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At the center of every tooth is a hollow area that houses soft tissues, such as the nerve, blood vessels, and connective tissue. This hollow area contains a relatively wide space in the coronal portion of the tooth called the pulp chamber. These canals run through the center of the roots, similar to the way pencil lead runs through a pencil. The pulp receives nutrition through the blood vessels, and sensory nerves carry signals back to the brain. A tooth can be relieved from pain if there is irreversible damage to the pulp, via root canal treatment. The space inside the root canals is filled with a highly vascularized, loose connective tissue, called dental pulp. The dental pulp is the tissue of which the dentin portion of the tooth is composed. The dental pulp helps complete formation of the secondary teeth (adult teeth) one to two years after eruption into the mouth. The dental pulp also nourishes and hydrates the tooth structure, making the tooth more resilient, less brittle and less prone to fracture from chewing hard foods. Additionally, the dental pulp provides a hot and cold sensory function. Root canal is also a colloquial term for a dental operation, endodontic therapy, wherein the pulp is cleaned out, the space disinfected and then filled. Root canal anatomy consists of the pulp chamber and root canals. Both contain the dental pulp. The smaller branches, referred to as accessory canals, are most frequently found near the root end (apex), but may be encountered anywhere along the root length. The total number of root canals per tooth depends on the number of the tooth roots ranging from one to four, five or more in some cases. Sometimes there are more than one root canal per root. Some teeth have a more variable internal anatomy than others. An unusual root canal shape, complex branching (especially the existence of horizontal branches), and multiple root canals are considered as the main causes of root canal treatment failures. A dental implant (also known as an endosseous implant or fixture) is a surgical component that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor. The basis for modern dental implants is a biologic process called osseointegration where materials, such as titanium, form an intimate bond to bone. The implant fixture is first placed, so that it is likely to osseointegrate, then a dental prosthetic is added. A variable amount of healing time is required for osseointegration before either the dental prosthetic (a tooth, bridge or denture) is attached to the implant or an abutment is placed which will hold a dental prosthetic. Success or failure of implants depends on the health of the person receiving it, drugs which impact the chances of osseointegration and the health of the tissues in the mouth. The amount of stress that will be put on the implant and fixture during normal function is also evaluated. Planning the position and number of implants is key to the long-term health of the prosthetic since biomechanical forces created during chewing can be significant. The position of implants is determined by the position and angle of adjacent teeth, lab simulations or by using computed tomography with CAD/CAM simulations and surgical guides called stents. The prerequisites to long-term success of osseointegrated dental implants are healthy bone and gingiva. Since both can atrophy after tooth extraction pre-prosthetic procedures, such as sinus lifts or gingival grafts, are sometimes required to recreate ideal bone and gingiva. The final prosthetic can be either fixed, where a person cannot remove the denture or teeth from their mouth or removable, where they can remove the prosthetic. In each case an abutment is attached to the implant fixture. Where the prosthetic is fixed, the crown, bridge or denture is fixed to the abutment with either lag screws or dental cement. Where the prosthetic is removable, a corresponding adapter is placed in the prosthetic so that the two pieces can be secured together. The risks and complications related to implant therapy are divided into those that occur during surgery (such as excessive bleeding or nerve injury), those that occur in the first six months (such as infection and failure to osseointegrate) and those that occur long-term (such as peri-implantitis and mechanical failures). Planning for dental implants focuses on the general health condition of the patient, the local health condition of the mucous membranes and the jaws and the shape, size, and position of the bones of the jaws, adjacent and opposing teeth. There are few health conditions that absolutely preclude placing implants although there are certain conditions that can increase the risk of failure. Those with poor oral hygiene, heavy smokers and diabetics are all at greater risk for a variant of gum disease that affects implants called peri-implantitis, increasing the chance of long-term failures. Long-term steroid use, osteoporosis and other diseases that affect the bones can increase the risk of early failure of implants. Treatment is multidisciplinary, involving oral and maxillofacial surgeons, plastic surgeons, head and neck surgeons, ENT doctors, oncologists, speech therapists, occupational therapists, physiotherapists, and other healthcare professionals. Dental bridges are false teeth, known as a pontics, which are fused between two porcelain crowns to fill in areas left by missing teeth. Two crowns hold it in place, these are attached to adjacent sides of the false tooth. This is known as a fixed bridge. This