WELCOME TO "CHILD DENTISTRY"

Dentistry for infants, toddlers, children and adolescents up to the age of 18 years old.

Your child's first dental visit

According to the American Academy of Paediatric Dentistry, your child should visit a dental
clinic by his/her 1st birthday. You can make the first visit to the dentist enjoyable and positive.
At any age you should inform your child of the visit and tell her/him that the dentist and their
staff will explain all procedures and answer any questions. The less to-do concerning the visit,
the better.

How are appointments scheduled?

The office will attempt to schedule appointments at your convenience. However, we recommend
preschoolers to be seen in the morning because they are fresher and we can therefore work more
slowly with the child for their comfort. School children with a lot of work to be done, should be
seen in the morning for the same reason. Dental appointments are an excused absence. Missing
school can be kept to a minimum when regular dental care is continued. Since appointed times
are reserved exclusively for each patient, we ask that you please notify our office 24h in advance
of your scheduled appointment time if you are unable to keep your appointment. Another patient
who needs our care could be scheduled if we have sufficient time to notify them. We realise that
unexpected things can happen, but we ask for your assistance in this regard.

Do I stay with my child during the visit?

We welcome the parent(s) presence during examination and treatment visits. However, the
privilege will be evalued according to each child's behaviour. The parent(s) should be a passive
observer at all times during the child's dental visit. We want your child's visit to our office to be a
happy one.

Payment policy

Payment for professional services is due at the time the dental treatment is provided. Every effort
will be made to provide a treatment plan which fits your timetable and budget, and gives you
child the best possible care . We accept cash, debit cards and most major credit cards.

Please note:
• No healthfunds refund 100% of the cost of dental procedures
• Benefits are not determined by our office.

Your child's first visit

1
The first "regular" dental visit should be just after your child's third birthday. The first
dental visit is usually short and involves very little treatment. We may ask you to sit in the dental
chair and hold your child during the examination. You may also be asked to wait in the reception
area during part of the visit so that a relationship can be built between your child and your
dentist.

We will gently examine your child's teeth and gums. X-rays may be taken (to reveal decay and
check on the progress of your child's permanent teeth under the gums). We may clean your
child's teeth and apply topical fluoride to help protect the teeth against decay. We will make sure
your child is receiving adequate fluoride at home. Most important of all, we will review with you
how to clean and care for your child's teeth.

What should I tell my child about the first dental visit?

We are asked this question many times. We suggest you prepare your child the same way you
would before their first haircut or trip to the shoe store. Your child's reaction to his first visit to
the dentist may surprise you.

Here are some "First Visit" tips:

 Take your child for a "preview" of the office.

 Read books with them about going to the dentist.
 Review with them what the dentist will be doing at the time of the first visit.
 Speak positively about your own dental experiences.

During your first visit the dentist will:

 Examine your mouth, teeth and gums.

 Evaluate adverse habits like thumb sucking.
 Check to see if you need fluoride.
 Teach you about cleaning your teeth and gums.
 Suggest a schedule for regular dental visits.

What about preventative care?

Tooth decay and children no longer have to go hand in hand. At our office we are most
concerned with all aspects of preventive care. We use the latest in dental sealant technology to
protect your child's teeth. Dental sealants are space-age plastics that are bonded to the chewing
surfaces of decay-prone back teeth. This is just one of the ways we will set the foundation for
your child's lifetime of good oral health.

2
Cavity prevention

Most of the time cavities are due to a diet high in sugary foods and a lack of brushing.
Limiting sugar intake and brushing regularly, of course, can help. The longer it takes your child
to chew their food and the longer the residue stays on their teeth, the greater the chances of
getting cavities.

Every time someone eats, an acid reaction occurs inside their mouth as the bacteria digests the
sugars. This reaction lasts approximately 20 minutes. During this time the acid environment can
destroy the tooth structure, eventually leading to cavities.

Consistency of a person's saliva also makes a difference; thinner saliva breaks up and washes
away food more quickly. When a person eats diets high in carbohydrates and sugars they tend to
have thicker saliva, which in turn allows more of the acid-producing bacteria that can cause
cavities.

Tips for cavity prevention

 Limit frequency of meals and snacks.

 Encourage brushing, flossing and rinsing.
 Watch what your child drinks.
 Avoid giving your child sticky foods.
 Make treats part of meals.
 Choose nutritious snacks.

The first baby teeth that come into the mouth are the two bottom front teeth. You will notice this
when your baby is about 6-8 months old. Next to follow will be the 4 upper front teeth and the
remainder of your baby's teeth will appear periodically. They will usually appear in pairs along
the sides of the jaw until the child is about 2 1/2 years old.

At around 2 1/2 years old your child should have all 20 teeth. Between the ages of 5 and 6 the
first permanent teeth will begin to erupt. Some of the permanent teeth replace baby teeth and
some don't. Don't worry if some teeth are a few months early or late as all children are different.

Baby teeth are important as they not only hold space for permanent teeth but they are
important to chewing, biting, speech and appearance. For this reason it is important to
maintain a healthy diet and daily hygiene.

For years we have been creating awareness among the people about the importance of the milky
teeth. We have organized many health camps and checkups for children and now we are getting
the results. Pedodontics or pediatric dentistry deals with oral care of children. We not only care
about the teeth but we also put a lot of stress on studying child psychology. We normally treat a
child patient according to his/her behavioural patterns. Following is the normal chart to
understand the growth patterns of the teeth in your child.

3
4
The primary teeth or the milky teeth are always followed by the permanent teeth
which are growing below the milky teeth and are beneath the gums.

We normally make everybody understand the importance of primary teeth. Just

have a look at the sequence of events below which will make you feel that, "SAVE
MY CHILD'S TEETH AT ANY COST"

DECAY STARTED IN THE

PRIMARY TOOTH

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 IF DECAY NOT TREATED, IT
WILL DAMAGE THE
PERMANANT TOOTH

PRIMARY TOOTH REMOVED

THE SPACE MEANT FOR THE

PERMANANT TOOTH CLOSED

There are many problems that children face and visit our clinic. They are:

Decayed milky teeth.

Unerreputed permanent teeth.
Many harmful habits like thumb sucking, lip sucking, teeth grinding etc.
Crooked teeth.
Fractured teeth due to injuries.
Nursing bottle decays

6
 Clept lip and cleft palate.

DOCTOR'S WORDS : don't panic after any problems your child faces. We have a
solution for all. We advice to fill up the with the best fluoride containing materials after
removing all the decay from the tooth before it reaches the canal and harms the
permanent tooth below. We have solution for any kind of harmful habits your child
have.

We can correct your child's crooked teeth with an orthodontic treatment. we can repair
fractured teeth and nursing bottle decays. We also correct the cleft lip and palate
related teeth irregularities. We often advice the parents to get the check up of their
children done at regular intervals. WE ADVICE TO PREVENT RATHER THAN
CURE. And so the solution for that is get the PIT AND FISSURE SEALANTS
applied to your child's teeth before it decays.

We also have the solution for injuries. Just don't stop your children from playing
getting afraid that they may injure or break their teeth. We have a solution for that. It is
an appliance called the mouth guard which your child wears during playing. A mouth
guard (gumsheild) acts like a helmet for teeth protecting them from damage in physical
sport.

"MOUTHGUARDS FIGHT WEEKEND WARRIOR INJURIES"

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 FOR FURTHER QUERIES PLEASE CONTACT US

ORIGINAL ARTICLE

Year : 2009 | Volume : 12 | Issue : 4 | Page : 154-159

Comparison of fracture resistance of endodontically treated teeth using different coronal

restorative materials: An in vitro study

Prashant Monga, Vivek Sharma, Sukesh Kumar

Departments of Conservative Dentistry and Endodontics, D.J. College of Dental Sciences and
Research, Modinagar, U.P, India

Click here for correspondence address and email

Date of Submission 04-Feb-2009

Date of Decision 20-Feb-2009

Date of Acceptance 01-Mar-2009

Date of Web Publication 15-Dec-2009

Abstract

Aim/Objective: To evaluate the in vitro effect of bonded restorations on the fracture resistance of
root canal-treated teeth.
Materials and Methods: One hundred twenty extracted, maxillary, permanent premolars were
collected. After preparing the access cavity, the teeth were biomechanically prepared and
obturated. Samples were divided into six groups based on the type of restorative material used to
restore them. Teeth were embedded in acrylic resin and their fracture strength was measured
using a Universal Testing Machine. Data were evaluated statistically using one-way ANOVA-F

8
and unpaired t-test.
Results: Teeth restored with bonded amalgam and composite resin showed higher fracture
resistance than those restored with conventional amalgam. Fracture strengths of bonded
restorations and intact teeth were not statistically different. The results suggested that the group
restored with conventional amalgam had the lowest fracture resistance. No statistically significant
differences were found between the bonded amalgam and composite resin groups.
Conclusion: Conventional amalgam core showed the least fracture resistance whereas; composite
resin and bonded amalgam core showed fracture resistance was similar to that of natural tooth.

