How do I compare bleach products?

There is a vast number of bleaching products out there. Anything from over the counter options, to doctor dispensed take-home trays, and in-office bleaching. But did you know that just because one bleach is labeled a higher percentage, it does not necessarily mean it is stronger?

Let’s talk about how to compare the strength of tooth whitening agents.

Not all tooth whitening is created equal. All bleaching agents break down into a gel form of hydrogen peroxide. This is what does the actual whitening, but that doesn’t mean it is hydrogen peroxide that is in your bleaching gel. The active ingredient in bleaching gel comes in two formations: Hydrogen peroxide and Carbamide peroxide. Hydrogen peroxide is already in its active form, carbamide peroxide breaks down into ⅓ the amount of hydrogen peroxide. That means a concentration of 30% Carbamide Peroxide to equal 10% Hydrogen Peroxide.

That asks the question, why bother with something that is only ⅓ as strong? The reason is the duration of action. If your bleaching agent’s active ingredient is hydrogen peroxide, then it is actively working for about 30-60 minutes before that hydrogen peroxide is spent. Carbamide peroxide breaks down much slower. That means it remains actively bleaching for up to 8 hours. Some types of stains need more contact time with the bleaching agent to be removed. Also, the slower bleaching process usually gives you less sensitivity. Both hydrogen peroxide and carbamide peroxide have been shown to have equal results in bleaching as long as the equivalent hydrogen peroxide percentage is the same.

There are multiple whitening options out there and knowing their relative strengths can help you decide what product is right for you. Typical over the counter bleaches you get from the store average about 6% hydrogen peroxide. The bleach gels your dentist dispenses for you to use in your custom trays are anywhere from 10%-35% carbamide peroxide. This is the equivalent of about 3% to 12% hydrogen peroxide. The in-office bleaching where you sit in the chair and we monitor your progress is about 30%-40% hydrogen peroxide. This is 3-4 times stronger than anything you can use at home. 

So which bleach option is the best? That depends on a lot of factors and we always look to cater those to the individual. Knowing what option is best for you starts with a thorough exam, so if you are interested in whitening please do not hesitate to call our office. I look forward to hearing from you!

When can YOU watch vs fill the tooth?

One of my jobs in dentistry is to let patients know what problems they have in their mouths. Most of the time this means telling a patient they have cavities or decay that need to be filled. Many patients ask me if the cavity is one that needs to be filled or can it be “watched”. So how do we determine if a cavity needs to be filled or watched, especially when the cavity is between the teeth?

Tooth Anatomy

Before we cover that, let’s take a brief look at the anatomy of a tooth. Teeth have 3 main layers: Enamel, Dentin, and Pulp tissue. Enamel is the hard white layer on the outside of the teeth that we can see. Enamel is fully mineralized and has no feeling. Dentin is the underlying layer that is mostly mineral but has some tubes that the pulp tissue runs through giving this layer feel. The pulp is the innermost layer of the tooth where the nerve and blood supply of the tooth live. 

We can “watch” and area if the cavity is less than ¾ of the way through the enamel. When a cavity is not past the ¾ mark we can stop the growth of the cavity with good oral hygiene, reducing sugar intake, and increasing the use of fluoride. This will help the minerals in our saliva re-harden that area. A filling needs to be done when a cavity extends over ¾ of the way through the enamel layer of the tooth. Once a cavity has made it this far into the tooth it cannot be halted or reversed, it will only get bigger over time. We can determine approximately how large a cavity is with a good x-ray. 

Dental Filling

In this example, the second to last tooth in the upper right of this x-ray has a small cavity on the back side that is less than half way through the enamel. This looks like a small grey triangle of half circle. On the front side of the same tooth, you will see a grey triangle that extends completely to the second layer (dentin) of the tooth. For this tooth, we would do a filling on the front side and monitor the backside.

