How do you go about picking an appropriate shade for someone?

Contrary to the opinion of some, teeth do not need to be super white to look good. In fact the desired shade should be determined by holding a shade guide next to a patients lips and seeing which shade looks best. Some people's complexions can make overly whitened teeth look unaesthetic.

Shade selection can be trickier if a patient either has many different shaded teeth and I am picking a color of just one tooth. In that case I place different shade guides adjacent to the tooth being repaired to get a feeling for which shade looks best.

Some patients teeth require custom shade colors. There teeth do not match any existing shade guides or have maverick colors in them. Maverick colors exist in teeth that have non homogeneous shading . Instead the teeth have different zones of color, so a dentist or ceramicist will need to formulate a 'shade map' of a patients teeth , that details all the different colors that are present and need to be duplicated. In this case I also often take a close up photo a patients teeth that helps the ceramicist create appropriate shaded dental restorations.

Why does my tooth hurt after a root canal?

There are a number of possible causes of pain after the completion of a root canal. After a root canal is completed no living pulp tissue remains inside the tooth, but nerve endings remain in the ligaments that attach the tooth to the surrounding bone. These ligaments have nerve fiber associated with them that can feel pain. They are the source of any post root canal pain.

One possible cause of pain are numerous and include inflammation of the periapical tissues post root canal. This inflammation may be due to extruded sealer or 'over instrumentation during the endodontic procedure. Sometimes the root canal files go past the apical terminus and can either inject some debris periapically or just damage the ligaments. This inflammation usually resolves by itself given enough time.

Another source of post root canal discomfort is a high bite and this can easily be corrected by a dentist. If a patient bites down, with no food in their mouth and their root canaled tooth hurts, then the bite should be adjusted. Teeth undergoing root canals should be not be in a heavy occlusion.

Other possible causes of pain are a persistent infection or a root fracture. If a root canal is completed, but an infection still is present around the periapical area then a retreatment may be indicated especially if significant time has gone by without a resolution of the infection. Sometimes an infection can be caused by a fracture of the tooth in question and in that case the tooth usually has a hopeless prognosis and requires extraction.

It is also possible, but not as common that persistent pain exists due to a sensitization of a nerve ganglion We have all heard of 'phantom limb pain'. This a similar phenomenon. Some of these patients can have pain even after the offending tooth is removed.

Are root canal overfills a problem?

Root canal overfills occur when a dentist is obturating (filling) a root canal. If the gutta percha extrudes out the end of the root it is called an overfill. Usually over fills are not a problem as long as the resulting apical seal that is created is good. Sometimes this is not the case, since the gutta percha may have slipped through because it was not of sufficient diameter to bind at the apex.

As far a the body is concerned gutta percha is a relatively inert material . It is my opinion that failures of rootcanals with overfills are usually caused by a lack of apical seal. If a guttapercha that is too small is used, it can slip thru the tiny apical foramen (a hole at the tip of the root) and the resulting over fill may or may not form good seal . If the gutta percha does not adequately obturate (seal) the apex, then bacteria can repopulate any left over space. This bacterial colonization is most likely the actual cause of most endodontic failures associated with overfills.

How much reduction is required for free hand composite veneer placement?

Free hand composite veneers can be applied with or without prior tooth preparation. If patients would like the bonding to match the shade of the preexisting shade of their teeth, then often little or not preparation is necessary. Veneered teeth, done without a prep, can be anywhere form a half millimeter to one millimeter more prominent than the preexisting teeth. Many smiles actually look better with this additional prominence.

Often there are good reasons for a cosmetic dentist to prepare the teeth. If a patient is only changing several teeth in an arch, then the additional prominence may not be aesthetic. Also, if the patient desires their veneered teeth to be lightened, than preparation is usually needed to provide the opaquing needed to mask the underlying darker tooth structure.

The decision on whether to 'prep' or not, and the amount needed, usually should be determined on a tooth to tooth basis. As long as enamel is left on the prepped tooth to bond to, prior preparation of a tooth surface causes no real harm.

Although patients may feel that they would like the procedure to be entirely reversible, very few patients, who choose bonded veneers, ever choose to go back to their old look. Reversibility may be desirable if a patient is considering orthodontics in the future.


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How long does bonding last?

Usually when this question is asked, the patient actually means bonded composite filling material. This material can be used either to restore cavities or can be applied to add to a patient's teeth for solely cosmetic reasons.