Keywords: Bonded restorations; fracture resistance; root-filled teeth.

How to cite this article:

Monga P, Sharma V, Kumar S. Comparison of fracture resistance of endodontically treated teeth
using different coronal restorative materials: An in vitro study. J Conserv Dent 2009;12:154-9

How to cite this URL:

Monga P, Sharma V, Kumar S. Comparison of fracture resistance of endodontically treated teeth
using different coronal restorative materials: An in vitro study. J Conserv Dent [serial online]
2009 [cited 2010 Sep 10];12:154-9. Available from: http://www.jcd.org.in/text.asp?
2009/12/4/154/58338

Introduction

Restoration of root canal-treated teeth with a permanent, definitive, postendodontic restoration is

a final step for successful root canal treatment as these teeth are considered more susceptible to
fracture. The reason most often cited for this finding has been the dehydration and loss of dentin
after the endodontic procedures and the removal of important anatomic structures such as cusps,
ridges, and the arched roof of the pulp chamber, all of which provide much of the necessary
[1]
support for the natural tooth.

Therefore, intracoronal strengthening of teeth is important to protect them against fracture,

particularly in posterior teeth where stresses generated by occlusal forces can lead to fracture of
unprotected cusps. Restoration of root canal-treated teeth is an important step that complements a
technically sound endodontic treatment. [2] Thus, root canal treatment should not be considered
complete until a coronal restoration has been placed. An optimal final restoration for
endodontically treated teeth maintains aesthetics, function, preserves the remaining tooth
[3]
structure, and prevents microleakage.

Studies suggest that complex amalgam restorations, complete cast coverage, cast restorations, and
composite materials can all be used as postendodontic restorations. Although dental amalgam has
favorable mechanical properties, it lacks adhesion to the tooth structure. This diminishes the

9
fracture resistance of the remaining tooth structure due to microcrack propagation under fatigue
loading. [4] Cast restorations and complete cast coverage procedures involve multiple visits and
increased cost, which can lead to increased chances of discontinuation of the treatment. [5],[6]

With the recent advancements in adhesive technology and stronger adhesive materials, it is now
possible to create conservative, highly aesthetic restorations [7] that are bonded directly to the
[8]
tooth structure and strengthen it.

Introduction of new bonding agents has also led to the possibility of restoring root-filled teeth
with a bonded restoration instead of a crown or onlay restoration. [2] The ability to predictably
restore a root-filled tooth to its original strength and fracture resistance without the placement of a
full coverage restoration could provide potential prosthodontic and economic benefits to patients.

The aim of the study was to evaluate the in vitro effect of bonded restorations on the fracture
resistance of root canal-treated teeth.

Materials and Methods

One hundred twenty freshly extracted, intact, noncarious, human, maxillary, premolar teeth with
similar anatomic characteristics were selected. All soft tissue and debris on the teeth were
removed using an ultrasonic scaler and the teeth were stored in saline at room temperature. To
minimize the influence of size and shape variations on the results, the teeth were classified
according to their mesiodistal and buccolingual dimensions. The teeth were randomly divided
into six experimental groups of 20 teeth each and subjected to the following procedures:

Group 1 - Unaltered teeth (control)

Group 2 - Standard endodontic access cavities were prepared with No. 245 straight burs

Group 3 - MOD (mesial-occlusal-distal) cavities were prepared with airotor no. 245 straight burs
so that the buccolingual width of the occlusal isthmus was one third the width of the intercuspal
distance, and the buccolingual width of the approximal preparation was one third of the
buccolingual width of the crown. The approximal boxes were prepared straight (nonundercut) and
limited to 2 mm coronally in the depth from the cemento-enamel junction.

An endodontic access cavity was then prepared; the root canals instrumented to a size 40 file
(Mani, Inc, Tochigi, Japan) and filled with gutta-percha (SPI Dental Mfg. Inc., Inchon, Korea)
and AH 26 root canal sealer (Dentsply DeTrey, Konstanz, Switzerland) using a lateral
condensation technique.

Group 4 - The teeth were prepared and the root canals were filled as in group 3. Cavities were
restored conventionally with high-copper amalgam [Dispersalloy, Dentsply] [Table 1] according
to the manufacturer's instructions.

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Group 5 - The teeth were prepared and the root canals were filled as in group 3. Prior to the
restoration with amalgam, the Adper Scotchbond Multi-Purpose plus Adhesive system (3M
ESPE) was applied according to the manufacturer's instructions. Etchant (37% Phosphoric acid)
was applied to the enamel and dentine for 15 seconds. The cavity was rinsed and excess water
removed with a gentle, five-second air blast. One drop each of activator (bottle 1.5) and primer
(bottle 2) were mixed and applied to the etched enamel and dentine for 15 seconds; the
preparations were dried gently for five seconds. One drop each of adhesive (bottle 3) and catalyst
(bottle 3.5) were then mixed and applied to the primed enamel and dentine. The amalgam was
mixed and placed before the bonding material had set; the restorations were then polished.

Group 6 - The teeth were prepared and the root canals were filled as in group 3. Prior to the
restoration with composite resin, the Adper Scotchbond Multi-Purpose plus Adhesive system
(3M ESPE) was applied according to the manufacturer's instructions. Both enamel and dentine
were etched with 37% phosphoric acid for 15 seconds. The surface was rinsed with water and the
excess water was removed with an air syringe. Scotchbond multipurpose primer (bottle 2) was
applied to the enamel and dentine and was dried gently for five seconds. Adper Scotchbond
Multi-Purpose plus Adhesive was then applied to the enamel and dentine and light-cured for ten
seconds. The composite resin (Filtec P60, 3M ESPE) was placed in the cavities in increments of 2
mm thickness, and each increment was light-cured for 20 seconds. After the removal of the
matrix band, the restorations were contoured and polished.

Teeth were stored in 100% humidity at 37° C for seven days. Cylindrical moulds (2.5 cm × 2.5
cm) were made using stainless steel pipes. Self-cure acrylic resin [Ashwin Pvt. Ltd. India] was
used to fill the mould and the teeth mounted to 1 mm level apical to the cemento-enamel junction.

Fracture strength testing was done using a Universal Testing machine [Llyold, UK]. Prepared
specimens were then mounted on a holder slot which was fixed to the lower arm of the universal
testing machine. A metal indenter of 6 mm diameter was fixed to the upper arm of the universal
testing machine which was set to deliver an increasing load until fracture occurred.

The crosshead speed was 1.0 mm per minute, and the load was applied to the occlusal inclines of
the buccal and lingual cusps vertically down the long axis of the tooth. The force required to
fracture each tooth was recorded in Newtons. Statistical analysis was performed using one way
ANOVA-F test and unpaired t-test to determine the significance of differences between different
groups.

Results

The mean forces at fracture, the minimal and maximal values and the SD for each group are
presented in [Table 2]. The mean forces at fracture were: Group 1 (1193.75 N), group 5 (968.00
N), group 6 (867.38 N) followed by group 2 (683.10 N), group 4, (501.10 N) and group 3 (248.50
N), respectively. The overall significant difference between the groups was found at the 0.01
level (P< 0.01). According to the unpaired t-test results, significant differences were found
between the teeth restored with conventional amalgam or bonded amalgam (groups 4 and 5, P<

11
0.01) and those restored with conventional amalgam and composite resin (groups 4 and 6, P<
0.01). There were no significant differences between unaltered teeth and bonded amalgam groups
(groups 1 and 5) or between groups 2 and 4. In addition, no statistically significant difference was
found between the bonded amalgam and composite resin groups (groups 5 and 6). The mean
force at fracture in group 3 (MOD plus access cavity) was significantly lower than in the other
groups ( P < 0.01). Groups with significant difference are shown with different superscripts in
[Table 2].