Just like anything in dentistry, this rule is not 100% hard and fast. We have to look at the whole mouth, not each tooth individually. This means we may choose to fill some of these smaller areas if you are a high cavity risk patient. This means you have multiple other cavities or a history of new cavities forming quickly. This x-ray is of a patient that is at a high cavity risk. As you can see there are multiple teeth with grey triangles between the teeth. This is an example where we may choose to also fill some of those smaller areas. We may also opt to watch a slightly larger area if it is the only one in your mouth and you have a history of little to no other cavities. 

Hopefully, this gives you a little insight into how we make our treatment decisions. The first step to having a healthy mouth is getting an exam. So please give our office a call to make your appointment. I look forward to hearing from you!

I was told a need a deep cleaning, do I really need one?

Your dentist told you that you need a deep cleaning, but you have some questions. First and foremost you are probably wondering if you even need one. 

Unfortunately, this is the number one area that I see patients being taken advantage of. Deep cleanings, also known as scaling and root planing, are a vital procedure for people who need it, but it also gets heavily overused on people that do not need it. Especially in the corporate dentistry setting.

Let’s start with what a deep cleaning, or scaling and root planing, actually is. Scaling and root planing is the first line of treatment for someone with periodontal disease. Periodontal disease is defined by what we call attachment loss. It is the loss of the bone and associated structures that hold your teeth in. The most common visible sign is gum recession. Basically, the calculus or tartar build-up on your teeth works its way below the gums. This calculus is full of bacteria and causes inflammation of the gums and bone. This inflammation slowly destroys the bone that holds your teeth in. If left untreated, teeth will start to get loose, and eventually they will fall out or need to be extracted. Once this bone is gone there is no way to get it back. Scaling and root planing is the process of cleaning below the gums to remove this calculus and associated bacteria in order to allow the gums to heal and stop this process of bone loss.

There are specific ways we determine if someone needs a deep cleaning. First, we need a complete set of x-rays to evaluate your bone levels. We then use a small probe to measure the pockets in your gums around the teeth. In a person with healthy tissues, this pocket is typically about 3mm deep and the bone levels are normal. In a person with periodontal disease, we will see a reduction in the normal bone levels on the x-rays. We may actually see the calculus buildup on the x-rays if it is significant enough. We also will see pocket depths of 5mm and up in all or some areas of the mouth. 

How can you know if you really need a deep cleaning or if someone is trying to take advantage of you? Here are a few guidelines to try and help you out.  Have you been seeing a dentist regularly for cleanings every 6 months? If you have then rarely would you need a deep cleaning? I have seen some cases of neglect where a prior dentist never probed the patient’s gums, but this is pretty rare. Has it been a long time since you had a professional cleaning at a dentist? Even if you are diligent at brushing and flossing, we all still build up calculus. If it has been over 1-2 years since a cleaning, there is a high chance you have the beginnings of periodontal disease. Are your gums red and puffy or are they a nice pink color? Typically if you need a deep cleaning you will find some redness or puffiness around the edges of your gums. Do your gums bleed when your brush or floss? If they do then you could need a deep cleaning. Do you have a strong case of bad breath? Periodontal disease produces a particular odor that is very unpleasant. Did your dentist show you your x-rays and probing depths and thoroughly explain them to you? If they have not, or will not, it might be worth getting a second opinion.

Scaling and root planing is a necessary part of periodontal therapy, but it often is abused as a way for offices to make more money. I strongly believe that you should include your patients in the treatment planning process. That means showing you all of our x-rays and diagnostic findings. That way we are all on the same page and you feel comfortable starting treatment. If you are in need of an honest second opinion do not hesitate to contact our office. I look forward to meeting you!

Why did my dental crown fall off? 

Have you ever had one of your dental crowns come off? Why does that happen? There are actually quite a few reasons a crown can come off. Let’s look into what those are.

When a patient comes to me with a crown off, the first thing I ask is how long have you had the crown? If you have had the crown for a long time there are usually 3 reasons the crown has come off. The first is you may have some new cavity or decay starting under the crown. Cavities will destroy the good tooth structure under the crown and make it come loose. This means the best-case scenario is a new crown, the worst is an extraction if the decay is too extensive. The other option is if the crown has an open margin and was never properly sealed. Open margins allow saliva to seep in and eventually dissolve away the cement holding the crown on. If the crown has a poor seal then the best option is to make a new crown that does not have an open margin. The third option is the old cement just wore out. Nothing lasts forever and eventual cement can break down. If this is the case and the crown still fits well it can be recemented.

