Teeth Discolouration

Prestige Dental Care

Topics

  • Tooth Colour
  • Tooth Discolouration
  • Extrinsic Causes
  • Intrinsic Causes

Tooth Colour

Tooth color is determined by a combination of phenomena associated with optical properties and light. Essentially, tooth color is determined by the color of dentin and by intrinsic and extrinsic colorations. Intrinsic color is determined by the optical properties of enamel and dentin and their interaction with light. Extrinsic color depends on material absorption on the enamel surface. Any change in enamel, dentin, or coronal pulp structure can cause a change of the light-transmitting properties of the tooth – teeth discolouration.

Tooth Discolouration

Tooth discoloration varies in etiology, appearance, location, severity, and affinity to tooth structure. It can be classified as:

  • extrinsic
  • intrinsic
  • or a combination of both

according to its location and etiology.

Extrinsic Causes

Mouthwash (Chlorhexidine) staining

The principal causes are chromogens (colour agent) derived from habitual intake of dietary sources, such as wine, coffee, tea, carrots, oranges, licorice, chocolate, or from tobacco, mouth rinses, or plaque on the tooth surface.

Extrinsic staining caused by tobacco and coffee

The most commonly used procedure to remove discoloration from a tooth surface is by using abrasives (such as prophylactic pastes) or a combination of abrasive and surface active agents such as toothpastes. These methods prevent stain accumulation and to a certain extent remove extrinsic stains; however, satisfactory stain removal depends on the type of discoloration. Unfortunately, the chemical interactions that determine the affinity of different types of materials that cause extrinsic dental stains are not well-understood.

Intrinsic Causes

Unlike extrinsic discolorations that occur on the surface, intrinsic discoloration is due to the presence of chromogenic (coloured) material within enamel or dentin, incorporated either during tooth developing (odontogenesis) or after eruption. This type of stain can be divided into 2 groups, preeruptive and posteruptive. The most common type of pre-eruptive staining is endemic fluorosis caused by excessive fluoride ingestion during tooth development. Post-eruptive stain usually associated with pulp problems such as pulp necrosis, or root canal material. Generally, intrinsic stain can be divided into:

Systemic causes are

  • drug-related (tetracycline), excessive fluoride ingestion;
  • metabolic: dystrophic calcification, fluorosis;
  • genetic: congenital erythropoietic porphyria, cystic fibrosis of the pancreas, hyperbilirubinemia, amelogenesis imperfecta, and dentinogenesis imperfecta

Intrinsic staining: Tetracycline staining

Intrinsic staining: Fluorosis

Local causes are

  • pulp necrosis,
  • intrapulpal hemorrhage,
  • pulp tissue remnants after endodontic therapy (RCT),
  • endodontic/RCT materials,
  • coronal filling materials (eg. Crown, filling material),
  • root resorption,
  • aging

Intrinsic staining: Non-vital tooth

Intrinsic staining: Intrapulpal hemorrhage

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Non-vital (Internal) Bleaching

Prestige Dental Care

Topics

  • Internal Bleaching
  • ‘Walking bleach’ technique
  • Complication
  • Limitation

Internal bleaching procedures are performed on devitalized (dead) teeth that have undergone root canal therapy (or RCT) but are discolored due to internal staining of the tooth structure by blood and other fluids that leached in. Unlike external bleaching, which brightens teeth from the outside in, internal bleaching brightens teeth from the inside out.

Yellow-brown discoloration of tooth after RCT treatment and the clinical results after 3 applications of the walking bleach technique.

Bleaching the tooth internally involves drilling a hole to the pulp chamber, cleaning, sealing, and filling the root canal with a rubber-like substance, and placing a peroxide gel into the pulp chamber so the gel can work directly inside the tooth on the dentin layer.In this variation of whitening the peroxide is sealed within the tooth over a period of some days and replaced as needed, the so called “walking bleach” technique.

‘Walking bleach’ technique

  1. Before treatment a radiograph would be made to check the quality of the root filling.
  2. The quality and colour (shade) of any restoration present are assessed.
  3. Tooth colour was evaluated and clinical photographs were taken at the beginning  of and throughout the procedure.
  4. Rubber dam should applied to isolate the treated tooth, to prevent reinfection of the root canal, and to protect the adjacent structures from the bleaching agent.
  5. The restorative and the obutarating material was removed until below gum margin
  6. A layer of cement was applied on top of the obturating material.
  7. Bleaching agent: sodium perborate mixed with 30% hydrogen peroxide into paste form was be loaded into the pulp chamber of the tooth.
  8. Finally, a temporary restoration was used to cover the cavity
  9. The patient was rescheduled approximately 1 month later and the procedure was repeated 2 to three times.

