Our Services

Tooth Whitening

This is very popular these days--it seems everyone wants a brighter smile. One way to get there is porcelain veneers, but if your teeth are merely stained, at-home tooth whitening, or "bleaching," is an excellent option. It works well for brown and yellow stains; gray discolorations usually aren't stains, but are the intrinsic color of the teeth. Teeth with lots of fillings don't bleach well--the fillings stay dark as the teeth get light. A few people get sensitive teeth or gums from the bleach, but this resolves when they quit using it. Teeth will stain again over time, but they can be touched up as needed.

Whitening involves taking impressions of the teeth, and making custom bleaching trays to fit snugly over the teeth. A small amount of bleaching gel is placed in each tray and the trays are snapped over the teeth. Depending on the gel used, the trays may be worn overnight, or an hour at a time (20-30 hours total contact time). The overnight gel is the most popular, but not everyone can tolerate this. Frequently you can see results within 48 hours, and the cost is reasonable, currently under $200 for routine cases.

Bleaching can also be done in the office, using more concentrated solutions and dentist supervision. The cost is somewhat higher, but you do get instant gratification. There are over-the-counter whitening systems available in stores, but the bleach is much less concentrated and results are usually disappointing. One exception to this is Crest Whitestrips: these will whiten an amazing amount if you use them long enough. They're a bit difficult to use, and if you need several boxes to get whitened, you won't save much money. You also have to keep persevere with a lot of strips to get results, but they do work well.

Periodontal (Gum) Treatment

This includes preventive treatment, such as routine cleanings; maintenance visits for those with a history of gum disease; "Deep Cleaning" for active gum disease; and surgical treatment (we refer this to specialists). An average adult in good oral health should have their teeth cleaned twice a year. Those with a history of gum disease, or deep pockets around the teeth (where the teeth have come "unzipped" from the gums) may need cleanings more frequently. In both cases, the most important part of treatment occurs at home: removing bacterial plaque on a daily basis with brushing and flossing. Sad to say, even the new sonic toothbrushes aren't a substitute for flossing, but the good news is you can skip flossing once a week and nothing bad happens. OK, so we're grasping to find something fun and exciting about flossing, but it works, so quit complaining and do it :-)

Pain Control: if you find routine cleanings uncomfortable, you may want to try nitrous oxide, sometimes referred to as "laughing gas." This is available for cleanings at a reduced fee, but you need to reserve it in advance. Just specify "I want nitrous" when you make your appointment. (Nitrous is also available for other dental appointments, at an hourly fee.)

Patients with active gum disease, as evidenced by gums that bleed when brushed or flossed, or that show bleeding and pus when checked by the hygienist, will usually need Scaling and Root Planing treatment, sometimes referred to as Deep Cleaning. This involves anesthetizing the teeth and removing all the bacterial deposits below the gums, usually only part of the mouth at a time. After scaling is complete, the gums are rechecked in a few weeks to see if the disease is responding to treatment. There is no cure for gum disease at this time, but we can usually get it into indefinite remission by Scaling and Root Planing, followed by maintenance visits.

For advanced cases of gum disease, surgery is sometimes required. The specialist we work with is Dr. Stig Osterberg here in Port Townsend. He is an excellent surgeon and also places implants. There are a few other types of surgery that he performs, such as exposing decay below the gumline prior to placing crowns. Our office will explain why you need to see him and coordinate the process for you. Generally, you will still get your routine care at our office, and only see Stig on a one-time basis, although there are exceptions to this.

Fillings

Our office no longer places amalgam fillings, the mixture of silver/mercury that has been used for over 100 years. The scientific evidence is that amalgam fillings are safe, but it's a fact that you, the patients, prefer the tooth-colored fillings whenever possible. Tooth-colored fillings have been greatly improved in the past several years, and about 1997 we made the decision to leave amalgam. Amalgam will likely be phased out in this country within the next 10-15 years.

