Apr 212017


Short Answer: Probably not. Tooth sensitivity can be caused by many things besides cavities. Cavities need to be really deep to cause any symptoms at all.

Long Answer: In my office, when a patient comes in to see me with a complaint, about 9 out of 10 times that complaint is, “my teeth are sensitive”. In many cases, their assumption is that they have a cavity. It’s important to know that about 90% of the time, those sensitive teeth have nothing to do with cavities at all. The culprit is usually something that has sensitized teeth to biting pressure, cold, hot drinks or sweets. Below are the most common causes of tooth sensitivity (besides cavities) and some things to try to troubleshoot the problem.

Typical causes (besides cavities):

1. Sinus infection – Above your top back teeth is an air space which connects to your nose. That air space is called a sinus and it can fill up with fluids, especially when you have a cold or allergies. When this happens, it can directly impact the sensation felt by your teeth and you might describe it as an “ache” which is hard to pinpoint as coming from one specific tooth. Symptoms that would indicate your sinus is the likely culprit for your tooth sensitivity include pain that changes as your head position changes (if you tilt your head to the side, does it hurt more or less?), pain during a time you have a sinus infection, allergies or just a cold/flu.

2. Wear (on the tops or sides of your teeth) – You may be grinding your teeth at night and are unaware of it. Before you confidently profess, “I don’t grind my teeth!”, I would ask how you know that? You are not aware of nearly anything you do when asleep, and grinding your teeth during the night is extremely common. That grinding wears away protective enamel that keeps your teeth from being sensitive much like you might strip a house of its insulation.

Similar to wear on the tops of your teeth, you can also have excessive wear along the sides of your teeth as well. This can occur when you brush your teeth too hard or with a brush that isn’t soft. You would be surprised how much tooth you can wear away even with a soft brush. Need convincing? Remember that the Grand Canyon was formed by just water! If you use “whitening” toothpaste, the problem gets compounded because whitening toothpaste doesn’t actually whiten your teeth chemically, it simply removes stains more aggressively by using rough sandpaper-like material in the toothpaste. This makes them appear whiter, but that sandpaper-like material also strips away more insulation around your teeth.

If the biting surfaces of your teeth have too much wear, you might even feel a little “zap” on one tooth when you bite on it with a specific piece of food. Your next bite may have no pain at all and then five bites later…”zap!”. This is usually caused by a food particle pressing on just the right spot where you have excessive wear and where the tooth is more sensitive.

3. Foods and Acids – There are many foods/drinks that sensitize teeth because they are rather acidic. Acids actually strip away a microscopic film of protection around teeth that makes them more sensitive (examples: soda water, lemon juice, apples, pineapple, citrus, tomatoes, sauerkraut, etc.). If the acids are particularly strong, they can literally melt small craters on the tops and sides of your teeth and we call that “erosion”. This can sometimes occur if you have GERD (heartburn) as the acids from your stomach literally come back up into you mouth (usually at night) and then sit on your teeth. There are other causes of erosion, but untreated heart burn is a common cause.

4. Tooth Grinding– We already discussed how tooth grinding can wear away your tooth and cause problems, but in this case I am referring to pain caused by the actual pressure of your teeth clenching and grinding together for hours at a time at night. Again, you are not likely to be aware of this problem just as you are generally unaware if you snore or talk in your sleep. If you do grind your teeth, that pressure can cause the nerves around your teeth to get sensitized and hurt during the day. Imagine you are a couch potato and I somehow convince you to run a half marathon in the morning. The next day your muscles will be very sore and even if you just walk to the kitchen, you will feel pain with every step. The same thing can happen with teeth.

5. Referred Pain – Sometimes we feel pain in our teeth even when the source of the problem is not actually our teeth. Pain from a sinus problem is one example we already discussed. There are many other causes like an issue with your jaw joint (TMD), teeth that are erupting like adult teeth in children or even wisdom teeth in adults, a cold sore, gum infections and even some diseases can create a situation where you feel pain in your teeth when the teeth are perfectly fine.



Signs you might have a cavity:

  1. Severe pain – Usually the sensitivity caused by the five causes above is not severe. On a scale of 1 to 10, most people would describe the pain as a 2 or 3 out of 10 and sometimes as high as five. Pain caused by a cavity typically feels much worse like a 9 or 10 on that scale. Tooth pain might keep you from sleeping at night.
  2. Constant and lingering pain – Tooth pain generally does NOT start when you drink something cold and then disappear. A tooth problem will hurt and continue to hurt for a long time, perhaps for days or longer. If you feel pain when you drink something cold and the pain disappears immediately after you swallow, it is unlikely to be caused by a cavity and more likely from one of the causes in the list above.
  3. Spontaneous pain – A problem caused by a cavity usually isn’t triggered by cold or sweets. The pain usually happens spontaneously.
  4. Swelling – If you see swelling around a particular tooth, a bubble that “pops” right next to a tooth or see pus coming from specific area, this is more likely to be related to a specific tooth problem.
  5. Focused pain – If you feel an “ache all over”, something else is likely going on besides a cavity. Pain caused by cavities typically cause one specific tooth to hurt, not a group of them. If you can tap on just one tooth and feel a problem, then that is more likely a cavity or tooth-related issue.

You might have one of these issues above and it does not necessary mean you have a deep cavity. There may be other explanations, but when I see patients that do have a deep cavity, they usually present with one or more of the symptoms listed above.


Hopefully I have made it clear that when you have sensitive teeth, there are usually many good explanations besides a cavity. The most effective advice I give to patients when I have ruled out cavities as a cause of their sensitivity is:

  1. Discontinue use of any whitening products (rinses, toothpastes, bleach gels, etc).
  2. Buy sensitivity toothpaste (ANY toothpaste that has 5% Potassium Nitrate). No need to buy any specific brands, they are all identical.
  3. Brush gently with the softest toothbrush you can find or use a good quality electric toothbrush, which I think is better than a manual brush anyways.

Remember that if you feel pain when you drink something cold and the pain disappears immediately after you swallow, it is unlikely to be caused by a cavity.

Lastly, if in doubt, see your dentist for peace of mind and confirmation.

Please leave a comment if you have further questions or feedback.

Jan 302017

Short Answer: It is mostly safe in very small quantities and you should use it, but only in topical form (not swallowed). Say NO to fluoridated drinking water.

Long Answer: I don’t think I could take on a more contentious dental question than this one. There are two opposing views on this subject ranging from “fluoride is poison” to “fluoride is one of the greatest public health achievements in the 20th century (Source: cdc.gov).”. Both sides are extremely passionate about their point of view.


The American Dental Association (ADA) has been a vocal proponent of fluoridating drinking water for over 40 years and today, over 70% of the U.S. population is served by fluoridated water. [source].  The ADA is certain that fluoride supplied by drinking water and toothpaste lowers the chance of developing tooth decay and that it is perfectly safe.

Opponents simply feel that fluoride is a poison, even at very low concentrations.  They equate fluoride to lead, arsenic and other harmful materials.  They attribute the use of fluoride with things ranging from Alzheimer’s disease and Attention Deficit Disorder to irritable bowel syndrome, joint pain and cancer.

The trouble lies in the fact that non-biased information is hard to come by, and most sources are either strongly for or strongly against fluoride. I have some mixed feelings on the topic myself, and it would be disingenuous to claim I have the right answer – but I do think I have a reasonable, middle-of-the-road answer.