Discussion

Tooth restoration is the final step in root canal treatment. [5] Numerous studies have been
conducted to determine the ideal method to restore endodontically treated teeth as these teeth
have decreased fracture resistance due to the loss of tooth structure during endodontic access and
cavity preparation procedures. Cusp separation rarely occurs in noncarious, intact teeth because
of the presence of the pulp chamber's roof and marginal ridges, which can be considered to be
tooth-reinforcing structures. The presence of palatal and buccal cusps with intact mesial and
distal marginal ridges forms a continuous circle of tooth structure which reinforces and maintains
[8]
the integrity of the tooth.

It has been shown that the weakening of teeth due to restorative and endodontic procedures
increases with the reduction of tooth structure. [4],[2] Endodontic procedures reduce the relative
rigidity of the tooth by 5%, which is contributed entirely by access opening. In contrast, loss of
the marginal ridge has resulted in a 46% loss in tooth rigidity whereas an MOD preparation has
resulted in a loss of 63% relative cuspal rigidity. [9] Other authors reported that the mean fracture
strength for unrestored teeth with MOD preparation was 50% less than that of unaltered premolar
teeth. [5] It was observed that cavity preparations made with occlusal opening and marginal ridge
removal resulted in elevated strain values, supporting the premise that teeth are weakened by the
removal of tooth structure. [8] This highlights the importance of prevention and early diagnosis of
carious lesions before they involve the marginal ridge.

Traditionally, root canal-treated teeth have been restored with cast restorations and full/partial
coverage crowns which include cusp coverage to improve the fracture resistance. [9] To further
increase the fracture resistance, several attempts have been made to restore endodontically treated
teeth with different post systems to increase the fracture resistance of the root structure. However,
some studies have proved that these posts decrease the fracture resistance instead of increasing it.
Endodontic posts do not reinforce the crown as enlargement of the root canal space after
completion of root canal treatment can weaken the tooth structure. Another method that has been
used is cusp reinforcement with the use of pins. Although restored teeth can be as strong as intact
teeth, these pins create stress and suffer corrosion in the dental tissue. [10]

Numerous materials have been used as substitutes for dental tissues. Amalgam, for instance, is
the most common material used for more than 100 years in posterior restorations. Although
amalgam has high compressive strength, it does not adhere to the dental structure. Cuspal
fractures in amalgam restoration result from the fatigue caused by crack diffusions subjected to

12
repeated loading. Also, the presence of mercury and the types of interactions among its metal
components make this material exhibit higher deformation levels when submitted to occlusal load
[8]
application.

In the recent past, the introduction of new bonding agents with bond strength between 20 and 25
Mpa (and sometimes even more) has led to the suggestion that endodontically treated teeth may
be restored with a bonded restoration instead of a crown or onlay preparation. These bonding
agents have the advantages of providing greater strength and fracture resistance without the
placement of full-coverage restoration and also limiting coronal microleakage which may emerge
as an important factor in the selection of bonding agents for the coronal buildup of endodontically
treated teeth. [11] These qualities provide potential prosthodontic and economic benefits to
patients. [10] For these reasons, the use of adhesive materials has been considered useful for tooth
reinforcement. These observations have been confirmed by other studies also. [12]

Teeth restored with amalgam bonded to etched enamel have a significantly greater fracture
resistance than those restored with conventional amalgam due to its adhesion to the tooth
structure. Adhesion occurs between the amalgam and the tooth structure through the use of the
bonding agent between them. The adhesive resin develops mainly micromechanical retention
with the tooth structure. It may also develop some chemical bonds via phosphate esters that
interact with calcium ions in the tooth. When the amalgam is packed into the cavity over the wet
resin, a mechanical interlocking of the resin and the amalgam occurs. This interlocking is
probably a much more significant factor in the retention of the amalgam than are the chemical
bonds that occur between the resin and the components of the amalgam. [13]

In addition to aesthetics, modern composite materials have got high compressive strength for
posterior restorations. It has been suggested that the use of resin composite in restorations
reinforces dental stiffness as the adhesive nature of the composite binds the cusps and decreases
their flexion. Flexion is considered to be the main cause of fracture in conventional, nonbonded
amalgam restorations. Due to its low elastic modulus, composite resin can transmit the energy
produced by the compressive forces to the adjacent dental structure, thus reinforcing the
weakened tooth structure. Although, the tooth restoration interface suffers elastic stresses
generated by the contraction of the material during polymerization, these stresses can be
[12]
dissipated by cuspal movement.

In our study, conventional amalgam, bonded amalgam, and composite resin were used to restore
endodontically treated maxillary premolars. Maxillary premolars were used because studies have
shown that these teeth are more prone to fracture. Reasons cited for this greater susceptibility to
fracture are: i) the anatomical shape of maxillary premolars that creates a tendency for the
separation of their cusps during mastication. Clinically restored maxillary premolars may undergo
palatal and buccal strain as a result of occlusal load application, which may be associated with
high levels of stress concentration inside the tooth restoration complex. The cusp inclines of these
teeth are much greater than in maxillary molars and can result in a different pattern of fracture
resistance. It has also been reported that the incidence of fracture is greater in maxillary
premolars than in mandibular premolars. The lowest 20 years' survival rate was found in
maxillary premolars. [13] ii) Other authors have noted a difficulty in obtaining uniform fracture
strengths for human teeth due to natural variations in tooth morphology. [14],[15] Maxillary

13
premolars were selected as it is known that they show the least variations. iii) Direct composite
restoration of premolars can be considered to be more predictable than that of molars due to the
small amount of composite needed for restoration which, in turn, leads to lower polymerization
contraction stress. iv) Also, the interproximal margins of premolars are more accessible for
[16]
inspection and finishing procedures.

Mesio-occlusal distal (MOD) cavities were prepared in our study to simulate this preparation that
is often found clinically and has been extensively reproduced in other clinical studies. The
general effect of MOD cavity preparations is the creation of long cusps; thus, there is the need for
a restorative material that not only replaces the lost tooth structure, but also increases the fracture
resistance of the residual tooth and promotes effective marginal sealing.

Several studies have shown that applying the force to the long axis of the, tooth transmits the
force uniformly. [17],[18],[19],[ 20] In our study, force was also applied vertically at a constant speed
using a universal testing machine. When the cylindrical-shaped tool makes contact with the tooth,
it acts as a wedge between the buccal and lingual cusps in unrestored teeth and decreases the
mean fracture resistance values, while promoting more catastrophic types of fracture. Our
research evaluated the capacity shown by the material to support vertical tension, vital in areas of
high masticatory effort.

In our study, the highest mean fracture value was found in intact teeth (Group 1) because there
was no loss of tooth structure.

The difference between groups 5 and 1, i.e., the bonded amalgam and intact teeth groups was not
statistically significant. These findings may be related to the reinforcement of tooth structure due
to adhesion of the amalgam, thus increasing the fracture resistance. These findings are in
accordance with other studies that found that bonding amalgam to the tooth structure not only
increased fracture resistance of teeth, but could also restore the strength and rigidity lost by cavity
preparation. [21],[22] It was also found that teeth restored with bonded amalgam were significantly
more resistant to fracture than those restored with conventional amalgam. [19],[23],[24]

The fracture resistance of group 6 (restored with composite resin) was not significantly different
from group 5 (restored with bonded amalgam). These findings can again be related to the
adhesive nature of composite resin to the tooth structure and the increased strength of newer
posterior composites available in the market. These findings are in accordance with similar
studies conducted in the recent past that found that endodontically treated teeth restored with
composite resin had higher fracture resistance than those restored with nonadhesive restorations.
[25],[26]
When the clinical success rates of endodontically treated premolars restored with direct
composite restorations were evaluated after three years of service, they were found to be
equivalent to a similar treatment of full coverage with metal ceramic crowns. [27] Thus, composite
[8]
resin plays an important role in recovering tooth strength.

Group 4 (restored with conventional amalgam) exhibited significantly lower fracture resistance
than groups 5 and 6 (i.e., bonded amalgam group and composite resin group respectively)
probably due to the fact that conventional amalgam did not adhere to the tooth structure. These
findings are in accordance with similar studies that compared the stiffness of endodontically

14
treated premolars, and found that teeth restored with amalgam were the weakest whereas those
restored with composite restoration were as strong as unaltered teeth. The results of our study
suggest that adhesion plays an important role in increasing the fracture resistance of
[24],[28]
endodontically treated teeth.

