Frequently Asked Questions

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Teeth suffer trauma over time from heavy bites, accidents, overloading, fractures, cracks, pulp stones, canal calcification, decay, wear, etc. Edema inside the tooth is the common reaction. Also, some part of the nerve could be infected and dying with that process releasing gases inside the tooth. Just drilling on a tooth to fill it irritates the nerve to some degree also causing intra pulpal  fluid pressure. 

When the Dentist seals up the tooth, this pressure has no where to escape to and pain can result. If the pain is mainly from a REVERSIBLE irritation type edema, some Ibuprofen., Tylenol or  Steroid type medication might end the problem. If the pain is from an IRREVERSIBLE form of fluid pressure, the discomfort continues  and the nerve and vessels must be removed and the canals sealed in a Root Canal (Endodontic) Treatment, followed by a “Post” to reinforce the hollow inside of the tooth, and usually a Full Crown.

 Sometimes one can”buy time” by placing a “Big Filling” instead of a crown. While this solves the immediate problem, the “Big Filling” will likely not last long and the crown still needs to be done for long term reliability.

In cases where the decay is deep, close to, or entering the Pulp Chamber, and the tooth is still vital (alive) inside, the doctor may place a layer of medication over the deepest area to stimulate healing and then fill or crown the tooth over that. This is called a “PULP CAP” procedure and has a 50% chance of working (relieving pain and symptoms) at the time it’s done.

 About half ofthe PULP CAPPED teeth need Root Canal (Endodontic) Treatment within the following year, and an even higher percentage will need Root Canal (Endodontic) Treatment over the following decades. The Pulp Chambers and Nerve Canals close down by Calcification over the years and can “Strangle” the nerve by cutting off the blood supply which would require Root Canal (Endodontic) Treatment at that time. Sometimes they close so tightly that Root Canal (Endodontic) Treatment is impossible.

A “FILLING” is something that fills a void INSIDE something else - like a “cream filled cupcake” has the filling completely surrounded by cake and a “pie filling” is held in place by the crust and the pie pan on four sides.  Once one or more side surfaces of a tooth are gone, the “filling“ is no longer strongly held in place, AND the reduced amount of sturdy tooth structure is weaker and more likely to break off. Sort of like placing the FILLING upon a stair step.

In general, if a FILLING’s width is over 1/3 of the biting table (the Occlusal. Surface) the tooth is weak enough to need a FULL CROWN. because the enamel walls are too thin and are likely to break. Additionally, if a tooth‘s SUPPORTING CUSP (Palate Side cusps of Upper Teeth and Cheek Side cusps of Lower Teeth) is gone or cracked, FILLING materials are not strong enough to maintain the bite over time so a FULL CROWN is needed.

For financial reasons, you may opt to have the extensively damaged part of your tooth restored with a BIG FILLING, but it is a weak situation likely to need more work in the near future. If you choose to have a severely damaged tooth repaired by a BIG FILLING, and the filling breaks down before two years pass, your insurance will not pay to replace the filling and will likely subtract the current cost of a large filling from what they will pay on the FULL CROWN when you have that done (If under 2 years since the filling).

So, it is better to have a BIG FILLING than to EXTRACT THE TOOTH, if your situation cannot cover the FULL CROWN at that point in time, but, OVER THE LONG RUN,  a FULL CROWN is the most predictable and affordable option.

It‘s OK to get the BIG FILLING if you understand a FULL CROWN IS STILL NEEDED.

The best answer to this question will come after your dentist has had an in person visit with you along with necessary x-rays, history, and long term planned treatment. Below is a general discussion of the best types of crowns for the most common situations.  Precision fittings, implants, long bridges and other unique situations may change this preference. 

Historically there have been  a variety of Full Cast Metal, a variety of Porcelain Fused to Metal, and a variety of All Porcelain Crowns. At present the newer, super high strength Zirconium based All Porcelain Crowns are superior for most applications. They are processed in very high heat and high pressure, then porcelain coated in high heat vacuum machines and can have strong edges as thin as a razor blade.

The machines that make these are only available in large dental laboratories.