If the crown is newer then there are some other reasons that would cause a crown to come off. Like before, there could be an open margin leading to the cement washing out. Another reason has to do with how the tooth was prepared. To make sure a crown stays on we need 2 main things. We call them retention/resistance form and ferrule effect. What those terms mean is we need to shape the tooth in a way that prevents the crown from coming off and we need enough teeth to grab onto. When we shape a tooth for a crown we remove some tooth from the top and sides to allow the crown to slide into the prepared tooth. We want this prepared tooth to be as tall as possible and the walls of the tooth to be as parallel as possible. The prep would look similar to a top hat, with the brim of the hat being the margin the edges of the crown rest on and seal against, and the rest of the hat being the parallel walls and flat top of the rest of the prep. A tall vertical prep gives you a lot of teeth to grab onto and good resistance to chewing forces that try to push and pull the crown off. If your prepared tooth is too short or the walls are heavily tapered, this leaves us with less tooth to grab onto and less resistance to the pushing and pulling forces of chewing.

Dental Crown Loss

Poor preparation design can happen for 2 reasons. Sometimes the dentist has no choice. There are some times where the decay is so extensive we have to compromise our preparation design to try and save the tooth as opposed to extracting it, or your natural tooth is unusually short. If the prep is over tapered and too short and the decay was not particularly extensive then the problem is poor attention to detail by the dentist. Unfortunately, this is something I see more often than I would like to admit. Unfortunately, if someone has removed too many teeth we cannot get that tooth back. Therefore, trying to correct this can be a challenge and there is a combination of things we use to try and reshape the tooth. We will often drop our margins deeper below the gums to try and grab onto a more solid tooth structure. If possible we will try to reshape the walls to be more vertical. If that cannot be done then we will place vertical grooves into the tooth to make our own vertical walls to lock the crown on. 

Even with all these tricks, there are times where there is just not enough tooth to reliably work with and the only option is to remove the tooth and replace it with something like an implant or a bridge. A well-prepared crown should last you for many years. If you are having problems with a crown that came off or repeatedly comes off, please give us a call and we will be happy to go over the options of how we can properly restore your tooth. 

Will my teeth be sensitive after whitening?

Patients often ask me if bleaching will make their teeth sensitive. The honest answer is, we won’t know until we start bleaching. Everyone’s teeth respond differently to bleaching materials and everyone has a different level of baseline sensitivity. Typically if you are a person who already has sensitive teeth, it is safe to assume bleaching will probably make you a little more sensitive.

Typically you can assume that the stronger the concentration of the bleach you are using, the more likely you will have some sensitivity. Stronger bleach can penetrate farther into the tooth to remove stains, but this also gives it the potential to irritate the nerve in the tooth.

If you are experiencing sensitivity there are a few things you can do to help. You can switch to a sensitivity reducing toothpaste like Sensodyne. You can also start using this a week or two before you start bleaching for even better sensitivity protection. We can also prescribe a high fluoride gel you brush onto your teeth after bleaching which also helps with sensitivity. Another option is to bleach less often or for a shorter amount of time. If you are bleaching every day, then switch it up to every other day or every 2 days. If you wear your trays for an hour, shorten that to 30 minutes, or any combination of the above. Finally, if none of that works then we may need to use a lesser concentration of bleach material. While your results may not be as dramatic, it is better than painful sensitivity.

Everyone wants a whiter smile and bleaching is a safe and effective way to get one. Please give our office a call with any questions you may have about whitening. I look forward to hearing from you.

What are my bleaching options? 

You want to whiten your teeth, but there are so many products out there. Have you wondered what your options for bleaching are? There are three main categories to talk about when it comes to whitening. These three options are over-the-counter whitening products, dentist made bleach trays and in-office whitening. 

