How can I whiten my teeth?

You may want to start by speaking with your dentist. He or she can tell you whether whitening procedures would be effective for you. Whiteners may not correct all types of discoloration.

Is bleaching for you?

Generally, bleaching is successful in at least 90 percent of patients. Consider tooth bleaching if your teeth are darkened from age, coffee, tea, or smoking.

For example, yellowish colored teeth will probably bleach well, brownish-colored teeth may bleach less well, and grayish-tinged teeth may not bleach at all. Likewise, bleaching may not enhance your smile if you have had bonding or tooth-colored fillings placed in your front teeth. The whitener will not effect the color of these materials, and they will stand out in your newly whitened smile. In these cases, you may want to investigate other options, like porcelain veneers or dental bonding.

If you have very sensitive teeth, periodontal disease, or teeth with worn enamel, your dentist may discourage bleaching.

How does it work?

The active ingredient in most of the whitening agents is 10 percent carbamide peroxide (CH4N202), also known as urea peroxide; when water contacts this white crystal, the release of hydrogen peroxide lightens the teeth.

Bleaching options

Teeth can be whitened by several methods:

Dental Supervision

• Chairside bleaching is done in the dental office and usually takes about 30 to 60 minutes. A shield protects the teeth from the oxidizing agent which is "painted" onto the teeth. A special light may be used at five-minute intervals to help activate the agent. Sometimes the teeth may become sensitive following bleaching treatments. This procedure may require more than one office visit.
  
  
• With nightguard bleaching, a mouthguard is custom-made. The bleaching gel is dispensed to the patient by a dentist. The patient places the gel into the mouthguard which is worn up to two hours daily or at night for about two weeks. Some bleaching agents say you can wear them all night but your teeth may get very sensitive after doing this. You may continue using the product until you reach your desired whiteness. Sometimes you can not achieve the desired whiteness and will have to settle for something less.
  
  The dentist may have you come in periodically to check the progress and the reaction to the gum tissue, if any. Noticeable improvement usually takes place within 2 weeks. After you have lightened your teeth, you may need to periodically (once every couple of months) bleach them for a session to keep the whiteness. Average cost is $200-300 per arch (top or bottom). People with gum recession and certain dental conditions may not be good candidates for this type of bleaching. These products are not recommended for habitual tobacco and alcohol users.

At-Home Procedures and Products

There are several types of products available for use at home, which can either be dispensed by your dentist or purchased over-the-counter.

Bleaching solutions.

Many of these products contain peroxide(s), which actually bleach the surfaces of the teeth. These products typically rely on 10 percent carbamide peroxide (which is equivalent to 3 percent hydrogen peroxide). In the last decade, carbamide peroxide has been demonstrated as a safe and effective whitening agent when used as directed.

Peroxide-containing whiteners typically come in a gel and are placed in a mouthguard, which you wear for about two hours a day over about two weeks. If you obtain the bleaching solution from your dentist, he or she can make a custom-fitted mouthguard for you that will fit your teeth precisely.

Toothpastes.

There are a number of toothpastes currently available that rely on chemical or polishing agents to remove surface stains from the surface of the teeth. Many of these types of products will be effective while you are using them to remove stains.

Although over the counter products (those you can by directly in a store) have been approved and shown to be generally safe when used as directed. However, many dentists do not encourage using these products because uninformed use of such products can cause both injury and less than optimal results when used improperly. If you have any doubts about how to use such products make sure and consult with a dentist.

IS it safe? Any side effects?

Several studies have proven its safety during the past five years. The American Dental Association has also granted its seal of approval to some tooth bleaching products. Some patients may experience slight gum irritation or tooth sensitivity, which will resolve when the treatment ends.

How long does it last?

Lightness should last for about one to five years depending your personal habits such as smoking and drinking coffee and tea. At this point you  could use a touch up. The procedure will not be as costly the next time because you can probably still use the same mouthguard. The retreatment  time also is much shorter than the original treatment time.

I've heard about laser whitening. Is it safe?

This technique may be safe, but the ADA has not evaluated it. Laser whitening products have not been submitted to the ADA for testing, nor has the ADA seen any published data on the safety and effectiveness of laser whitening.

When teeth are missing and there are teeth on either side of the space a bridge can replace the missing teeth. When there has been the loss of a tooth or teeth and there is a tooth on either side of the open space, replacement teeth can be attached to two crowns constructed for the 2 teeth on either side of the open space. This is called a bridge because it bridges the open space.

What is a Bridge?

A fixed bridge is used to replace one or several teeth. The teeth on each end of the space are used as anchors (abutments). Bridges are not removable by the patient. As with other types of crowns (caps), a bridge can be made of metal or porcelain, or a combination of these two. 

Why is a Bridge needed?

When a tooth is lost 5 or more other teeth may drift so it is essential to place a replacement tooth as soon as possible. The space left from missing teeth may cause one of several problems. Teeth may drift into the space changing your bite, this changed bite may result in sore jaws, gum disease, or decay (due to more difficult hygiene). 

How is a Bridge made?

To prepare a bridge, diagnostic models are taken to study the optimum way to perform this procedure. After studies are completed, the teeth used to attach the bridge are carefully reshaped. Impressions are taken and from these impressions, the bridge is made by a certified dental technician. This laboratory time is usually 2 to 3 weeks - during this time a temporary acrylic bridge is cemented to place.

CARE FOR BRIDGES

Brush and floss daily all areas around the bridge. It is not possible to floss between the replacement tooth and the attaching crowns (it is made as a solid piece). In order to solve this problem - it is necessary to use a special type of floss to go under the replacement tooth and keep this area of gum tissue healthy.

Crowns are made of natural looking porcelain and are made to improve your overall smile or to blend in with your own teeth. An underlying metal shell is used under the porcelain if additional strength is needed.