There is no debating the fact that fluoride is poison, but it’s equally important to put that statement into perspective:  Everything is potentially poison at a high enough dose and fluoride is no exception.  Take Vitamin D for example, which has been credited with strengthening bones, reducing the risk of certain cancers and many other important beneficial purposes.  It is so widely supported, that most store-bought milk and breakfast cereals are fortified with it.  Yet, at too high a dose, Vitamin D can cause your heart to beat irregularly, damages your kidneys and even increases your risk of cancer [source]. At a high enough dose, Vitamin D will kill you.  But then again, just about anything at a high enough dose, including plain water, will kill you too.  So the point is this: like Vitamin D, fluoride is toxic at the right dose.  The difference in opinion often comes from what constitutes a “toxic” dose.  While the ADA feels that 0.7-1.2 parts per million in drinking water is perfectly fine, holistic sources feel that no amount is safe.  So who is right?


Let’s start by discussing the supposed advantage of fluoride:  When minerals like calcium and phosphate leech out of your teeth in acidic conditions, the resulting softness is known as a cavity (caries).  Acidic conditions are usually caused by a specific strain of bacteria that digests sugar in your mouth and converts it into acid. But studies show that when fluoride is present, it helps tooth structure take back some of that lost calcium and phosphate. It actually forms a new material called fluoroapatite.  Unlike the original calcium and phosphate ions, fluoroapatite leeches out of the tooth in significantly more acidic conditions (pH 4.5) than just calcium and phosphate do normally.  In fact, it takes an environment that is about TEN TIMES more acidic to cause fluoroapatite to leech out than just normal calcium and phosphate ions. Bottom line: It takes a lot more acid for a cavity to form, thus, fluoride makes the tooth resistant to cavities.

It is hard to debate the science behind fluoride and the beneficial effects it has on a tooth’s resistance to tooth decay.  At the same time, the potential toxicity it possesses cannot be dismissed.


Before drawing conclusions, it’s important to make some assumptions:

  1. Let’s assume that fluoride is potentially toxic even at low concentrations. This is because you cannot scientifically prove that fluoride is completely safe at any dose.
  2. Since I have found little to no scientific evidence supporting the idea that fluoride is absorbed readily through the inside of your mouth, let’s also assume any fluoride placed in your mouth that is then rinsed out thoroughly will have a negligible impact on the blood level of fluoride in the body. If you want to argue that an undetectable amount of fluoride does get absorbed, then I address that in point #5.
  3. Let’s assume that the cavity-fighting effect of fluoride occurs when it contacts the teeth directly in the mouth, not when it is secreted by saliva or when it is circulating in the blood. We know this to be true from other scientific articles I agree with.
  4. Let’s assume you believe, as I do, that ridding your life of fluoride would likely increase your chances of getting a cavity. Most studies agree with this point so we will take it at face value.
  5. Lastly, we assume it is impossible to live a completely 100% fluoride-free life, because fluoride is found in almost everything from rain water to tea, vegetables, fruits, meats, milk and eggs. It is everywhere. Do a little research and you will see. Here is a nice start.

One final assumption I have to make is that most people want to keep their teeth healthy and want to have cavities properly fixed.  But doing so involves many chemicals that are equally or more toxic to the body.  It is common to use materials that contain bisphenol A, mercury, strong acid gels and other toxins when repairing tooth decay.  So if one were to get more cavities and need more fillings as a result of using less fluoride, would they not be ironically exposing themselves to different unwanted chemicals over the long-term?  And since fillings often don’t last a lifetime and need replacement and repair, this could be a potentially serious concern for fluoride-free advocates.  On the other hand, some believe chronic low level fluoride exposure could lead to potential health implications. So which is worse?  We have already assumed that no meaningful amount of fluoride is absorbed through the mouth and that the positive effects of fluoride happen locally in the mouth, not systemically when it is swallowed.  So there is no need to ingest it. I believe the bulk of the problem is solved when you limit fluoride exposure to just your mouth and for a short time.


Perhaps the pro-fluoride crowd is 100% correct and there are absolutely no adverse health implications to chronic low levels of fluoride.  Or, perhaps they are wrong and this won’t be revealed for another two decades?  My logic guides me to not risk it if I can easily help it – and I can.  I have chosen to use reverse osmosis filtration in my house to remove fluoride (among other things) but I do use fluoridated toothpaste. After brushing with it once a day using a pea-sized portion and for two minutes, I thoroughly rinse my mouth out with water.  I continue to rinse until I don’t taste any of the toothpaste flavors.  In this way, I get the benefits of fluoride with minimal risk.

As for municipal water fluoridation, this is a contentious issue.  My world view largely dictates a more libertarian approach, whereby, I prefer to empower people with knowledge and let them make informed decisions.  I am personally not in favor of forcing anyone to ingest anything in the name of public health.

Perhaps fluoride is indeed one of the “greatest public health achievements of the 20th century”, but my personal issue with water fluoridation is that one has to actively take measures to remove it if they disagree. Adding iodine to salt has been a very important step in reducing iodine deficiency, something that leads to a host of terrible and preventable health problems.  Nevertheless, when I go to the grocery store, I can still choose between iodized and non-iodized salt.  When I drink from a public water fountain, I do not get that choice.

The pro-fluoride movement also feels strongly that they are helping the “under-served” and “poor” who cannot afford the best dental care or aren’t as empowered with knowledge that prevents tooth decay. I personally find that a bit simplistic and borderline patronizing. Just because someone is poor doesn’t mean they are not intelligent enough to make an informed decision. But if they are poor then they are much less likely to afford a filtration system which rids their tap water of fluoride. In other words, the poorest in our population are being forcibly medicated while the well-off can opt out more easily.


♦ I think fluoride that only touches your teeth and the insides of your mouth is probably safe. Doing so will decrease your risk of getting cavities, which is good.

♦ I recommend brushing your teeth with a very small amount of fluoridated toothpaste at least once a day and rinsing it out completely afterwards.

♦ Do not expect to live a 100% fluoride-free life. You are living in a dream world if you do.

♦ I strongly disagree with medicating the population by fluoridating tap water and also causing the masses to actually ingest this medication (fluoride is only useful when it touches the teeth). I find it disingenuous to use the argument that the poor don’t know enough to make their own decision.

♦ Filter out fluoride from your water if you can and don’t ingest fluoride if you can help it.

Care to comment? Concerns? Questions? Give me your thoughts below.

May 172016

Short Answer: Yes, but it requires some homework.

Long Answer: This question recently came up and I thought it was an important topic. Many times when my patients leave the area and need to find a new dentist, they ask me for tips on finding an “honest” one. Dentistry is one of those industries that can harbor unscrupulous practitioners and doesn’t always have the best reputation in that regard. I believe that stems from the fact that most dentists practice alone or with a partner in a small clinic setting with little or no oversight.

Imagine if you went to work every day and your boss had no idea what you were doing. All they knew was whether you were sitting at your desk doing work or not, and they were checking to see you weren’t causing harm to the company. You were generally paid well whether you did a good job or not. Now also imagine telling your boss you had more work to do today than you did yesterday, even though you basically made up most of that “new” work. Not only would you still get away with doing a crummy job, but your boss would also give you a raise for supposedly doing more!

This is the situation most small clinic private dental offices find themselves in. The patient only knows if it hurts or not, if it costs a lot or not and if it looks good or not. Beyond that, there are few metrics the typical patient can measure against. But what about all the stuff behind the curtain? Were good materials and labs used? Will the work hold up like it’s supposed to? Were possibly better and less expensive options presented? Was any work needed in the first place? That’s where ethics come into play. So here are some tips on finding an honest and ethical dentist. Feel free to add comments if you have your own ideas or tips. Keep in mind this discussion is most relevant to USA-based doctors and patients. I am not well-versed with international dental practices (with few exceptions).