Over-the-counter teeth whitening strips are good for people who have very mild stains, are not in a huge rush to get whiter, and are prone to sensitivity because the bleaching agent is fairly mild. For people with heavier staining, these strips may not be strong enough to be effective. 

For a more professional teeth whitening option, custom-fit bleach trays are a great choice. Custom bleach trays are soft clear trays made by your dentist that allow you to use some of the stronger levels of bleach. This process starts with making a set of impressions of your teeth which are used to fabricate your custom-fit trays. You then use your bleaching gel in the trays and wear them anywhere from an hour to overnight. The bleach used in these trays can come in a variety of strengths to suit your particular needs. Bleach trays are good for people with heavier or more difficult to remove stains, people who are prone to sensitivity, and people who want to get whiter faster. The beauty of bleach trays is that you control the time and frequency of your bleaching. If you become sensitive you can bleach less often or for a shorter amount of time. 

In-office bleaching is for people who want to reach their bleaching goals as quickly as possible. You may have heard of Zoom teeth whitening. This is one example of in-office bleaching. In-office bleaching can be delivered in a variety of ways, but what makes it special is the strength. Due to its strength, we supervise the placement of the gel and monitor your sensitivity as we do multiple rounds of bleaching. In-office whitening can remove stains more quickly and remove deeper, more challenging stains that other products cannot. The trade-off is a higher chance of tooth sensitivity. 


When you are missing all your teeth or the time has come to remove what teeth you have left, there are 3 main types of dentures that might be right for you. One option is a traditional denture. This is an acrylic base with acrylic teeth that rests on the gums. Traditional dentures are typically held in by suction or adhesive. Their fit can vary greatly depending on the person’s individual anatomy.

Another option is a snap-in denture. This involves placing 2-4 implants in each arch and fitting snap attachments into a denture. Since it is now the snap-in attachments holding the denture in place, we often can shorten all the edges of your denture and sometimes, in an upper denture, remove the area that covers the roof of the mouth. These attachments greatly improve the fit and remove the need for any adhesive. You will still have the ability to take your dentures in and out yourself, making them very easy to clean.

The final option to replace an entire arch of teeth is called an all on 4 or permanent denture. For a permanent denture, we place 4 implants and permanently affix an arch of teeth to those implants. This is as close to natural teeth as we can get when it comes to replacing a full arch of teeth. You cannot take them out yourself because you need special tools to remove the screws that fix the teeth to the implants. 


Partial Dentures


Partial dentures are an alternative for people missing multiple teeth that do not want dental bridges or implants. A partial denture is one piece, similar in design to a denture, with clasps or hooks that grab on to the teeth next to the areas we want to fill in. Since they are able to grab on to existing teeth, they do not need adhesive and tend to fit quite well. The more teeth we have to adequately clasp on to, the more stable your partial denture will be. While they have a much better fit than traditional dentures, they do suffer from some of the same problems. A partial denture can rock or move when eating and will cover the roof of the mouth when used to replace upper teeth. Partial dentures are also commonly used to temporarily restore a missing tooth while an implant is healing.

What is a Dental Crown?


A dental crown is one of our more common procedures to restore a tooth that needs more than just a filling. The purpose of a crown is to hold a tooth together and prevent it from breaking. This is needed when you either have a large cavity, a large filling, or a large part of the tooth is missing due to breakage. When there is not enough tooth to hold a filling, then you need to cover it with a crown to hold it all together. Think of a dental crown as a new outside layer for the tooth. It is cemented over your existing tooth to give it back its shape and strength.


What is the procedure?


The dental crown procedure involves removing a set amount of tooth structure from the top and sides of the tooth. We are creating a shape that lets us slide the crown over the existing tooth. Once your tooth has been appropriately shaped, we will then take an impression of that prepared tooth. This impression, or mold, of your tooth, is what the lab will use to fabricate your new crown. We will then make you a temporary crown to wear until we receive your permanent crown from our lab. Once your crown is back, we take off the temporary, make any adjustments to your new crown to make sure it fits properly, then permanently cement it on.


