding.

By the time they get an appointment, the patient often reports the symptoms have subsided but the tooth feels a little tender.

What has happened in this case is that the nerve inside the tooth has been irritated or damaged by decay, a fracture or under a large filling, to the extent that the nerve has become highly inflamed (pain) and now, unfortunately, has died. In most of these cases, the nerve needs to be removed either by extracting the tooth or via the dreaded "root canal" treatment!

Ideally, you should seek dental treatment and advice as soon as you detect a problem. I particularly advise my patients who have old restorations to pay attention to their symptoms! If there is a niggle, usually to hot, sweet or cold stimuli, which lasts more than a week or, if it is enough for them to take "painkillers", then I  advise them to return to have it checked out.  Sometimes the initial symptoms can be treated more easily at the early stages of pain (e.g. just repairing a fractured tooth, restoring a lost filling or removing decay).

Most serious dental problems arise if these initial symptoms are ignored.

If you are thinking about your teeth when you are eating rather than the food then there usually is something going on and it is best to see your dental professional for advice. (There are many more causes of swelling, so please contact me with a photo or concern if it is not an emergency and you wish to know about something else!)


Just a word on the "home remedies"...

toothache-home-remedies

I know of no scientific evidence for the relief of pain from remedies such as garlic, onions, salt and pepper. They do however make you feel better if you take them after heating with your favourite meat and vegetables in a wok!

tooth-ache-stir-fry

Just because someone has reported that these remedies worked 'x' amount of hundred years ago does not make it true! Just look at the bible! If you do want to try it though, I cannot see how it can do any harm!

MY CROWN JUST CAME OFF - WHAT CAN I DO?
crown-cartoon

A "CROWN" is a descriptive word for any false tooth that is cemented or bonded onto the surface of an existing broken down tooth. It is often also called a "CAP". (I unfortunately advised one lady, after getting my words mixed up that she needed a "crap" on her tooth! Thankfully she laughed!)

In theory....lost-crown-crowning-process

In reality...lost-crown-over-core

They can be used to restore front or back teeth,lost-crown-types

can be metallic, porcelain or even diamond studded!lost-crown-tooth-embellishment-gold-diamonds


Unfortunately they can come off from time to time, either due to trauma, eating sticky toffees or due to the underlying tooth fracturing or rotting.  When the crown comes off, the underlying tooth can often be sensitive unless the nerve has previously been removed (via "root canal" treatment), however this sensitivity is seldom severe. Try to avoid biting on it until you can see a dentist. The edges of the underlying tooth structure may also be quite sharp to the tongue. The tongue, being a curious creature then tends to find the sharp edge and can often become ulcerated or sore! Rubbing a little topical anaesthetic on the tongue will help. (e.g. "Bonjela").

Sometimes the crown can be successfully re-cemented. If the crown was on a BACK tooth then just contact your dentist as soon as possible to make an appointment to have the tooth and crown assessed. If it came off a FRONT tooth, then it will probably be more of an "emergency" given the obvious cosmetic issues! Murphy's Law dictates it will likely happen the day before the wedding, so please do call your dentist. I have attended many "cosmetic emergencies" like this in the past and we do understand your predicament!

lost-crown1

It really helps if you are able to send in any photos via your phone to your dental professional as there a many different problems that can arise. The more information you can give them the easier it will be for them to determine how soon you need to be seen and for how long to schedule your appointment. A photo of the mouth like this and also of the crown or tooth fragments would be extremely helpful. Your dentist will also be able to advise you if the crown can be reused or whether a new crown or alternative treatment is necessary.

lost-crown-gold-core


When your crown comes off, there are three things to look out for and hopefully advise your dentist... 

1.  The crown looks hollow with remnants of cement on it.   If your crown looks like this then it could possibly be cleaned, etched and re-cemented if the underlying tooth is OK, at minimal cost to yourself.

lost-crown-cement-inside

2.  There is a substantial amount of tooth substance or filling within the crown i.e it looks full.  This can often be a quite complicated fix, needing a new crown or more extensive (and expensive!) work. In these following photos you can see the remnant of the tooth that has fractured within the crown... Unfortunately, a new crown is often indicated..

lost-crown-core-fracture

lost-crown-fractured-off-at-crownmargin-the-fracture-interface
3.  There is a post or pin sticking out of the tooth.   A crown is often placed over a root filled tooth which has had a post placed inside the root.

lost-crown-molar-post

If the crown is attached to the post underneath and both structures de-bond from the tooth, it will look something like this...

lost-crown-post-and-core

lost-crown-and-post-core

lost-crown-and-post

Unfortunately, this may also be an indication of a fractured root of the tooth which again, may involve extensive work or more likely, extraction.

lost-crown-fractured-root-xray

Dentists will often need more time and often multiple visits to remedy the last two scenarios and it would be very helpful to describe in detail to the reception staff, what has happened.  This is where emailing or messaging photos will be most helpful.


So to cap off (pardon the pun!), if what you have in your hand looks like this, then it usually signifies bad news, sorry!

lost-crown-bad-news

So what to do in the meantime....

lost-crown-recapitlos-crown-dentemp

You can try cementing your crown on by yourself, using temporary cement preparations found at chemists, pharmacies or drug stores.  Just follow the instructions on each packet. This may help for a front tooth which has an obvious cosmetic issue but for the back teeth I would advise leaving the crown off until you see a dental professional. If the temporary cement fails whilst chewing, you do not want to be retrieving the crown from another orifice!

Just a few more hints...

*NEVER use "Superglue" or any of its imitations. This can damage the tooth or the crown, complicating what could have been a simple fix!

* It is not necessary to place a lost post and crown in milk for transporting to the dentist as it will make no difference to the outcome (this is only necessary for a natural tooth that has been completely knocked out)

* Do not worry about the gap!  Your dentist will be able to construct a temporary crown or false tooth usually within 24 hours if not immediately.

This could be a 'spoon denture' or 'flipper' ...lost-crown-temp-denture

flipper2

or a vacuum formed splint, which should get you by whilst  you are waiting for the definitive replacement...lost-crown-temp-retainer

Most people will know if they have a crown, as it would have been an expensive restoration. It pays to really look after your investment by avoiding sticky foods especially candy, sweets and lollies, and pork crackling or sourdough crusts! It is also imperative that you use interdental brushes or floss to clean the margins of the crown as this is the 'weak spot'.

If you do notice something not quite right, I would advise you get your dental professional to check it out. Numerous times I have seen a patient who mentioned that food was packing between the teeth (when it did not used to) or there has been a 'rough spot' or 'chip' on the crown for many months. They failed to do anything about it as it was not hurting (commonly with 'root filled' teeth). Unfortunately these are the cases where decay may have advanced to a point where the tooth cannot be saved!

lost-crown-cartoon-thumbs-up

So, if in doubt, get it checked out!

 

I HAVE LOST A FILLING - WHAT SHOULD I DO?

Don't Panic!

Losing a filling is probably not going to give you severe pain. I advise patients to make an appointment as soon as they can to have the tooth assessed and hopefully repaired. Fillings come away from the tooth for several reasons...

1. It is old (over 7 years) and leaky.  Either the bond has broken down or the material has passed its use by date! Here the old filling has fractured leaving a sharp edge to the tooth. This can be fixed by just replacing the filling.

2. This filling has also fractured and likely to be giving symptoms of hot and cold sensitivity, food packing or floss catching in the gap...

3. A piece of tooth has cracked away then the filling follows. Here the cusp has fractured and the old silver filling has dropped out (darker stain in the middle of the tooth)...

Trauma- i.e. biting on hard substances like stones in fruit, pork crackling, sourdough crusts or opening packets, biting nails, chewing pen tops etc. is a sure-fire way of cracking fillings and teeth!
(Pretty obvious advice for this one!)

4. Or indeed there is decay around the filling, which then loosens it. Here you can see the left tooth (as we look at it) has lost the white filling and the right one is about to break away. Again this is a relatively straight forward fix. However, it would be preferable to have sought treatment before this occurs. The dark stain around these white fillings is decay which could have been removed earlier! If you see this staining, then get your dentist to check it out before more expensive work is necessary!

Please also advise the receptionist when making an appointment if it is a front tooth as this will probably be given priority along with pain. Taking a photo and texting or emailing it to the dental office will also help enormously. The doctor can then decide how much chair-side time needs to be allocated to sort your problem.


What to do in the meantime...

If the tooth is painful, you could take over the counter 'painkiller' medications as directed by your Pharmacist or Chemist. Placing a drop of clove oil into the cavity on a cotton bud may also help (try not to get this on the gum though, as it may cause irritation). See also the previous question of "WHAT CAN I DO FOR TOOTHACHE".

If the tooth is not painful itself, but the edges are sharp to your tongue or cheek, you could try gently rubbing a little nail polisher/file over the sharp edge or use a piece of "Wet & Dry" sandpaper or "Emery cloth" (available in any hardware store or dad's shed !)

You will also be able to obtain temporary dental filling cement that you could find in your local pharmacy, chemist or drug store. It is not a bad idea to keep a packet in your medicine cabinet! Just follow the instructions and it should look something like this...

You could also try a little wax stuffed in the cavity if you wish. It should do no harm and it will help stop the food packing and irritating the gum. Either method should see you through to your appointment. However, if pain persists then let your dentist know as he/she should be able to see you sooner.

I HAVE FRACTURED MY TOOTH - WHAT SHOULD I DO?

It depends on the nature of the fracture! Some require urgent attention and others can "Wait 'til Monday morning"!

There are many causes of a fractured tooth, from facial trauma after coming off your bike or scooter or football/rugby injuries to simply biting hard on a pip or fruit stone, not to mention those festive beauties like pork crackling or hard lollies/sweets! Either way, there are a few things you should do depending on the severity of the fracture. The first and most common scenario is when part of a tooth breaks away from a large filling...

The tooth can sometimes be sensitive to cold but usually, patients do not report severe pain. However, the soft tissues tend to rub on the sharp or ragged edges, causing soreness and ulceration of the tongue or cheek.

Try avoiding anything that may make it sensitive and contact your dental professional who will probably be able to repair or restore the tooth. In the meantime, you can try smoothing the rough edge by gently rubbing a little nail polisher/file over the sharp edge or use a piece of "Wet & Dry" sandpaper or "Emery cloth" (from the local hardware store or dad's shed!).

If you do develop an ulcer then use of a topical anaesthetic (e.g. "Bonjela teething gel") to rub onto the affected area is indicated. This can be purchased from any good chemist, drugstore or pharmacy.


The second scenario is a little more serious and can give quite severe pain and discomfort. A tooth can fracture vertically down the root.

Pain can arise immediately after cracking a tooth like this due to exposure of the nerve. It is highly advisable that you contact your dentist for an appointment as soon as possible. This kind of fracture often happens in root filled teeth. Fortunately, in that case, there is usually only discomfort when pressure is applied on chewing (as there is no longer any nerve in the tooth). If this is left for days or weeks, however, there is a high chance of an infection setting in (abscess) which can complicate matters. When teeth fracture like this there is little we can do and unfortunately, the tooth will more likely need extracting.

