I’ve since seen my general dentist, and she seemed very impressed with the work, so I am not concerned about the quality of the workmanship. Is this standard, to have crowns instead of veneers for a cosmetic smile makeover?

Thanks for your insight,

Ben in Oregon

Dear Ben,

Porcelain crowns and veneers differ only in degree–there really is no specific line of demarcation where a veneer becomes a crown. The fee for a porcelain veneer is usually the same or nearly the same as that for a porcelain crown, because the effort to place each type of restoration is about the same.

It is actually quite common to see porcelain crowns used on the front teeth for cosmetic reasons rather than protective ones. If your teeth were not weakened or damaged, your dentist might have decided to go with crowns to control your bite.

It is surprising that the dentist did not discuss this in detail with you during the course of your treatment. Typically, smile makeovers involve a great deal of give and take between the dentist and the patient, because the dentist will want to make absolutely sure he or she knows exactly what the patient wants.

The simplest solution is simply to ask your cosmetic dentist why he decided to go with porcelain crowns rather than veneers. Crowns are the more aggressive form of treatment, and require more reduction of the natural tooth structure. Veneers require only a little bit of shaving on the front of the tooth. For that reason alone, I would expect your dentist to have a sound reasoning for choosing the crowns. Most dentists will always pursue the least aggressive form of treatment and strive to preserve as much of the natural tooth structure as possible.

He has at least four cavities that I can see. Two of them are small in diameter, but seem to be quite deep, and two other teeth have actually started to chip away from the decay. I’m afraid there may be more, but he won’t let me get a really good look in his mouth to tell.

What are my options with these kinds of problems? I really don’t want to have any teeth pulled if we can possibly avoid it. They are all molars, and from what I have read so far that could really screw up the alignment of his teeth later on. Can they do some kind of porcelain crowns or white fillings? I don’t want them to look bad and make him embarrassed, either. I’ve read that with kids they often do some kind of metal crown, but those are so ugly!

I also wanted to ask about sleep dentistry (also called sedation dentistry). I think I am going to have to locate someone who does this kind of dentistry, because my son just will not open his mouth for the dentist or the hygienist. We’ve tried three different dentists with no luck. I was hoping he would mature enough to cooperate, but we just can’t wait any longer.

I appreciate your help,

Maranda in New Brunswick

Dear Maranda,

You’ll want to find a pediatric dentist who also performs sedation dentistry. I think you are correct in saying that you simply cannot put of your son’s dental care any longer.

You are also correct that removing the molars without also putting in some kind of space holder will cause a lot of problems down the road. Those molars are also important in helping him eat, so ideally your dentist will try to salvage the teeth rather than extracting them. In pediatric dentistry, much of the work is often geared toward short term maintenance and temporary fixes, because those teeth will not remain in place forever. Usually they will place a stainless steal crown, but if you are adamantly opposed to the steel, your dentist can work with you to find a suitable material.

Another issue that must be addressed is the eating pattern that probably produced this kind of severe decay in such a young child. The kind of decay you’ve described is caused by constant eating. If you want to put a stop to these kinds of serious dental problems, you’ll have to put a stop to the eating habits that produce them.

Thanks in advance for your help,

Antonio in Chicago

Dear Antonio,

The only kind of over-the-counter whitening products I would recommend in your case would be Crest Whitestrips, or some other version of that product produced by another manufacturer. The whitening agent, peroxide gel, is held to the teeth by the strips so the can penetrate the tooth structure and whiten the teeth. Be extremely cautious about the product you select–some products have acid that etches the enamel of the teeth, after which you apply a white pigment. These products do give the appearance of a temporary whitening, but will ultimately allow more stains to adhere to the teeth via the damage to the enamel of the teeth.

There is a problem with Whitestrips in your case as well. The strips are designed to cover only the front six teeth, so to use them, you will have to trim the strips themselves. That is quite a lot of messing around, especially when you consider that it may take several applications to get the degree of whiteness you want. By the time you purchase all the kits, you may very well wind up spending as much as you would just getting the professional teeth whitening done at your dentist’s office.

In your shoes, I would likely go to an office to get the the whitening done. In the end, you’ll probably spend about the same amount of money, and you will save quite a lot of time.

I hope this was helpful.

With the support of my dentist, I have tried almost every over-the-counter teeth whitening product available. If anything, my teeth look WORSE now. The spots did not change in color one bit, but the contrast with the surrounding tooth material (which whitened considerably) is even more noticeable and ugly. Now my dentist is suggesting a “trial” treatment, where he will grind away at the spots until they are gone. The problem is he doesn’t know how much he will have to grind, and I just cannot imagine how this will ever look good!