  1. Avoid Over-Marketed Dentists – If you have been seeing ads all over town for a dental office, be careful. This may be a sign of a “hungry dentist” (see next point). An office that advertises heavily has spent a lot of money on marketing and possibly less on patient retention and patient satisfaction. I had to market myself when I first opened my practice, but I did it for a limited time and it had limited scope. Once people started coming, I developed a reputation and word-of-mouth took hold. If I was not doing a good job, then I would have had to keep marketing to get a steady flow of patients in the door. This is why your Spidey-senses should be tingling if you see an ongoing heavy marketing presence for a particular office. Also, advertising is very expensive and it takes a lot to make back that investment. When ads get someone to call for an appointment, there is extra pressure to make sure that new patient generates a worthwhile profit. Finally, be weary of big “one-time” promotions, coupons and special deals just to get you in the door.
  2. Avoid Hungry Dentists – Hungry dentists are those that desperately need to generate more work in order to keep their practice afloat, so they are also highly motivated to recommend excessive treatment. There are dentists that are generally “hungrier”, like new graduates with very high debt, dentists having financial problems, dentists that are seeing a steady decline in new patients, etc..  Not to say all the latter are dishonest, but a desperate dentist is not your friend and it’s not always possible to explain how to spot one. One way is if a dentist recommends treatment and then exerts a great deal of pressure on you to commit and proceed with treatment immediately. There are other ways, but suffice it to say that most people can spot a hungry lion a mile away. This is no different and I would stay away from both. When in doubt, trust your instincts.
  3. Avoid Offices That “waive your deductible and co-pay” – If you have insurance, you probably have a deductible or co-payment (co-pay) for certain dental procedures. Some dental offices know that if they waive this co-pay, you will be less likely to resist their questionable recommendations for treatment. Hey, if it doesn’t cost you anything, who cares, right? Wrong! Just because a procedure is free doesn’t mean you need it, want it or it won’t cause you more pain and problems later. But even if you are convinced you need the treatment, the dentist usually has a contract with your insurance company which dictates the maximum fee they can charge and your required co-pay. The insurance dictates a co-pay is required because they know they will pay for fewer procedures if a patient has to pay for some of it. That calculation ultimately affects your insurance premiums. So when a dentist waives the co-pay, he is inadvertently making the delivery of care more expensive for everyone AND he is also potentially violating his contract with the insurance company. Bottom line: do you think a dentist that is unethical when dealing with the insurance company is suddenly going to be ethical when dealing with you? You know the old saying: “Once a cheater, always a cheater.”.
  4. Avoid Office’s That Get New Patients Through the Insurance Company – If you have insurance, they will send you a list of dentists you should go to. They really, REALLY want you to go to one of them. That’s because they have a contract with the dentists on that list which dictates how much the dentist can charge and other terms and conditions, most of which they control. Dentists that rely on the insurance company to refer patients to them often have not invested their time and energy in making their practice driven by referrals from other patients. They don’t really need all their patients to be so happy because the insurance keeps sending them new ones. Also, the insurance typically pays these dentists much lower fees for procedures that are covered. The dentist is required to accept these lower fees in exchange for all those new patients the insurance company sends them. So to get around accepting those very low fees, the dentist may recommend you do more expensive treatment that is normally not covered by your insurance (see next point below). Bottom line: find a dentist on your own, not necessarily through the insurance.
  5. Watch Out For Up-Selling – This was touched on above. Dentists that are “In-Network” for many insurance companies make the lion-share of their income by “up-selling” treatment. For example, you haven’t had a cleaning in a while but there are no underlying gum issues. A shady dentist will tell you a “deep cleaning” is required even though a basic cleaning would have been perfectly fine (CLICK HERE for a thorough explanation about this). You need a crown on a tooth but the dentist tells you that it costs extra if you want it to be metal-free or made from special materials not normally covered by your insurance. You have a small stain on the biting surfaces of some of your back teeth and the dentist tells you fillings are required there even though the area could be easily monitored for the time being. These are examples of up-selling. If you plan to meet a potential new dentist before your first real appointment (see item #3 below), then consider asking about their style. Ask, “If I have a really, really tiny cavity on the biting surface of my back tooth, would you be comfortable watching that to see if it develops or do you think that needs treatment right away?”. Ask, “If I need a crown, will it be white or do I have to pay more for that?”. Ask, “If I haven”t been in for a while, do you generally think it is better to do a deep cleaning or try doing a simple cleaning first? (you are asking this before they have even looked in your mouth)”. There is no one right answer to these, but the answers you do get should give you great insight into how the dentist and the practice operate. Did the dentist answer thoughtfully and give you a reasonable answer? An honest dentist should be easy to distinguish from a dishonest one.
  6. Be Cautious About High-Technology – Technology is great, but if a dentist advertises that they use lasers, crown-in-a-day machines, special cavity-detection lights, etc., it doesn’t mean they are a fraud. But that technology costs a lot of money and the salespeople they bought it from helped them calculate how many times a month they need to use that machine to make back their investment. Fun Fact: Did you know that a crown-in-a-day machine costs upwards of $165,000? When an expensive machine is sitting there, it is just begging to be used. But not every situation calls for the use of such a machine in the first place. The reality is that an office that has a lot of these expensive gizmos is more tempted to use them even when inappropriate or unnecessary because they are trying to justify their investment. That’s when some of the dishonesty can creep in. And by the way, a lot of the new technology is useful and wonderful, but you don’t need most of it to receive extremely high-quality world-class dental care. Bottom line: Do NOT avoid office’s that use a lot of technology, but DO be more alert about the potential downside to all that technology. If technology and gadgetry is the focus and main selling point of an office, I would look elsewhere. 


  1. DO Look Up Dentists Online – Yelp.com is not perfect at all, but it is a starting point. You might not find a great dentist necessarily, but you will likely avoid a really dishonest one. Look up a potential name at the Better Business Bureau. You can also look up any dental license at the State Dental Board. In California, the site is found (HERE), but you can look up your own state board and search for actions against the dentist’s license.
  2. DO Find a Dentist With His Or Her “Name On the Door”  This means you aren’t going to a corporate or franchise office where you might see a different dentist every time you visit. Also, typical corporate or franchise offices are quota-based, which means they are hungry lions right from the moment you get in the chair (refer back to the points at the top of the page). When a dentist has their “name on the door” it means their reputation is on the line, not the faceless corporations’. Dentists work hard, spend a lot of time and money to open up their own practice. They are less likely to engage in shady behavior if their personal reputation, and thus their livelihood, is at stake. There is also a far smaller risk of dishonesty when a dentist is free from quotas.
  3. DO Make a Short Consultation Appointment – When you have narrowed your list of potential dentists down to 2 or 3, ask to make a short 5 minute appointment to meet them. This is an opportunity to see what kind of style the potential office has and the appointment should be completely free. You shouldn’t have to tell them more than your name because you are just a “potential patient” and would like to “meet the doctor” to see if it s a “good match”. If they are a reputable and honest business, they should have no problem accommodating this request. When you meet the dentist, you can tell him or her about your fears, concerns and expectations but also hear about their practice philosophy. Consider asking the questions mentioned in the first section (#5 Watch Out For Up-Selling). Your gut will usually tell you who is naughty and who is nice!
  4. DO Get a Second Opinion – When you have found someone and that dentist recommends treatment, consider getting a second opinion just to see if the new dentist is in the ballpark. This builds trust for a long-term relationship. Again, a good and honest dentist should have absolutely no problem with providing you with a written treatment plan, x-rays and his blessings to confirm his diagnosis. If a dentist becomes offended or aggressive about getting more opinions, that is a red flag. The only warning I give about second opinions, and it’s very important to remember, is that dentists recommending the LEAST treatment seem to be the most honest. That is NOT necessarily true. Choosing one dentist over another according to who recommends the least is not in your best interest. Regrettably, some dentists giving a second opinion hope you will switch to their practice, so they low-ball the amount of work they think you need in the hopes this will convince you to see them instead. This is the one caveat to a second opinion. I know…confusing!  So I think the real goal of a second opinion is not to see if another dentist comes up with the same treatment plan, but to see if the first dentist was in the ballpark, if their recommendations were reasonable and if there was anything unusually aggressive that stands out. Incidentally, the best place to get a second opinion is a dental school. Unfortunately, it tends to be a long process and generally too time consuming for the purpose of getting another opinion. Also, many people are geographically too far from a dental school; however, if you are faced with a complex and difficult plan by your dentist and you have doubts, it is exceedingly unlikely you will be bamboozled by a dental school.