A patient of mine fractured his root-filled tooth. He had no sensitivity but discomfort when chewing so came up with this alternative use of floss until he could get an appointment.....

This literally tied him over until he could be seen!

Ingenious!


The third scenario involves trauma. Most commonly a cycling, scooter, skateboard or sports injury and often involve children!

As luck would have it, accidents often occur on a weekend when access to dental care may not be easy. You may also need to attend an "Accident and Emergency" or "Casualty" department due to your injuries (fractured teeth may be of secondary significance).

The priority is to be assessed by a medical doctor and get the "all-clear" from serious head injury before worrying about the teeth. 

If you do see a fracture of any part of a front tooth, especially with children over the age of 5 or 6 then reassure the child and try not to panic. If you can locate the fractured piece of tooth, also take that to your dental appointment. This does not need to be placed in milk, and can sometimes be reattached to act as a perfect temporary restoration.

Tooth fractures are often complex, needing specialised long-term treatment and follow-up (depending on the nature and severity of the injury). Have a look in at the fractured tooth, if you see a pink or red halo or if there is bleeding from inside the tooth like this, then the nerve has been exposed. The tooth is usually very sensitive to cold and unfortunately, it is highly likely the nerve will become infected. You need urgent dental attention!

In my experience, being on call for the past 15 years, many medical doctors, whilst being extremely well qualified, are not equipped to treat the intricacies of dental enamel fractures. If they seem unsure how to proceed and say "Just contact your dentist on Monday morning!" then ask them to take photos (with their phone) and send them to a dentist who is "on call".  The dentist may not necessarily need to come and treat you immediately but should be willing to offer advice based on the history of the injury and photos available. Between them, they should be able to agree on how soon you may need to be seen by a dentist, or indeed reassure you that things can wait until you contact a dentist on Monday!


Just a word on prevention.....

Before any such accidents arise, it is advisable to perhaps check out your local phone directory for dentists who may be "on call" over weekends and holidays, in your area, (even if it is just for advice over the phone).  If you have a good rapport with your own dentist, possibly ask him or her for an out of hours contact number (only to be used for such emergencies). If the worst does occur, then sending photos of your predicament to your dental professional is a great way of getting the correct advice and a timely appointment.

IMPORTANT.....   Wear a mouth guard for contact sports!

MY CHILD'S MOUTH IS FULL OF ULCERS AND HE FEELS UNWELL - WHAT CAN I DO?

There are two common infections that commonly affect young children that present with a mouthful of painful ulcers.

They can be very distressing for all concerned as the patient often has a fever, is irritable, restless and has difficulty eating.


Firstly,  Acute Primary Herpetic Gingivo-Stomatitis. Caused by a virus (Herpes Simplex,  which can also become reactivated in adulthood as a "cold sore"!).

This primary infection usually affects children under 6 years of age and presents with sudden onset, whitish vesicles which evolve to yellowish ulcers on the tongue, throat, palate and inside the cheeks. There is usually a striking underlying redness of the gums which can be swollen and look overgrown, raw and sore.  The gums can also bleed easily and will usually have a foul smell.  The patient also may have flu-like symptoms with enlarged, tender glands.    Whilst these vesicles are still present, the patient is highly infective. The lesions usually heal in a few weeks but can remain infective for up to three.


Secondly Hand, Foot and Mouth Disease. Caused by many viruses (such as Coxsackie A, enterovirus and echovirus), it has absolutely nothing to do with "Foot and Mouth Disease" seen in cattle!

The infection is generally mild and often presents with small red dots which later develop into ulcers that appear on inside the cheeks, gums, and on the sides of the tongue. Blisters also appear on the palms of the hands and soles of the feet (hence the name).

The incubation period is usually around 3 to 5 days and the infectious period remains while there is fluid in the blisters.  It can begin with a mild fever and a runny nose followed by a sore throat then the blisters/ulcers. Blisters sometimes appear around the nappy area in babies, but this is less common. It mainly occurs in children under 10 years of age but can also occur in older children and adults. Many adults, fortunately, would have developed immunity to this infection as a child.


Treatment ?

The diseases are self-limiting and should resolve in 7-10 days.  Any active treatment usually involves alleviating the symptoms with the use of medications to relieve the fever (such as paracetamol or acetaminophen), keeping fluids up and use of topical anaesthetics such as "Bonjela" or antiseptic and anaesthetic mouthwashes such as "Cepacol".

Gently cleansing the gums with a damp cloth or very soft toothbrush will also be beneficial although this will be difficult in very young children.  Do not worry if this proves too difficult as 10 days of bacteria will not make a huge difference in the long term, however, try to get back on track with normal brushing and oral hygiene procedures as soon as possible.

Allow blisters to dry out naturally and try not to scratch or burst them as the fluid within them is infectious. Unfortunately, there is no cure for either disease as they are viral in origin, however, in severe cases and with immuno-compromised patients, antivirals may be prescribed and sometimes antibiotics to prevent a secondary bacterial infection.

Important!

If your child is generally unwell, it is advisable to seek medical attention with your GP or hospital to make sure they are not dehydrated or indeed suffering from any other condition. Signs that an infant or older child might have a more serious form of infection include any of the following:

  • Persistent fever (38°C or above for 72 hours or more)
  • Abnormal jerking movements
  • Rapid breathing
  • Excessive tiredness, drowsiness
  • Excessive irritability
  • Difficulty walking
  • Back or neck pain or stiffness.

If any of these signs are present then the child should be seen by a medical doctor urgently, even if they have been checked earlier in their illness.


How can these infections be prevented?

Hand, foot and mouth disease is usually spread by person-to-person contact. The virus is spread from the faeces (poo) of an infected person to the mouth of the next person by contaminated hands. Like primary Herpes, it is also spread by secretions from the mouth or respiratory system, and by direct contact with the fluid from blisters and ulcers. This is why outbreaks may occur in child-care settings where young children's hygiene procedures might not always be as rigorous as we would like!

Good general hygiene is the best protection:

  • Wash hands with soap and water after going to the toilet, before eating, after wiping noses, and after changing nappies or soiled clothing.
  • Avoid sharing cups, eating utensils, items of personal hygiene (e.g. towels, washers and toothbrushes), and clothing.
  • Thoroughly wash any soiled clothing and any surfaces or toys that may have been contaminated.
  • Teach children about a cough and sneeze etiquette:
    • Cover coughs and sneezes with a tissue. Coughing into an elbow is better than coughing into your hands.
    • Dispose of used tissues in the bin straight away
    • Wash your hands afterwards with soap and water
  • Children with either of these infections should be excluded from school or childcare facilities until their blisters and ulcers have dried-up, any rash has gone and any fever has settled.

MY CHILD JUST SWALLOWED A LOT OF TOOTHPASTE - WHAT SHOULD I DO?

 You may have read something like this on your toothpaste tube...

With scary new labels on toothpaste, many parents are left wondering what to do when they catch their child eating toothpaste straight from the tube, but given the relatively low fluoride content in most brands, it's fairly difficult for a child to consume a lethal dose of fluoride at home. While swallowing a small amount of toothpaste is generally considered safe, ingesting large amounts can cause stomach pain, possible intestinal blockage or other problems. In most cases, your child may feel unwell with a stomach upset, usually of sudden onset.

  If you can ascertain that toothpaste has been ingested then:

1. Provide a drink of milk if possible

2. Monitor the child’s condition closely for any deterioration

3. Contact your local or National Poison Control Centre for advice (see below for 24/7/services)

4. Contact your General Medical Practitioner if available or Emergency Services as necessary

Helpful information to provide would be

  • The patient's age, weight, and condition
  • The name of the product (as well as the ingredients and strength, if known)
  • The time it was swallowed
  • The approximate amount swallowed

Based on this information, they will be able to advise whether you can safely stay home or need to seek further assistance.


Poison Control Centre Hotline Contact Numbers:

The following contact numbers should be available 24 hours a day, 7 days a week. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency and you can call for any reason.

Australia        = 131126
USA                   = 1-800-222-1222  
New Zealand  =  0800 POISON (0800 764 766)
UK                      = 111 

(111 is the National Health Service's non-emergency number. It’s fast, easy and free. Call 111 and speak to a highly trained adviser, supported by healthcare professionals. They will ask you a series of questions to assess your symptoms and immediately direct you to the best medical care. For more information go to www.npis.org.

Canada = Many numbers available depending on your Province or Territory. Check out this link for your specific contact details:

 Poison-Information-Centres-in-Canada.

 


To put things in perspective...

A two-year-old, 10Kg (22Lb) child would need to consume about two full tubes of toothpaste for serious complications to occur. A 6-year-old child weighing approximately 20Kg (44Lb), about four tubes. However, potentially toxic effects could occur with as little as half a tube of toothpaste in younger children, so if in doubt please call the above Poison Centre Hotlines for advice as they are there to help!

I recently called the Australian Centre and they were more than helpful!  They advised me that of all the calls they get there is approximately 1 case per year that may need to refer for medical attention (we have a population of about 24 million).

Preventive measures

Parents should supervise the use of all fluoride products, including toothpaste, in the home.

Keep fluoride toothpaste and 'mouthwash' stored safely away from young children.

Do not stockpile pastes or washes.

I do not advise the use of fluoride tablet or drop supplements (as it is not easy to correctly dose).

PLEASE NOTE:

If your child is unresponsive or unconscious or shows signs of impaired breathing, DO NOT DELAY- Call Your Emergency number in your country immediately as this is a Medical Emergency

Australia = 000

USA & Canada = 911

UK = 999

New Zealand = 111

You can also access Emergency Services on mobile phones by dialling 112.

Please make sure all your family members know your specific emergency numbers - write them down next to the phone or put them on your speed dial. A full list of numbers can also be found here:

World-Wide Emergency Phone Numbers

General Dentistry

WILL THE INJECTION HURT?
No, It won't hurt me at all but thanks for asking!

Seriously though, we are trained in techniques to minimise the discomfort of injections. I constantly hear tales of how adult patients have been adversely affected by the cruel way the old "School Dentist" gave the injections. Thankfully times have changed!

I pride myself on trying to give comfortable injections as I know exactly what they are like. Yes, I have had fillings and I can appreciate what patients are going through.

Personally, I rub some topical anaesthetic on the gum first and then inject the local anaesthetic very slowly. Nervous patients sometimes get very worked up prior to even coming into the surgery. These patients benefit from a calm quiet manner and monotone speech. With children, this may seem, especially to parents, that I am ignoring the patient's fear but I am just using subtle diversion techniques.

Indeed if I get the child to listen to me instead of the concerned parent (raising their voice, saying to little Tommy that he has to "be brave") then the whole procedure usually goes very well. I then wait an appropriate length of time for the anaesthetic to take effect but these days that is usually only a few minutes.

This photo is staged, (who on earth would wear blue and purple at the same time!)


Please do not suffer in silence!  I had a young lady once who exclaimed AFTER  the whole procedure that it was the most painful thing she has ever done! There are signs that we can see and know that the patient is uncomfortable but the easiest way is for the patient to signal that all is not well. I make a  point of telling patients to raise their hand (preferably not in my direction) if they want me to stop the treatment. Just ask your dentist if that is OK. They would rather stop and top up the anaesthetic than

I am sure they would rather stop and top up the anaesthetic than having a nervous jumpy target! I reassure patients that if a top up is necessary then it really would be painless as the injection site is already numb.