What about professional whitening? I just really need to get this issue addressed. My teeth are holding me back, and my self-confidence is really taking a beating. I don’t want potential employers to think that I am the type of person who doesn’t even properly care for their teeth!

Thanks so much for your help,

Leta in Albany

Dear Leta,

First and foremost, find a different dentist. Your current dentist obviously does not understand the principles of teeth whitening or he would not have had you wasting your time and money on repeated attempts of the same treatment. Professionally whitening is unlikely to yield the results you want, either. And the idea of grinding away the spots could go horribly wrong.

You need to seek the services of a talented, experienced, educated cosmetic dentist. Make sure you thoroughly check their credentials, and ask to see pictures of their work.

Depending on the severity of the spots, there is a very small chance that a technique called microabrasion might work. This is often used with white spots, but is only effective with brown spots when they are very superficial.

If the spots are small, dental bonding may work to cover them. This is one of the most difficult and artistically demanding skill sets in cosmetic dentistry, so make very sure the dentist you chose is not just competent, but exceptional. If bonding will not work, porcelain veneers may be a solution. Both of these treatments require a high degree of artistry and skill.

I hope you can find the right dentist to help you.

What should I do? I did not go through two years of ortho to have ugly teeth!

Thanks for your time,

Savannah from Council Bluffs

Dear Savannah,

I don’t think your orthodontist caused this damage, though it is not unheard of that damage can happen during bracket removal. The patches you describe sound like areas of decalcification. These are areas where your teeth have lost some minerals, and those areas are porous, which is causing the staining you are seeing. Those spots may eventually turn brown, and even chip away, leaving pitted holes in your teeth. I am sure this is NOT what you envisioned as you went through orthodontic treatment, and that missing enamel is what is making your teeth so sensitive.

Teenagers are not always as diligent as they should be about brushing their teeth after eating, and when a teen has braces, the problem is magnified. The brackets allow food to sit against your tooth, and underneath the brackets, the acid in your saliva that helps digest food is busy working away at the surface of the tooth. The extent of the problem becomes really evident when the braces come off.

It is important to address the issue before it gets any worse. Bleaching will not help the stains. It will probably make them look worse, so I would not recommend going that route. If the damage is just to a few small spots, a treatment choice might be dental bonding. Freehand dental bonding is one of the most challenging cosmetic dentistry techniques from an artistic standpoint, and if it is not done well, you will not be happy. Make sure you chose a cosmetic dentist who is trained and experienced. Direct dental bonding requires a very high degree of artistry and technical skill that very few dentists possess.

If the damage is extensive and/or severe, you may be looking at porcelain veneers. That is a daunting prospect after two years of orthodontic work, but it is better to be prepared.

If you have friends that still have braces, you can be their cautionary tale. People with braces simply MUST brush after every single time they eat. At the very least, they must rinse thoroughly with water if brushing is impossible. It is very frustrating to go through all those years of ortho work, only to continue struggling with dental issues when you are done.

One of the reasons our dentist gave for the delay is that the root of the broken tooth needs time to “desensitize”. Is that customary? If it is, then I guess we will wait, but my instinct is to take her to a different dentist, one who will treat this with some urgency.

I hope you can answer this quickly. I don’t want to wait, but I’d like some expert advice about what to do.

Nora in Bar Harbor, Maine

Dear Nora,

Your instincts are correct – there is no reason to wait to address this.

If you have the piece of the tooth that broke off (and see this response promptly!), an expert cosmetic dentist might be able to reattach that portion of the tooth. If you don’t have the piece or it is too badly damaged, a likely procedure to repair both teeth is direct dental bonding.

For this reason, I strongly suggest you chose an expert cosmetic dentist for this procedure. Direct dental bonding requires more than excellent technical skills and training. It requires artistry. The bonding material must be color matched and placed with an eye to the gradients of color that comprise her natural teeth. Only truly gifted cosmetic dentists can do really beautiful direct bonding work.

You don’t say how old your daughter is, but because of your reference to t-ball I am guessing that she is under 10. Direct bonding is a great solution for younger patients. When she is older, she will probably need a single dental crown for the tooth that was broken, but your dentist will have to make that decision when the time comes. If the other tooth is severely damaged, both front teeth may need crowns.

Do I need to find ANOTHER new dentist? Why in world would she want to use something that clearly doesn’t work for me?

Edith in Tulsa, OK

Dear Edith,

The white fillings are not the problem. The technique your former dentist used to place them was the problem.