Walking bleach, A, Internal staining of dentin caused by remnants of obturating materials (OM) in the chamber as well as by materials and tissue debris in pulp horns (PH). B, Coronal restoration is removed completely. C, A protective cement base (B) is placed over the gutta-pecha. A paste (P) of sodium perborate and hydrogen peroxide is placed. D, A thick mix of temporay cement (Z) seals access. E, At a subsequent appointment when the desired shade reached, a permanent cement is placed (TS) at the pulp chamber and composite resin (C) to seal of the access

Complication

External resorption – Internal bleaching occasionally induces external cervical root resorption. Chemicals combine with heat are likely cause necrosis of the cementum, inflammation of the periodontal ligament, and root resorption.

Crown (Coronal) fracture – Increased brittleness of the crown part of the tooth, particularly when heat is applied resulting in the tooth is more susceptible to fracture.

Chemical burn – 30% hydrogen peroxide is caustic and will cause chemical burns and sloughing of gingiva. Therefore, rubber dam is needed to protect the gum from chemical burn.

Limitation

Even though internal bleaching can produce satisfactory result in most cases, no all will achieve the desirable result. Therefore,  other options such as full porcelain crown, porcelain veneer will be the alternative to whiten non-vital tooth!!

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Root canal therapy

Full porcelain crown

Porcelain Veneer

Resin Veneer

Complications of Dental Extraction

Complications of dental extraction

Infection: Although rare, it does occur. The dentist may opt to prescribe antibiotics pre- and/or post-operatively if they determine the patient to be at risk.

Prolonged bleeding: The dentist has a variety of means at their disposal to address bleeding; however, it is important to note that small amounts of blood mixed in the saliva after extractions are normal, even up to 72 hours after extraction. Usually, however, bleeding will almost completely stop within eight hours of the surgery, with only minuscule amounts of blood mixed with saliva coming from the wound. A gauze compress will significantly reduce bleeding over a period of a few hours.

Swelling: Often dictated by the amount of surgery performed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth). Generally, when a surgical flap must be elevated (i.e. and the periosteum covering the bone is thus injured), minor to moderate swelling will occur. A poorly-cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone, will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur.

Sinus exposure and oral-antral communication: This can occur when extracting upper molars (and in some patients, upper premolars). The maxillary sinus sits right above the roots of maxillary molars and premolars. There is a bony floor of the sinus dividing the tooth socket from the sinus itself. This bone can range from thick to thin from tooth to tooth from patient to patient. In some cases it is absent and the root is in fact in the sinus. At other times, this bone may be removed with the tooth, or may be perforated during surgical extractions. The doctor typically mentions this risk to patients, based on evaluation of radiographs showing the relationship of the tooth to the sinus. It is important to note that the sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but remains intact, a “sinus exposed” has occurred. If the membrane is perforated, however, it is a “sinus communication”. These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own or may need to surgically obtain primary closure—depending on the size of the exposure as well as the likelihood of the patient to heal. In both cases, a resorbable material called “gelfoam” is typically placed in the extraction site to promote clotting and serve as a framework for granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, as well as careful instructions to follow during the healing period.

Nerve injury: This is primarily an issue with extraction of third molars, but can occur with the extraction of any tooth should the nerve be close to the surgical site. Two nerves are typically of concern, and are found in duplicate (one left and one right): 1. the inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. 2. The lingual nerve (one right and one left), which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch). Such injuries can occur while lifting teeth (typically the inferior alveolar), but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary, but depending on the type of injury (i.e. Seddon classification: neuropraxia, axonotmesis, & neurotmesis), can be prolonged or even permanent.

Displacement of tooth or part of tooth into the maxillary sinus (upper teeth only). In such cases, almost always the tooth or tooth fragment must be retrieved. In some cases, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the Canine fossa–a procedure referred to as “Caldwell luc”.