If a dentist can give a relatively pain-free injection then it shows that they do have empathy so feel free to recommend those dentists to others. If they have time to take this aspect of patient care seriously then their clinical work is probably going to match that skill.

DO I NEED TO REMOVE MY AMALGAM FILLINGS BECAUSE OF THE MERCURY?

No, but you can if you want!

amalfills

Amalgam fillings have been placed in teeth for over 150 years and placed in millions of teeth throughout the world. It is a metal gold-fillsalloy which includes a proportion of mercury. Thousands of studies have been carried out and unequivocally they have shown no detriment to people's health. However, there are many people around the world that, for whatever reason, just do not want this substance in their bodies. These days, there are good alternatives such as ceramic or porcelain crowns, composite fillings or even gold!

porcelain-onlays

Amalgam has been an excellent filling material. However, times move on and patients now want "white" fillings or ceramic inlays and crowns.

Since qualifying in 1989 I have had many patients wanting their amalgam fillings replaced for health reasons. Throughout the 90s and noughties, patients became increasingly aware of medical and dental issues thanks, I believe, mainly to the development of the internet and better patient awareness. Whilst it is fantastic to see patients taking such an interest in their health, there was a flip side! That is, the increase in the number of people disseminating false and unsubstantiated claims regarding how mercury in amalgam fillings are affecting people's health detrimentally. These charlatans also claimed miraculous healing of serious conditions after patient's amalgams were removed. This is untrue and should be treated with a deal of caution.

Over the past say 5, years, patients seem to just want "white"  fillings for cosmetic reasons and rarely comment on the mercury issue. The conversations I had 10 years ago are completely different yet the facts about amalgam fillings have not changed. I have worked in practices that routinely placed amalgam fillings and indeed in "non-amalgam" practices in the UK and Australia. I firmly believe amalgam placed correctly is a fantastic restorative material in the right circumstances. There is also nothing more over-rated as a poorly placed composite (white) filling and I have seen plenty of these!

amalgam-composite-filling

Just to put things in perspective... if you get 10 years out of an amalgam filling before it needs to be replaced, I think you have got your money's worth. I have seen many 20-30 year old amalgam fillings but I would not expect my composites to last that long (however good I think I am!). However, with modern technological advances in materials, the white fillings are constantly improving and I do expect my fillings to last at least 5-7 years (and even longer if people look after them with regular flossing)!

I do not believe there is a need to place an amalgam restoration in children's teeth as there are viable alternatives that have more benefits these days (i.e. contain fluoride) and longevity is not a problem as most deciduous teeth lasting only 10 years.  A majority of new restorations I place in adults are also of the non-amalgam variety mainly for aesthetic reasons as discussed previously, but on occasion, I still place amalgam (about 5% of my patients). These are in cases where I think the "white " fillings just will not last either because the margins of the restoration are under the gums and difficult to maintain, or due to the patient's poor oral hygiene.

Anyway, answering the question... I do not think you need to have your fillings replaced because of the mercury but of course, if you want them replaced, then that can be arranged.


How do I replace them?

If you do decide to have your amalgam fillings replaced for health reasons then you will be able to find several dentists (unfortunately mainly only in metropolitan areas) who specialise in doing so. They often advertise as "non-amalgam" dental clinics. They should be able to measure mercury in your body before and after the treatment and advise you as to the best course of action. There are 2 caveats:

*  Your regular dentist, may be a little reticent to maintain and look after new restorations that have been placed by another operator. Expect to be charged again if, unfortunately, they do fail prematurely. Do not be surprised if they refer you back to the dentist who placed them if that is practical. Hopefully, the non-amalgam dentist would have the professional courtesy to report and liaise with you regular dental provider as to what restorations were placed and when (please ask them to send such a report). This helps a great deal, but unfortunately, from experience, this is not always the case! Some are so 'up-themselves' that they do not give us the time of day as they think we are poisoning our patients!

*  Please do not think that you will be miraculously cured of any ailments that you have. Some dentists I know, have been 'struck off' by making unsubstantiated claims about removing amalgams as a cure for medical conditions. If you have found a non-amalgam clinic that you would like to contact, just ask your regular dentist to check out their website first and make sure they are not cowboys. After all, your regular dentist does not want to supervise, maintain and explain substandard work (my apologies to those non-amalgam dentists who are great technicians of dentistry and are indeed, extremely ethical)!

If I needed to dress like this to treat you, to be perfectly honest I would retire! If dentists think you are that toxic - would you kiss your kids!

wtf

I am not saying don't go to these clinics but just get a second opinion before you fork out your hard earned money for minimal gain!

WHY DO I GET BAD BREATH?

 couple-in-bed

Bad breath (or fetor oris) is commonly referred to as halitosis (a made up term coined by a mouthwash company!) and affects everyone at some stage of their life.  This can range from just a temporary embarrassing episode or sometimes a sign of an underlying chronic medical condition (rare).

Most commonly it is due to the build up of specific sulphur-producing bacteria in the mouth and throat. These bacteria start to break down proteins at a very high rate and smelly volatile sulphur compounds (VSC) are released from the back of the tongue, throat and gum pockets.  Please rest assured that halitosis is not infectious. Common causes include:

1.  Poor Oral HygieneYes this patient's breath would be on the nose!

Not everyone has this advanced state of gum disease which by the way, is preventable!  Bacteria accumulates daily on the teeth, gums cheeks soft palate (roof of the mouth) and importantly on the tongue. We are told from a young age to just brush your teeth but this only comprises a fraction of the total surface area that bacteria grow on. Get into a good habit of brushing all surfaces and not just the teeth. By the way, flossing and use of interdental brushes will greatly enhance your ability to clean the whole tooth. If you want to be convinced then just floss a few teeth and then smell the floss!

The surface of the tongue, unlike a tooth, is not smooth (unless you just ate a chilli!) and harbours millions of bacteria in the grooves, pits and fissures. Scraping the tongue as part of your hygiene routine will go a long way to reducing the bacterial count and smell!

tongue-scraper-613x300


2.  Infections

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People commonly suffer from infections other than chronic gum disease.  They may occur from bacteria (such as around wisdom teeth) or fungi (underneath dentures or orthodontic retainer plates) or viruses. Viruses can be quite debilitating especially for the younger patients. Despite being self-limiting, viral infections are particularly frustrating as we can only treat the symptoms.  If your child has become ill and suffering from severe mouth ulceration with bad breath then keep them hydrated and seek medical attention. It is probably viral in origin, very common yet extremely distressing for all concerned. Treatment is symptomatic but may be necessary for a few weeks. 

Throat infections and inflamed tonsils are two common causes of bad breath. Accompanying illness also often leads to dehydration, again compounding the body's ability to produce the all important self-cleansing saliva.


3.  Smoking

woman_smoking-324x2434

Most non-smokers can tell if a person is a smoker by their breath which smells like an "ashtray". Smoking can also contribute to the lack of healing of gum disease, another cause of bad breath.

Fresh breath mints can be disastrous to the health of your teeth if they contain sugar so please use sugar-free mints to mask the smell if you need to. Stopping smoking is the only cure for this type of bad breath. It also has the added bonus of enabling you to live longer and, let's be honest, it is not really all that sexy! (Well, it doesn't float my boat)!


4.  Diet

surstromming800x600smelly-foods-600x400

Most people are familiar with the smell of strongly flavoured foods like garlic, onions, spicy foods and alcoholic drinks on people's breath. This type of bad breath is temporary (unless you eat spiced food every day) and easily cured by avoiding those foods or cleaning the mouth effectively.

One caveat, please do not meddle with the Swedish delicacy called Surströmming! It apparently is one of the vilest smelling substance on the planet. However some people eat it! Ahh those Scandinavians are a crack up! Warning- Do not YouTube it as it will make you turn green!

Crash dieting or fasting has become trendy over the past few years and can contribute to a sickly sweet smell on the breath. This is due to chemicals called ketones being made by the breakdown of fat. Some ketones are then released with each breath.


5.  Dry Mouth

Temporary dry mouth (morning breath)

morning-breath-300x194Most people have some degree of bad breath after a night's sleep. This is normal and occurs because the mouth tends to get dry and stagnate overnight. Saliva has fantastic self-cleansing property but at night, saliva production is decreased leading to the dryness in the morning. This usually clears when the flow of saliva naturally increases soon after thinking about breakfast.

People who wear their false teeth overnight have the added problem of more bacteria and fungi multiplying in the relative moist area under the denture. Hint: leave dentures out at night so it gives the soft tissues time to 'breath'. Imagine what your feet would be like if you wore your shoes 24/7!  


Long-term dry mouth (Xerostomia)

Some people suffer from a dry mouth (not necessarily at night) due to medical conditions such as Sjögren's Syndrome or as a side effect of medications. (If you suspect a medicine is causing the problem then discuss it with your medical doctor as there may be an alternative medication). Other people may have a reduced ability to produce saliva following head and neck radiotherapy, or indeed because they are just dehydrated. 


6.  Medical Causes

Underlying medical causes are uncommon and in these cases, there are usually other symptoms that would manifest themselves. Some people with nasal problems can get bad breath, as a lump (polyp) in the nose, sinusitis or a small object stuck in a nostril (occurs most commonly in children) can cause a noxious smell.  

Throat infections are particularly common and can also contribute to whiffy breath but is usually transient.

Sore spots, infections or ulcers at the back of the mouth, tongue or throat that do not resolve within a few weeks should be viewed as a little suspicious. It could possibly be a manifestation of rare but more serious conditions.

As with any unexplained illness or ulcers that do not heal, please get things checked out by your dentist or doctor. Early diagnosis is the key!

Early diagnosis is the key!



How can I tell if I have bad breath?

breath-test480x-360

Another problem with bad breath is that often the only person not to notice is the person affected (you become used to your own smell and do not tend to notice your own bad breath.) Often, the only way to know about it is if a person comments on it. However, most people are too polite to comment on another person's bad breath. You may have to rely on a family member or a close friend, to be honest, and tell you if you have bad breath.

A simple test which you can do yourself is to lick the inside of your wrist and wait a few seconds for the saliva to dry. Then smell the licked part of the wrist. If you detect an unpleasant smell, you are likely to have bad breath. The next time you have a check-up, you can always ask your dentist (not to lick your wrist though- that's just weird!).  Some dentists also have special equipment that can detect certain smells. Your own dentist may be able to refer you for further investigation if the problem continues.

DO I NEED FLUORIDE SUPPLEMENTS?

It really depends if you have fluoride in your drinking water. First, contact your dentist or local council or water authority to check. If the concentration is below the range of 0.6-1.1 ppm (parts per million or mg/L) then it is not optimally fluoridated (in Australia).

glass-of-water515x396

A fantastic resource written by the New South Wales Govt about water fluoridation can be seen here.

Many people do not drink fluoridated water either because they are in an area where reticulated water is unavailable or if they just choose not to drink the public water for some reason i.e. the fluoride is poisoning them and they prefer to drink rain water.