Many modern dental offices have 5 axis milling machines that carve your crown out of a preformed block of porcelain while you wait in the chair. These materials are good in that they wear about the same rate as tooth structure and expand  and contract to temperature at a rate similar to tooth structure. The porcelain block from which there are milled are a single, frosted color throughout. Due to the milling process and the weakness of the material in thin sections, the margins must be 1-2 mm thick, so a great deal of tooth structure needs to be removed to allow adequate thickness for the crowns to be strong. This leaves you with a smaller, weaker tooth base, and a solid color porcelain crown which is not too noticeable in back teeth.

. Also, they rely entirely on composite adhesion (sticking to the tooth stub) to keep them in place, If the bond fails or leaks in one place, the crown stays in place, the tooth can decay a great deal underneath the crown without your knowing there is a problem. You could end up with decay into the nerve or a stub decayed so badly that the tooth cannot be re-crowned without much warning. They are a valid choice, though, and better than some of the older crown types.

Dr. Manuel has used this type of milling machine in the past, but now prefers the newer, super thin Zirconium crowns since they require less tooth reduction (leaving a stronger natural tooth base), rely on almost parallel sides for mechanical holding power in addition to the bonding cement, and have a cosmetic porcelain layer fired to better match natural teeth.  The new Zirconium crowns are strong in thicknesses as thin as a razor blade, so they preserve your natural structures better than the in-office milled porcelain crowns.

In addition, we use a cement to bond them in place that releases fluoride to prevent decay and usually comes loose if there is a leak, so your crown would loosen at a point where it could be removed, allowing the underlying decay to be cleaned out, and the crown to be re-cemented. This is assuming you come in for regular dental cleanings and exams so we can catch this early.

The Root Canal (Endodontic) Treatment process removes the nerve and circulation inside the pulp chamber and canals in the roots. This dries the tooth and it becomes more brittle than a vital (live) tooth. Additionally, the process of cleaning out the decay and broken tooth structure leave less sturdy tooth structure. Root Canal (Endodontic) Treated teeth are much more likely to break or crack than normal, vital (live) teeth. Increasing age exacerbates the problem, so older patients have even more risk of breakage. 

Placing a FULL CROWN on these teeth strengthens them and reduces breakage, however, weakened teeth could break off at the gum line even after having been CROWNED.

A recent exception to this rule is when the tooth has a great deal of undamaged dentin and enamel, mainly on front teeth with little damage. Sometimes it is a valid option to just place a POST and FILLING and check the progress over time.

The best answer to this question will come after an in person discussion with your dentist along with the necessary x-rays, history, insurance, and long term treatment plan.

In short, the least expensive tooth replacement involves Removable Partial Dentures. These can be acrylic/composite/vinyl construction and make a good emergency solution even if you will eventually place an implant. The cost is the same for replacing one or many teeth in most cases using Removable Partial Dentures. If you have lost bone or facial support, Acrylic Removable Partial Dentures can help to replace the lost bone and gum tissue and “plump out” the sinking cheek and lip tissues.

The down side is that the Acrylic Partials must be thicker than the more close fitting Chrome Framed Partial Dentures. As such, they may effect speech for awhile and tend to catch food where the partial contacts the teeth. All Removable Partial Dentures should be taken out and rinsed clean after eating or the accumulated food and material will decay the supporting teeth.

Repairs and additions (e.g., if you lose another tooth) are fast and inexpensive on Acrylic Partial Dentures so if you have a lot of weak, challenged teeth or advanced gum infection, they may be a better option for you.

Custom Chrome Removable Patrial dentures are thinner and smaller and stronger than the Acrylic Partial Dentures. If your remaining teeth are healthy and strong, Custom Chrome Removable Partial Dentures are the best removable choice.Adding teeth, clasps, or otherwise repairing Chrome Partial Dentures is more time consuming in the lab, and more costly to the patient than is modifying Acrylic Partial Dentures.

Note that there are “Precision and Semi-Precision” Chrome Removable Partial Dentures  that even more tightly fit to your teeth and even atop dental implants. These are very comfortable, but they are specially designed for each patient’s unique needs and may need expensive modification or replacement should you lose one of the supporting teeth.