Dry socket (Alveolar osteitis) is a painful phenomenon that most commonly occurs a few days following the removal of mandibular (lower) wisdom teeth. It is commonly believed that it occurs because the blood clot within the healing tooth extraction site is disrupted. More likely,alveolar osteitis is a phenomenon of painful inflammation within the empty tooth socket because of the relatively poor blood supply to this area of the mandible (which explains why dry socket is usually not experienced in other parts of the jaws). Inflamed alveolar bone, unprotected and exposed to the oral environment after tooth extraction, can become packed with food and debris. A dry socket typically causes a sharp and sudden increase in pain commencing 2–5 days following the extraction of a mandibular molar, most commonly the third molar. This is often extremely unpleasant for the patient; the only symptom of dry socket is pain, which often radiates up and down the head and neck. A dry socket is not an infection, and is not directly associated with swelling because it occurs entirely within bone — it is a phenomenon of inflammation within the bony lining of an empty tooth socket. Because dry socket is not an infection, the use of antibiotics has no effect on its rate of occurrence. The risk factor for alveolar osteitis can dramatically increase with smoking after an extraction.

Bone fragments Particularly when extraction of molars is involved, it is not uncommon for the bones which formerly supported the tooth to shift and in some cases to erupt through the gums, presenting protruding sharp edges which can irritate the tongue and cause discomfort. This is distinguished from a similar phenomena where broken fragments of bone or tooth left over from the extraction can also protrude through the gums. In the latter case, the fragments will usually work their way out on their own. In the former case, the protrusions can either be snipped off by the dentist, or eventually the exposed bone will erode away on its own.

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Bone Graft

Dental-Implant

What is bone graft in dentistry?

bone block

Bone Block

bone graft

Bone Graft

 

Bone graft is a material that used to replace missing bone or bone defect in the face and mouth region, particularly in jaw area for support of  implant during implant placement. Bone graft can also be use support the cheek or the chin area for aesthetic reasons.

Usage of bone graft in dentistry:

  • Orthognathic (Corrective jaw surgery) Surgery
  • Alveolar Bone Grafting (ABG) procedure in cleft patient
  • Periodontal surgery (eg. Guided Bone Regeneration)
  • In implant dentistry, bone grafts are widely used  in:
    • Sinus augmentation
    • To preserve the socket after dental extraction of implant placement later
    • To repair defect after dental extraction
    • To cover exposed implant fixture during implant placement

Bone augmentation is a term that describes a variety of procedures used to “build” bone so that dental implants can be placed.

 

Bone graft was use during open sinus augmentation

Bone graft was use during open sinus augmentation

When do we use bone graft in implant surgery?

Bone graft is used when there is not enough of bone at the site where implant is intended to be placed. Usually, when the width or the height of the jaw bone is not enough to support the placement of implant.

Bone graft can be obtain from outside or from patient’s own bone (autologous bone). Autologous bone is the best bone to substitute missing bone due to its high survival rate  and its capability of attract new bone formation.

 

Bone-graft-procedure

Xenograft material was used to graft bone defect after implant placement

 

Bone graft sources

Autograft (Autogenous Bone)

Autologous bone grafting involve taking bone graft from patient’s bone of the  same individual who is receiving the graft. Bone can be harvested from intra-oral (in mouth) or extra-oral (outside the mouth); example iliac crest, rib, cavarium.
In oral and maxillofacial surgery, bones are harvested extra-oral under general anaesthesia to repair alveolus in cleft patient, reconstruct mandible or maxilla after tumor resection, condyle reconstruction etc.
 
autologous-bone-graft

Autologous bone graft taken from the external ridge of the ramus of lower jaw

In implant dentistry, the usual site in the mouth that used to get bone graft (Donor site) usually depends on surgeon preference, the quality and quantity required:

  • External oblique ridge (bone behind the lower last molar)
  • Chin area
  • Tuberosity (bone behind the upper last molar)

Advantages of autograft:

  • Less rejection because graft originated from the patient’s own body
  • The graft doesn’t carry any disease
  • Using autograft bone as grafting material produce the highest successful outcome and predictability because the graft is a vital (living) bone which has the property of  osteoinductive and osteogenic, as well as osteoconductive to regenerate new bone.

Disadvantages:

  • Additional surgical site is required (2 site surgery)
  • Post-operative pain and complications

 

Allografts

Allograft bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone can be taken from cadavers that have donated their bone so that it can be used for living people who are in need of it.

puros-from-zimmer

Puros from Zimmer is allograft bone particles

 

There are three types of bone allograft available:

  1. Fresh or fresh-frozen bone
  2. Freeze-dried bone allograft (FDBA)
  3. Demineralized freeze-dried bone allograft (DFDBA)

Allograft bone used in dentistry uses bone from cadaver that undergo process of removal of unwanted material such as fats, cells, antigens, and inactivates pathogens, while preserving the valuable minerals and collagen matrix. This material is than freeze-dried before package.