Types of Dental Crowns


While all dental crowns serve the same purpose, there are a few different types of materials they can be made of. Each one has its own set of strengths and weaknesses. The main types of crowns used today are Full Zirconia, Veneered Zirconia, Lithium Disilicate, and Porcelain Fused to Metal.


Full Zirconia (BruxZir)

Full Zirconia is an all Ceramic/Metal free crown. It is currently one of the strongest crown materials we have and is mostly used on back molars and back tooth bridges. It only needs a minimal amount of tooth to be removed and its esthetics are good, but there are better-looking options.


Lithium Disilicate (Emax)

This is another all Ceramic/Metal free crown. It has very good strength but is not as resilient as full Zirconia restorations. It is used for premolars and front teeth and short bridges in the front. It has very good esthetics.


Layered Restorations

Another type of all Ceramic/Metal free crown. The inner core is either Emax or Zirconia with traditional feldspathic porcelain layered on the outside. This gives you excellent esthetics for difficult to match front teeth. Strength is good due to its core material, but the esthetic layer of traditional porcelain has a higher chance of chipping or breaking, especially along the edge of front teeth.


Porcelain fused to metal

This type of dental crown has a metal core with a traditional feldspathic porcelain outer layer. This type of dental crown has been used for decades in dentistry. It has good strength with good esthetics and is best for long bridges due to the strength of its metalcore. Its largest downfall is the gum recession. If you experience any gum recession the metal layer will become visible. When this metal layer starts to show it causes a visible gray line along the gums. Another problem is the traditional porcelain layer can chip allowing that grey metal to show through.


Dental Crown Cost

The question of how much does a dental crown cost can vary depending on your insurance coverage. If you have insurance, your out-of-pocket cost can range anywhere from about $600 to $800 depending on your particular plan. Without insurance, the cost of a crown can range anywhere from $1000 to $1800. At Bellingham Family Dentistry we take most major PPO insurances and have an in-house discount plan to help those without insurance.

What is a Dental Bridge?


A dental bridge is one of the ways we can replace a missing tooth or teeth. To replace a tooth with a dental bridge, you must have a tooth on each side of the space where you are currently missing a tooth. The process is very similar to the one used to crown a tooth. We prepare the tooth on each side of the space in the same way we would for a crown. We then make an impression of these prepared teeth. This is what the lab uses to make a permanent bridge. We will then make you a temporary bridge to wear while the lab fabricates your permanent dental bridge. To deliver your permanent bridge, we will remove your temporary and adjust the permanent bridge to ensure a proper fit. If we are happy with the look and fit, we then permanently cement the bridge.


Dental Bridge vs Implant


Dental bridges and implants are both great options for replacing a missing tooth and each has its own pros and cons. For this example, we will talk about a bridge or implant that replaces a single missing tooth.

The advantages of dental bridges typically involve cost and time. If you have insurance, they will typically cover a portion of the cost of a dental bridge. Also, the process of a dental bridge is typically completed in less time than an implant since we are not waiting for anything to fuse to the bone.

           The cons of dental bridges typically involve problems with the teeth you have attached the bridge to. Any time you prepare a tooth for a crown or bridge there is a chance one or both could end up needing a root canal. Dental bridges are also more challenging to clean than a single implant. If not kept clean you will have a higher chance of getting new cavities on one or both of the teeth used for the bridge. These new cavities will require removing the old bridge to clean out the decay and fabrication of a new bridge. If extensive, these cavities can cause the loss of one or both of the teeth the bridge is connected to. Periodontal disease can also start around the bridge if it is not properly cleaned. This can also lead to the loss of one or both teeth involved with the dental bridge.

Dental implants are another great option for replacing a missing tooth. The main advantage of an implant is its inability to decay or get cavities. Single implants are also easier clean and maintain than a dental bridge. You can brush and floss a single implant like you would any other tooth since it is not attached to adjacent teeth. Rarely do implants have complications involving the teeth on either side of the space you are filling in since those teeth are not being utilized in any way.