Bonding can remain in place for many, many years if the conditions in the mouth are right. I have many composite restorations in my patient's mouths for over twenty years without a significant deterioration. That being said, composite material reacts adversely to dental plaque that is not removed on a daily basis. It seems that the acid generated by the plaque makes the composite material become more porous. Some bonded fillings, especially in mouths that are not kept clean, can look almost 'water logged'. Composite material can imbibe some of moisture around them and this phenomenon seems most pronounced when plaque is left on their surface for long periods of time.

Bonded fillings are sensitive to the forces placed on them and can react poorly to excessive occlusal forces. Sometimes this can cause bonding to chip or crack after a period of time. If this happens the filling either needs to be repaired or replaced.

Some bonding can fail prematurely due to a poor bond to tooth structure. This can happen if there is excessive moisture contamination usually from saliva. Saliva is a terrific lubricant and most bonding agents do not work well when placed in the presence of saliva.

Also Occlusal forces should be taken into account when a dentist is finishing a filling. Care should be taken to have a patient check their teeth excursions to make sure that composite does not make overly hard contact with the opposing jaw's teeth.

To sum up, usually bonded fillings that are carefully done, and placed out of harms way (in terms of occlusal forces) can last a long time. I would expect in ideal conditions that their average life expectancy would be nine to fifteen years.

Does Tooth Whitening really work?

This is a common question that I am asked in my New York dental practice. Another version slightly different version is : Is Tooth Whitening a good idea? and still another variation:Is tooth whitening safe? The answer to all these questions is YES.

As a dentist who has been whitening teeth in New York for over twenty years I can confidently answer yes to all these questions. Further more all three of the most popular forms of tooth whitening work well and are safe.
Over the counter products, although sometimes harder to use, usually have carbamide peroxide as their active ingredient and this is an extremely effective whitening agent.

In office bleaching works well and is super fast (about an hour and half treatment time). When it is combined with tray bleaching , it is one of my favorite ways to whiten teeth.

Custom tray bleaching is also a fine stand alone treatment for whitening teeth. It has the advantage of being affordable, customizable and allows for inevitably needed touch ups down the road.

There are limitations to teeth whitening ; your bonded fillings and any crowns will not lighten at all. If you have these in the anterior of your mouth you may have to be prepared to change them, especially if they end up appearing darker than your natural teeth after bleaching is finished. Also some intrinsic stains such as tetracycling stains will not necessarily come out. Teeth whitening works best to get the yellow out of your teeth, and sometimes greyish hues can remain even after whitening.

If you have been thinking about getting a whiter smile, go ahead and ask your dentist! See if he or she thinks you are a good candidate for tooth whitening!

Is it possible to give a painless local anesthetic injection?

The answer is yes. The secret is not to rush and to take your time. There are a number of steps involved with a painless injection.

When I give a local anesthetic, the first step is to use topical anesthetic and let it work prior to giving the injection. After 3o seconds to two minutes in place, the tissure is ready to inject.

I use a small bore needle (guage 27 or 30) and inject very slowly. This usually provides for a relatively painless injection. For some injections I tug on the cheek(infiltration injections) while injecting, to cause a distraction. On other injections I press a Q-tip (palatal injections)or my finger tip (mandibular blocks), adjacent to the injection site for the same reason.

Ocassionally if the needle contacts a nerve during a mandibular block, a patient will experience an unpleasant sensation, but most of the time paitients are pleasently suprised at how painless injections can be.

After and an injection my heart raced and I felt shaky, What happened?

Often the local anaesthetics that dentist use have epinephrine added as a vasoconstrictor. This small amount of epinephrine can cause some patients to feel their heart race and feel shaky. If you experience this symptom, you should tell your dentist.

He should not start your dental procedure until the feeling passes, and you should probably request that he use a local anaesthetic without vasoconstrictor in the future.

Anaesthetic without vasoconstrictors are not likely to cause palpitations and the shaky feeling that some patients report after an injection. Their sole drawback is that they have a shorter anaesthetic duration and sometimes provide less profound anaesthesia.

Aren't there a lot of Dentists in New York City?

Yes, there are an awful large number of dentists in New York City, and it is a competitive environment to develop a dental practice. Even though we probably have a very high proportion of dentists to the general population, surprisingly New York is a cooperative place.

In my office building alone we have over forty dentists practicing in close proximity. Although you could say we are ‘competitors’, I have found my New York dental colleagues to be helpful and generous with their broad knowledge of dentistry.

New York has historically been an innovative place and probably the thing most responsible for our innovations has been the density of talented people all in one place. New Yorkers have drive and general desire to be the best at what they do!

This seems to be true about Dentistry in New York. Although dental innovation occurs through out the world, I proudly point out that New York has had more than its share. Dental trends that started or were nurtured by Dentist in New York include, Porcelain fused to metal restorations, Implant Dentistry, and Porcelain Veneers.