  1. Treatment Options – An honest dentist should tell you about all your treatment options (including the option to do nothing). If you have a problem and the dentist only talks about one treatment option or completely dismisses other options, this should be a red flag. Also, you should expect the dentist to explain the options to you, not an assistant or financial coordinator. 
  2. Risks Associated With Treatment and No Treatment – Every procedure has risk. If a dentist recommends doing work, especially expensive elective work, and doesn’t take the time to talk about some of the bad things that could happen, then this is a red flag. There is also risk associated with not doing any treatment, and this needs to be explained as well.
  3. No Bait and Switch – Any treatment that is recommended for you should be given in writing. It should be very clear what the total cost of the treatment will be, with and without insurance. And if there is any question about what other additional treatment could be needed (like a root canal), that should be discussed in advance as well. An honest dentist will not try to sell you on less expensive treatment and then switch to a more expensive one after the work is started.
  4. More Opinions – Again, an honest dentist will have no problem with you getting another opinion at any time.

Is the list above exhaustive? Absolutely not. There is no perfect formula for finding a good and honest dentist, but this is a start and I hope it helps you. If you have more suggestions or comments, please share below and I will update this post as new ideas surface.

Jul 222015

Short Answer: Maybe

Long Answer:

When reading comments online and hearing concerns from patients, issues revolving around deep cleanings are some of the most common. But hold on to your hats, this is going to be a doozy. If you don’t want all the nitty-gritty about deep cleanings, stop now and go back to whatever else you were doing. This subject takes some work to do it justice.


Healthy gums are tight, pink and don’t bleed when they are brushed or flossed. A dentist or hygienist can take a little ruler called a periodontal probe and measure the depth of the pocket of gum that forms near the base of your tooth. A measurement of 1-3mm with no bleeding is considered healthy and normal.

Normal tooth

Normal gums and jaw bone. Notice the probe is measuring less than 3mm in pocket depth and the gums appear pink and hug the tooth tightly.

When teeth are surrounded by a constant irritant like food debris or plaque (the soft white film that you can scrape off with your fingernail), the gums swell a little and they tend to bleed easily. Because the gums swell slightly, it makes the pocket of gum seem deeper and it may be 4-5mm in depth. This is called gingivitis and it is reversible. But if the soft white plaque is not properly removed for a few days, it begins to mineralize into a hard cement-like substance called tartar (“calculus”, also known in other countries as “stone”.) Tartar cannot be removed with a regular toothbrush or by flossing.  Over time, tartar builds up under the gums where it can be difficult to see, and this creates a constant irritation to the gums and bone it contacts. Ultimately, the jaw bone holding the teeth tends to “melt” away. This gradual, non-reversible bone loss is called “periodontitis” and this will be reflected in even deeper pocket depth (usually exceeding 5mm). Again, to clarify, if there is no actual loss of bone and only the gums are red and inflamed, the condition is called “gingivitis”.

Although bone loss is a key component to periodontitis, the term is surprisingly not perfectly defined and two dentists can look at the same patient and come to different conclusions. That’s because a dentist uses a combination of periodontal probing measurements, x-rays, clinical observation and their experience to make the diagnosis. If, however, periodontitis is diagnosed, it is common to recommend a deep cleaning as a first step. Subsequent steps may include surgical intervention. If periodontitis continues unabated and untreated, the teeth affected could eventually become loose, painful or fall out. This is because the support structure for the teeth (your jaw bone) is no longer present in sufficient quantities. See the figures below:

Moderate perio

This shows both gingivitis (swelling of the gums) and periodontitis (a more advanced state where bone loss occurs)

Severe perio

This is the most severe form of periodontitis. There is basically no more bone holding the tooth in the jaw and the gums bleed easily when touched. Some people may see pus coming out of the gum pockets when pressed. Teeth in this state tend to move more easily and some people report noticing their teeth have “shifted” from their original position.

In addition to losing teeth, many studies point to evidence that periodontitis can exacerbate or trigger problems throughout the body. There have been links to arthritis, diabetes, heart disease, stroke and more. Obviously that doesn’t mean periodontitis causes these things directly, but it is thought that chronic inflammation in the body can trigger or exacerbate other medical conditions. There is even a link between gum disease (periodontitis) and pregnancy-related problems like pre-term deliveries, miscarriage, low birth weight and other issues. It is important to remember that the surface area of the gums in your mouth is about equivalent to that found on the palm of your hand. Imagine if your palm was red, inflamed and bled when you touched it. One would think that would be reason enough to seek treatment. Clearly, periodontitis is a serious problem with potentially serious consequences.


A deep cleaning, also known as scaling and root planning (SRP), is the procedure which removes the deposits (tartar) under the gums which cause the chronic irritation and bone loss. In a SRP procedure, not only are deposits removed from the root surfaces, but those surfaces are then smoothed (planed) so they become more resistant to further buildup. Sans surgical intervention, the bone lost will never regenerate and this is why many authorities consider periodontitis a treatable but incurable disease. Since deep cleanings require the dentist or hygienist to clean under the gums, most people find the experience too painful to do without anesthesia. It is very common to have one half of the mouth cleaned at a time. After two visits, the process is complete. It is then recommended that the patient return every 3 or 4 months for a “maintenance” procedure. This assures the dentist that the tartar is kept from reforming under the gums and evidence that the therapy was effective is gathered. It is not uncommon for dentists to also make a referral to a gum specialist (a periodontist) to further evaluate and treat periodontitis.


I agree with the merits of a deep cleaning and I, occasionally, recommend it to my patients. The unfortunate thing is that many practitioners use this service to augment their bottom line and the patient is powerless to know if the recommendation was warranted or not. Remember in the above discussion that the term “periodontitis” is not defined in stone. It is diagnosed by looking at many different things. Some dentists define periodontitis so liberally that nearly all their patients are recommended this procedure. But most dentists use guidelines set by insurance companies to define periodontitis and the need for a deep cleaning. In other words, if the insurance company would agree to pay for the procedure, the dentist is likely to recommend it. Most insurance companies expect pocket depths to be more than 4mm and across several teeth in each quadrant of the mouth before they agree to cover a deep cleaning. Most insurance companies also require a copy of recent x-rays and a written diagnosis to approve the procedure. But even with x-rays, the pocket measurements are somewhat subject to interpretation and to the specific operator. Combined with the fact that there is a large financial interest in doing a deep cleaning over a regular cleaning, the operator may be motivated to use the most liberal of interpretations when probing pockets. This may not be in your best interest. To illustrate these points, we will look at two scenarios:

Scenario #1:

Trevor, who hasn’t been to a dentist for “several years”, comes to the dental office for a “check up and cleaning”. The dentist completes an exam, x-rays, evaluates the pocket depths and the overall health of his gums. Since Trevor hasn’t been seen by a dentist in quite a while, he has some plaque and calculus (tartar) around his teeth and in some areas where it cannot be seen easily, but it is minimal. In looking at the x-rays, the dentist confirms some of what he saw in the exam and confirms the problems are present but localized to a few areas. The dentist completes a full mouth probing and finds that Trevor has a few back teeth with 4mm and even 5mm pockets. The dentist also notices that some areas bleed slightly when he does the probings. The dentist decides to take a more relaxed approach and proceed with a regular cleaning (prophylaxis). He advises Trevor to return in 6 months to recheck the areas and to look for signs of chronic and persistent problems. The dentist receives about $100 when his hygienist does this simple cleaning, it takes an hour to do it and the office will earn another $100 in 6 months when Trevor returns for his second cleaning. Since the hygienist is paid $50 per hour, the office makes a profit (before non-salary expenses) of about $50 for this cleaning.