If your are missing only one or two teeth and the adjacent teeth are very strong, Fixed Porcelain Bridges are an excellent choice. They don’t come out, trap less food and effect speech far less than Removable Partial Dentures, but you must learn to clean out from under the “fake teeth (Pontic’s)” or decay can get under the crowns of the supporting ”abutment” teeth and you could lose the bridge. Short fixed bridges are a fast way to replace a few teeth surrounded by very strong teeth. They are more costly than Removable Partial Dentures, but less costly than Implant Supported Crowns.

Fixed Porcelain Bridges are strong and do a good job at replacing the missing teeth, but they cannot provide the needed cheek and lip tissue support in areas where the bone and gums have shrunk. Acrylic Removable Partial Dentures and Full Dentures can easily help support sunken cheeks , sagging lips, etc.

Removable Partial Dentures and Complete Full Dentures can be designed to rest heavily upon a few implants with snap or friction fittings to provide a very comfortable, reliable solution to missing teeth while supporting the cheeks and lips better than implants or bridges alone.

You should bring your child to a dentist when the child's first tooth appears, or by the child's first birthday, whichever occurs first. Beyond that, we recommend you bring your child to the dentist with you and your family on their visits even earlier, so the child gets to know us and can see others having a good experience at the dentist. At this early point, a preventive program can sharply reduce the child's need for invasive procedures later. Also, it prepares the child to know us before an accidental trauma when emergency work may be necessary.

As with most dental specialists, it is best to see your family dentist first for a cleaning, exam, etc. If your child is comfortable with the family dentist and in need of no major dental work, staying with the family dentist is likely the best option. However, if great fear, non-cooperation, and serious dental needs are present, the family dentist will likely refer you to the Pedodontist to get the urgent care done with the least emotional trauma on the child. Many times, the child can then get regular checkups with the family dentist without suffering anxiety.

The answer is a balance between Benefits versus Risks. Nitrous Oxide, available in our office, has a strong relaxing effect without completely knocking the child unconscious, and thusly has a very low risk of problems. Some children have severe dental problems, but are too fearful to allow normal dental procedures, so a stronger sedative may be indicated. We would refer these children to a Pediatric Specialist for major work. All of these stronger sedatives have risks, but under a trained operator, those risks are small compared to problems arising from untreated serious dental conditions.

Other than some superficial stain removal, most of the whitening effect of bleaching comes from the "frosting" damage to the surface of the enamel coating. Sort of like when frosted glass appears whiter than clear glass. As such, there is a benefit to limiting the depth of this damage by using less powerful bleaching systems over longer time.

While we have the powerful One-Visit, light/heat enhanced bleaching systems available in our office, there are significant negative side effects of these concentrated techniques:  The teeth can get very sensitive to cold, air, biting, etc. due to the cleaning out of cracks and other tooth defects and the irritation of the tooth nerve by the bleach, heat and light. The teeth become "hyperemic", i.e. fluid pressure builds inside the pulp chamber, a sort of edema. This irritation exaggerates the

tooth's response to any stimulus. In some already challenged teeth, this could lead to the need for root canal therapy in rare cases.

 Another problem with the deep etching caused by this one visit technique is that the enamel is open to absorbing new stains for weeks after the procedure. You could end up with very deep, severely dark stains from drinking coffee, tea, grape juice, chocolate or any other strong stain that could settle deep into the newly opened enamel surface.

On the other extreme is the Over the Counter bleach trays and sticky pads, which are not close fitting to your personal dentition. While they do work to some degree, the bleach can irritate the gums and any open tooth defects.

The best option is to have a Custom Bleaching Tray made in a dental office that exactly matches your teeth and gums. Then you can choose from a wide variety of Home Bleaching Gels in local stores or online to put inside of your Custom Bleaching Tray. The best thing to do is to start slowly with milder bleaching gels, and to reduce the number of home bleaching treatments if sensitivity develops. These milder treatments are less likely to cause serious sensitivity and you can increase or decrease the frequency to match your personal comfort.

NOTE that, as we age, the INSIDE of our teeth, the dentin, gets darker and the Enamel gets clearer, so the teeth appear darker. Only veneers or full crowns can effectively correct this deep, much darker discoloration.