It has been and will be my pleasure to practice in the Big Apple and I look forward to collaborating with my New York dental colleagues for many years to come!

Why does my tooth hurt after the placement of a post and core?

The truth is that after a post and core is placed a tooth should not hurt. Occasionally patients can have pain after a post is placed. This pain can come from a number of causes. The most benign is that the bite has changed slightly after the placement of a post and core. This can be remedied with a simple bite adjustment.

A more disturbing possibility is that the root canal in the tooth is failing and placement of the post has somehow made the problem more symptomatic. This may happen because the drilling and placement of the post may have disturbed the guttapercha or just stirred up an already present 'hornet's nest'.

Endodontically treated teeth, that are not properly sealed with an interim restoration. can become contaminated in as little as thirty days. It has been my experience that when some of these teeth have a post placed, they can become symptomatic.

Still a third possibility is that the placement of the post has resulted in either a perforation of the root or caused possibly caused a crack to form .

Rarely, patients can even have pain stemming from a sensitization of an intermediate ganglion from a past trauma or infection, so it is possible to feel pain due to a previously cured endodontic infection.

If you are having prolonged pain in a tooth with a post it is advisable to visit your dentist or go for a consultation with an endodontist. They will take a radiograph and examine around the tooth to check for evidence of infection.

What is a rubber dam and why is it used?

A rubber dam is a latex sheet that dentists use to isolate a tooth or a group of teeth, either for sterility or to achieve moisture control. The dam has a hole or holes punched in it and is usually held in place by a clamp and stretched out with a rubber dam frame.

Rubber dams are extremely useful for root canals, since they hold the mouth open and protect the patient from accidental aspiration of any of the files or drills used during an endodontic procedure. It also acts like a surgical drape to help keep the canal system free from contamination and helps contain the irrigants used during root canal procedures.

Dentists can utilize rubber dams during operative procedures as well. If they are placed prior to removing a silver filling, they can minimize the amount of metal filings that the patient is exposed to. Instead, the assistant can easily suction them off and none are ingested.

Some dentists use rubber dams during bonding procedures, for which moisture control is extremely important. Although there are other good ways for dentists to achieve moisture control, rubber dam is one of the best!

Occasionally, patients do not like having the rubber dam placed in their mouths and some claim it makes them feel like they can not breathe. Usually cutting a small hole in the dam allows patients the option of either breathing through their nose or mouth and is helpful to patients whom the dam makes 'claustrophobic'.

How long should I brush my teeth for?

Two minutes is the time most often quoted by dentists, but that recommendation is somewhat arbitrary. Actually, I think the time needed differs for each person. I recommend that they be systematic and brush each surface adequately and see how long it takes them.

When I brush my teeth I start in the upper right quadrant on my back teeth and gradually work my way to the upper left. Then I do the upper insides in the same manner. After that, I usually do the same for my lower teeth. I use an electric and I allow about 3 seconds per tooth surface.Using a manual brush might take longer per surface area- lets estimate about 10 seconds per area.

You just want to be thorough and systematic job and not go over the same areas repeatedly during the same session. I do not believe that even using a manual brush it in necessary to spend more than 10 seconds on a particular area. Using the technique I have described above brush your entire mouth and see how long it takes. That is the average time you will need.

What should I do if my temporary crown breaks?

This is an easy one. Call your dentist! Temporary crowns function in multiple ways. They act as space maintainers, and protect the tooth from the effects of bacteria, sweets , and hot or cold liquids. Either a new temporary should be made or the old one should be repaired.

No real harm will come to a patient because they do not have an intact temporary crown for two or three days, but the longer a patient waits to have the temporary replaced, the more likely that shifting of the prepped tooth will occur. This may make it more difficult to fit the permanent crown.

Often times, when patients go for long periods of time without a temporary crown, the prepped tooth extrudes and lessons or eliminates the 'clearance' that the dentist had created between the preparation and the opposing teeth. Also the teeth on either side can start to shift which is undesirable.

Is it possible for a tooth's nerve to die without any symptoms.

It is not uncommon to take a full set of radiographs for a patient and find a tooth with a periapical radioluscency around to apex of a tooth. When I ask the patient if they have had any symptoms with that tooth, they sometimes report they have no discomfort.

When continue the discussion with these patients , some remember having some symptoms in the remote past, but at the tooth stopped bothering them(the pulp died?). Some do admit that the tooth does bother them from time to time.

Sometimes, when I percuss these teeth the patient does report that the do feel slightly different than the adjacent teeth and when I do open these teeth up to do a root canal procedure I invariably find that the pulp is non vital (dead).