Advantages of allograft:

  • Less antigenic rejection because allogaft bone originated from the same species
  • No need additional surgical site is required (2 site surgery)
  • The success of grafting using allograft will be lesser than autograft as the material used is basically a dead tissues
  • However, this material still carry property of  osteoinductive and osteoconductive to regenerate new bone

Disadvantages:

  • Allograft bone might carry certain unknown diseases that resist the cleaning process during preparation of the graft
  • The graft usually resorb faster than xenograft material
  • Additional cost to the surgery

Xenografts

Xenograft bone substitute has its origin from a species other than human, such as bovine bone (or recently porcine bone) which can be freeze dried or demineralized and deproteinized. This material still has the property of  osteoinductive and  osteoconductive to regenerate new bone.

 

Bio-oss

Bio-Oss from Geislich contains xenograft material

Advantages of xenograft:

  • No need additional surgical site is required (2 site surgery)
  • This material still carry bone regeneration property of  osteoinductive and osteoconductive.
  • However,  success of grafting using xenograft will be lesser than autograft as the material used is basically a dead tissues
  • Xenograft material last longer in the mouth therefore, it with maintain the bone thickness for years

Disadvantages:

  • Just like allograft, xenograft material might carry certain unknown diseases that resist the cleaning process during preparation of the graft
  • Additional cost to the surgery

 

Alloplastic grafts

Alloplastic grafts may be made from hydroxylapatite, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass. Hydroxylapatite is a Synthetic Bone Graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone.

 

boneceramic

BoneCeramic isone of the example of alloplastic graft

 

Some synthetic bone graft are made of calcium carbonate, which start to decrease in usage because it is completely resorbable in short time which make the bone easy to break again.

Tricalcium phosphate which now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability.

Polymers such as some microporous grades of PMMA and various other acrylates (such as polyhydroxylethylmethacrylate aka PHEMA), coated with calcium hydroxide for adhesion, are also used as alloplastic grafts for their inhibition of infection and their mechanical resilience and biocompatibility. Calcifying marine algae such as Corallina officinalis have a fluorohydroxyapatitic composition whose structure is similar to human bone and offers gradual resorption, thus it is treated and standardized as “FHA (Fluoro-hydroxy-apatitic) biomaterial” alloplastic bone grafts.

 

Biological mechanism

Properties of various types of bone graft sources.
  Osteoconductive Osteoinductive Osteogenic
Alloplast +
Xenograft +
Allograft + +/–
Autograft + + +

Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis.[1]

Osteoconduction

Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.

Osteoinduction

Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteins (BMPs). A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft.

Osteopromotion

Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example, enamel matrix derivative has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft (DFDBA), but will not stimulate de novo bone growth alone.

Osteogenesis

Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms.

 

 

Air Polishing with EMS:Air Flow®

Air polishing is an alternative, non-contact, method of polishing teeth using a polishing cup and paste after teeth scaling. It requires a special ultrasonic unit (e.g. Air Flow from EMS) that allows use of this insert in the handpiece.

Air polishing uses medical-grade sodium bicarbonate and water in a jet of compressed air to “sandblast” the surface of the enamel smooth. Examples include the Prophy-Jet® and Cavitron Jet® (Dentsply Ltd.). The nozzle is held 3 to 5 mm from the tooth, centred on the middle third of the tooth. Use at 60° to the long axis of the root. Do not direct into the gingival sulcus.

Air polishing with EMS Air Flow®

Before air polishing

Afer air polishing

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ZOOM!! Whitening System

ZOOM!! Whitening System

The Zoom! ™ In-Office Whitening System is a revolutionary tooth whitening procedure. It’s safe, effective and fast, very fast. In just over an hour, your teeth will be dramatically whiter. Zoom!™ Whitening is ideal for anyone looking for immediate results. The convenience of Zoom!™ in comparison to days of wearing trays and gradual whitening makes it the perfect choice for the busy individual.

Get ready to Zoom!