Scenario #2:

Trevor goes to a different dentist under the same circumstances. In this case, the second dentist makes a different judgment call and recommends a full mouth deep cleaning (four quadrants of SRP). The hygienist completes this service in about three hours which is spread over two appointments and the office collects $1,000 for the procedure. As is customary after a deep cleaning, Trevor is instructed to return in 3 months for a maintenance procedure which costs about $150 (maintenance procedures cost more than regular cleanings and are recommended more frequently). In this scenario, the office took three hours to make a $850 profit in the time they would normally make $150 ($50 x 3 hours) with regular cleanings. Furthermore, Trevor is now expected to return every 3 months for a maintenance procedure which translates to a $100 profit at each appointment (as opposed to $50 for regular cleanings). Since this procedure is recommended much more often than a 6 month cleaning, the office makes a $400 profit the following year as opposed to $100 when only considering the “maintenance” Trevor will need.


The numbers add up quickly: Over two years, the dentist in the first scenario doing only regular cleanings made $400 using 8 hours of his hygienist’s time ($50/hour profit). The dentist in the second scenario doing a deep cleaning made $1,550 using 10 hours of his hygienist’s time ($155/hour profit). So when a dentist is looking in Trevor’s mouth and deciding on the diagnosis to make, it becomes extremely tempting to choose the path which assures a much greater profit. Most patients would assume that the licensing authority, dental society or even the insurance companies would catch a dentist who over-recommends SRP. Unfortunately, that assumption would be wrong. One reason is that measuring pockets is time-dependent and, as discussed previously, is relatively subjective in nature. For example, a dentist accused of recording pockets deeper than they actually were could say the gums were particularly swollen on the day the readings were done. That would be nearly impossible to disprove. Also, when measuring pockets, the ruler used is typically based on 1mm increments (see the first figure at the top of this post). Dentists are typically taught to round up not down. If a pocket is 3.5mm deep, the dentist will almost always record it as 4mm. That could be the difference between “healthy” and “diseased”. Also, there is quite a lot of difference in how pocket measurements are done. Some practitioners push really hard and others use a very gentle touch. A firm hand will cause the ruler to go further into the gums which will give the impression that the pocket was deeper than was recorded by the gentle operator. Firm probing is also more likely to make the gums bleed, again, reinforcing the diagnosis of periodontitis. Even x-rays can be misleading, giving the illusion that there is no bone loss, when in fact, there is, and vice versa. That is because x-rays look at 3-dimensional objects in 2-dimensions. This is why some insurance companies don’t require x-rays at all and why a dentist can claim a diagnosis of periodontitis without any objective evidence. Unless the situation is overtly fraudulent and the dentist is diagnosing periodontitis for every single patient, it will be nearly impossible to prove any nefarious intentions. Some unscrupulous dentists take advantage of this situation and convince patients they need a deep cleaning when, in fact, it is totally unjustified. I have seen this more times than I wish I had…


Since a deep cleaning is relatively invasive, it is my opinion that any dentist who recommends it without genuine need is behaving unethically. There is nothing worse than taking advantage of someone’s lack of knowledge for profit and these situations are extremely troublesome.

In my office, if a patient has a few 4mm or 5mm pockets, some bleeding gums and a little bone loss in isolated locations, I don’t rush to recommend a deep cleaning. Typically we start with a simple cleaning and have the patient return in 6 months or less. At that appointment we evaluate the situation again. If the buildup of tartar under the gums is persistent, there is still bleeding and the areas we worked on have not improved, we will have a discussion with the patient about the merits of SRP. We will review the risks, benefits and alternatives before making a decision together. Sometimes we decide to wait another 6 months, sometimes we recommend they see a periodontist (gum specialist) and sometimes we elect to do SRP.

If a new patient comes to my office who hasn’t seen a dentist in a few years, there is calculus under the gums throughout their mouth, many deeper pockets in excess of 5mm, obvious bone loss and bleeding on probing throughout the mouth, we will recommend SRP or refer them to a periodontist. In this case, I believe (remember, this is all dentist-specific) the recommendation is justified. Sometimes patients that clearly need SRP will ask to postpone the procedure and to instead get a simple cleaning. This is usually discouraged. If only the areas above the gums are cleaned (this is what’s done in a simple cleaning) and calculus remains under the gums, this can cause the top part to heal and the deep parts not to. In the worst case, this can lead to a gum infection which can then lead to more serious issues. Ironically, these are cases where it is better to do nothing than to do a simple cleaning (if those were the only options).

There are some important things to keep in mind if a deep cleaning is recommended and a decision to proceed is made. Most patients cannot tolerate the procedure without local anesthesia because the work happens fairly deep under the gums. Suspicions should be raised about the quality or need for SRP if very little or no anesthesia was required to complete the procedure (unless you know yourself to be quite pain tolerant). Time is also a factor in assessing the quality of the work completed. A deep cleaning is labor intensive and requires a substantial amount of time to complete. This is why more suspicions should be raised if a dentist suggests doing all four quadrants (the entire mouth) in one visit or if the procedure takes too little time to complete. A reasonable amount of time to do half the mouth would be 90-120 minutes. If the dentist or hygienist is able to complete half a mouth of SRP in less than 75 minutes, this is usually a sign that all or part of this procedure was never needed or that the procedure was done poorly. I recommend asking the office how long the procedure will take before committing to it – some judgments can be made based on the answer.

Keep in mind that when SRP is done correctly, there are multiple injections of anesthesia involved (four, five or more injections is not uncommon). Usually, half your face (either right or left) will be numb and most patients find the experience to be quite unsettling and somewhat exhausting. The process of removing calculus under the gums can be intense and many patients describe it as the hardest part of their dental treatment (when compared to crowns, fillings and even extractions). Some patients find it to be a much better experience if they are lightly sedated either with nitrous oxide (laughing gas) or with pills (valium, triazolam, etc.). SRP is also challenging for the patient because of the time involved and the significant amount of “scraping” required to remove all the calculus and smoothing of the root surfaces. Naturally, patients respond to treatment differently and some people find the experience to be no problem at all. But since most people find it intense, it would raise some concerns in my mind if nearly everyone in a dental practice was getting deep cleanings that they described as relaxing and easy. There will always be those patients that are highly tolerant of medical procedures with high pain thresholds, but they are not in the majority.

The latter description sounds rather awful to most people, which is why we don’t recommend SRP lightly to anyone. Nevertheless, if a patient genuinely needs it, there is simply no other way to circumvent the problem but to do SRP. This is why I discourage patients from automatically assuming a recommendation for SRP is just a money-making tactic or some sort-of gimmick. When indicated and properly performed, SRP is an important step towards improving total health as well as keeping teeth longer and healthier. It is worth doing under the right circumstances and this point cannot be overstated.


It is a patient’s right to understand why a recommendation for a deep cleaning is being made. It is helpful to have the dentist point out the calculus and bone loss on the x-rays (which can be seen in the majority of cases). The dentist should also freely share the full mouth probing and explain where deeper pockets were found and how they relate to the general health of the gums. If the dentist or hygienist never recorded pocket depths at all, then this further raises suspicions of how the diagnosis was made. Some more advanced cases can be easily diagnosed with x-rays alone, but most cases require a full mouth probing as well. Independently of the dentist, if you see blood every time you brush, this adds support to the diagnosis of periodontitis. It is always appropriate to ask the dentist to explain why he or she recommended a deep cleaning as opposed to something simpler. If in doubt, I always recommend getting a second opinion.