The most controllable way to lighten the color of dark teeth is to use Facial Veneers or Full Coverage Porcelain Crowns. Other than some thin surface stain from berries, tea, tobacco, coffee, etc., most of the darkest coloration is from deep inside the tooth - the dentin - which gets darker as we age. Some deep dentin stains in young people are due to antibiotic use, other meds, or inherited factors. These are called "intrinsic stains". They come from deep "inside" the tooth and are not easily corrected by bleaching procedures.

Veneers are thin porcelain or composite covers for the fronts of your teeth - kind of like sophisticated fake fingernails. We can place one appointment, in office, veneers using the new composite materials. We prefer this type since they are easily corrected or repaired in one appointment.

The laboratory made porcelain veneers are fixed in their shape and color, so we cannot easily modify them if a color change or shape change is desired. Also, they are fairly clear and the cement that bonds them onto your tooth changes color as it sets, so we can only guess at the final color unless we use totally opaque porcelain, which doesn't look very natural.

At time passes, and the veneers get chipped or cracked or stained, the laboratory porcelain veneers cannot be modified nor repaired. You'd have to replace the entire veneer and may have problems exactly matching the adjacent veneers or teeth. That is why we prefer the composite, direct bonded, in office, veneers. They can be repaired, modified or replaced easily in one visit with shade matching correction available.

The most advertised form of “All on Four” involves placement of only four implants Upper or Lower Jaw by specialty clinics, upon which a rigid arch of 8-12 teeth are fastened. These specialty treatment facilities place very long implants very deep into the jaw’s base bone layer, deeper than the “alveolar bone” in which your natural teeth reside. They are fast and expensive.

If any thing happens to one of the four implants or to the rigid arch of replacement teeth, you could lose the whole apparatus and even considerable bone deep into the facial structures, e.g. the cheekbone, the base of the nose and the deep borders of the lower jaw.

Less invasive “All on Four” designs can be done in the normal dental office using special short implants and attachments to hold the arch of replacement teeth in place. The main expense in these simpler “All on Four” therapies is the construction of a very rigid “U-shaped” arch form to hold the teeth. These arches can be made of rigid Zirconium or Milled Titanium with Porcelain teeth built up on top of them. If anything happens to these rigid arch forms, the entire restoration may need to be redone.

Dr. Manuel prefers a rigid BASE upon which Acrylic/Composite teeth and gums are constructed. This provides a form of shock absorption  to protect the implants and attachments, while allowing simple, inexpensive repairs and modifications to the teeth and gums bonded over the rigid retainer.

Overall, most people do really well with a custom designed, well-fitting Full Upper Denture (no implants) and a Reinforced Lower Full Denture with only TWO small implants with snaps underneath the cuspid areas.

An in person discussion with your dentist along with the proper history, x-rays, and exam will give you the best answer fo your implant questions. The following are general factors to consider with the knowledge that there is NO UNIVERSALLY PERFECT IMPLANT - only the types that would best apply to your current situation and needs. Patients may have a broad range of choices in implant treatment.

Mini Implants:

In general, One Piece, Screw Type Implants with a diameter of 1.3 to 2.7 mm are considered “Mini Implants. They look like a small long screw with either a Ball Snap Head for a Snap Fitting, or a Square Abutment Head to hold a Full Crown. They are good for cases of thin boney ridges where the precise location of the implant is not critical and the possible need to replace a particular implant is not catastrophic.

The most common  application for Mini Implants is to place 5 or 6 of them in a narrow, small edentulous (toothless) ridge in an elderly person (over 60 ish). Under a Full Denture the eventual loosening or fracture of these thin screw type implants is not catastrophic as a replacement can be placed nearby if the original boney site is compromised. Over time, they usually work loose, become invaded by gum tissue, or work harden and break off at the gum line. For a person in his/her 60’s to 80’s with dentures, the possible need to replace them is not a big problem and they are a valid treatment option.

Mini Implants are One Solid Piece, so if the gums/bone become infected there is no way to detach the snap or crown abutment head to allow the doctor to treat the infection or to place gum or bone grafts around them. There is no way to change the head from Ball Snap to Square Abutment.

Understand that many people have tiny thin bones ridges incapable of housing the larger sized, two piece, Regular Implants.