We suggest that bonded composite resin restoration can be considered as the first choice for
aesthetic reasons. However, if for some reason, the clinician chooses amalgam, bonding amalgam
to tooth structure could be expected to produce a higher fracture resistance compared with a
conventional amalgam restoration.

We are in the process of carrying out additional clinical studies to determine the long-term, in
vivo prognosis of extensive bonded restorations in endodontically treated teeth. More studies
involving the use of adhesive restorative materials in restoring root-filled teeth are required.

Conclusions

1. The teeth restored with conventional amalgam were significantly weaker than the teeth
restored with bonded amalgam and composite resin (P , 0.01).
2. No statistically significant differences were found between the bonded amalgam and
composite resin groups or between the bonded amalgam group and sound teeth.

References

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teeth: Comparison of two restoration techniques. Int Endod J 2006;39:136-42.
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new generation dentine bonding adhesives. Int Endod J 2003;36:770-3.
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15
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16. Eakle WS, Staninec M, Lacy AM. Effect of bonded amalgam on the fracture resistance of
teeth. J Prosthet Dent 1992;68:257-60.
17. Chen RS, Liu CC, Cheng MR, Lin CP. Bonded amalgam restorations: Using a glass
ionomer as an adhesive liner. Oper Dent 2000;25:41-7.
18. Lindemuth JS, Hagge MS, Broome JS. Effect of restoration size on fracture resistance of
bonded amalgam restorations. Oper Dent 2000;25:177-81.
19. Dias de Souza GM, Pereira GD, Dias CD, Paulillo LA. Fracture resistance of premolars
with bonded class II amalgams. Oper Dent 2002;27:349-53.
20. Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR. Three- year clinical comparison
of survival of endodontically treated teeth restored with either full cast coverage or with
direct composite restoration. J Prosthet Dent 2002;88:297-301.
21. Rasheed AA. Effect of bonding amalgam on the reinforcement of teeth. J Prosthet Dent

16
 2005;93:51-5.
22. Zidan O, Abdel-Keriem U. The effect of amalgam bonding on the stiffness of teeth
weakened by cavity preparation. Dent Mater 2003;19:680-5.
23. Pilo R, Brosh T, Chweidan H. Cusp reinforcement by bonding of amalgam restorations. J
Dent 1998;26:467-72.
24. Trope M, Tronstad L. Resistance to fracture of endodontically treated premolars restored
with glass ionomer cement or acid etch composite resin. J Endod 1991;17:257-9.
25. Daneshkazemi AR. Resistance of bonded composite restorations to fracture of
endodontically treated teeth. J Contemp Dent Pract 2004;15:51-8.
26. Plotino G, Buono L, Grande NM, Lamorgese V, Somma F. Fracture resistance of
endodontically treated molars restored with extensive composite resin restorations. J
Prosthet Dent 2008;99:225-32.
27. Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR. Three- year clinical comparison
of survival of endodontically treated teeth restored with either full cast coverage or with
direct composite restoration. J Prosthet Dent 2002;88:297-301.
28. Hernandez R, Bader S, Boston D, Trope M. Resistance to fracture of endodontically treated
premolars restored with new generation dentine bonding systems. Int Endod J 1994;27:281-
4.

What is Pediatric Dentistry?

Pediatric Dentistry is a dental specialty that focuses on comprehensive oral health care for infants
and children through adolescence, with an emphasis on children with special needs. Training to
become a pediatric dentist occurs in a residency program following graduation from dental
school. During this training, the dentist learns to provide high quality comprehensive care to
pediatric patients (0 – 18 years old). This care includes the ability to perform oral conscious
sedation, and use various behavior guidance techniques. A goal of pediatric dentistry is not only
to treat pediatric patients but to keep children comfortable in a dental setting throughout life.

What is the best way to treat a cavity?

At Children’s Dentistry of Lithonia we believe that the best way to treat a cavity is to prevent it
from forming. There are three things that must be present for a cavity to form:

1. A susceptible tooth
2. Cavity causing bacteria
3. A source of carbohydrates

17
This combination of factors can be avoided by cleaning your child’s teeth and staying on a
healthy diet.

How do I clean my child’s teeth?

• Brush your child’s teeth twice a day for 2 -5 minutes, with a soft-bristled brush that has
been run under warm water. The size and shape of your brush should allow you to reach
all areas easily. Brush the outer tooth surfaces, the inner tooth surfaces, and the chewing
surfaces of the teeth. When cleaning the inner and outer surfaces of the teeth you want to
aim for the area where the teeth and gums meet and use gentle brushstrokes to clean out
debris.
• Brush your child’s tongue to remove bacteria and freshen your child’s breath.
• If your child is old enough to spit without swallowing, use toothpaste that contains
fluoride, which helps protect your child’s teeth from decay. Make sure that you use a
pea-sized amount of toothpaste when brushing your child’s teeth. Children too young to
spit properly without swallowing (typically less than 4 years old) should be brushed with
non-fluoridated (training) toothpaste unless otherwise instructed by their pediatric dentist.
• Cleaning between the teeth once a day with floss or floss picks removes plaque from
between the teeth, areas where the toothbrush can't reach. The toothbrush cannot
typically clean areas where teeth are touching side by side which first occurs on back
teeth when children are between 2 and 3 years old. Flossing greatly reduces the
likelihood of your child getting cavities and gum disease.
• Children usually cannot tolerate adult floss for cleaning between teeth so it is
recommended that most children use floss picks.

What types of food should my child eat?

• A healthy diet includes the following major food groups every day: Fruits and
Vegetables; Breads and Cereals; Milk and Dairy Products; Meat, Fish and Eggs.
• A food with sugar or starch is safer for teeth if it's eaten with a meal, not as a snack.
• Sticky foods, such as gummie’s, dried fruit, soft candy, and fruit snacks are not easily
washed away from the teeth by saliva, water or milk. So, they have more cavity-causing
potential than foods more rapidly cleared from the teeth.
• Reduce the levels of juices and milks to those that are recommended by your child’s
pediatrician. It is important to note that juices, punches, and gatorade can be harmful to
your child’s teeth due to the acid and sugar contents in these drinks. Try to limit your
child’s consumption of non-water beverages to mealtimes and avoid sipping these
drinks. Also, make sure that your child doesn’t consume these beverages at night or
before they go to sleep.
• Encourage your child to drink fluoridated water as much as possible for both a clean
mouth and important minerals that help protect their teeth.
• Emergency visits

If your child has a dental emergency during normal office hours, please call the
office to schedule an appointment. After hours, you may call the office at 770-469-
4192 and you will be guided towards the appropriate course of action.

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 • Trauma

In the case of dental trauma, the first step is to ensure that your child has not received any
injuries to other areas of their body. If your child has received trauma to areas outside of
the mouth please go to your nearest pediatric emergency center or contact your
pediatrician. If your child has received dental trauma please call the office at 770-469-
4192.
• Toothache / Swelling

If your child has a toothache, first examine the area for swelling and obvious cavities.
Clean the area with warm salt water and use dental floss to dislodge any debris in the
area. You can give your child over the counter pain medication but do not place aspirin
or any other medications directly on the painful area. If your child has swelling outside
of their mouth, apply a cold compress and monitor the area for spread of swelling. Call
the office at 770-469-4192 to schedule an emergency visit following the completion of
these steps.
• Go directly to the hospital emergency room if your child’s temperature is >102 °F, or you
notice difficulty breathing, vomiting, or diarrhea.
• Lip biting following dental procedure

It is common for children to bite their cheeks, lips, and tongue following dental
procedures if they are not watched closely. If your child has bitten their oral soft tissues,
apply ice and pressure to the area. If bleeding does not stop after 15 min, call the office
at 770-469-4192 or take your child to the hospital emergency room.

Related Links:
Thumb-sucking habit- Uncontrolled can damage
Tooth Decay
teeth and facial looks
When Cavities start Hurting
Bad Breath
Thumbsucking is a common habit of preschool children,
Gum Problems
if continued it can hard teeth and looks of the kid. The
Children's Teeth
activity is normal for infants and toddlers, but should
Know Your Teeth
decrease by ages three to four and stop by age five.
How to Brush & Maintain your teeth
Unfortunately, many youngsters can't break the habit by
this time. Is parental anxiety over thumbsucking
warranted?