The Zoom! ™ Whitening procedure is simple and painless. It begins with a short preparation to isolate your lips and gums. The Zoom! ™ clinician then applies the proprietary Zoom!™ Whitening Gel, which is activated by a specially designed light. Teeth typically become at least six to ten shades whiter, sometimes more. A fiveminute fluoride treatment completes the procedure. You’ll be amazed with the results. In most cases, teeth get even whiter the first few days after the procedure.

How Zoom! works

The Zoom!™ light activated gel was developed after years of research by Discus Dental, the leaders in professional take-home tooth whitening. The gel is a scientifically formulated, pH balanced Hydrogen Peroxide that, when activated by the Zoom!™ light, gently penetrates the teeth to remove deep stains and discoloration. With proper care and an occasional touch-up at home, your whiter smile will sparkle for years.

Zoom! Teeth Whitening procedure

The Zoom! Whitening procedure is simple. It begins with a short preparation to isolate your lips and gums.

Isolation of lips and gums before bleaching

The accredited and trained dentist then applies the proprietary Zoom Whitening Gel, which is activated by a specially designed light.

Activation of bleaching gel with Whitening Lamp

Teeth typically become at least six to twelve shades whiter, sometimes more. A fluoride treatment for a few minutes completes the procedure. You’ll be amazed with the results. In most cases, teeth get even whiter the first few days after the procedure. We recommend a consultation and a thorough clean around one or two weeks before the Zoom! Teeth Whitening procedure if you have tartar or superficial stains.

Tune in to Zoom!

Ask your dental professional how the Zoom!™ In-office Whitening System will work for you. Take your first step to feeling good, looking great and making a memorable impression every time you smile. You owe it to yourself!

Frequent Asked Questions

Q. What is Zoom!™ tooth whitening?

A. Zoom!™ is a bleaching process that lightens discoloration of enamel and dentin.

Q. What causes tooth discoloration?

A. There are many causes. The most common include aging and consumption of staining substances such as coffee, tea, colas, tobacco, red wine, etc. During tooth formation,  consumption of tetracycline, certain antibiotics or excessive fluoride may also cause tooth discoloration.

Q. Who may benefit from tooth whitening?

A. Almost anyone. However, treatment may not be as effective for some as it is for others. Your dental professional can determine if you are a viable candidate for this procedure through a thorough oral exam, including a shade assessment.

Q. Do many people whiten their teeth?

A. More people than you might imagine. A bright, sparkling smile can make a big difference for everyone. The Zoom!™ Whitening System makes it easier and faster than ever before.

Q. Is whitening safe?

A. Yes, extensive research and clinical studies indicate that whitening teeth under the supervision of a dentist is safe. In fact, many dentists consider whitening the safest cosmetic dental procedure available. As with any tooth whitening product, Zoom!™ is not recommended for children under 13 years of age and pregnant or lactating women.

Q. How does Zoom!™ work?

A. The Zoom!™ light-activated whitening gel’s active ingredient is Hydrogen Peroxide. As the Hydrogen Peroxide gel is broken down, oxygen enters the enamel and dentin bleaching colored substances, while the structure of the tooth is unchanged.

Q. What does a patient experience during the  Zoom!™ procedure?

A. During the procedure, patients may comfortably watch television or listen to music. Many actually fall asleep. Individuals with a strong gag reflex or anxiety may have difficulty undergoing the entire procedure.

Q. How is exposure to the Zoom!™ light controlled?

A. The Zoom!™ procedure requires that all soft tissue in and around the mouth be protected. The clinician is required to monitor the procedure to insure any exposed skin or tissue is isolated and protected. Protective eyewear is required during the procedure. Light sensitive individuals including those undergoing PUVA therapy (Psoralen+UV Radiation) or other photochemotherapy, as well as patients with melanoma, should not undergo the Zoom!™ in-office procedure. Also, patients taking any light sensitive drugs or substances, whether over-the-counter, prescription or homeopathic, should consult their primary physician prior to procedure.

Q. How long does Zoom!™ Whitening take?

A. The complete procedure takes just over an hour. The procedure begins with a preparation period followed by one hour of bleaching. A five minute fluoride treatment completes the procedure. (A cleaning is recommended prior to the actual Zoom!™ Whitening session)

Q. Are there any side effects?

A. Sensitivity during the treatment may occur with some patients. The Zoom!™ light generates minimal heat which is the usual source for discomfort. On rare occasions, minor tingling sensations are experienced immediately after the procedure but always dissipate.