Middle Sized Implants:

There actually is not a single clear term to describe the implants sized between “Mini Implants” and “Standard Implants”, so “Middle Sized Implants“ is the one used here to denote One Piece, Screw Type Implants with diameters from about 2.8mm to 3.8 mm. Like Mini Implants, Middle Sized Implants have either a Ball Snap head for a Snap Fitting or a Crown Abutment Head to hold a Full Crown. Like the Mini Implants, the doctor cannot remove the head portion to allow infection treatment, bone graft, or tissue graft.

As the name suggests, “Middle Sized” Implants are designed for thicker ridges than cannot hold the full sized implants. If the patient is very healthy and compliant in maintenance, Middle Sized Implants will likely last longer than Mini Implants, but this prediction varies a lot with each patient and the type of restoration. 

The most common use of Middle Sized Implants is to replace congenitally missing small teeth like Upper Lateral Incisors or Lower Incisors where there is too little room to place Standard Implants.

It is generally not a good idea to place implants in teenagers since their jaws continue growing and changing shape where the vital teeth are adapting andmoving right along, but the implants are rigidly bound to bone and will not move with the changing bone shape. They usually will end up set behind the natural teeth and/or sunken in the non changing bone. Some close evaluation could allow implants in certain teens in the 18-19 year range, but the bone can keep growing until age 21-25 (varies with each individual). As such, they may need modification or replacement or removal .

 You’d need a detailed consultation with 3D imaging to evaluate the best implant for any particular use in any particular patient.

Standard Implants:

Standard Implants range in diameter from 4 - 12 mm and are usually in two pieces: an Implant Body and an Implant Abutment.  The greater strength and the dozens of Abutment options allow a wide variety of applications.

The 2-pieces allow the Implant Body to be placed without the Abutment sticking out of the gums, and covered for best bone healing and bone or tissue grafts at the start. They  also allow for detailed cleaning and treatment of infected implants down the years as the doctor can remove infection and place bone or tissue grafts allowing better healing due to tissue coverage with the abutments removed

Additionally, the 2 piece Standard Implants allow the patient to change the final restoration at any time over the years - changing from a single crown to a snapped retention, to a coping type of partial, or even a full arch bridge later in some situations..

If the patient does not have adequate bone volume at the start, significantly sized bone grafts can be placed by a specialist or the treating doctor. Standard Implants are by far the best option if the patient has the necessary bone, tissue, etc..

The heads, faces, teeth, bone and gums of teenagers are in a constant, dynamic growth process in which the Upper Jaw and Teeth generally grow down and forward. Since the teeth are alive and held in place by growing, adaptable periodontal ligament, they follow along with the developing jaw. This process can continue up until the mid 20’s in age.

Implants, however, are rigidly attached to the bone in place at the time of placement. That bone stops participating in the normal growth and development functions. As such, the implant and the crown will end up sitting behind and sunken deeply into the newly developed jaw. Similar conditions apply to the Lower Jaw.

Very careful consideration should be done before placing Implants in teenagers. There are situations where it might be workable or acceptable considering the risks.

The patient needs to understand that the implants and or crowns will likely need modification or removal once they are in their mid 20’ in age. An example might be lateral incisors in a 18-19 year old girl.

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The best advice would come after an in person visit with your doctor, your history, your needs, and the proper records. What follows is a general advisory which will change depending upon your unique situation.

If your are 70 years old, have very little boney ridge, and are in a hurry, then the 5 Mini Implants may be the optimal solution for you. Mini Implants and their snaps can be placed in one single office visit, or maybe a few over short time. Standard 2 part, 2 stage implants have the implant placed and left to heal for 3-6 months before the Snap Abutments can be placed, so there is a great difference in the time needed to complete the process.

On the other hand, if you are in your 50’s and want many decades of fairly trouble free, strong retention, the Standard 2 part, 2 stage implants may be the best. They also allow effective treatment of any infections or placement of grafts over the years. 

Standard 2 part, 2 stage implants may be able to be combined with several additional implants later to allow an “All on Four“ or other restorative option.

It’s not just the age. The expectations and available bone are the major selection factors.

Dr. Manuel prefers the Standard, 2 part, 2 stage implants since they give you the most reliable, flexible, long term option to your loose denture problem.

Other than some superficial stain removal, most of the whitening effect of bleaching comes fro