Thumbsucking is a very normal response to anxiety and stress and does not point to insecurity or
emotional problems in your child. Most children give up thumbsucking by age four, when some
children continue to suck their thumbs as a means of exerting independence. Aside from some
minor problems with thumb and fingernail infections, the most damage from thumbsucking
occurs to the teeth and jaw.

A well-known pediatrician recently stated on television that continued sucking of thumbs or

fingers does not cause serious dental problems in children and is not cause for parental alarm.
Wrong! In fact, prolonged thumb activity produces significant problems with chewing, speech,
and facial appearance.

19
The pleasure in the habit is derived from the contact of skin of thumb with oral mucous
membrane. Thumb sucking also creates an intense negative pressure in oral cavity/mouth which
has detrimental effects on over all development of facial area and narrowing of dental arches.
These effects can last life long because the cheek muscles become hyperactive due to over
action. BUT there is NO cause for worry, if the kid stops the habit before the age of 4-5 years.

Not all thumb sucking causes equal harm, three factors affect the outcome of damage. These are
Duration, Intensity and Frequency of the habit. Higher the three, higher will be damage to teeth.

Effects on the jawbone

The more time a child sucks his thumb and the greater the sucking pressure, the more harm done
to teeth and jaws. Day and night forceful thumbsucking makes front teeth move, and can even
reshape the jaw bone. Upper front teeth flare out and tip upward while lower front teeth move
inward. But, how can something as small as a child's thumb or finger effectively move bone?

The reason that thumbs and fingers are effective tooth-movers and bone shapers is that the jaw
bones of children under age eight are especially soft and malleable. Children have upper and
lower jaws rich in blood supply and relatively low in mineral content, especially calcium.
Unfortunately for children and parents, prolonged thumb or finger sucking easily deforms the
bone surrounding upper and lower front teeth, producing a hole or gap when teeth are brought
together known as an "open bite".

If a child stops thumbsucking before loss of baby front teeth and permanent front tooth eruption,
most or all harmful effects disappear within six months. However, if the habit persists through
permanent front tooth eruption, there can be lasting damage: flared or protruded upper teeth,
delayed eruption of upper or lower front teeth, and the aforementioned open bite. This can result
in chewing difficulties, speech abnormalities, and an unattractive smile.

Do home remedies work?

Some parents try home remedies to break the habit. Some try placing gloves on their children
before bedtime. Others paint thumbs and fingers with various foul-tasting substances, while still
others wrap bandages around the offending digits. Yet all of these measures are typically easy to
overcome and are usually unsuccessful, because thumbsucking is a deeply ingrained behavior.
One method which might help is to tie/roll a used x ray film on the elbow of the child so that
child can not bend the hand. You can tape the edges of the film of avoid sharp ends. Any method
will work only if child agrees to cooperate.

You should repeatedly educate/motivate the kid that his face will look bad. The kid can also be
asked to coinciously suck thumb sitting in front of a mirror daily for few minutes, this is a
biofeedback technique which has been found to be useful. It is very important not to get obsessed
with this matter, overdoing also will hut the kid, gentle and consistent approach is needed. It
would be considered safe not to initiate any steps until 3 years. Once kid understands your
obsession he can also use this as an ATTENTION drawing technique. It has been found that kids
who are breast fed are less likely to take to thumb sucking.

20
The dental solution: a crib that's not for sleeping

One answer to this parental dilemma is a simple device called a "crib." Placed by an orthodontist
on the child's upper teeth, the crib usually stops the habit cold the first day of use.

The appliance's technical name is a "fixed palatal crib," and is a type of brace that sits full-time
on the upper teeth and the roof of the mouth. The crib consists of semicircular stainless steel
wires connected to supporting steel bands or rings. The half-circle of wires fits behind the child's
upper front teeth, barely visible in normal view. The bands are fastened to the baby upper second
molars. There are a number of different crib designs used by orthodontists, all variations on the
same theme.

The first step for parents is to make an appointment for their child with an orthodontist. At the
initial visit, the doctor examines the child for problems with tooth position and bite. The teeth of
confirmed thumbsuckers have the tell-tale pattern described above, and the doctor will ask about
any habit history. With a diagnosis of intractable thumbsucking, the orthodontist will usually
recommend a crib to eliminate the habit. A second appointment is then arranged, where clay
impressions are made for plaster study models, together with facial and dental photographs and
jaw x-rays.

The orthodontist begins crib construction at the third visit, and cements the appliance at the
fourth. The child experiences soreness of upper back teeth for a few hours, and modified speech
for one or two days. Instructions are given on avoiding gum chewing, hard and sticky candy,
popcorn, peanuts and other brace-destroying foods. The patient is asked to not pull on the crib
with fingers. Thorough toothbrushing after each meal is stressed to prevent food and plaque
build-up and gum infections or cavities.

Once the crib is cemented, there is nothing to adjust and no moving or removable parts. It is one
of the simplest, yet most effective orthodontic devices. Fearsome looking open bites, on the
order of 8 to 10 millimeters, can close within a few months. And at $250-$350 per crib, the price
is not too prohibitive, given the amount of future dental problems that are averted.

Effectiveness of the crib

Why is the crib so effective in stopping thumbsucking? Simply because it takes away the habit's

21
gratification. Crib wires prevent the thumb or finger from touching the gums behind the front
teeth and on the palate (roof of the mouth), turning a pleasant experience into an unpleasant one.
Deriving no satisfaction from the activity, the child has no incentive to continue.

Parents should know that the child with a newly placed crib will have a nonrestful first night's
sleep. A child who is accustomed to thumb-provided security will be very unhappy the first night
or so. Be sure to offer lots of tender loving care, words of support, and congratulations so as to
provide a smooth, nontraumatic transition.

After crib placement, the patient is checked in two to four weeks, and then seen every one to two
months until the appliance is removed. These visits are short, and not painful. In cases where
hard or sticky foods have loosened the bands, recementation may be necessary. Avoidance of the
offending foods should eliminate this annoyance.

How long does it take?

Improvement in front tooth position is typically noted within two weeks after crib placement. It
takes four to six months for the open bit to close and the front teeth to straighten. However, the
brace is left on nine to 12 months, a sufficient time for the habit to be a distant memory and
relapse potential minimal.

What is a good age to begin crib treatment? The ideal time is when upper front baby teeth
become loose, just prior to eruption of adult or permanent front teeth. This usually occurs just
before or after age six. Prompt thumb removal at this time allows permanent teeth to assume a
much better position than waiting until their full eruption to break the habit.

Thumb, finger or blanket sucking may be noted in pre-teens, teen- agers and even adults. Despite
the age differences, the initial orthodontic treatment is the same for all: placement of a crib to
break the habit. For teens and adults, counselling may be indicated to deal with any underlying
psychological problems.

Dental health is certainly important to a child's well-being. So is parental peace of mind. For the
thumbsucking patient, the orthodontic crib provides the answer to both.

Resources

Bergersen, E.O. "Preventive eruption guidance in the 5- to 7- year old." Journal Clinical
Orthodontics, vol. 29, pp. 382-85, 1995.

Gawlik, J.A., Oh, N.W., Mathieu, G.P. "Modifications of the palatal crib habit breaker appliance
to prevent palatal soft tissue embedment." ASCD Journal Dentistry Children, vol. 62, pp. 409-11,
1995.

Josell, S.D. "Habits affecting dental and maxillofacial growth and development." Dental Clinics
North America, vol. 39, pp. 851-60, 1995.

22
Rosenberg, M.D. "Thumbsucking." Pediatrics in Review, vol. 16, pp. 73-91, 1995.

American Academy of Pediatric Dentistry

+1-312-337-2169

http://www.aapd.org/ "Thumbsucking"

Disney's Family.com http://family.go.com/

After Cosmetic Reconstruction

Remember that it will take time to adjust to the feel of your new bite. When the bite is altered or
the position of the teeth is changed it takes several days for the brain to recognize the new
position of your teeth or their thickness as normal. If you continue to detect any high spots or
problems with your bite, call our office so we can schedule an adjustment appointment.