I personally am of the belief that if you do not have fluoride in your drinking water, you and your family are missing out on a fantastic free health benefit. That is just my opinion and you can choose to disagree if you wish. I have treated patients who have grown up in fluoridated and non-fluoridated areas. There has been more work for me in the latter. With the amount of sugar ingested in the modern diet on the global scale, however, I think the benefits of fluoridation of water supplies will eventually be nullified, but that is another issue altogether! There are a couple of simple rules that I tell my patients:

When not drinking fluoridated water....

Twice daily brushing with an ADULT (full strength) toothpaste from 6 months. Just a small smear of paste for the first few years then about a small pea size blob of toothpaste is all that is necessary).pea-and-smear-of-tp-800x600

(Please note use only under supervision for kids up to 7-8 after which they have gained the dexterity to brush by themselves). Try to expectorate (spit out) the paste but do not rinse out after (i.e. leave to settle on the teeth to do it's magic overnight!).

After the age of 6 or 7 (when the permanent teeth start to erupt) and whenever your child can adequately spit out rather than swallow then you can add a simple daily fluoride mouth rinse and continue this into adulthood. Please note that this is not a general mouthwash 'with fluoride'. It has a specific, high concentration of fluoride and needs to be used the correct way to maximise benefits. I advise you to treat this like a 'medicine' for the teeth and keep in a locked medicine cabinet away from very young children.

If your drinking water is fluoridated....

Exactly as above except just use a children's (half strength fluoride) toothpaste up to the age of 6-7 and change to full strength when the adult teeth start erupting. Apart from toothpaste, this is the only supplement I recommend.

The 220 stands for 220 parts per million of Fluoride ions.

You could consider supplements in drop or tablet forms but I believe it is a very onerous task to get right and continue this long term i.e. first six years of life. I do not recommend it for those reasons. Please talk to your dentist about your own particular circumstances as you may have other high-risk factors for dental disease which may need addressing. (There are even higher strength fluoride toothpastes available but you will need to be vigilant in their storage away from younger children).

I AM MOVING AWAY - DO YOU KNOW A GOOD DENTIST?

Unless your own dentist can recommend anyone, then I would certainly ask around your friends and acquaintances in your new Town. Social media e.g. Facebook and Twitter are invaluable aids to find out who's 'who' and often have reviews of local professionals. I was surprised to find reviews of myself which I did not know existed until a staff member advised me! Please note word of mouth is still very powerful these days and that glitzy advertising may just be that! If a well-established dentist needs to advertise then he is probably struggling for patients. Just ask yourself why!

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Just as an aside, I usually find that with new patients to my clinic, the children usually turn up first, to test me out. If I pass the test, mum comes in for a check up then possibly a few years later dad plucks up the courage to come in! Sound familiar?


Something to consider...

If you have had radiographs (X-rays) taken with your old dentist then ask them if you can take a copy of them with you (along with your dental records). Most dentists, these days, have digital copies and will have no trouble in emailing them to you (or just give them your USB stick or flash drive to place them on). This information is invaluable to your new dentist. They will be able to see if you have had regular and timely care and if there are certain areas that need attention or monitoring.

I recently saw a patient for a second opinion who attended a new dentist as she had moved interstate. She had no problems that she was aware of, however, she was advised she needed 11 fillings at a cost of nearly AU$4000! They could also start the work that day! Alarm bells should be going off!!! 

It would be wise for your new dentist to ask for your old records and x-rays to get a picture of the long term condition of your teeth and mouth before re-appointing you (unless you need obvious or emergency treatment). In this case, when we obtained the old x-rays, it showed that there were many lesions that had been present for over 5 years and were in effect, stable (and therefore did not need filling!).  The lady did indeed need 3 filings but only at a cost of AU$500!

Having your old records and x-rays to hand is fantastic for a new dentist especially if you are in pain and treatment needs to be carried out expediently. If things do not seem right...

GET A SECOND OPINION!

WHY HAVEN'T YOU GOT DORY IN YOUR TANK?


dory

Sorry, just could not find her!

But maybe you can...

WHAT TOOTHBRUSH SHOULD I USE?

 I believe in the KISS principle of Keeping It Simple!

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There are so many toothbrushes on the market these days  (soft, medium, hard, indicators of use, double tufted, angled, rotary, oscillating, the list goes on!). It can be overwhelming.

choosing-brush640x300

Why do we brush our teeth (and gums)?

Basically to remove the "plaque" that builds up every day and food left behind after eating.  This plaque is a sticky layer of bacteria which is often harmful to our teeth (causing decay) and gums (causing gingivitis).  The plaque layer is very soft and does not need a hard brush or brushing action to remove it. If you use a hard brush with a strong scrubbing action you will wear away your gums and teeth prematurely causing annoying sensitivity. Remember, you can always replace a brush but not your gums!

With this in mind, I always recommend a SOFT brush to my patients.

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What size brush do I need?

Size does matter but not in the way you might think! The largest tooth you have is about a centimetre wide and not much longer so why do we need a brush 3 times as large?  I recommend a SMALL brush to my patients and often advise adults to use a kid's size brush. It just makes sense that you can get around all the curves of the tooth with a smaller brush!

Does it need to be electrified?

girl-choosing-electric-tb-500x-334

Electric or rotary brushes have come a long way over the past 10 years with rechargeable batteries, interchangeable heads, musical timers and now even "app" connectivity - yes, you read right! Some also have the ability to make a cup of tea afterwards - only kidding!

To be honest, as long as it has a small, soft head then I cannot see any problems with them. As to whether they are better than "normal" brushes, then personally I think the over-riding factor is the brusher and not the brush.  If you have a good brushing technique and understand what you are trying to achieve the choice of brush is extremely simple:

Any small brush with soft bristles will do the job!

But don't forget to floss!

WHAT IS THE BEST MOUTHWASH?

There is no such thing as a “mouthwash”!

I do not know who termed the phrase but the only things that “wash” teeth are toothbrushes and floss (or interdental brushes). 


Mouthwashes that claim to wash your teeth by "blowing off barnacles" or pre-brushing rinses are a waste of money. You may as well use water and save your money for floss! There are, however, two reasons to use "mouthwashes” or what I like to term "topical medicines". It is important to cut through the advertising crap and look at the labels to see what the active ingredients are.

For teeth, that is fluoride and I recommend a DAILY  mouthwash containing at least 220 ppm F- such as Colgate Neutrafluor 220:
productshot_neutrafluor220

For gums, the ingredients to look out for are chlorhexidine  (e.g. Curasept or Savacol) or hydrogen peroxide (Colgate Peroxyl). 

curasept-ads-perio-mouthwash-with-012-chx-ads-ha-pvp-va-200-ml

peroxyl-480x800

By the way, I do not have shares in Colgate but they seem to provide the ingredients I prefer, and are available worldwide, as is Curasept. 

Any brand with these active constituents will serve the purpose. 

Note:  Chlorhexidine can stain the teeth if used in the long term (this is only a temporary surface stain which is easily polished off).  Look for the non-stain variety such as Curasept.

Peroxyl is a great alternative as it does not stain yet still has the desired antiseptic affect on the gum bacteria. It also helps target the bacteria that cause bad breath. 

That said, I often advise the combination of a daily fluoride mouthwash (Neutrafluor) at night, in combination with Hydrogen Peroxide (Peroxyl) in the mornings.

To use any fluoride rinse, you should use immediately after a thorough brush and floss. Ideally, rinse for a minute then spit out the excess and do not rinse with water afterwards. This leaves the fluoride to rest and get absorbed onto the tooth surface to perform it's magic! Using fluoride on a dirty tooth surface will waste your money as it does nothing - so use it wisely!  Peroxyl has a more direct effect on the bacteria themselves and works wonders on those that cause that bad 'morning breath'. 

I do advise that use of these medicaments is useless by themselves and is no substitute for effective brushing and flossing for cleaning of teeth and gums.  They just help! 


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Another 'mouthwash' for specific situations is Biotène. This is a very gentle mouthwash that helps maintain a healthy oral environment for people with a dry mouth (Xerostomia).

If you have had good success with different mouthwashes especially when it helps a dry mouth then please let me know!

Please note

Always keep these medicaments locked away from young children and always supervise their use.

It is also important to check the labels and avoid 'mouthwashes' that contain alcohol. 

DO I NEED TO FLOSS ALL MY TEETH?

flossing_shark

No. Only the ones you wish to keep!

Please see the question...

"Why Do I Still Get Holes When I Brush My Teeth Twice A Day?"

for further information.

WHY DO I STILL GET HOLES WHE I BRUSH MY TEETH TWICE A DAY?
 How many surfaces of a tooth are exposed to the oral environment?
3, 4, or 5?

tooth-surfaces

Yes 5 is the answer....you may recognise some of these terms called out by your dentist and assistant:

The top (0cclusal) or biting surface, one closest to the cheeks (buccal), one nearer the tongue (lingual) and then the two surfaces where the teeth contact each other (mesial & distal).

Each one of these surfaces has the potential to form holes in your teeth (decay or caries). However, some of the surfaces are harder to clean than others making them more prone to decay, especially if you have a high sugar diet.

Imagine teeth as a row of bricks placed together end to end. If you want to wash all surfaces of the bricks then it would be relatively easy to brush the sides and the top. However, it is very difficult to pass the brush between the bricks (where the mortar usually goes). So how can these hard to get to surfaces be cleaned? Hey here's a novel idea, maybe you could swipe a piece of string through the gaps to clean those awkward areas. Now let's give it a fancy name such as floss!

Unfortunately, most of us attempt to clean our bricks (sorry, teeth) with a brush which can only reach the 'easy-to-get-to' surfaces. We tend to neglect those tight surfaces in between the teeth and alas, these are the places that are likely to decay. So, even when you brush your teeth more than twice a day, if some areas are not cleaned, then they can still rot and eventually form holes. You will greatly decrease your chances of decay if you clean ALL the tooth surfaces!

Please think about "cleaning" your teeth rather than "brushing" them as a brush is only one tool you have available to "clean" your teeth!

Perfectly clean teeth can only be achieved with both

BRUSH and FLOSS!

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I recall and stand by the old adage that "a clean tooth will never rot!"

By the way, the next time you are in the surgery, remember that if your dentist is calling out "mesial" and "distal" there is a fair chance he or she will bang on about the need for that piece of string (floss) to swipe between your bricks or, if it is too late, the need for fillings!

Oral Surgery (wisdom teeth)

WHY DO WE HAVE WISDOM TEETH?

Popular theory deals with the natural wear of the teeth, and their migration (or drifting capacity). 

Human teeth are narrower at the gum-line than on the chewing surface. So, over time, the chewing surface wears away, gets closer to the gum-line and thus becomes smaller in all 3 dimensions (this may take over 50-60 years in 'modern man'). There is also a natural tendency for teeth to drift towards the front of the mouth, in so doing, room is naturally created for a full eruption of the wisdom teeth.wisdom-teeth-side-jaw-500x414

Our early ancestors did not have our life expectancy and rarely do ancient skulls show signs of wisdom teeth impactions. So what is the difference for us today?