There are some insurance issues with the placement of tooth-colored (composite) fillings. They are somewhat more difficult to place than amalgam, so they take a little longer and are more expensive. Some insurance companies only reimburse for an amalgam fee when a composite is placed, which leaves a higher patient co-payment. There really isn't any way around this, but as more and more offices quit doing amalgam, the insurance companies will slowly follow--dragging their heels the whole way, unfortunately. A similar situation exists with payment for implants; in the past few years, the insurance companies have finally started covering them.

Crowns and Bridges

Crowns are used when teeth are too broken down or decayed to be restored with fillings. As a rough rule of thumb, if more than about 40% of the tooth is gone, a crown is a better choice, although a filling can sometimes be placed as a short term solution. Placing a crown will sometimes require a foundation or "buildup" filling first, then about 1.0 mm of tooth structure is removed from all surfaces of the tooth. An impression of the prepared tooth is taken, and the assistant will make a temporary crown out of plastic to wear while the laboratory makes the final crown out of gold, porcelain, or a combination of gold and porcelain. Usually the lab will have the crown ready in about two weeks, at which time the temporary crown is removed, the tooth is cleaned up, and the permanent crown is adjusted and cemented permanently into place. (Often this final appointment does not involve any local anesthetic.)

Bridges are used when teeth are missing and implants are not appropriate. A bridge involves preparing the teeth on both sides of the gap for crowns, and taking an impression as above. When the lab makes the crowns, a false tooth or "pontic" is welded between the two crowns. The entire assembly is then permanently cemented into place, and the end result feels just like your own tooth.

How long do crowns and bridges last?

This varies, but typical lifespans are 15 years or so for a single crown, and 12-15 years for a bridge. Of course, some bridges last longer than that, and there are a few 40 year old bridges, but 12-15 years is a reasonable estimate.

Below are links to illustrated descriptions of crowns and bridges. They may take awhile to download, and are still being edited for content as of December 2004. WARNING: THESE ARE GRAPHIC, CLOSE-UP PHOTOS OF ACTUAL TEETH, AND VIEWER DISCRETION IS ADVISED.

crown preparation and temporary

crown cementation appointment

partial crown

bridge cementation

Implants

Implants are like crowns, except that the first stage is placement of a titanium root form in the bone. Dr. Stig Osterberg usually does this step for us, after which the bone grows into the titanium root for several weeks. When the implant root is stabilized, a machined post is screwed down with a cute little torque wrench (calibrated in Newton-centimeters) and an impression is taken of the post in the same fashion as when doing a crown. The rest of the procedure is the same as for a regular crown, or a bridge if more than one implant is involved.

Implants can't always be done, since they require enough bone to stabilize the titanium root. They have the advantage of not requiring any teeth be cut back for crowns, but if the adjacent teeth already have crowns--particularly old crowns that will need replacing soon--a bridge is frequently a better choice. The cost of a typical single implant is generally slightly higher than a typical bridge ($2500 for a bridge, vs. $2900 for an implant, as of May 2007).

conventional implants

Mini-implants are a relatively new clinical procedure; they are used to help stabilize dentures. Typically they are done for the lower denture only, since that tends to float around a lot. The cost is less than traditional implants, about $2500 for several implants and modifications to an existing lower denture. For more information, check out this website:

http://www.imtec.com/demo/education_resource.php

Here's some photographs of one of our patients who has a set of the mini-implants (warning, fairly large file size). You can see the five implants, as well as how his lower denture has been modified to snap onto the implants.

implant photographs

Norm says they work great, he can eat pretty much anything he wants. He thinks they're the best thing since the invention of peanut butter--which, by the way, he can now eat just fine thanks to his implants.

Porcelain Veneers and Bonding

White teeth have always been popular with movie stars and the glamour set. Until about 20 years ago, this was usually done with crowns, but for those with healthy teeth-stained or dark but otherwise intact--veneers are a better option. Only the front of the tooth is prepared, and minimal tooth is removed. An impression is taken, and the lab makes a thin layer of porcelain, which is then bonded onto the tooth. By making the porcelain a lighter color, and varying the shape, teeth can be whitened, reshaped, and straightened at the same time. Veneers appear to last about as long as crowns, and the fees are similar.