It is normal to experience some hot and cold sensitivity. The teeth require some time to heal after
removal of tooth structure and will be sensitive in the interim. Your gums may also be sore for a
few days. Warm salt water rinses (a teaspoon of salt in a cup of warm water) three times a day
will reduce pain and swelling. A mild pain medication (one tablet of Tylenol or Ibuprofen
(Motrin) every 3-4 hours) should ease any residual discomfort.

Don’t be concerned if your speech is affected for the first few days. You’ll quickly adapt and be
speaking normally. You may notice increased salivation. This is because your brain is
responding to the new size and shape of your teeth. This should subside to normal in about a
week.

Daily brushing and flossing are a must for your new dental work. Daily plaque removal is critical
for the long-term success of your new teeth, as are regular cleaning appointments.

Any food that can crack, chip or damage a natural tooth can do the same to your new teeth.
Avoid hard foods and substances (such as beer nuts, peanut brittle, ice, fingernails, or pencils)
and sticky candies. Smoking will stain your new teeth. Minimize or avoid foods that stain such
as coffee, red wine, tea and berries.

If you engage in sports let us know so we can make a custom mouthguard. If you grind your
teeth at night, wear the night guard we have provided for you. Adjusting to the look and feel of
your new smile will take time. If you have any problems or concerns, please let us know. We
always welcome your questions.

After crown and bridge appointments

Crowns and bridges usually take two or three appointments to complete. In the first visit, the
teeth are prepared and molds of the mouth are taken. Temporary crowns or bridges are placed to
protect the teeth while the custom restoration is being made. Since the teeth will be anesthetized,

23
the tongue, lips and roof of the mouth may be numb. Please refrain from eating and drinking hot
beverages until the numbness is completely worn off.

Occasionally a temporary crown may come off. Call us if this happens and bring the temporary
crown with you so we can re-cement it. It is very important for the temporary to stay in place, as
it will prevent other teeth from moving and compromising the fit of your final restoration.

To keep your temporaries in place, avoid eating sticky foods (gum), hard foods, and if possible,
chew on the opposite side of your mouth. It is important to brush normally, but floss carefully
and don’t pull up on the floss which may dislodge the temporary but pull the floss out from the
side of the temporary crown.

It is normal to experience some temperature and pressure sensitivity after each appointment. The
sensitivity should subside a few weeks after the placement of the final restoration. Mild pain
medications may also be used as directed by our office.

If your bite feels uneven, if you have persistent pain, or if you have any other questions or
concerns, please call our office at 845-562-1108.

After Tooth Extraction

After tooth extraction, it’s important for a blood clot to form to stop the bleeding and begin the
healing process. That’s why we ask you to bite on a gauze pad for 30-45 minutes after the
appointment. If the bleeding or oozing still persists, place another gauze pad and bite firmly for
another 30 minutes. You may have to do this several times.

After the blood clot forms, it is important not to disturb or dislodge the clot as it aids healing. Do
not rinse vigorously, suck on straws, smoke, drink alcohol or brush teeth next to the extraction
site for 72 hours. These activities will dislodge or dissolve the clot and retard the healing process.
Limit vigorous exercise for the next 24 hours as this will increase blood pressure and may cause
more bleeding from the extraction site.

After the tooth is extracted you may feel some pain and experience some swelling. An ice pack
or an unopened bag of frozen peas or corn applied to the area will keep swelling to a minimum.
Take pain medications as prescribed. The swelling usually subsides after 48 hours.

Use the pain medication as directed. Call the office if the medication doesn’t seem to be
working. If antibiotics are prescribed, continue to take them for the indicated length of time, even
if signs and symptoms of infection are gone. Drink lots of fluid and eat nutritious soft food on
the day of the extraction. You can eat normally as soon as you are comfortable.

It is important to resume your normal dental routine after 24 hours. This should include brushing
and flossing your teeth at least once a day. This will speed healing and help keep your mouth
fresh and clean.

24
After a few days you will feel fine and can resume your normal activities. If you have heavy
bleeding, severe pain, continued swelling for 2-3 days, or a reaction to the medication, call our
office immediately at 845-562-1108.

After Composite Fillings (white fillings)

When an anesthetic has been used, your lips and tongue may be numb for several hours after the
appointment. Avoid any chewing and hot beverages until the numbness has completely worn off.
It is very easy to bite or burn your tongue or lip while you are numb.

It is normal to experience some hot, cold & pressure sensitivity after your appointment. Injection
sites may also be sore. Ibuprofen (Motrin), Tylenol or aspirin (one tablet every 3-4 hours as
needed for pain) work well to alleviate the tenderness. If pressure sensitivity persists beyond a
few days or if the sensitivity to hot or cold increases, contact our office.

You may chew with your composite fillings as soon as the anesthetic completely wears off, since
they are fully set when you leave the office.

If your bite feels uneven, if you have persistent pain, or if you have any other questions or
concerns, please call our office at 845-562-1108.

Nutrition and Your Teeth

It has long been known that good nutrition and a well-balanced

diet is one of the best defenses for your oral health. Providing
your body with the right amounts of vitamins and minerals helps
your teeth and gums-as well as your immune system-stay strong
and ward off infection, decay and disease.

Harmful acids and bacteria in your mouth are left behind from
eating foods high in sugar and carbohydrates. These include
carbonated beverages, some kinds of fruit juices, and many kinds of starch foods like pasta,
bread and cereal. While no links have been actually made between gum disease and a poor diet,
nutrition problems (including obesity and overeating) can create conditions that make gum
disease easier to contract.

Children's Nutrition and Teeth

Good eating habits that begin in early childhood can go a long way to ensuring a lifetime of good
oral health.

Children should eat foods rich in calcium and other kinds of minerals, as well as a healthy
balance of the essential food groups like vegetables, fruits, dairy products, poultry and meat.
Fluoride supplements may be helpful if you live in a community without fluoridated water, but
consult with our office first. (Be aware that sugars are even found in some kinds of condiments,
as well as fruits and even milk.)

25
Allowing your children to eat excessive amounts of junk food (starches and sugars)-including
potato chips, cookies, crackers, soda, even artificial fruit rollups and granola bars-only places
them at risk for serious oral health problems down the road, including obesity, osteoporosis and
diabetes. The carbonation found in soda, for example, can actually erode tooth enamel.
Encourage your child to use a straw when drinking soda; this will help keep at least some of the
carbonated beverage away from the teeth.

Adult Nutrition and Teeth

There's no discounting the importance of continuing a healthy balanced diet throughout your
adult life.

If you develop a weight problem, change your diet and get regular exercise. Be aware that some
so-called fad diets have been known to cause serious deficiencies in recommended levels of
minerals and vitamins.

Of course, good oral hygiene helps ensure that harmful bacteria and plaque-the sticky substance
that coats your teeth during sleep and after meals-are effectively minimized. Adults also are
encouraged to avoid eating "sticky" foods such as caramels and dried fruits because they leave
behind stubborn substances on teeth and only encourage needless plaque formation

Why is oral hygiene so important?

Adults over 35 lose more teeth to gum diseases (periodontal disease) than from cavities.
Three out of four adults are affected at some time in their life. The best way to prevent cavities
and periodontal disease is by good tooth brushing and flossing techniques, performed daily.

Periodontal disease and decay are both caused by bacterial plaque. Plaque is a colorless film,
which sticks to your teeth at the gumline. Plaque constantly forms on your teeth. By thorough
daily brushing and flossing you can remove these germs and help prevent periodontal disease.

How to Brush

If you have any pain while brushing or have any questions about how to brush properly,
please be sure to call the office at (847) 253-8505.

Dr. Manos-Balis recommends using a soft to medium tooth brush. Position the brush at a 45
degree angle where your gums and teeth meet. Gently move the brush in a circular motion
several times using small, gentle strokes brushing the outside surfaces of your teeth. Use light
pressure while putting the bristles between the teeth, but not so much pressure that you feel any
discomfort.

When you are done cleaning the outside surfaces of all your teeth, follow the same directions
while cleaning the inside of the back teeth.

26
To clean the inside surfaces of the upper and lower front teeth, hold the brush vertically. Make
several gentle back-and-forth strokes over each tooth. Don’t forget to gently brush the
surrounding gum tissue.