Once a deep cleaning is done, maintenance is an important step to keeping things healthy; however, I do not believe that maintenance procedures need to be continued indefinitely for everyone. The topic of maintenance and the need for it will be covered separately.

Jun 212015

Short Answer: Silicone for a mouth guard and Gold for a night guard

Long Answer: This question comes up occasionally because there is more and more public awareness about the dangers of plastics. Most people know about Bisphenol A (BPA) which is a chemical used in the production of plastics. It can be found lining soda cans, plastic wrap, canned food and even in the thermal paper of sales receipts (which is readily absorbed through your skin when you handle them). It was banned from use in all children’s products in 2012 due to concerns about health effects. But companies soon started substituting BPA with a different compound called Bisphenol S (BPS). Many scientist believe BPS is even more potent and potentially more toxic than BPA. I really couldn’t make this up!

The marketing departments of these manufactures get to slap a big and proud “BPA-Free” label on their products but fail to mention what new chemicals they substituted in its place. Additionally, it also doesn’t mean your only concern should be BPA or BPS. There are other chemicals found in some plastics like Phthalates, Vinyl Chloride, Dioxins and Styrenes. Suffice it to say, I believe that no matter what a manufacturer claims, plastics are generally not to be trusted and they should be avoided when it is practical and reasonable. I have personally gone to great lengths to avoid contacting these chemicals, from getting a stainless steel blender, having the butcher put meat in my own glass container, not touching store sales receipts with my bare fingers and having absolutely no canned-anything in my house. That is just a short list of everything I have done 🙂 Am I a little crazy? Maybe. But I really believe plastic is not a good thing.


So what is a patient to do if they need an athletic mouth guard?  99% of all these products are made of some plastic. Typically, athletic mouth-guards are soft and are made of a variety of plastics and usually some kind of copolyester. It is both impractical and not beneficial to make an athletic mouth guard from a rigid material, which is why it must be relatively thick and somewhat soft. In my own research, I have found that silicone is an exceptionally safe and effective alternative to traditional plastics. I use it in situations where I require a soft and pliable material. For example, I use a silicone spatula, baking sheet and reusable sealable bags, all made from 100% silicone. You can do your own research, but suffice it to say, I believe silicone is the only safe material out there that behaves like typical plastic. The good news is that you can have athletic mouth guards made from silicone, and that would be my preferred material for making one.


As for a night guard designed to protect from bruxism (tooth grinding), that is a whole different situation. I do not recommend anything soft for addressing bruxism, because a poorly adjusted soft night guard has the potential to cause jaw joint issues (TMD) and can also lead to an increase in grinding during the night. I will leave the issue of night guards for another post, but the bottom line is that a night guard should be rigid. Typically, dentists make hard night guards from acrylics, and usually (MMA) Methyl Methacrylate, Urethane Methacrylate, Stearyl Acrylate and others. Picture of a gold and plastic night guardThese materials do work very well and I make night guards using them for my patients today. That is because most people are not as health obsessed as I am and all these materials have been evaluated by the FDA and other health governing bodies like the American Chemistry Council. They have been found to be safe, so I cannot honestly say that I am sure a hard night guard made of plastic will harm you in any way. Also, since the majority of hard night guards are acrylic-based, you can rest assured they have no BPA or BPS in them. That doesn’t mean other harmful chemicals are not present, but at least you can know there is no BPA/BPS in any of them. With few exceptions, no modern dental material has BPA in it and all dental materials made in a lab have been evaluated by the Food and Drug Administration. http://www.ada.org/en/member-center/oral-health-topics/bisphenol-a

When in doubt, ask your dentist for the “MSDS” (Material Safety Data Sheet) for whatever product the lab is making your night guard from. Most will provide it and you can verify what is being used. There are some states where dental labs are not required to disclose the materials being used, so your situation may be different.

Despite any reassurances, if you are deeply concerned, then the best alternative I have found is to make a device out of gold (or gold alloy). You can also read here to find out why I think gold is safe. Unfortunately, it is not cheap to make a gold night guard. A typical well-adjusted hard night guard made of plastic would cost you about $500 at a dental office. An equivalent gold night guard could run in the $3,000-$4,000 range, and most dentists would look at you funny if you even asked about it. You would have to be pretty concerned to justify such an expense. On the other hand, a gold night guard could potentially last a lifetime, as opposed to a plastic one which requires replacement every 5 years or so. And you would rest assured (pun intended) that the product you have sitting in your mouth for 1/3 of your life has no potentially harmful chemicals. I personally think it’s worth it, but then again, I admit to being a little weird.Gold night guardA gold night guard in use

The bottom line is this: If you need an athletic mouth guard, I would recommend having one made of 100% silicone with no added coloring or scents, etc.. If you need a night guard, I would always recommend a well adjusted hard one. And if you could afford it, the safest material to make it from is clearly gold.


Apr 062015

Short Answer: Not necessarily

Long Answer:
When we talk about sealants, we are almost always talking about a very thin plastic-like film a qualified dental professional places over the grooves on the tops of adult teeth (the chewing surface). It is thought to work by preventing food and plaque from going deep into the crevices of the teeth where cleaning is impossible. By preventing debris from going into these grooves and crevices, cavities are less likely to form. Although it is (in my mind) debatable whether sealants prevent cavities from forming on the tops of the teeth where they are placed over the long haul, everyone agrees that they do absolutely nothing to prevent decay in between the teeth (where you would place dental floss). Cavities between the teeth are where many cavities form in children, which makes sealants useless for at least a big portion of possible cavities. Nevertheless, the overwhelming scientific literature and the opinion of most dentists is that sealants are good.  For those not interested in the minutia, suffice it to say that the typical sealant using the most popular material (composite resin) can fail over time or they can cover up problems which may be detected too late. This can lead to much more costly and painful problems in the long-term. I think the alternative, which is doing very small fillings should the child actually develop a cavity, is much more rational and less-invasive in the long term. Another alternative is a newer sealant material made of something called “glass ionomer” which I believe is much better and I recommend these. The product goes by the brand name “GC Fuji Triage”. Unfortunately, the vast, vast majority of dentists still use a “resin-based” material which I believe is far inferior and possibly harmful. Now let’s delve into some more details if you have the interest :).