Bonding is a generic term for any filling or crown bonded to the tooth using composite resin. Most people think of this for cosmetic work, and porcelain veneers are an example of bonding. It is possible to bond veneers directly from composite resin filling material, and whiten, reshape, and straighten just like porcelain veneers. The result is not quite as esthetic, and the useful life of such restorations is usually 5 - 8 years; costs are about half that of porcelain veneers.
Direct Bonding is ideal for younger patients, or for that high school reunion you suddenly decide you need to look great for.

Removable Dentures

For patients who already have dentures, or those whose teeth are too far gone to save, complete dentures are necessary. Upper dentures work quite well, as suction and the shape of the jaw holds them in place. Lower dentures are another story; they float around during talking and eating. Using them is an acquired skill, and some people never acquire it. Because of this, we strongly recommend trying to save at least one root on each side if possible. Small clips can be attached to these roots to stabilize the lower denture. If no teeth are restorable, implants and clips are an option.

Immediate Dentures are inserted at the same appointment as the teeth are extracted. This has obvious advantages, since it takes up to three months for the gums to heal after extractions, and nobody wants to run around without teeth that long. The procedure is a bit more complex, and there are more follow-up appointments to adjust the denture. The denture has to be "relined" later to fill in where the gums have shrunk, and the cost is thus higher.

Sometimes a number of teeth are missing-not enough to require full dentures, but too many to allow for a bridge (or making it too expensive). In this case a removable bridge or "partial" is an option. For about the cost of two crowns, this replaces all missing teeth. Disadvantages are that the partial is not as solid as natural teeth; there are clips holding it to the remaining teeth which are frequently visible; and unless brushing and flossing is done exceptionally well, the remaining teeth can get cavities. Partials can be combined with implants or the root clips mentioned above.

Extractions and Wisdom Teeth

We perform all but the most complex extractions in our office, but we do have a good relationship with an excellent oral surgeon, Dr. Denise Clarke in Port Angeles. Dr. Clarke can put you completely out for surgery, which is not something we can do; she is also more experienced in difficult extractions. For those desiring all four wisdom teeth out at once, we strongly recommend you see Dr. Clarke--trying to do that with local anesthetic ("Novocain") can run into problems. In our office, we normally only extract two wisdom teeth per session. For all extractions, you will need to read, understand, and sign the Oral Surgery Consent form, a copy of which is included here:

oral surgery consent form

Root Canal Therapy

Nothing inspires fear like a root canal (a.k.a. rrrrrrrooooootttttt!!!!!!! canal), but in fact this is a relatively innocuous procedure. Once in a blue moon a root canal will be painful, and the dental problem necessitating the root canal can be excruciating, but the treatment itself is generally no worse than a crown or filling--it's certainly less traumatic than an extraction. The procedure can be somewhat tedious, however.

Root canals are needed for a variety of reasons. Most commonly, a cavity or fracture of the tooth will expose the nerve; this is usually very painful, and the tooth may become infected. Sometimes so much of the tooth is gone (decay, fracture, wear) that there's not enough to grab with a crown or filling; a root canal allows us to put a "post" in the root and make a better foundation. For teeth used under dentures or partials, a root canal is necessary to allow for the little clip holding the denture. And sometimes, for inexplicable reasons, a tooth will just die, and a root canal is needed to eliminate the abscess.

The procedure involves removing all the live or dead material from the center of the roots, enlarging the canals, and then rinsing with disinfectant for approximately 30 minutes. Finally, the canal are sealed and a temporary filling is placed--this last varies depending on the status of the tooth. Most root canal teeth will need buildups and crowns to restore them; a lot of the tooth is already missing, and the root canal procedure makes what remains hollow.

The link below shows X-rays of a typical root canal tooth. The first film is the tooth with an active abscess--the dark area around the root tips. The next picture is the tooth immediately after treatment; the old filling is still present. And the final X-ray was taken several months after treatment. At this point, the abscess has nearly resolved, and the tooth has been restored with a buildup and crown. Warning: this is a half-megabyte file, and it will take awhile to download if you have dial-up access.

root canal sequence