Next you will clean the biting surfaces of your teeth by using short, gentle strokes. Change the
position of the brush as often as necessary to reach and clean all surfaces. Try to watch yourself
in the mirror to make sure you clean each surface. After you are done, rinse vigorously to
remove any plaque you might have loosened while brushing.

How to Floss

Periodontal disease usually appears between the teeth where your toothbrush cannot reach.
Flossing is a very effective way to remove plaque from those surfaces. However, it is important
to develop the proper technique. The following instructions will help you, but remember it takes
time and practice.

Start with a piece of floss (waxed is easier) about 18” long. Lightly wrap most of the floss
around the middle finger of one hand. Wrap the rest of the floss around the middle finger of the
other hand.

To clean the upper teeth, hold the floss tightly between the thumb and forefinger of each hand.
Gently insert the floss tightly between the teeth using a back-and-forth motion. Do not force the
floss or try to snap it in to place. Bring the floss to the gumline then curve it into a C-shape
against one tooth. Slide it into the space between the gum and the tooth until you feel light
resistance. Move the floss up and down on the side of one tooth. Remember there are two tooth
surfaces that need to be cleaned in each space. Continue to floss each side of all the upper teeth.
Be careful not to cut the gum tissue between the teeth. As the floss becomes soiled, turn from
one finger to the other to get a fresh section.

To clean between the bottom teeth, guide the floss using the forefingers of both hands. Do not
forget the back side of the last tooth on both sides, upper and lower.

When you are done, rinse vigorously with water to remove plaque and food particles. Do not be
alarmed if during the first week of flossing your gums bleed or are a little sore. If your gums hurt
while flossing you could be doing it too hard or pinching the gum. As you floss daily and remove
the plaque your gums will heal and the bleeding should stop.

Caring for Sensitive Teeth

Sometimes after dental treatment, teeth are sensitive to hot and cold. This should not last long,
but only if the mouth is kept clean. If the mouth is not kept clean the sensitivity will remain and
could become more severe. If your teeth are especially sensitive consult with your doctor. They
may recommend a medicated toothpaste or mouth rinse made especially for sensitive teeth.

Choosing Oral Hygiene Products

27
There are so many products on the market it can become confusing and choosing between
all the products can be difficult. Here are some suggestions for choosing dental care
products that will work for most patients.

Automatic and “high-tech” electronic toothbrushes are safe and effective for the majority of the
patients. Oral irrigators (water spraying devices) will rinse your mouth thoroughly, but will not
remove plaque. You need to brush and floss in conjunction with the irrigator. We see excellent
results with electric toothbrushes called Rotadent and Interplak.

Some toothbrushes have a rubber tip on the handle, this is used to massage the gums after
brushing. There are also tiny brushes (interproximal toothbrushes) that clean between your teeth.
If these are used improperly you could injure the gums, so discuss proper use with your doctor.

Fluoride toothpastes and mouth rinses, if used in conjunction with brushing and flossing, can
reduce tooth decay as much as 40%. Remember, these rinses are not recommended for children
under six years of age. Tartar control toothpastes will reduce tartar above the gum line, but gum
disease starts below the gumline so these products have not been proven to reduce the early stage
of gum disease.

Anti-plaque rinses, approved by the American Dental Association, contain agents that may help
bring early gum disease under control. Use these in conjunction with brushing and flossing.

Professional Cleaning

Daily brushing and flossing will keep dental calculus to a minimum, but a professional cleaning
will remove calculus in places your toothbrush and floss have missed. Your visit to our office is
an important part of your program to prevent gum disease. Keep your teeth for your lifetime.

Habit Breaking Appliances

What are the different habits that can be encountered in children?

This can be thumb sucking, finger biting, nail biting, lip biting, mouth breathing, tongue
thrusting etc.,

What are habit breaking appliances?

These are appliances that is made by a dentist to combat the above mentioned habits in
children. They can be either a fixed or removable type.

What are the deleterious effects of these habits?

If these habits are continued for a prolonged period of time that can result in gum disease,
change in position of teeth and change in shape of the jaws.

28
 Is there any ideal age when these habits can be corrected?

No. whenever the habit is first noticed it is better to consult a pediatric dentist. He may give
suggestions depending upon the habits.

Is there any common cause for these habits?

One can probably assume that there may be some kind of psychological disturbance in the
child's mind. this must be identified and rectified at an earlier stage whenever possible
because these kind of things can affect the child's overall development.
Sometimes the first child starts thumb sucking once the second child is born because of lack
of attention.

Preventive Dental Care

Dental Care Tips

When you consider the high cost of poor Dental Hygiene, including cavities, fillings, or a root
canal, it makes much more sense to follow basic dental care and hygiene tips and keeps your
teeth healthy.

Preventative care, including basic brushing and flossing, sealant, and regular visits to the dentist
every six months, is much less expensive than having to pay to fix cavities.

Dental Tips

• Have a dental checkup at LEAST EVERY 6 MONTHS.

• Brush at least twice a day with soft toothbrush and fluoride toothpaste.
• Use floss every day.
• Use a interdental brush daily
• Use an anti-microbial mouth rinse to control gingivitis.

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 • Use a topical application of fluoride for dry mouth
• If your gums bleed when you brush or eat see your dentist

Smoking makes your gums worse, quit.

People with diabetes get gum disease more often.

• Gum infections make it hard to control blood sugar.

• Once a gum infection starts it takes a long time to heal it.
• If the infection is severe, you can loose your teeth.

Natural teeth help you chew foods better and easier than dentures.

• Check the fit of your dentures yearly to prevent sores.

• Brushing Tips
• Use a soft bristled brush, preferably one with rounded, synthetic bristles.
• Replace your toothbrush approximately every two to three months or as soon as the
bristles are worn or bent. A worn-out toothbrush does not clean your teeth properly, and
may actually injure your gums.
• You should also replace your toothbrush after you've had a cold.
• Be sure your brush is the right size (in general, smaller is better than larger).
• Place the bristles at a 45-degree angle to the gum line, and slide the tips of the brush
under the gums.
• Gently jiggle the bristles or move it in small circles over the tooth and gums.
• Brush the outside, the inside, and the chewing surfaces of your teeth. For chewing
surfaces, use a light back and forth motion.
• For the front teeth, brush the inside surfaces of the upper and lower jaws: Tilt your brush
vertically and make several strokes up and down with the front part of the brush over the
teeth and gum tissues.
• Brushing your tongue will help freshen your breath. Debris and bacteria can collect on
your tongue and cause bad breath.
• Since your toothbrush will only clean one or two teeth at a time, change its position to
clean each tooth properly.
• Brush at least once every day, preferably at bedtime. Adding a brush time after breakfast
increases your chances of thorough daily plaque removal.
• Don't brush your teeth too vigorously, and don't use a hard bristled toothbrush, since it
causes the gums to recede and exposes root surfaces. It also wears down the tooth
structure. Both of these conditions can lead to tooth sensitivity.

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 • A pea-sized amount of fluoridated toothpaste is sufficient.
• Replace your brush when the bristles begin to spread, as a worn out toothbrush will not
properly clean your teeth.

Flossing Tips

• Wrap about 18 inches of floss around the middle fingers of your hands.
• Hold the floss tightly, using your thumbs and forefingers, and gently guide it between
your teeth.
• Don't "snap" the floss as this can cut the gums!
• When the floss reaches the gum line, curve it into a C-shape against one tooth and gently
slide it into the space between the gum and the tooth until you feel pressure against the
tooth.
• Gently scrape the side of the tooth with the floss.
• Repeat this method on all your teeth.
• Move to a clean area of floss after one or two teeth.

Dental care - tips if teeth are knocked out

• If permanent teeth are knocked out, there is an excellent chance that they will survive if
they are immediately placed back in the tooth socket and dental advice is sought straight
away. Every minute the tooth is out of the socket, the less chance it has of surviving.
• First aid for permanent teeth knocked out -
o Handle the tooth by the crown not the root.
o Gently rinse the tooth in milk or normal saline solution if it has debris on it. Rinse
for a few seconds only.
o Replace the tooth in its socket, if the person is conscious - make sure it is facing
the right way around.
o Hold the tooth in place with some foil or by getting the victim to gently bite on a
handkerchief.
o Contact your dentist immediately.
o If you can't put the tooth in its socket Wrap it in glad wrap or store it in milk or
normal saline solution.
o Do not try and clean the tooth with vigorous scrubbing or cleaning agents.
o You should not attempt to put a milk tooth back in its socket as it may fuse to the
socket, which leads to difficulties when it is time for the tooth to be shed. It may
damage the permanent tooth underneath the socket.