Apart from slightly more fashionable loin-cloths, we tend to have an extremely soft diet which does not wear the teeth down. By the age of 18 or so, our ancestors would have had significant and rapid wear on the teeth, from grains and nuts. As their teeth wore down, they would become smaller and migrate forward. The theory holds that, at the time of the wisdom tooth eruption, the first and second molars would have moved forward far enough for the wisdom teeth to have sufficient space in the mouth to function properly.

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Our modern teeth, being the same size as when first erupted, tend not to create room for the wisdom teeth and so they become "impacted". There is just physically no room for another one in each corner!

The fact that only a minority have no wisdom teeth at all may just be the early stages of Darwin's theory of evolution in progress. Eventually, the majority of future generations may not develop wisdom teeth at all as they become non-functional and bred out of existence.

DO I HAVE TO HAVE MY WISDOM TEETH OUT?

 

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In a word, NO but I would estimate about 70-80% of my patients would need to. Again, this is very much an individual thing. Some patients are lucky enough not to have developed wisdom teeth so they have no problem! However, a majority of us do.

So what are "wisdom teeth"?

wisdom-teeth-side-jaw-500x414

We have the potential to develop three sets of molars in the first 12 or so years of life. The first erupt about 6 years of age, the second molars at around 12 years of age and the third molars (the "wisdom teeth") usually come through roughly around 18 years of age.

pericoronitis

There are several reasons why wisdom teeth should be removed such as pain, recurrent infections, no room to erupt, decay, damage to adjacent teeth and sometimes after orthodontic treatment to prevent further crowding (although this is controversial).

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Your dentist is probably the best judge of whether you need your wisdom teeth removed and will make this assessment roughly around the age of 18. Don't be surprised to hear that you will need a special "X-ray" called an OPG, sometimes taken in the surgery but often in a separate radiology department attached to a hospital.

opg-impacted-wisdom-teeth-structures

This will show the relationship of the teeth to several important anatomical structures and your dentist will be able to advise if they do indeed need to be removed. They will also be able to determine if the extraction(s) are within their scope of expertise or if you need to be referred for a specialist opinion (oral-maxillo-facial surgeon).

If you have no symptoms and the teeth have room to erupt fully, then there is absolutely no reason to have them removed.

wisdom-tooth-way-back-there

It may be difficult, but just look after them like any other tooth!

CAN A DENTIST REMOVE MY WISDOM TEETH OR DO I HAVE TO GO TO A SURGEON?

Sure, if they are suitably trained. 

opg-wisdom-tooth-circled1516-x-856

All dentists are trained (to differing degrees) in minor oral surgery procedures. Many who are interested in this field of dentistry, go on to further postgraduate training and become competent in removing many wisdom teeth. However, there are situations where the surgical process may be too complex due to the position or the anatomy of the teeth. In these cases, it is justifiable and prudent to refer to a specialist (oral-maxillo-facial surgeon) to have these particularly difficult teeth safely and comfortably removed.

You have the choice of removing wisdom teeth under local anaesthetic (injections in the gums), with or without sedation or even a full general anaesthetic (sleeping) in a hospital environment.

wisdom-surgery1280x720

Just talk to your dentist about what they feel competent and comfortable doing and they will obviously refer you to a specialist if necessary!

IS SURGERY PAINFUL?

wissy-bandage

The actual operation is not the most pleasant sensation in the world but it should be relatively pain-free, given the effectiveness of modern local anaesthetics (injections). If you have the surgery with sedation or general anaesthetic (sleeping) then there would be no pain during the procedure at all.

swelling-2swelling

However, you can expect a degree of discomfort in the healing phase over the next 10 or so days. This ranges from a low-grade ache with minimal swelling (where the patient wonders what the fuss was about) to the other end of the spectrum with moderate pain (and sometimes marked swelling of the soft tissues) and of course anywhere in between.

Your dentist or surgeon will likely prescribe painkillers and antibiotics and it is imperative that you adhere to the post-operative instructions that will be given to you (usually in writing). Please ask for a copy of these instructions at the initial consultation appointment so that you will be prepared for the healing phase with your recommended medications and heat packs. Remember to take your Smart Phones for the funny photos and videos to show your friends in exchange for buckets of sympathy!

Please send any stories photos or videos of your post-operative face for us to share with the world!

Check out this link to the "Fun Page" and search the 'videos' for a wonderful reaction to sedation anaesthesia, from a lady who has just had her wisdom teeth removed!  Be happy in the knowledge that you really only have to go through this once in your lifetime. Bear in mind that I have to watch Richmond Footy team play each week and it can be just as excruciating!

A lady patient once exclaimed that she would rather have a baby than have her wisdom teeth out. I replied that was OK but I would have to adjust the chair!  (Only joking... she actually said "filling" rather than wisdom teeth")!

Orthodontics (Braces)

DOES MY CHILD NEED BRACES?

There is a big difference between need and want!

girl-with-braces-604x238

Basically, there are two reasons why you may need braces.overjet

Firstly is functionDentists and orthodontists can usually predict if young patients will have a bite related problem into your adulthood. In these cases, I urge patients to at least seek an opinion from a specialist orthodontist (and a second or even third opinion if they are still unsure or do not get on with the orthodontist).

The second reason (and probably more important from the patient's point of view) is for aesthetics or looks! We all want a nice smile and your orthodontist can help! There is much to be said for correcting crooked teeth if your child is being teased or suffers from low self-esteem. It really can build confidence.

darla-braces400x200However, there are limits and we still get many people who want the perfect smile when personally I think they look wonderful as they are. That is when I say it is totally up to the patient (and parents). dinosaur-braces-236x-182Saying that - if your child does not want braces then I would seriously try to avoid orthodontic treatment as they are less likely to take sufficient time to clean them! Unfortunately, this lack of adequate oral hygiene may cause damage to the underlying teeth.....  Here you can see the brown and white marks of decay which would have been underneath the plaque that this patient did not clean off his braces. The original and undamaged tooth colour is shown in the 'square' in the middle of each tooth where the orthodontic bracket would have been cemented.

damage-from-bad-oral-hygiene-around-braces-510-x-317Braces did not cause this! -Bad oral hygiene and sugar did!

Just a word on costs...piggy-bank-with-coin

I also tend to advise parents to start saving ($$$) when I see a patient who could benefit from braces in 2-3 years time! When it comes to the time for referral, if their child needs braces then usually there is enough money saved up! If they do not need braces (e.g. borderline aesthetic cases) then go on a holiday with the money you just saved up!

sealion-with-bracesIt's a 'win-win' situation and you've got to love that!

WILL I NEED TO HAVE TEETH REMOVED?

This really depends on the individual case. No one rule fits everyone.too-many-teeth1280x720Where would all these teeth fit in?

overjetoutlocked-premolars2

A diagnosis of the actual problem is paramount and treatment options will follow but sometimes there are limits to what can be achieved with braces alone, especially in severely crowded cases.

There are two main components of ideal occlusion (the way teeth meet together), firstly the jaws and secondly the teeth themselves (i.e. are they crooked or rotated?)! The teeth may appear "straight" yet the jaws may be out of whack so that the teeth do not meet correctly.This can result in what people term as an "overbite". You may notice some of your friends or colleagues that have a nice smile yet their lower jaw is receded or prominent.

burns-chinstan-chin-2

Usually, these severe jaw discrepancies are corrected by surgery when the patient has stopped growing. However many patients do not wish to embark on a surgical path but would still like a straighter teeth, so a compromise may be in order. This is where some teeth could be removed and the others moved into the space created to camouflage the jaw relationship. The result may not be ideal but is often very acceptable given the options.

Sometimes there are borderline cases where the orthodontist may start treatment on a non-extraction basis with a view to removing teeth if things are not working out satisfactorily. The patient and parents would always be informed of this before starting treatment. Orthodontists importantly always take the patients' and his/her parent's views about extracting teeth into consideration and sometimes it is better not to embark on any orthodontic treatment at all, rather than having a less than satisfactory outcome with a compromised treatment plan. Just get as much information from your orthodontist you can before you start treatment (ask to see other patient's photographic results) and then you make a fully informed decision.

So to answer the question, your treating orthodontist is the best person to tell you after diagnosing your individual malocclusion.

Some general dentists (and even some specialist orthodontists) believe you should not extract under any circumstances but this, in my opinion, is taking a rather narrow-minded and simplistic approach to an often complex situation. After all, we are individually very different so it does not make any sense that everyone should receive the same treatment regime! If you are not happy with what your dentist or orthodontist is telling you then please feel free to get a second or even third opinion.

It is, after all, you (or your child) that needs to be comfortable with your individual personalised treatment plan.

CAN I JUST HAVE BRACES ON MY TOP TEETH?

Sure, anything is possible...

top-braces-600x400

....and I am sure you can find some dentists or orthodontists who may do this but you just need to understand that it is usually a compromise, especially if the lower teeth are also crowded.

It certainly may be all that is needed for some individuals if the problem is limited to the top teeth. Please do not be surprised, however, if your orthodontist says you need top and bottom braces even if you cannot see why. Just ask them to explain the situation. They should be more than happy to do so, as they ultimately want the patient to be comfortable with their treatment rather than have a chip on their shoulder thinking full braces were unnecessary.

retainer-placement

For long term stability, the occlusion (bite) needs to fit precisely between upper and the lower arch. When they do not meet properly, then it is more likely that the crowding would return. That is why it is also so important to wear a retainers after braces whether it is a compromise or not!

WHY DO I NEED TO WEAR RETAINERS?

Teeth can move and drift (usually forwards) throughout life!

retainer-smile-640x360

Retainers maintain your teeth in the desired corrected position!

Physically straightening your teeth is the active part of your orthodontic treatment. Once you and your orthodontist are happy with the result, you will then enter the equally important phase of RETENTION. If you do not physically retain your teeth in the new position, there is a higher tendency for them to move. They may eventually drift back into a crooked position again, undoing the work you have achieved over the past few years!

How do I know?

I see it every month! The typical scenario is little Harry or Charlotte now has a beautiful, post-brace smile in their late teens. They eventually move away from home or possibly to University and return a few years later for a check up. Without mum and dad nagging them about their retainers they perhaps have missed a few nights, which turns into weeks then months. Out of guilt they find the retainers one day and try them in only to find they do not fit - OMG "what is mum and dad going to say" and panic sets in!

Possibly too embarrassed to tell mum or dad they just continue to not wear them! Suck it up kid's it is not the end of the world if your parents find out! Remember the problem is easier to fix, the sooner you know things are on the move!

They appear for a check up one day with me and having seen a less than perfect tooth alignment, I proceed to quiz them about their retainer wear - sorry but it's my job!

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Oftentimes I see their lower teeth becoming squeezed out or crowded or they remark that one of their upper teeth did not use to cross over the other!  Invariably this is a result of not wearing their retainers for the past few years or so!

These days, most youngsters have the ability to take "selfies" which is a fantastic way to keep a record to see if your teeth are actually moving by the way!

Remember, it is cheaper to have a new retainer than it is to have your braces back on!