procedure is used to replace one or more missing teeth. Fixed bridges cannot be taken out in the same way that partial dentures can. In areas of the mouth that are under less stress, such as the front teeth, a cantilever bridge may be used. Cantilever bridges are used when there are teeth on only one side of the open space. In the situation that a tooth is considered so threatened (because of decay, cracking, etc.) that future infection is considered likely or inevitable, a pulpectomy, removal of the pulp tissue, is advisable to prevent such infection. Usually, some inflammation and/or infection is already present within or below the tooth. To cure the infection and save the tooth, the dentist drills into the pulp chamber and removes the infected pulp and then drills the nerve out of the root canal(s) with long needle-shaped hand instruments known as files (H files and K files). Starting with a smaller file size (sometimes termed a 'pathfinder'), progressively larger files are used to widen the canals. This process serves to remove debris and infected tissue and facilitates greater penetration of an irrigating solution (see 'irrigants' below). After this is done, the dentist fills each of the root canals and the chamber with an inert material and seals up the opening. This procedure is known as root canal therapy. With the removal of nerves and blood supply from the tooth, it is best that the tooth be fitted with a crown. For some patients, root canal therapy is one of the most feared dental procedures, perhaps because of a painful abscess that necessitated the root canal procedure. However, dental professionals assert that modern root canal treatment is relatively painless because the pain can be controlled with a local anesthetic during the procedure and pain control medication can be used before and/or after treatment assuming that the dentist takes the time to administer one. However, in some cases it may be very difficult to achieve pain control before performing a root canal. For example, if a patient has an abscessed tooth, with a swollen area or "fluid-filled gum blister" next to the tooth, the pus in the abscess may contain acids that inactivate any anesthetic injected around the tooth. In this case, the dentist may drain the abscess by cutting it to let the pus drain out. Releasing the pus releases pressure built up around the tooth; this pressure causes the pain. The dentist then prescribes a week of antibiotics such as penicillin, which will reduce the infection and pus, making it easier to anesthetize the tooth when the patient returns one week later. The dentist could also open up the tooth and let the pus drain through the tooth, and could leave the tooth open for a few days to help relieve pressure. A root treated tooth may be eased from the occlusion as a measure to prevent tooth fracture prior to the cementation of a crown or similar restoration. Sometimes the dentist performs preliminary treatment of the tooth by removing all of the infected pulp of the tooth and applying a dressing and temporary filling to the tooth. This is called a pulpectomy. The dentist may also remove just the coronal portion of the dental pulp, which contains 90% of the nerve tissue, and leave intact the pulp in the canals. This procedure, called a "pulpotomy", tends to essentially eliminate all the pain. A pulpotomy may be a relatively definitive treatment for infected primary teeth. The pulpectomy and pulpotomy procedures aim to eliminate pain until the follow-up visit for finishing the root canal. Further occurrences of pain could indicate the presence of continuing infection or retention of vital nerve tissue. In the last ten to twenty years, there have been great innovations in the art and science of root canal therapy. Dentists now must be educated on the current concepts in order to optimally perform a root canal. Root canal therapy has become more automated and can be performed faster thanks, in part, to machine driven rotary technology and more advanced root canal filling methods. Many root canal procedures are done in one dental visit which may last for around 1–2 hours. Newer technologies are available (e.g. cone-beam CT scanning) that allow more efficient, scientific measurements to be taken of the dimensions of the root canal. Many dentists use dental loupes to perform root canal therapy, and the consensus is that root canals performed using loupes, or other forms of magnification (e.g. a surgical microscope), are more likely to succeed than those performed without them. Although general dentists are becoming versed in these advanced technologies, they are still more likely to be used by specialist root canal doctors (known as endodontists). In the past, dental fillings and other tooth restorations were made of gold, amalgam and other metals—some of which were veneered with porcelain. Now, dental work can be made entirely of porcelain or composite materials that more closely mimic the appearance of natural tooth structure. These tooth colored materials are bonded to the underlying tooth structure with resin adhesives. Unlike silver fillings (amalgams) they are entirely free of mercury. Many dentists offer procedures to be cosmetic and because their patients prefer natural looking teeth. Cosmetic dentistry has evolved to cover many new procedures and new dental materials are constantly introduced. Bleaching methods use carbamide peroxide which reacts with water to form hydrogen peroxide. Carbamide peroxide has about a third of the strength of hydrogen peroxide. This means that a 15% solution