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Child Care - Dental Tips

• BRUSHING TIPS
o Start brushing your child's teeth as soon as they come in.
o Brush your child's teeth for the first 4 to 5 years until your child seems able to do
it alone.
o A good teaching method is to have your child brush in the morning and you brush
at night until your child masters the skill.
• FLOSSING TIPS
o Start flossing your child's teeth as soon as they touch each other.
• DIET TIPS
o Avoid high-sugar foods, especially sticky, sweet foods like taffy and raisins. The
longer sugar stays in touch with your teeth, the more damage it can do. Don't
snack before bedtime. Food is more likely to cause cavities at night because saliva
doesn't clean the mouth as well at night.
o Cheeses, peanuts, yogurt, milk and sugar-free gum are good for your teeth. They
can help clear the mouth of harmful sugars and reduce plaque formation.
• OTHER - If your local water supply does not contain enough fluoride, your child may
need a fluoride supplement.

Stop Thumb Sucking now!

“Amy must stop sucking her thumb! She is damaging her upper palate and
distorting her teeth”

With those words ringing in her ears, Cathy Sawbridge left her dentist where she had
taken her 2 year old daughter for a check up. She resolved to help her stop thumb
sucking, but how?

She tried all the old techniques: foul tasting paint, star charts and rewards, nagging
her… All with little or no success! When Amy was tired in went the thumb.

Then she found the answer! A discreet medical grade plastic guard which sits over the
thumb and is fixed firmly around the wrist with secure brightly coloured bracelets. It
works by preventing the child making a seal over their thumb and thereby preventing
suction, so they cannot suck.

Amy wore it 24/7. Cathy took it off daily to wash, replacing it with another bracelet.
Cathy says “I made the whole experience fun, we colour co-ordinated the bracelets with
her clothes each day. She wore it proudly to playgroup and explained to all who would

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listen it was to help her stop sucking her thumb. It did not inhibit her daily activities at
all.”

The Results: FANTASTIC

Amy wore it day and night for the first week.

The second week she only needed it at night.

Now she no longer sucks her thumb! The habit has been broken in 2 1/2 weeks. Amy is
a more confident child now and so much prettier without a thumb stuck in her mouth!
She also twisted her hair into impossible knots when she sucked her thumb, a habit
which has gone too.

Cathy and Amy are now looking forward to returning to the dentist so Amy can proudly
show off her pretty smile and tell the dentist that she has broken the habit!

The Kit contains: 2 plastic thumb guards, 60 coloured disposable bracelets,

Instructional CD/DVD and leaflet.

We also supply a finger guard which covers two fingers and works in the same way to
prevent finger sucking.

Teething - Teething and Eruption

1. What is teething?
2. What is eruption?
3. What are the signs of teething?
4. How to comfort a teething baby.
5. When do baby teeth start forming?
6. How long does the eruption process last?
7. What influences the final positioning of the erupting teeth?
8. Are spaces between a baby's front teeth a cause for concern?
9. The eruption chart for baby teeth.
10. The calendar of tooth growth and development.

Readers are recommended to view the Eruption Chart (#9) and the Calendar of
Tooth Growth and Development (#10), for a graphic illustration of the subject.

1. What is teething?

• Teething is the final stage of the eruption process.

It is during this time that the teeth of infants cut through the gum and become
visible in the mouth.
• The baby will eventually have ten teeth in each jaw, making a total of twenty
teeth in the mouth.

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 Teething 1 year later
"cutting through"

Return to Questions

2. What is eruption?

• Eruption is the process during which teeth grow through bone and push
through the gum into the mouth.

Permanent tooth
growing under baby tooth

Return to Questions

3. What are the signs of teething?

• The main signs of teething are:

o The gum over the erupting tooth can be swollen and red.
o A spot of blood may be found where the tooth "cuts" through the gum.
o The cheek on the side of the erupting tooth can appear flushed.
o There may be more dribbling than usual.
o The baby has the need to bite on a hard object.
o General irritability.
o Disturbed sleeping patterns.
o Diarrhoea and fever do not necessarily accompany teething.

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 Red swollen gum
over erupting tooth

Return to Questions

4. How to comfort a teething baby

• Gently massage the gum with a clean finger.

• A dummy (pacifier) may have a soothing effect.
• The baby's need to bite on something hard can be satisfied with a teething ring
or a sugar-free rusk.
• A sugar-free analgesic for babies will lessen the pain and help to settle the
baby. Consult your doctor or dentist about analgesics.

Return to Questions

5. When do baby teeth start forming?

• Tooth development starts between the 3rd and 6th months of pregnancy,
o The growth of baby teeth is only completed at the age of 4, when the roots
of all the erupted teeth are fully formed.
o The crown of the tooth is the first to develop deep in the jawbone.
o The root formation will only be completed about 18 months after
eruption.
o When the crown of a tooth erupts it is covered by a cuticle or covering
that protects the enamel.
It is slowly worn away by chewing and toothbrushing.

Return to Questions

6. How long does the eruption process last?

• The eruption of teeth into the mouth occurs between 6 months and 30 months
of age.
o The first teeth to erupt are usually the lower front teeth.
o The eruption chart shows the average age at which teeth emerge. This can
vary considerably from child to child. See part 9 of this subject.
o The calendar of tooth growth and development will reveal the miracle of
tooth growth and development at different ages.

Return to Questions

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7. What influences the final positioning of erupting teeth?

• The final position of a tooth is largely influenced by the lips cheeks and
tongue:
o The tongue exerts an outward pressure on the teeth.
o The lips and cheeks provide a balancing inward force.
o When biting and chewing takes place, the opposing teeth in the other jaw
prevent continued vertical growth of teeth.

• Other influences are thumbsucking and pacifiers:

o The outward pressure of a thumb sucking habit pushes the upper front
teeth and jaw forward and out of alignment.
o The extended use of pacifiers or dummies can have the same effect.

Return to Questions

8. Are spaces between a baby's front teeth a cause for concern?

• It is normal for the front teeth of babies to have spaces between them.
o It is also normal for the front teeth not to be spaced.
o Both of these tooth formations are considered to be satisfactory.
o Spaces between the baby teeth do not necessarily result in the spacing of
permanent teeth.

Tooth spacing

Return to Questions

9. The Eruption Chart for Baby Teeth

UPPER TEETH

TOOTH DENTAL NAME ERUPTION AGE ROOT FULLY FORMED

A CENTRAL INCISOR 7-9 MONTHS 20-22 MONTHS

B LATERAL INCISOR 7-9 MONTHS 20-22 MONTHS

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 C CANINE 17-22 MONTHS 30-35 MONTHS

D FIRST MOLAR 12-17 MONTHS 27-32 MONTHS

E SECOND MOLAR 24-33 MONTHS 38-48 MONTHS

UPPER TEETH

LOWER TEETH

LOWER TEETH

TOOTH DENTAL NAME ERUPTION AGE ROOT FULLY FORMED

A CENTRAL INCISOR 6-8 MONTHS 18-20 MONTHS

B LATERAL INCISOR 7-9 MONTHS 20-22 MONTHS

C CANINE 17-22 MONTHS 30-35 MONTHS

D FIRST MOLAR 12-17 MONTHS 27-32 MONTHS

E SECOND MOLAR 24-36 MONTHS 38-48 MONTHS

TOOTH GROWTH IS ONLY COMPLETE AFTER THE ROOT IS FULLY FORMED

Return to Questions

10. The Calendar of Tooth Growth and Development

• The calendar shows the stages of development of baby and permanent teeth
from the age of 5 months in the womb to 6 years.
• The permanent teeth are made to appear darker than the baby teeth.

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 • The growth patterns are clearly shown. The crowns of teeth are the first to
form, followed by the roots.
• The growth and replacement of teeth is well illustrated. The mixed dentition
stage reveals the way baby teeth make space for the permanent teeth to grow into.

Top: 5 Months in utero Top: at birth

Bottom: 7 Months in utero Bottom: 6 Months

9 Months 1 Year

18 Months 2 Years

3 Years 4 Years

5 Years 6 Years

Return to Questions

See calendar of tooth growth in adults section

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