Q. How white will my teeth become ?

A. The results are spectacular. Clinical studies have shown that the Zoom teeth whitening treatment achieves up to 12 shades lighter with the average being 8 shades (On Vita-Shade guide). Individual results may vary and will depend upon your age, type of stain, initial tooth colour and any visible restorations (White fillings, crowns etc). Please ask our qualified dental staff how much whiter your teeth can be and we will show you what is possible on a tooth shade guide as shown below.To boost your results we recommend using custom made whitening trays for only 30 minutes a day for 5 to 10 days.

Some whitening clinics will only recommend either surgery whitening or home whitening. We have found that combining both methods is the best way to get the most dramatic results and keep them for life.

Vita Shade Guide

Q. How long do the results last?

A. By following the Zoom!™ Post Whitening Care Instructions, your teeth will always be lighter than they were prior to the procedure. The Zoom!™ whitening procedure includes a take-home touch-up kit and trays that can be used whenever discoloration is noticed. Most often a touch-up once a year will maintain a whiter smile that sparkles for years.

A Note of Assurance

Tooth whitening is a well-established procedure in cosmetic dentistry. Hydrogen Peroxide, the active agent in Zoom!,™ has also been safely used for many years in the treatment of gums and other oral soft tissue. The whitening process is effective on most discolored teeth. Darker stains, such as those caused by antibiotics, are more difficult to whiten. The degree of whiteness will vary from patient to patient, depending on the structure of the teeth. If you have any questions, please ask your dental professional who is there to help maximize your smile using the Zoom!™ Whitening System.

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Electrosurgery

What is Electrosurgery?

Electrosurgery is the application of a high-frequency electric current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue. (These terms are used in specific ways for this methodology—see below). Its benefits include the ability to make precise cuts with limited blood loss. Electrosurgical devices are frequently used during surgical operations helping to prevent blood loss in hospital operating rooms or in outpatient procedures.

In electrosurgical procedures, the tissue is heated by an electric current. Although electrical devices may be used for the cauterization of tissue in some applications, electrosurgery is usually used to refer to a quite different method than electrocautery. The latter uses heat conduction from a probe heated to a glowing temperature by a direct current (much in the manner of a soldering iron). This may be accomplished by direct current from dry-cells in a penlight-type device. Electrosurgery, by contrast, uses alternating current to directly heat the tissue itself. When this results in destruction of small blood vessels and halting of bleeding, it is technically a process of electrocoagulation, although “electrocautery” is sometimes loosely and nontechnically used to describe it. (Source from Wiakipidia)

Electrosurgery unit

Using electrosurgery in oral surgery procedures

Electrocautery is a very useful tool to make a cut or excise soft tissue just like a scaple blade does. While a cut is made; at the same time, electrosurgery coagulate the surrounding blood vessels make surgery bloodless. This will improve visibility during surgery and less blood loss. More over, healing of a wound with electrosurgery is proven to be faster that wound made by scaple blade.

Electrosurgery: Coagulating the gum area before impression taking during tooth preparation for crown fabrication

Dental procedure which can be done with

  • Excision of  lesions (eg. cysts, tumors)
  • Gum surgery
  • Implant placement
  • Crown lengthening
  • Coagulating the gum area before impression taking during tooth preparation for crowns/bridges

Advantages of using electrocautery

  • Less bleeding
  • Can be use to control bleeding
  • Wound heal faster with electrosurgery than using scaple blade

Oral Sedation

Oral Sedation – Anti-Anxiety Medication

Oral sedation dentistry is a medical procedure involving the administration of oral sedative drugs (usually in the form of a tablet), generally to facilitate a dental procedure and reduce patients fear and anxiety related to the experience. It is the most commonly used method in relieving anxiety before a dental appointment. An anti-anxiety or a sleeping pill can be taken the night before the appointment, an hour before going to bed can help with falling asleep and getting some rest; or it can be just taken an hour before dental treatment.

 

Anti-Anxiety Pills (Benzodiazepines or “Benzos”)

In dentistry, the most commonly prescribed drugs for anxiety belong to the “benzodiazepine” family (eg. diazepam, triazolam, zaleplon, lorazepam, and hydroxyzine). You’ve probably heard of them by their tradenames – for example, Valium, Halcion, Xanax, or Ativan.

Benzos decrease anxiety by binding with receptors in the brain which tone down activity in those parts of the brain responsible for fear.

Travel warning!