I appreciate that young adults (I used to be one, albeit a while back now!) have far more pressing issues that retaining their teeth! After all, they are just hopefully taking opportunities as they present themselves and making the most of life whether it be work or play! I also know that retainers are low on life's priority scale (I have kids of my own and are constantly reminding them to wear their retainers!).

So, if you are reading this having just had your braces off or you have just forked out the last instalment to the orthodontist for your children, then PLEASE, PLEASE, PLEASE read the next few paragraphs, as it will save you thousands of $$$!

  • I advise patients to wear their retainers full-time for a least 6 months (removing only for eating, cleaning and sporting activities).
  • They can then switch to just nightly wear for a further 6 months. It is not over then!
  • After this, I suggest wearing the retainers perhaps every other night for a further few months then eventually one night a week.
  • It is critical to do this as you can detect whether your teeth are moving. i.e the retainer will feel too tight when you put them in!  If this is the case, then just wear it more frequently.
  • If it does not fit at all comfortably then I urge you to contact your dentist or orthodontist to have it adjusted or replaced.
  • And finally just get new ones if they just become a bit 'manky'!

Many patients do not pay as much attention to this aspect of orthodontic treatment as they should. You have paid probably thousands of dollars or pounds on your new smile yet ignore the easiest part of treatment in keeping your teeth straighter for longer!

Unfortunately I also even know of orthodontists who pay minimal attention to long-term retention which to me, is professionally unbelievable and personally frustrating, as I am the one who has to tell the parents why little Harry's teeth have become crooked again several years after braces!

retainer-collection-1600x-1200

There are many different styles of removable retainers. They only work, however, if they are worn! A wise orthodontist once told me in response to the question of "How long do I need to wear retainers for?"...

Answer:   "For as long as you do not wish your teeth to move!"

I do not disagree!

Paedodontics (Kid’s Dentistry)

WHEN SHOULD I FIRST BRING MY CHILD TO THE DENTIST?

Sorry, but I have not written this one yet!

If you contact me HERE,  I will get my proverbial in gear! 

Cheers, Dr. Mike

WHAT IS THE POINT IN FILLING BABY TEETH IF THEY ARE GOING TO FALL OUT?

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WHAT IS A FISSURE SEALANT?

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WHEN DOES MY CHILD GET HIS/HER FIRST ADULT TEETH?

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Cosmetic dentistry (crowns & Implants)

SHOULD I WHITEN MY TEETH?

Whether you should whiten your teeth or not, is solely up to you.

However, there are a few things you should bear in mind such as your age, complexion, the state of your teeth and how deep your pockets are!


Many people are unhappy with the colour of their teeth. Sometimes tooth whitening is unnecessary and I often advise some patients that their teeth are perfectly fine. They agree when they check out their teeth against a shade guide that all dentists would have.

A nice smile is enhanced if the colour of your teeth is sympathetic with your age and complexion. We all want to look younger but to be honest not many people can't pull it ooff with just making their teeth white! Don't get me wrong, I am not saying you should not bleach, after all, nice white teeth shows others you take pride in your appearance and look after yourself. It also gives the beholder great confidence.

However, you can go too far! I have found a great balance to obtain facial aesthetic harmony is when the colour of the teeth match the whites of your eyes.

It is hard to guild a lily but this lady would look even better with her teeth whitened slightly....

Place your hand over one side of her face and see what I mean. When you view the 'before' you can see that her eyes are more distinct. In this case, I would advise bleaching to enhance facial harmony. When you view the "after"  you will notice the white of the eye and the teeth are similar shades and this, to me, is a perfect result for her. I now see her whole face rather than just her teeth or eyes!

Just bear this in mind when deciding if bleaching is right for you!


Here are a few who should have been advised by their dentist that they have gone to 'wrong-town' and their teeth do not look natural!

A little too far- I just see teeth rather than a wiggle!!

Liz Hurley got it right but Shane looks like he has been plugged into something!

This is wrong, but if the rest of him looks as good as this, who cares!

However, this next one is just wrong on so many levels!

I won't go into how he became an Oompa Loompa!


There a few ways to achieve whiter teeth:

1.  Place a veneer of porcelain or white filling material (composite) over the front surfaces of the visible teeth.

2.  Crown each individual visible tooth.

3.  Bleach the required teeth.

The first two methods are relatively expensive but great for teeth that have been heavily restored, are extremely dark or need to be reshaped for better aesthetics.  I have discussed veneers and crowns in response to other questions in this section so check them out if you need to know more about them in particular.  Here I will guide you through my thoughts on tooth "bleaching" or "whitening".


Tooth Bleaching

This is an easy, safe, non-invasive and relatively cheap way of lightening up your teeth. Teeth bleaching is a billion dollar industry with a multitude of products sold world-wide. Unfortunately, I cannot comment on every product or system but I will share with you what I tell my patients on a daily basis.

I could do with your help here by informing me as to which products work! Just send in your photos and story and I will do some product reviews to help others. 

Click here to send me the information.


There are 4 ways to achieve the desired result.

Whitening toothpastes!  

Waste of time and money- they may work in laboratory rats but I cannot see how they can work in a clinical situation. Don't bother with them and don't believe the advertising crap of " 3 shades whiter in 3 days". If this was the case we would be selling it and chucking the expensive stuff out! Also, if it was strong enough to do this with just twice daily brushing for a few minutes then I would not want it in my mouth!

Bleach strips or paint-on gels.

These products seem to have some merit (mainly because the active gel is in contact with the tooth for a length of time). I personally have had limited experience with these products as we have stringent laws as to what we can provide here in Australia.

However I have had quite a few patients who have returned from the U.S with the strips and swear by them.

Some products may not be available in certain countries so I cannot comment on all of them out there. However, if you have had good results from any whitening products, please send in some photos so we can share your story. I am sure many people would be interested in a cheap alternative to the next methods.

Chairside whitening (by a dentist). This is the most expensive way as it involves quite a bit of the dentist's time. It may be advertised as "Zoom" or "Laser" whitening.  However there is no laser involved just a visible light with a blue filter!

Basically, your dental professional applies a gel to your teeth after isolating them. They then shine a light onto the gel which activates the bleaching agents. After a not so pleasant and sensitive hour or so, you will notice that your teeth have whitened quite a few shades.  You will be ecstatic! However. The shade you see immediately is NOT the resultant colour!  The teeth would have dehydrated during this time and become naturally white. When the teeth rehydrate over the next 24 hours the shade will revert back, albeit to a lighter shade (but not as white as you would have first thought).

Many dentists therefore provide (sometimes at extra charge!) a take home kit with custom made trays to enhance the effect. You may need to use this to enhance and maintain the initial bleaching effect.

The good...It is relatively fast way to lighten the teeth. Great if you forgot you were getting married at the weekend!

The bad...It can be quite uncomfortable whilst at the chair-side with the teeth 'zinging' (brief zaps of sensitivity) from time to time, which can also last a few days. It is also relatively expensive (at least twice the cost of the next method).

The ugly...Please note: In Australia there are some non-dental establishments advertising such whitening procedures but personally I would stay away! I would not advise you have this procedure performed by a 'beautician' or hairdresser with a product they may have procured from the internet. Bleach kits in this concentration are only legally supplied after rigorous testing and Government approval to the dental profession. These practitioners are also not trained to recognise if there are any contraindications to bleaching such as leaking fillings, gum recession, or dental cavities, nor trained on how to manage emergencies like allergic reactions or swallowing of instruments and materials.

At home whitening.

This is the technique I recommend. It is cheaper by far than chair-side whitening and much less sensitive. However, all bleaching systems have a degree of sensitivity and is dependent on the state of your teeth and how sensitive to pain you are in general. Please talk to your dentist to check which sort of bleaching, if any, is right for you.

The final result from this technique over the chair-side bleaching is exactly the same, however it is just slower.  If you decide to go with this procedure, then please give yourself a few months before that special day so that you can take your time and have less sensitivity. The technique involves the constructon of a soft, custom tray and provision of bleaching gel which you place within it.

You wear for 2-3 hours a day at a time of day to suit your lifestyle for up to 4 weeks. Time will vary for individuals based on how dark their teeth were, how light they want them to be and for how long they apply the gel to their teeth.Good... Cheapest way (that involves a dentist) and more predictable (you choose when to stop bleaching). You can also go at your own pace to minimise the effects of sensitivity. Does it matter if it takes 4 weeks instead of 2!

Bad... It is up to the patient to comply. If you do not wear the trays, you will not see the results.

Ugly...Will still set you back AUS$3-400 dollars as opposed to chair-side bleaching that I have seen advertised as much as Au$1200 (as of March 2017).


Just a word on teeth that have fillings.

As you can see from this photo, the teeth have been lightened successfully but the fillings now stand out more. The bleach gel does not penetrate the filling material so it remains the same old dark shade. This needs to be taken into account when consulting with your dental professional. You must be aware that any front fillings may need to be replaced with a lighter shades to blend in. This would be an additional cost and something your beautician may not be able to fix!

I am off to get a haircut and my nails done (I hope they did not read this article!)

WHAT IS A DENTAL IMPLANT?

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Cheers, Dr. Mike

WHAT IS A CROWN?

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WHAT IS A VENEER?

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Cheers, Dr. Mike

Endodontics (Root Canals)

WHAT IS "ROOT CANAL" TREATMENT?

Basically, it is a technique of saving a tooth to avoid extraction, but to answer this properly, I need to give you an idea of the structure of a tooth!

Inside a healthy tooth, there is a space which holds the nerves and blood vessels called the 'pulp chamber'. This extends down into the 'root' of the tooth in 'canals'. This is surrounded by a layer of living porous hard tissue called 'dentine' and covered by the usually white hard 'enamel' (the actual tooth shaped part that you see in the mouth). All teeth have this structure and vary only in size, shape and the number of roots.  

Now, if the pulp inside the tooth becomes damaged by trauma or decay then it can die, become infected and form an abscess (a localised collection of pus) under the tooth. This is often very painful necessitating urgent dental assistance. Generally speaking, irrespective of the cause of the abscess, 'root canal' or endodontic treatment will be necessary to save the tooth.

So what is it?

In a nutshell...  We remove the affected pulp tissue, disinfect the canal(s) and place a filling down the root - hence the term 'root-canal filling'! This promotes healing of the infected tissues, eventually restoring normal function to the tooth!

If the tooth is cleaned sufficiently, the body's healing process can take over to mop up any residual infection. Hopefully, the symptoms subside and the tooth can function normally for many years to come.

It sounds simple, but root canal treatment is technically difficult and can take several visits to complete (hence the high price tag!) All dentists are trained and very capable of performing such treatment, however, there are times when we come across complex cases that may need a referral to a specialist. These specialists are called Endodontists - if they cannot save your tooth, then nobody can!

DOES "ROOT CANAL" HURT?

Sorry, but yes and no!

It is very difficult to answer this, to be honest, as there are so many variables. YES, in the acute stage when the tooth is inflamed or infected, the treatment can be uncomfortable and NO, as I have often performed root treatment without local anaesthetic! It really does depend on the mix of dentist, patient and clinical circumstance. So there is no simple answer!