Many dentists have gone “mercury free”, meaning they no longer place silver amalgam fillings. Silver amalgam fillings are a source of ongoing controversy in the dental field, and more and more people in the general population are also aware of this controversy. Silver amalgam fillings are more than 50% mercury by weight, a known neuro-toxin. Recent studies are inconclusive about whether or not the small amount of mercury vapor released during chewing is harmful to the body, but many people are opting to err on the side of caution and just avoid them altogether. As an additional factor, properly placed white fillings are without question the better choice from an aesthetic standpoint.

Amalgam fillings require more of the tooth structure to be removed, and the material of the filling actually weakens your teeth. The only real advantage of amalgam fillings is that they are easier to place than white fillings, and the technique to place them is throughly covered in dental schools. Most dental schools do NOT require graduating dentists to know how to properly place a white composite filling.

If your new dentist only places white composite fillings, then chances are good that she is skilled at it. To put your mind at ease, ask her about her training for this kind of procedure. Placing white composite fillings requires strict adherence to the proper protocol. If your former dentist had followed this protocol, your teeth would not have been sensitive.

If you are satisfied that she has the proper training, then I think you can confidently go ahead with the white fillings in your wisdom teeth. The material of the filling bonds with your teeth to actually make the overall structure of your tooth stronger, and will serve to seal the tooth. White composite fillings also do not convey heat and cold the way amalgam fillings do, and so are more comfortable.

Thanks for your time.

Russel in Cripple Creek

Dear Russel,

We cannot empirically state that all Clear Choice dental implant centers are unethical, though many of what seem to be standard practices for them are highly questionable. Every center is obviously different, with different staff members, and different strengths and weaknesses. The stories that are emerging from people who have had evaluations or attended seminars seem to indicate that salesmanship and marketing are heavily emphasized within the entire Clear Choice organization, and those two priorities make the risk of poor dental health care choices very high. We are especially concerned with the consistent reports of treatment plans that recommend that ALL teeth be removed as part of the treatment. This is almost NEVER a good idea. If you do get a treatment plan from a Clear Choice facility, I would strongly recommend getting a second opinion.

Our best advice to you would be to find a dentist in your area who has experience, training, and credentials in dental implantdentistry. Look for a general dentist or prosthodontist that has several years of experience. A fellowship or membership in the International College of Oral Implantologists or the American Academy of Implant Dentistry is also a good sign. This Detroit cosmetic dentist has impeccable credentials - this will give you some idea of what to look for in a dentist in your area.

Vienne from New Hampshire

Dear Vienne,

There really is not any inexpensive way to address this issue. The entire structure of your crowns is the problem. A dentist could try to drill away the black line and cover it over, but there is likely a serious color match issue between the roots of your natural teeth and the color of the veneers. Trying to blend those colors together in that tiny space would be incredibly difficult if not impossible, and the results would almost certainly be very unattractive.

Essentially, you have to options: live with the black line, or replace the porcelain-fused-to-metal crowns with all ceramic or all porcelain crowns. Be absolutely certain you chose a skilled, artistic, well-trained cosmetic dentist to do this procedure for you. I would hate to see you spend thousands of dollars to still be unhappy with the results.

Anyway, my dentist diagnosed the problem in like two seconds, and I am kind of wondering how accurate that diagnosis can be. He is always in a really big hurry, and this time was no exception. He rushed in, barely listened to what I was telling him, then started squirting my tooth with air while asking impatiently if it hurt. Then he put some “desensitizing bonding agent” on the tooth, and the pain went away, and he said that it should heal on its own, then he was gone. I only know what he put on it because I asked the hygienist.

The tooth in question has a really large white filling, and when I went in I wondered if that was the problem. Could he really do a thorough diagnosis like I described? I could really use some advice.

Brent in Minneapolis

Dear Brent,

Sometimes it really is quite easy to diagnose pain issues, and from what you’ve written, yours fell into the easy-to-diagnose category. An unprotected, sensitive spot on a tooth will react to blown air with pain, and a desensitizing agent will help with that. If the pain only lasts for a moment and then goes away, that is an indication that the irritated nerve or pulp of your tooth has the chance of healing on its own. If the pain had lingered, your dentist would probably have recommended a root canal procedure, as that would have indicated irreversible damage and a need to remove the nerve.

The real issue here is that you do not trust your dentist. Your letter indicates that you do not appreciate your dentist’s abrupt manner, but more seriously, you do not trust him to provide you with thorough, careful dental care. Good dental care requires trust.

If you want to try and salvage this professional relationship, I would recommend an honest conversation with your dentist. If he responds with impatience or acts annoyed, I think you will have to find a new dentist.