You shouldn’t travel on your own after you’ve taken benzodiazepines – make sure you have an escort, even if you’re walking there! It’s easy to become disorientated and miss your stop if going by bus or train, or walk straight in front of a car – or you might even forget that you’re on your way to your dentist’s clinic.  So find someone to accompany you. And please don’t pop pills and drive!

Benzodiazepines has two main fuctions:

  1. Sedative-Hypnotics: drugs which induce drowsiness (“sedation”). In higher doses, they induce a state resembling physiological sleep (“hypnosis”).
  2. Anti-Anxiety Drugs: drugs which act primarily to relieve anxiety and make you feel calm.

Central Nervous System (CNS)

While all benzodiazepines act as sedatives and anti-anxiety drugs, some are more targeted at brain areas which control sleep and wakefulness, while others are more specifically targeted at brain areas which control emotions such as fear. The classification of whether a benzodiazepine is sedative-hypnotic or anti-anxiety is to some extent an arbitrary one, as the boundaries are quite fluid. As a rule of thumb, in higher doses benzos act like sedatives and may promote sleep, while in lower doses, they simply reduce anxiety.

 

Benzodiazepines are Central Nervous System (CNS) depressants (for example, there can be a decline in blood pressure and breathing – which is good, because if your heart isn’t racing, you’ll feel calmer). They should not be mixed with other CNS depressants such as alcohol. Don’t self-medicate and stick to the dose your dentist or doctor recommends (which may be a higher dose than specified on the drug package insert. Reason being that the package inserts recommend a dose to induce sedation or sleep in a nonstress situation such as the home environment). It is possible to overdose on these things, and overdoses could lower breathing to dangerously low levels, which could result in coma or even death.

People for whom benzos have worked well describe them as “working wonders”, as having a calming and relaxing effect, or as making you feel “out of it”. Giddiness, confusion and saying silly things are also common. Benzos may make you forget large parts of what happened while you were under their influence, which can be handy if you don’t want to remember very much! However, this effect is not reliable.

Dentists who offer oral sedation will have particular preferences, depending on their experience (and experiences) with various drugs. Commonly prescribed benzos include:

Midazolam (Dormicum):

We use this drug mostly to sedate our customers  for dental treatment.  Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss (amnesia). It is given in tablet form (7.5mg for adult) by dentist usually half an hour before procedure. It kicks in very quickly, after about 10-20 minutes. The effect last 1 to 2 hours.

Diazepam (Valium):

Diazepam is another sedative drug widely used for dental treatment as well as in the hospital setup. It  produces a mild level of sleep and amnesia, and takes effect about an hour after taking it. The average dose for an adult is 5 to 10 mg. The disadvantage of diazepam is that it stays in the system for much longer than it is needed (it has a half-life of 20-100 hours).

Temazepam (Restoril):

Temazepam is quite frequently used in the UK. In contrast to Valium, its half-life is about 10 hours, so quite a bit shorter. It kicks in after about half an hour. The recommended dose is 10 – 40 mg (with the most common one being 30 mg). Why this huge range? In some people 40 mg of temazepam produces minimal effects whilst in others as little as 10 mg produces profound sedation. This is a problem with all benzos – there is no known method of identifying who is susceptible and who is resistant to benzodiazepines.

Lorazepam (Ativan):

Lorazepam can produce a higher level of sleepiness and memory loss than diazepam. The usual dose is 2 to 3 mg. It kicks in after about one hour, like diazepam, but its half-life is much shorter (12 to 14 hours).

Midazolam (Versed):

Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss. It is given as a syrup or mixed into a drink. The drink would usually be given at the dentist’s. It kicks in very quickly, after about 10-20 minutes.

Triazolam (Halcion):

This is not available in the U.K., but is hugely popular in the U.S. Unlike the other benzos mentioned here, it is not so much used as a premedication, but as an alternative to IV sedation in the dental office. This can work really well for some people and many swear by it! But as with all benzos, other people find it has little effect on them.

Controversies in Dentistry – Titration of Oral Sedatives

Occasionally, Halcion is used in the United States as an alternative to IV sedation. One of the effects of Halcion is that it can induce amnesia (memory loss) for what’s happening from the point the drug kicks in to the point it wears off. (All benzos can have this effect to some extent, but Halcion somewhat more so than others. However, the amnesia effect is unreliable – this also applies to Halcion). If Halcion is given intermittently one hour before an appointment and then during treatment at intermittent intervals, it can work well for some people as a substitute for IV sedation.