When you scour the internet for the answer you will no doubt come across many patients who say it is the worst experience of their life and would never entertain another one. Most patients who have had a root canal without incident, probably don't hit the keyboard to tell everyone! So try not to be swayed by all the negative stories you hear on the internet alone.

People associate the pain in the 4 following ways...

1. Pain on presentation: Many people attend because they have pain from a tooth either from an abscess, trauma or decay. They are often very anxious and the pain leaves them extremely wary and often very jumpy (especially children). Initially, your dentist may prescribe painkillers and antibiotics to alleviate the symptoms but in most cases, active treatment may be warranted at that visit to relieve the pain (often instantly).

2. Pain during the procedure: Sometimes it is difficult to numb the tooth sufficiently to be absolutely pain-free. The initial procedure may, therefore, be uncomfortable but the relief of symptoms far outweighs this inconvenience. The pain is caused by the infection around the tooth rather than the root canal treatment itself and I sometimes abandon the procedure for another day if it becomes unbearable. The patient and I are often suitably relieved to find that the procedure is relatively pain-free the next visit!

Dentists welcome feedback at any stage of treatment and will strive to ensure the procedure is as comfortable as possible, so please do not hesitate to tell your dentist if you are struggling to cope. There are many technical, physiological and anatomical reasons why the tooth cannot be numbed properly, but I will bore you with these details in a separate blog post!  Taking paracetamol (acetaminophen) or ibuprofen an hour prior to subsequent appointments may also help.

3. Pain after the procedure:  An inflammatory response is often set up in the soft tissues after most root canal procedures. This can produce a mild ache or tenderness which alleviates usually within 48hours. Use of an anti-inflammatory painkiller such as ibuprofen can be beneficial over this time. Pain may also be experienced in the jaw joints after keeping your mouth open for such a long appointment. This discomfort will pass.

This guy obviously did not mind the treatment, having had 28 root canals!

4. Pain when paying!  Yes, root canals are not cheap especially if you need to be referred to a specialist Endodontist! While many General Dentists perform root canals predictably and well, some may refer difficult cases to these highly skilled specialists and they are worth the money! Please talk to your dental professional about the procedure as they are there to help you keep your teeth in your head. This is not a way for dentists to make a quick buck from you. It is technically demanding and can take many extended visits to complete the treatment. Look at it as an investment in your health rather than an unwanted expense!

If you do not experience any of the four types of pain then please give yourself a pat on the back, tell your friends not to worry and thank your dental professional for making a difficult task seem easy (paying his bill would probably suffice though!).

Whilst researching Google University, I did come across this article written by a well-informed patient (or a dentist pretending to be one) and I could not summarise the root canal experience better! It is worth a read!

 Click here to read the article.

WILL MY ROOT CANAL LAST FOREVER?

Forever is a long time and only a brave person would guarantee that ANY root canal will be successful for everyone all of the time!

There have been many studies that measure the 5, 10 and 15-year success rates, which can vary from 70%-93%, but the criteria for failure in these studies can be quite subjective. My only criteria for failure is when the tooth needs to be extracted due to a persistent or recurrent infection (which is what the root canal treatment is trying to address).

So what is "success"? If the tooth is performing some purpose or function with no symptoms or signs of infection (even if it is just keeping the surrounding bone structure from resorbing away) then, to me it is successful. I have seen many root filled teeth that may not look perfect on an x-ray but have been happily functioning up to 40 years or more!

A root filled tooth may subsequently be extracted due to recurrent decay or a fracture, so is not necessarily a failure of the root canal process itself. If your root filled tooth needs to be extracted, ask the dentist why?

Generally speaking, success rates drop, the further back you go in the mouth. Front teeth have a better prognosis as they have a relatively straightforward anatomy and being accessible, they are technically easier to complete. The back molars often have complex root anatomy and being so far back in the mouth, they are difficult to access.

Here you can see the front incisors have a single canal but the molars can have up to 5 or six, and often very curved.

Other factors that affect the success is the ability of the patient to sit comfortably for lengthy appointments, and actually, open the mouth wide enough for treatment to be performed. The dentists' skill level is also an important factor. Most dentists are comfortable and proficient with root fillings but there are cases where referral to a specialist Endodontist would be appropriate. Studies have shown better “success rates” when root canals are performed by a specialist over a general dentist but heck, that is why they have specialised!

Irrespective of who places the root filling though, if the tooth is not subsequently restored appropriately, it will be more at risk from fracturing or re-infection from bacterial leakage (undoing all your hard work and investment). Teeth also tend to get brittle after the nerve has been removed and the structural integrity of the tooth may already be compromised since it is often heavily filled, decayed or has suffered trauma.

Back teeth (bicuspids and molars) should usually be restored by placing a “cap” or “crown” over the biting surface. People sometimes try to save money by postponing the crown, but are often disheartened when the tooth subsequently breaks and then needs to be extracted (which again is not a failure of the root treatment)! Front teeth can often get by without a crown, as they are not used for heavy grinding like the back teeth (but talk to your dentist about what is best for your situation). Please ask your dentist BEFORE you embark on a root canal treatment if crowning is necessary (it is expensive and you need to be fully aware of any additional costs).

Protect your investment!

A good indication of whether your root filled tooth will outlast a healthy tooth is your general oral health. If it is excellent, and you have routine dental check-ups to diagnose early problems, then there is a better chance that a properly restored, root canal treated tooth will last as long as any other (non-root filled) tooth! However, if your general oral health is poor, then chances are that it won't last as long as it could.

You have to remember that a tooth with root canal treatment can still develop a cavity or suffer from gum disease like any other tooth. As the tooth has no nerve, patients rarely complain of pain so the presentation of problems are usually late, especially if regular dental check-ups are not maintained.

I cannot overestimate the importance of having an excellent oral hygiene routine which includes regular daily flossing. If I spent a few thousand dollars on something, you bet I would look after it! Here are several things you can do to maximise the success of your investment…

  1. Have the tooth appropriately sealed and restored - this may involve an expensive crown.
  2. Have regular dental check-ups - early diagnosis of problems is the key.
  3. Use floss daily especially around the crown margins - brushing by itself is not good enough.
  4. Avoid sugary foods - which cause decay.
  5. Avoid hard foods - reduces the risk of tooth fracture.
  6. Use a daily fluoride mouthwash - to strengthen root and enamel surfaces.

 

In summary...

Our goal as dentists is to help you keep your teeth for a lifetime, whether they are root filled or not. Successful root canal treatment is based on the skill of your dentist, the healing power of your body and the way you look after the tooth! Your tooth could last a lifetime after root canal therapy. However, just like anything else, if you don't take good care of your teeth afterwards, then a root-filled tooth may fail prematurely!

Every clinical situation is unique. Just because your neighbour or friend may have had a bad experience with a “failed” root canal treatment, the outcome for yourself may be more favourable!

Remember, you rarely hear about the good stories! Other people's bad experiences should not deter you from making a decision in your own individual and unique case. Just discuss the options with your dentist to find out what is right for you!

WHY IS MY TOOTH GOING DARK?

A tooth can darken for a number of reasons.

Most commonly it is due to either trauma (a knock from an accident or sporting injury) or damage to the nerve inside due to decay.

In deciduous (baby or first) teeth, trauma is the major factor. Many children knock their teeth one way or another but most do not have any issues (we would like to wrap them in cotton wool but it is slightly impractical!). These teeth start to erupt between the ages of 6 months to 2 and a half years. When toddlers take their first steps, they invariably fall down, and I have needed to console numerous distressed parents after their child has knocked their teeth in doing so.

If you are concerned about possible damage to their teeth then please call your dentist and possibly 'Email' or 'message' photos to help them decide on the appropriate timing of your appointment. If the baby tooth has not been knocked out, displaced or fractured, we usually play a waiting game and monitor for signs and symptoms.

These teeth commonly darken a few days later (this darkening is often the first time parents notice there is something wrong as children can shake off many innocuous knocks without symptoms).  Discolouration varies from light grey to black and even a pink hue. This is due to the damage to the blood vessels within the tooth and associated changes in the porous tooth structure.

The patient (after the initial shock of the bump) is usually not fussed and as long as they are eating and drinking well and there is no sign of tooth fracture or infection, I just tend to reassure the parents, advise a soft diet for a week and monitor the situation. Your dentist may advise taking x-rays to make sure there is no damage to the root or to see how soon the tooth may be lost naturally anyway (most front teeth are lost naturally around 6-7 years of age). I am constantly surprised how good the body is at healing and often see darkened baby teeth lighten up on their own after a few months.

However, things to watch for are obvious infection (lumps on the gum above the tooth), the patient reporting pain or excessive loosening which makes it difficult to eat.


We cannot predict which teeth may take a turn for the worse! So if you detect any of these signs or symptoms then please return to your dental professional to reassess the situation (extraction will be indicated). Do not get too depressed as there are usually no major complications.  There are worse things in life and the photos will make a good talking point for their 18th birthday!

The situation is a little different when permanent or adult teeth are darkened...

Inside a healthy tooth, there is a space which holds the nerves and blood vessels called the pulp chamber or canal. This is surrounded by a layer of living porous hard tissue called dentine and covered by the usually white hard enamel (the actual tooth shaped part that you see in the mouth).

When a tooth is traumatised by a severe knock or indeed a cavity caused by decay, the pulp tissue can die and produce toxins which discolour the dentine. This dark discolouration shines through the translucent enamel making the whole tooth look darker than the other teeth. The degree of darkness can vary greatly and usually, it is only an issue if it spoils your smile.

Sometimes the discolouration is so subtle that a dentist may ask you at a routine check-up if you have ever had a knock on a particular tooth in the past. They may have picked up on the colour change which is sometimes the first sign that the nerve inside the tooth may have died (pain is not always associated with this process). The treatment in most cases is to remove the affected pulp tissue, disinfect the canal and place a filling down the root, hence the term 'root canal filling'! The tooth can then be 'bleached' lighter. 

A root filling itself does not necessarily cause the darkness but rather, the darkness is a consequence of the initial death of the pulp. Most root filled tooth may appear dark for this reason.

If you present to a dentist with a dark tooth which has not already been root filled there is a high chance that the pulp has died and actually needs a root filling (there are some cases when it is not necessary but your dentist can explain).

Whatever the cause of the darkening the treatment options vary depending on the state of the affected tooth and are as follows...

1. Do nothing and accept the discolouration (if it has a satisfactory root filling then it is only a cosmetic issue)

2. Internal Bleaching is a relatively simple and cost-effective way to whiten the tooth by reversing (oxidising) the internal changes caused by the damaged pulp.

This tooth has suffered trauma and has discoloured. After placing a root canal filling, a whitening agent is placed inside the tooth for up to a few weeks. When the colour has matched the others, the tooth is sealed and restored. I try this first for most cases that do not need extensive restoration from fractures or old fillings.

3. Composite veneers. If the teeth are broken down or have old fillings then they usually need to be restored with a white filling material called 'Composite'. We often try and mask the darkness by wrapping around the composite to cover the front surface. Reasonable results can be obtained especially if the teeth are also internally whitened (see 2. above).