The REALLY Long Answer:
First I will review more about what sealants are: Most back teeth (molars) on children have lots of grooves on their top surface. The first adult molar to erupt is usually at around 6 years of age and they are the first to be “sealed”. A sealant attempts to literally seal off those deep and narrow grooves on the biting surfaces of the teeth. In most cases, the “sealing” material is made of a flowable resin material not very different than what a dentist places in a tooth when doing a regular filling. From this point on, I refer to the material as a composite resin sealant (CRS). It is important to differentiate this from a glass ionomer sealant discussed towards the end, which is a very different material. The process works like this: the  tooth is cleaned off in some way (sometimes mechanically or chemically) and then the CRS (a liquid about the consistency of maple syrup) is flowed into the grooves and crevices of the tooth. A special curing light is applied which hardens the liquid into a solid. As long as the CRS doesn’t come out with normal wear and tear and the bond between the CRS and tooth remains completely intact, sugars cannot get into the grooves of the tooth. Without sugars, bacteria that cause tooth decay are cut off from their food supply and they typically go dormant (they don’t die, they just stop causing a problem temporarily). Because the sealed surface is smooth and shallow, food and liquids don’t collect as readily in the grooves and anything on the teeth is easily brushed away. The end result is that the child should have fewer cavities on the biting surfaces of their teeth. Sounds great and it is no coincidence that dentists love this procedure. After all, it is theoretically healthy for the child and the dentist makes money for each sealant placed. Insurance companies gladly pay for this procedure.
So why am I not as enthusiastic as others? I too was once a big proponent of sealants until I started noticing troubling issues occurring with them. I have many children in my practice who have impeccable oral hygiene. They brush and floss, use fluoride toothpastes and come in regularly for checkups. Many of these children had CRS placed by their last dentist when they were around 6 or 7 years old. I noted that some of the sealed teeth had a darkened shadow appearing under them and that troubled me. Healthy adolescent teeth usually have no gray or shadowy colors under their top-most biting surfaces. Close examination of the x-rays yielded little in the way of new information. Dental x-rays show decay in between teeth much better than decay on their biting surfaces where sealants are placed. Although all I had to go by was an insidious dark shadow, it was suspicious enough that I recommended removing the sealants to determine the cause. One by one, as I removed the old sealants, I was shocked by what I discovered: In all cases where I saw a dark shadow under the sealant, and with no other indication or x-ray finding, there was a massive amount of tooth decay present (a huge cavity). In some cases, the decay was so deep that the child almost needed a root canal procedure. This was extremely disturbing to find and it was not isolated to just one or two children from one family. I have witnessed these findings over and over throughout the years and on many children from the Unites States and other countries.


Consider a wooden row boat. If the hull developed a very tiny leak, you would see it immediately. A timely repair could be made and there would be no additional problems. Now imagine the same boat with the same little leak, but this boat has a thin and flimsy plastic shell wrapping around it. If the integrity of this shell was broken, a near certainty over time and real-world use, you might not notice the leak. All the while, the wooden interior would rot away from the mold and constant wetness. But from the outside the boat would look brand new. In fact, the boat could be close to completely disintegrating on the inside and capsizing, yet there would hardly be any sign of trouble. This is the inherent issue with sealants. Unless they are closely monitored and the dentist knows exactly what to look for, the slightest debonding of its edges could be enough to feed the cavity-causing bacteria without having any of the typical outwardly signs. This could spell disaster. While my own findings and experience can in no way be interpreted as scientific, they do bring up some important concerns and questions about CRS.
As for the quality of work achievable when placing a sealant on children: Some kids are wonderful to work on and they make things easy and fun. But many children are understandably anxious and have a short attention span at the dentist’s office. The strategy many dentists use when working on children is to work as fast as possible so the job gets done before the child is “done”. This may be acceptable when doing a filling on a baby tooth which will eventually fall out. But sealants are placed on permanent adult teeth. If a sealant is not placed carefully and on a very dry tooth, it will not adhere as well and will leak more readily. A leaking sealant spells trouble, as we already established. So when an experienced pediatric dentist (specialist in children dentistry) or general dentist with years of experience places a sealant, it may be done optimally. But in many states, it is perfectly acceptable for a general dentist’s assistant or hygienist to place them too. Many dental schools send out students to place sealants on low income children as a public service. There are exceptions of course, but I believe most students, dental assistants and hygienists don’t have the experience, speed and knowledge to do such a procedure without making important compromises. This is why if a parent chooses to have CRS placed on their children’s teeth, I recommend making sure the practitioner is a dentist and experienced in working with children and in placing sealants, specifically.

But if a parent needed even more reasons to be wary of sealants, I conclude the discussion with some final thoughts: Since sealants should be evaluated or x-rayed every 6-12 months to check their integrity, I can’t imagine that is worth doing for a child that is showing no problems with tooth decay. Furthermore, some sealants leech out harmful chemicals, namely BPA. Although some studies show extremely low doses or doses below FDA allowances, any exposure to BPA could pose a problem.

[Exposure to bisphenol A from bis-glycidyldimethacrylate–based dental sealants The Journal of the American Dental Association March 1, 2006 vol. 137 no. 3 353-362]

Some, like Dr. Fred von Saal, a leading expert on BPA, believe children should only receive sealants if they have a clear tendency to develop tooth decay. And since BPA is potentially more dangerous to children than to adults, the issue becomes more relevant; nevertheless, a discussion of BPA and its potential effects are beyond the scope of this blog. I simply conclude the following: If a child is taking good care of their teeth, they show no predilection for heavy consumption of sweets and have little or no tooth decay, why subject that child to potentially toxic substances, to the potential trauma of dental treatment, to the challenges of constant checks, superfluous radiation from x-rays, ongoing costs with reapplication of a sealant and to the potentially devastating effect of having a sealant hide decay that leads to much larger problems later on? I believe it makes better sense to take a more liberal approach: That is, evaluate each child for their risk of developing decay. If and when they do develop a cavity, I feel it is appropriate to remove that tiny amount of decay, properly bond in a traditional composite filling and do nothing more. The thought of covering all the grooves of a child’s teeth with a weak un-bonded material and then replacing it several times over the years seems excessive and potentially hazardous to me.
Some studies do concede that typical middle and upper class children do not need sealants as they once did; however, these same studies feel that low-income children in areas that have poor availability to dental care need sealants much more. Even in these cases, I feel that placing sealants on every low-income child is not in their best interest. Almost all studies agree that the key to the success of sealants lies in their need for constant upkeep and monitoring. But it is precisely the children in low-income communities that are the least likely to have their sealants properly monitored and that causes me pause. If a sealant is placed on a tooth and that sealant leaks, the ensuing cavity might be detected very late or not at all. One might argue that the child would have gotten the cavity anyways, but it happened later in life than it would have otherwise. I argue that if the sealant leaked and the child did develop a cavity, that cavity would likely develop faster and with less chance of being detected. After all, this specific population is under-served and their sealants are not regularly monitored. Have they been done a favor or in actuality, harmed? Perhaps these questions will be better studied over time and new ideas and conclusions will be drawn. But for the time being, assuming your child is getting checked regularly and has not been told they are at a higher risk for developing new cavities, I am against placing sealants on their teeth with one exception:
There is an alternate sealant material which I discussed at the beginning of this post called glass ionomer. It is not a CRS and does not use the typical weak flowable resin material. It contains no BPA or BPS. Unlike resin materials, it sticks better in slightly moist environments and doesn’t suffer from many of the inherent issues typical sealants have. To my knowledge, there is only one manufacturer of this type of sealant. The product is called “GC Fuji Triage“. I have yet to find any fault with using this very specific material as a sealant except that they fall out more readily than CRS. That makes it a little less ideal but I would take a less retentive sealant over one that stays in place but leaks any day! If your dentist tells you this material (GC Fuji Triage) is  being used to do your children’s sealants, then I would be comfortable with that. I would continue to decline CRS in almost every other case I can think of. I would also especially encourage dental schools and other programs prodding along inexperienced people placing sealants to put away CRS materials and use glass ionomer instead.

Nov 142014

Short Answer: Maybe not

Long Answer: As dentists, one of our pet peeves is patients who refuse x-rays but then expect us to tell them why they have a painful tooth or if they have any other problems. Dentists are regularly challenged by patients who refuse x-rays because they don’t want to be exposed to them and they see little value in exchange for a higher risk of cancer. Some questionable dental advice forums even tell readers that a “skilled dentist” should be able to diagnose dental problems without x-rays at all. This is utter nonsense. The only way to detect cavities when they are small and between the teeth is with x-rays. A dentist who waits until a tooth hurts or a cavity is so large it can be seen without x-rays would be acting too late. By that point, far more expensive and complicated treatment would be necessary. Many of those treatments would require additional x-rays to complete and there would be an increased chance some of the affected teeth would be lost earlier in life. There is little disputing the enormous power of dental x-rays. As I tell my patients, upwards of 75% of my diagnosis comes from looking at them and only 25% comes from symptoms and a thorough clinical exam.