Implants typically have very few disadvantages. They mostly involve cost and time. Most insurances typically have little to no implant coverage which means you will be paying for the majority of the cost on your own. Another thing to consider is the time needed to complete treatment. Once placed, an implant needs to sit undisturbed for anywhere from 3-6 months before a crown can be placed on it. This is how much time it takes for your jaw bone to fuse to the implant, allowing it to be stable enough to chew with. Hygiene is also very important for any implant. Just because an implant cannot get cavities, does not mean you do not have to keep it clean. Anyone can develop periodontal disease and bone loss around teeth and implants without proper hygiene. This bone loss can happen twice as fast around an implant compared to natural teeth. If left unchecked this will lead to the loss of the implant. If you lose enough bone you may no longer have enough to place a new implant, potentially making that space impossible to fill.

If you are a numbers person, the 5 and 10-year survival rate of implants is typically about 97% and 95% respectively. The 5 and 10-year survival rates for dental bridges are around 95% and 90% respectively.


How much does a dental bridge cost?


The cost of a dental bridge is determined by how many teeth are involved. Again we will use our example of replacing a single tooth. This would be considered a 3 unit bridge as it involves the teeth on each side of the space and the one we are replacing. If you have insurance, then a bridge of this type would range from approximately $1800 to $2700. Your out of pocket portion will vary depending on your insurance plan. Without insurance, the cost of this same bridge would range from approximately $3000 to $5400. At Bellingham Family Dentistry we take most major PPO insurance plans and have an in-house discount plan to help those without insurance.

What is a root canal?


A root canal procedure is what is done to remove the dead or dying pulp tissue from a tooth. A root canal treatment is needed when you have a tooth that is causing pain when you chew, is very sensitive to cold, is causing swelling, or has radiographic evidence of infection at the tip of the tooth root. The tooth pulp is the nerve and blood supply that gives a tooth feeling.  The pulp comes up from the jaw bone, through small hollow canals in the tooth roots, into a chamber or box in the center of the tooth. It also has tiny little extensions that go all throughout the underlying layer of the tooth.

The reason you need a root canal is that the pulp tissue is dying or has died inside the tooth. Pulp tissue dies when it is exposed to bacteria or trauma. This can happen in a few ways. The most common is from cavities. If a cavity gets large enough, the bacteria from the cavity invade the pulp and begin the process of killing it off. Another way is from a cracked or broken tooth. If the crack is large or deep enough, this can provide a path for bacteria to make it into the pulp. There are also some unusual times where we find a tooth has died and we just don’t know why.


Why does my tooth hurt?


As the pulp dies the tooth becomes very temperature sensitive and aches and throbs. Once that pulp tissue dies it starts to rot. Then all that bacteria and byproducts leak out of the chamber and down the canals in the roots to your jaw bone. This causes inflammation and infection in the bone leading to pain, swelling, and eventually an abscess.


How do we treat it? 


The only way to treat a dead or dying tooth is to remove all the dead and dying pulp tissue. We then have to clean and seal the canal and pulp chamber.

The typical process starts to get the tooth numb. We then make a small hole in the tooth to access the pulp chamber (box it sits in) and use a series of instruments and medications to remove and clean out all the dead material and bacteria from inside the tooth. We then seal and fill the roots and chamber. Finally, we close up the tooth with a filling. Depending on the size of the access hole and amount of decay the tooth had, we often have to cover the tooth with a crown to keep it from breaking when you chew.


How long do root canals take?


A root canal can take anywhere from 45 minutes to 2 hours depending on the anatomy of the tooth and the severity of the infection.


Root canal recovery: What to expect afterward.


It is normal to have some pain after a root canal.  The tooth will be a little sore from all that work. This typically can be a dull ache for a few days and some tenderness if you bite on it. Depending on the severity of the infection, we may prescribe some antibiotics to make sure any lingering bacteria are taken care of.  After some healing time, the tooth will return to feel just like any other tooth.


Root canal cost


The cost of a root canal varies on what tooth is being treated and if you have insurance. The average cost of a root canal is anywhere from around $400 up to $1500 depending on the tooth if you have insurance, and what your particular insurance fee schedule is.