However, in 2002 the American Dental Association came out in a position paper against titration of oral sedation medication (titration means adding more of the drug, i. e. giving extra pills until the desired effect is achieved). This statement followed the rise of an organization called the “Dental Organization for Conscious Sedation” (or DOCS for short) which was founded in 2000 by a DDS called Michael Silverman and provides training in oral sedation. In 2004, DOCS had more than 1,900 member dentists in the US. DOCS is where the misleading term “sleep dentistry” (applied to oral sedation) was first invented. The training courses also advocate titration of oral medication. Many dentists feel that this practice is unsafe and/or that the training is not thorough enough. Even with thorough training, many dentists believe that titration of oral medication is too unpredictable. Oral medication can take up to two hours to absorb – so a patient could swallow a pill and the dentist, not seeing the effects of the drug an hour or two later, delivers a second pill. Meanwhile, the first pill is being absorbed and the patient has ingested twice the amount he or she needs. To be fair, it should be mentioned that there have been no adult deaths reported using the DOCS regime so far.

Because of the medical and legal situation, many dentists do not feel comfortable with this method.

Can I take benzos as a premedication before IV sedation?

Yes you can. You must however let your dentist know that you have taken them and what dose (unless your dentist has prescribed them and knows anyway). Be sure to inform your dentist beforehand, rather than on the day, because you may forget to mention it otherwise.

When not to take benzodiazepines (contraindications):

This varies from drug to drug. For example, some benzos are safe to take if you have liver problems, while others are not, and some are safe to take if you have heart problems, while others are not. You should be sure to inform your doctor or dentist if any of the following apply: known allergy to the drug, narrow-angle glaucoma, pregnancy, severe respiratory disease (COPD), congestive heart failure (CHF), impaired kidney or liver function, depression/bipolar disorder/psychoses, chronic bronchitis and some other conditions. Also if you’re taking other medications be sure to mention this.

Oral sedation – A hit-and-miss affair?

One problem associated with oral sedation is that it can be a bit of a hit-and-miss affair. Basically, you don’t know how well the drug will be absorbed from the stomach. Because the response to a drug is unpredictable anyway, you have to tailor the dose so that the 25% of people most susceptible to the drug won’t get an overdose. But that means that the 25% who are least susceptible won’t get enough… Body weight, height, or gender are not good indicators of how high the “ideal dose” should be, because the drug exercises its effects on the nerve cells in the brain. So, if you’re quite large, don’t take a little extra “just in case”. A standard dose might have virtually no effect on a petite female, but a large guy might be totally zonked after taking the same dose… you get the picture!

Other factors which may affect how well a benzo will work include whether you want it to work and your (and your doctor’s/dentist’s!) belief that it will work (the so-called “placebo effect”, which, BTW, has been shown to work even if you’re aware of it). If you don’t want the drug to work, for example because you’re scared of losing control, your brain may try and fight the effects of the drug. As a result, you may not experience much of an effect at all, or else experience the effect as unpleasant. In which case, oral sedation may not be for you.

What people said about benzos:

“My doctor prescribed me valium. I take one 30 minutes before my appt. It makes you a little sleepy and your anxiety disappears. It puts you in a “whatever” mood and helps you stop thinking about the pain or worries. ”

“I remember being taken to the chair and them giving me a vial of liquid Halcion…This stuff tastes like Peppermint Cherry…leaves a strong taste in your mouth, but no side effects… Everything around me went fuzzy and blurry, like I was in a dream or something. They moved me to the other room, where everything happened so fast!!! I don’t actually remember much, but I did feel bits and pieces… it wasn’t like a “Get me out of this chair now, feeling” but something that I could deal with… I remember them preparing the molds for my bridge and crown, but I didn’t quite care, and I didn’t even GAG! Which normally I would have!

I did have some amnesia, and I did feel somewhat calm and distant from the procedures, which made me feel good. The appointment was 2 hours, but it felt like I was in and out of there in like 15 minutes. I don’t remember walking to the car or the ride home.”

Zolpidem (Ambien)

Ambien is a sedative/hyppnotic drug designed to relax you and help you fall asleep. So it can be useful for the night before an appointment. It is chemically similar to benzodiazepines. It is not a barbiturate (the traditional “sleeping pill”, which thankfully has fallen out of favour).

Source: Dental Fear Central

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