Fear of dental x-rays is a valid concern, for as everyone knows, x-rays can lead to cancer. But what most patients don’t realize is that the average dose needed for dental x-rays is very small compared to what they are envisioning. This is especially true when considering digital x-rays. Many are also not aware of how much radiation they are exposed to naturally 24 hours a day. There is radiation coming from outer space (cosmic radiation), from the ground and in the air we breathe. Radon gas, found at higher doses in some homes, is one of the leading causes of lung cancer, yet few people are very aware of it. Just a seven hour flight across the country exposes you to 0.03 mSv of radiation (Note: Dose of radiation is commonly measured in millisievert (mSv)). On average, when taking into account all this “natural” radiation, you and I are exposed to about 3.5 mSv per year.  If you went to the hospital and received a lower gastrointestinal tract x-ray, you would be exposed to a little over 4 mSv. By comparison, a set of four bitewing films in a dental office would expose you to 0.005 mSv, which is about HALF of a one-day-equivalent of “natural” background radiation. The amount is truly miniscule, so it’s important to keep things in perspective.

Nevertheless, we must not forget that all ionizing radiation is, indeed, harmful. Therefore, all x-rays should be kept to the bare minimum necessary. This is why I do object to cart blanc recommendations for annual or bi-annual x-rays when they are prescribed without regard for the patient’s specific situation. Unfortunately, most dentists pay no regard to the American Dental Association and Food and Drug Administration guidelines which recommend far fewer and less frequent x-rays than are usually prescribed. In their most recent guidelines, it was recommended to take four individual x-rays of back teeth (bitewing films) every two to three years, so long as the patient had no cavities and was not at an increased risk of developing them. For patients that have cavities and are susceptible to other dental problems, their recommendation is to take x-rays every six to eighteen months. Yet most dentists take updating x-rays on everyone every twelve months regardless of the circumstances. I believe this is largely a product of most dental insurance plans which pay for diagnostic x-rays once a year.

I have patients in my practice that are in their 30’s, they have never had a cavity, keep their mouth impeccably clean, use no medications and have no medical problems associated with increased dental problems (like diabetes or blood pressure medications). I believe it is unnecessary to prescribe annual x-rays for these patients, because the risk of radiation outweighs the extremely miniscule chance a dental problem will be discovered. The American Dental Association agrees with that perspective. For these patients I feel perfectly comfortable extending their x-ray frequency to every two or three years. Even average patients who have completed all their recommended dental treatment and have a track record of dental stability can easily extend their x-ray frequency to every 18 months. The patients I insist on seeing annual x-rays for are those with, among other things, previously diagnosed but untreated tooth decay, a history of recurring problems, many large/deep fillings, teeth that had root canals recently, changes in medications/medical situation, those with poor oral hygiene and those with active gum disease. When these patients insist on not having any x-rays, it puts me in a difficult situation. We as dentists are responsible for the patient’s oral health but want to honor their request. Some dentists have dealt with the problem by having affected patients sign a release form stating they don’t hold the dentist liable for not taking x-rays. This would likely not test well in court, because a medical provider cannot be released from practicing the Standard of Care (which is to take x-rays at least sometimes) by a patient. Nevertheless, the issue of x-rays remains a point of friction for many dentists and their patients.

As for children, my recommendation for frequency also falls in line with the American Dental Association recommendations. The frequency depends on whether or not the dentist can see between the teeth visually and whether the child has an increased risk or a history of cavities. In children, decay develops more quickly because baby teeth are softer and smaller than adult teeth. This makes it more important to catch cavities early.


If a dentist recommends annual x-rays and you are concerned, ask what it is about your specific dental situation that leads to the recommendation. If the answer is something like, “Because it is our policy to take x-rays on everyone every year.”, then this would be a legitimate reason for further inquiry. If, on the other hand, the answer is, “Because you have several teeth we think have cavities, we’re not sure your gum disease is under control and we are still working out the kinks in your home care routine.”, this would be far more reasonable and well-thought-out on the part of the dentist.

It is important to remember that if indicated, refusing x-rays will increase your risk of enduring more expensive and potentially painful problems later on. Like most medical problems, early detection of dental disease is easiest to treat. While reducing exposure to x-rays is a legitimate concern, it should also be a concern that undiagnosed dental disease will affect your health and the health of your mouth. The key is to question whether your prescribed frequency is customized for your specific situation or not.

Oct 302014

Short answer: At least 30 minutes and typically 45-60 minutes.

Long answer: During a routine cleaning, the dentist or hygienist needs to review any changes in your health, they need to evaluate the health of your teeth and gums and then counsel you on any improvements that should be focused on at home. Sometimes, the evaluation of your gums requires that they measure the gum pockets to look for signs of inflammation and bone loss. They then need to clean off any accumulations on your teeth, floss them and remove any stains. For most people, this takes a half hour at minimum and more likely longer. Some offices have special assistants that help the hygienist and this expedites the process. During a simple (routine) cleaning, only the surfaces above the gum (supracrestal) are cleaned. That’s why a simple cleaning is usually a comfortable procedure and doesn’t take much time to complete. Some people, in fact, have so little accumulation on their teeth that it is actually possible to do a thorough job in less than 30 minutes. But these are precisely the patients who are good candidates for less frequent cleanings. See, “Do I need a cleaning every six months?”. One other exception is patients with far fewer natural teeth than normal. If someone has half the normal set, then it would clearly take less time to clean them yet a decreased frequency may not be the best option. Also, it’s important to remember that a regular cleaning is very different than a “deep cleaning” and this is a topic that will be covered in an upcoming blog entry.

If you feel your cleaning is too short, inquire as to why that is. Consider asking for a less frequent cleaning if the answer is simply, “you don’t have much to clean.”. A thorough cleaning will remove the vast majority of stains and all hard tartar (calculus) on the surfaces of the teeth. In most people, this process takes more than 30 minutes to complete and usually 45 minutes or more.

Oct 162014

Short Answer: No

Long Answer: Most dentists will argue that a checkup every year is a wise thing to do and I would be hard pressed to disagree. But if a patient requested an exam every 18 months or even 24 months, I would not necessarily object so long as some criteria were met: they had a history of few or no cavities, they maintained good oral health and they did not start new prescription medications or have significant health changes. We are concerned with prescription medications because many of them cause xerostomia (dry mouth). A dry mouth doesn’t have the normal saliva flow which would otherwise buffer acids and wash away bacteria that cause decay. If a patient had some cavities every few years, had many teeth with fillings and other dental work or had a few health problems (this describes the majority of people) then an annual exam is appropriate. There has been some research looking for scientific evidence that frequent checkups by a dentist leads to fewer cavities. Recent reviews of these studies have shown that there is no specific recall frequency which is best for everyone. In fact, there is plenty of evidence to support the position that an exam frequency every 2 years does not result in a person having more cavities in the long run. And since dental decay takes anywhere from two to eight years to progress into an irreversible form, I can find little harm in waiting one to two years between dental exams. There are very rare situations when a person is at high risk of developing dental problems and they would need to be examined more frequently. But these situations are so rare that for the sake of answering the question, a checkup more frequently than once a year for the average person is not necessary.

[A Systematic Review of Dental Recall Intervals and Incidence of Dental Caries; The Journal of the American Dental Association May 2010 vol. 141 no. 5 527-539] [IS THERE A SCIENTIFIC BASIS FOR SIX-MONTHLY DENTAL EXAMINATIONS? The Lancet, Volume 310, Issue 8035, Pages 442 – 444, 27 August 1977 doi:10.1016/S0140-6736(77)90620-1 ]