of carbamide peroxide is the rough equivalent of a 5% solution of hydrogen peroxide. The peroxide oxidizing agent penetrates the porosities in the rod-like crystal structure of enamel and breaks down stain deposits in the dentin. Power bleaching uses light to accelerate the process of bleaching in a dental office. Another bleaching agent is 6-phthalimido peroxy hexanoic acid. White-spot decalcification may be highlighted and become more noticeable directly following a whiting process, but with further applications the other parts of the teeth usually become more white and the spots less noticeable. Bleaching is not recommended if teeth have decay or infected gums. It is least effective when the original tooth color is grayish and may require custom bleaching trays. Bleaching is most effective with yellow discolored teeth. However, whitener does not work where bonding has been used and neither is it effective on tooth-color filling. Other options to deal with such cases are the porcelain veneers or dental bonding. Power or light-accelerated bleaching, sometimes colloquially referred to as laser bleaching (a common misconception since lasers are an older technology that was used before current technologies were developed), uses light energy to accelerate the process of bleaching in a dental office. Different types of energy can be used in this procedure, with the most common being halogen, LED, or plasma arc. Clinical trials have demonstrated that among these three options, halogen light is the best source for producing optimal treatment results.[6] The ideal source of energy should be high energy to excite the peroxide molecules without overheating the pulp of the tooth.[7] Lights are typically within the blue light spectrum as this has been found to contain the most effective wavelengths for initiating the hydrogen peroxide reaction. A power bleaching treatment typically involves isolation of soft tissue with a resin-based, light-curable barrier, application of a professional dental-grade hydrogen peroxide whitening gel (25-38% hydrogen peroxide), and exposure to the light source for 6–15 minutes. Recent technical advances have minimized heat and ultraviolet emissions, allowing for a shorter patient preparation procedure. Most power teeth whitening treatments can be done in approximately 30 minutes to one hour, in a single visit to a dental physician. In preparing a tooth for a restoration, a number of considerations will come into play to determine the type and extent of the preparation. The most important factor to consider is decay. For the most part, the extent of the decay will define the extent of the preparation, and in turn, the subsequent method and appropriate materials for restoration. Another consideration is unsupported tooth structure. In the photo at right, unsupported enamel can be seen where the underlying dentin was removed because of infiltrative decay. When preparing the tooth to receive a restoration, unsupported enamel is removed to allow for a more predictable restoration. While enamel is the hardest substance in the human body, it is particularly brittle, and unsupported enamel fractures easily. Restoring a tooth to good form and function requires two steps, (1) preparing the tooth for placement of restorative material or materials, and (2) placement of restorative material or materials. The process of preparation usually involves cutting the tooth with special dental burrs, to make space for the planned restorative materials, and to remove any dental decay or portions of the tooth that are structurally unsound. If permanent restoration can not be carried out immediately after tooth preparation, temporary restoration may be performed. Dental composites, also called "white fillings", are a group of restorative materials used in dentistry. As with other composite materials, a dental composite typically consists of a resin-based matrix, such as a bisphenol A-glycidyl methacrylate (BISMA) resin like urethane dimethacrylate (UDMA), and an inorganic filler such as silica. Compositions vary widely, with proprietary mixes of resins forming the matrix, as well as engineered filler glasses and glass ceramics. The filler gives the composite wear resistance and translucency. Full-porcelain dental materials include Dental porcelain (porcelain meaning a high-firing-temperature ceramic), other ceramics, sintered-glass materials, and glass-ceramics as indirect fillings and crowns or metal-free "jacket crowns". They are also used as in-lays, on-lays, and aesthetic veneers. A veneer is a very thin shell of porcelain that can replace or cover part of the enamel of the tooth. Full-porcelain restorations are particularly desirable because their color and translucency mimic natural tooth enamel. Another type is known as porcelain-fused-to-metal, which is used to provide strength to a crown or bridge. These restorations are very strong, durable and resistant to wear, because the combination of porcelain and metal creates a stronger restoration than porcelain used alone. Socket preservation is a procedure to reduce bone loss after tooth extraction to preserve the dental alveolus (tooth socket) in the alveolar bone. A platelet rich fibrin (PRF) membrane containing bone growth enhancing elements can be stitched over the wound or a graft material or scaffold is placed in the socket of an extracted tooth at the time of extraction. The socket is then directly closed with stitches or covered with a non-resorbable or resorbable membrane and sutured.


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