4. Crowning the teeth. This is the more expensive option but you will have the best aesthetic result. The teeth are often bleached then prepared to receive a porcelain crown. this is subsequently cemented in place to add strength, as well as restore your smile.

These options are just that, options! They vary in cost from hundreds of dollars/pounds to thousands, so it is important to choose the one (or combination) that best suits your individual and unique situation.

Please discuss what is best to restore your smile with your dental professional.

Periodontics (gums)

WHY DO MY GUMS BLEED?

I can answer this with one word...

"Plaque"

Or more specifically, dental plaque, the furry stuff that accumulates on our teeth daily!

Now the biology lesson...

Everyone (without exception) has millions of bacteria in and on their body. Some are good and some are harmful. Vast numbers reside on all surfaces of the mouth, including the cheeks, tongue, palate (roof of your mouth) and of course, the teeth!

Bacteria are the smallest living organisms, so small they are not visible to the naked eye. However, they multiply so quickly that just within 48 hours they can expand to create a creamy, gelatinous, smelly mass called a biofilm, which is a posh word to impress your dentist with at your next visit!

This biofilm is what we notice as that "furry coating" on our teeth when we have not brushed them for a few days!

In a short time (just a single day), it can become so thick that you can scrape it off with your fingernail! If you placed that under the microscope this is what you would see...

Modern technology can show these critters in a way that you will not believe. Check out these SEM (scanning electron microscope) images of the bacteria in dental plaque.

I am amazed that something with such beauty can cause us so much pain and suffering and, en masse, look like this....

The disease in these pictures is called gingivitis which can have degrees of severity (these photos are of advanced cases)! Any degree of gingivitis, however, have these things in common:

1. The gums bleed!

2. It is reversible with suitable treatment!

3. It is totally preventable!

These gums look like they would bleed just by looking at them but surprisingly, the amount of plaque does not always correlate with the severity of the disease.

I have seen many youngsters with minimal plaque deposits yet their gums bleed easily. On the flip side, I have also seen many older patients who have only slight gum problems, yet their oral hygiene is atrocious.  Plaque is a seething mass of many different kinds of bacteria, some being more destructive to the tissues than others.

So the actual makeup of the plaque is just as important in the disease process as the amount that forms on the teeth. You have no control over this as it depends on susceptibility and genetics! This is why it is so important to remove all the plaque when cleaning your teeth! This is something that you do have total control over!

However, this is only achievable if you floss as well as brush daily!

WHAT IS GUM DISEASE?

There are many conditions and diseases that affect the gums but by far, the two main chronic diseases are,

GINGIVITIS & PERIODONTITIS.

The patients in these photos suffer from a disease called gingivitis. It is an inflammatory response to the plaque (bacterial) build up in our mouths and can range from a localised condition to severe generalised cases.  Any degree of gingivitis, however, have these things in common:

1. The gums bleed!

2. It is reversible with suitable treatment!

3. It is totally preventable!

These gums look like the would bleed just by looking at them but surprisingly, the amount of plaque does not always correlate with the severity of the disease.

I have seen many youngsters with minimal plaque deposits yet their gums bleed easily. Conversely, I have seen elderly patients who have only slight gum problems yet their oral hygiene is atrocious.  Plaque is a seething mass of many different kinds of bacteria, some being more destructive to the tissues than others.So the actual

So the actual makeup of the plaque is just as important in the disease process as the amount that forms on the teeth. You have no control over this as it depends on susceptibility and genetics! This is why it is so important to remove all the plaque when cleaning your teeth! Something that you do have total control over!

However, this is only achievable if you floss as well as brush daily!

Gingivitis is one of the most common diseases affecting mankind. I would say probably everyone in the world would have had gingivitis to some degree at some stage in their lives. So if your dentist informs you that you have gingivitis do not panic!

Saying that, you should still be concerned. Inflammation is your our body's response to something it does not like and believes is harmful. In this case, the stimulus is the bacteria in dental plaque. It only takes a number of hours for the body to detect a build-up of plaque around the teeth (the main reason we advise at least twice daily brushing). The gums appear swollen as they fill with blood to combat the bacterial infection. They also become very friable and they can bleed easily when touched (with a toothbrush for example).

As mentioned, gingivitis can affect just a small area of gum or the entire dentition depending on your level of oral hygiene.  It can be severe (as in the pictures above) or, more commonly mild like this...

Where gums are loose, swollen, bright red and bleed easily when touched.

I see this daily in our practice despite my nagging about oral hygiene! It can get depressing seeing the same thing every check up when I know it can be easily avoided!

Yes, that's right. Gingivitis is reversible! The gums can heal if you remove the plaque sufficiently on a daily basis. 

Now compare this next photo showing healthy gums which are light pink, firm, tight and importantly....do not bleed when touched! 

These gums are flossed and brushed daily. What a difference!

I must confess to getting a warm tingly feeling when someone turns up with gums like this (call me odd!). It does not happen often but when it does it makes my day!

PERIODONTITIS.... When gingivitis goes bad!

Gingivitis affects the soft tissues i.e. the gums, and starts as soon as teeth erupt. If you do not get your act together and address you cleaning habits into your 20s and 30s, the bacteria can start to affect the bone underneath the gums. That is, they eat away at the supporting structures. This is called periodontitis and is (usually) a slowly progressing, chronic, non-painful disease.  You will be left with what is termed "receding gums" as the bone gets slowly resorbed in the process and shrink away!

You may have heard the term "getting long in the tooth" as an expression of ageing! Well, the teeth appear to be getting longer as the gums shrink and expose more of the tooth root for you to see. Periodontitis usually affects us as we age, hence the term!

This next photo shows untreated gum disease which has reached the point of no return. The loss of bone and recession of gums makes these teeth very loose, sensitive and uncomfortable to eat with. Yes, they still bleed!

You can have a perfectly functioning set of choppers with healthy gums even if you decide to take better care of your teeth later in life!  That's right...Periodontitis is treatable but once you loose the bone it will not grow back.

However, it is never too late to get into good habits, and the results can be outstanding...

This patient sought treatment from their dentist or a gum specialist (called a Periodontist). They got their toothbrush in gear and sorted their flossing out!

They now have a perfectly healthy, functioning set of teeth with no pain, no mobility, no smell and NO BLEEDING!

(Also see the question on "why do my gums bleed?")

WHAT IS DISCLOSING SOLUTION?

Disclosing solution is a harmless water-based dye that is used by dentists or hygienists to show up the plaque on peoples' teeth during oral hygiene instruction. After painting it onto the teeth, it immediately stains up the bacteria (germs) a contrasting colour, enabling the patient to clearly see how good (or bad) their brushing has been.

Plaque is the layer of germs that develop onto the teeth throughout the day and needs to be removed to maintain healthy gums and teeth. However, it is often invisible to the naked eye, so people think their teeth look clean but actually they may be worse than they think! Check this out...

This patient's teeth looked relatively clean on first glimpse.

But after having the disclosing solution painted on the teeth and rinsing out, the result shows they were not so clean after all! Patient's are often surprised at what they have left on their teeth even if they report brushing before their appointment!

The light pink shows plaque that has formed within the last 24 hours. The blue plaque has been there for more than a day. Note the thicker deposits tend to accumulate around the margins of the teeth by the gums. This causes inflammation of the gums ('gingivitis' or gum disease) and is why most people's gums bleed when they eventually touch them with a brush!  I do clean the teeth afterwards, so you won't see any pink/blue teeth around Town!

I do clean the teeth afterwards, so you won't see any pink/blue teeth around Town!

I often encourage patients to check their brushing using this technique but it can get a bit messy (especially for children)! I, therefore, advise they use DISCLOSING TABLETS which are available from all good pharmacies, chemists or drug stores...

They are ideal for the older child/teenager trying to learn why and how to clean their teeth and gums. Just chew a tablet, without swallowing it, for about a minute (or as long as possible). Then rinse out and check the teeth in the mirror. It will give instant feedback to you and your child on how the brushing is going!

I advise families to have a bit of a laugh with this procedure once a week and is a great oral hygiene training aide. Why not try and get the siblings to have a competition as to who can brush off the stained plaque the quickest, or indeed get them to brush first, then disclose to see who is the best brusher!

WHY IS MY TOOTH LOOSE?

There are 3 main reasons why you may have a loose tooth...

1. Natural exfoliation (loss) of a baby tooth.

All baby teeth are destined to be in the mouth only for a certain time and appear from roughly 6 months to 3 years. The adult teeth develop underneath each one and gradually, starting around 6 years of age, the baby teeth become loose and are replaced by the adult teeth. When each adult tooth has finished cooking, they push the baby teeth out of the way making them loose.                           

It really is exciting for most kids to start wiggling their first tooth out, in the hope a tooth fairy may reimburse them! This is a perfectly natural phenomenon (I don’t mean the Tooth Fairy)!

2. Trauma

We cannot wrap each other up in cotton wool, no matter what you do in life. Unfortunately, we see many accidents with elbows, fists, heads, skateboards or bikes and the like, that can result in dislodged or loose teeth! Depending on whether they are baby teeth or adult teeth will determine the treatment and your dental professional will obviously advise you when you attend.

 

You can even dislodge tusks!

3. Gum Disease.  This is the most common, (non natural) reason for loose teeth.

These teeth have severe gum disease (through dental neglect) which has resulted in the supporting bone being eaten away by plaque ('bacteria') left in the mouth. These teeth would be loose and they are on the way to being beyond help. Treatment is available, albeit difficult, but would start with the patient realising there is an issue and seeking help. 

Most people have some degree of gum disease (see question of “why do my gums bleed”). It ranges from 'gingivitis' which generally affects the soft tissues or gums (making them bleed) to 'periodontitis'  which involves the destruction of the underlying supporting structure of bone.

Gingivitis is reversible with sustained improvement in our oral hygiene procedures. However, when you loose the boney support with advancing and untreated periodontitis the teeth eventually become more mobile (loose). This may not necessarily be painful, but at the end stages, the tooth would lose all support and be extremely uncomfortable to chew with. In most cases, the offending tooth (or teeth) would be either removed by a dentist or sometimes by the patient if left too long!

If your adult tooth/teeth do not seem firm it is worth seeking advice from your dental professional as soon as possible. The earlier you are aware of the cause in your particular case, the sooner any long term damage can be avoided.

Remember, it t is not normal to have loose adult teeth.

Please seek professional dental treatment before you get pain!

Oral Medicine (Lumps, bumps & ulcers)

CAN I GET CANCER IN MY MOUTH?

Sorry, but I have not written this one yet!

If you contact me HERE,  I will get my proverbial in gear! 

Cheers, Dr. Mike

WHAT IS TMD?

Sorry, but I have not written this one yet!

If you contact me HERE,  I will get my proverbial in gear! 

Cheers, Dr. Mike

WHY DO I GET A DRY MOUTH?

Sorry, but I have not written this one yet!

If you contact me HERE,  I will get my proverbial in gear! 

Cheers, Dr. Mike

CAN MOUTHWASHES CAUSE CANCER?

Sorry, but I have not written this one yet!

If you contact me HERE,  I will get my proverbial in gear! 

Cheers, Dr. Mike

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