Indications for a crown includes:

• - A previously filled tooth that contains more filling than tooth. The tooth structure becomes weakened and can no longer support the filling.
• - Extensive damage by decay.
• - Discolorations / unattractive teeth.
• - Fractures
• - Root canal - After root canal, teeth tend to become brittle and are more likely to fracture. These teeth need to be protected by a crown.
• - Bridges - When missing teeth are replaced with a bridge, the adjacent teeth require crowns in order to support the replacement teeth.

Crowns strengthen and protect the remaining tooth structure and can improve the appearance of your teeth. Crowns can be made from different materials which include the full porcelain crown, the porcelain fused-to-metal crown and the all-metal crown. You and your dentist will decide which type is appropriate, depending upon the strength requirements and esthetic concerns of the tooth involved.

Fitting a crown requires at least two appointments. During your first visit, the tooth is prepared for the crown, an impression or mold is made of the tooth, and a temporary crown is placed over the prepared tooth. At the subsequent visit, the temporary crown is removed and the final crown is fitted and adjusted and cemented into place.

What types of filling are there?

Dental fillings are of two main types:

Silver (Amalgam) fillings
Dental amalgam is a mixture of mercury, and an alloy of silver, tin and copper. Mercury makes up about 40-50 percent of the compound. Mercury is used to bind the metals together and to provide a strong, hard durable filling. After years of research, mercury has been found to be the only element that will bind these metals together in such a way that can be easily manipulated into a tooth cavity.

Composite (White) fillings
A composite resin is a tooth colored plastic mixture filled with glass (silicon dioxide). Following preparation, the dentist places the composite in layers, using a light specialized to harden each layer. When the process is finished, the dentist will shape the composite to fit the tooth. The dentist then polishes the composite to prevent staining and early wear.

Why do I need to have my cavities filled?

Cavities are caused by breakdown of tooth enamel which exposes underlying structures that are much less resistant to infection and decay. Left untreated cavities can result in both the destruction of involved teeth as well as infection of the surrounding gums and bones. Filling cavities stops this process.

Which type of filling is best?

There is no single correct answer to this. Factors to consider (in conjunction with a dentist) include cost, cavity location, cavity size, cosmetic results and possible health considerations.

Amalgam fillings
In use for over 150 years, with over 1 billion amalgam restorations (fillings) placed each year.

Today, dental amalgam is used in the following situations:

• in individuals of all ages,
• in stress-bearing areas and in small-to moderate-sized cavities in the posterior teeth,
• when there is severe destruction of tooth structure and cost is an overriding consideration,
• as a foundation for cast-metal, metal-ceramic, and ceramic restorations,
• when patient commitment to personal oral hygiene is poor,
• when moisture control is a problem,
• when cost is an overriding patient concern.
• It is not used when:
• esthetics are important, such as in the anterior teeth and in lingual endodontic-access (root canal) restorations of the anterior teeth,
• patients have a hisotry of allergy to mercury or other amalgam components,
• a large restoration is needed and the cost of other restorative materials, such as crowns, is not an important factor in the treatment decision.

Composite (White) fillings
In use since the mid 1960's, the quality of composite resin fillings has continued to improve.

Advantages

Esthetics are the main advantage, since dentists can blend shades to create a color nearly identical to that of the actual tooth.

Disadvantages

Along with the higher cost and the extra placement time, the patient can experience postoperative sensitivity. Also, the shade of the composite can change slightly if the patient drinks tea, coffee or other staining foods. Composites tend to wear out sooner than silver fillings in larger cavities, although they hold up as well in small cavities.

Are silver (amalgam) fillings safe?

Although amalgam fillings have been used for over 150 years and no verifiable adverse health effects have been documented aside form a rare allergic reaction no large scale studies have been done demonstrating either the presence or absence of adverse health effects.

Consensus among major dental organizations, based on years of use and lack of verifiable toxic effects of dental amalgam, is that amalgam fillings are certainly safe. Indeed, a vast majority of persons with amalgam fillings probably have little to worry about from their fillings.

However, all forms of mercury are toxic to humans and very small amounts of mercury vapors are released from amalgam fillings. The minimum amount of mercury exposure required to cause symptoms in the most sensitive individuals is not known.

Currently, all dental, public health and major scientific organizations agree that amalgam based fillings should not be replaced for prevention of "potential mercury toxicity". Replacement of perfectly good fillings adds great expense as well as increasing mercury exposure. Dentists touting such preventative removal services while claiming amalgam fillings cause a wide spectrum of human disease are viewed as opportunistic and possibly unethical.

If the jawbone is too narrow or short for immediate placement of root form implants the area may be enlarged with bone grafting. When the jawbone is too narrow and not a good candidate for bone grafting, a special narrow implant, called "plate form", can be placed into the bone.

In cases of advanced bone loss, the "subperiosteal" implant, may be prescribed. It rests on top of the bone but under the gums.

Root implants generally require two surgical operations:

The first implant placement is followed by a healing phase. For a full set of teeth, four to six fixtures are needed in the lower jaw, and six to eight in the upper, where bone is less dense. Patients wear temporary bridges while the bone heals, which takes three months for the lower jaw and six for the upper.

The second stage involves uncovering the implant when soft-tissue healing is complete. It can take three or more months to take impressions, fashion individual teeth or multi-tooth segments, and attach them to the fixtures. The exposed replacement tooth (or teeth) are then connected to the implant by means of an occlusal screw, to create a unit that can be removed by a prosthodontist. The replacement teeth can take some time to get just right. The bite needs to be well adjusted to distribute pressure evenly.

• Look for a team that has done at least 50 cases overall and 10 to 15 like yours.
• Ask to speak with some other patients.
• Ask any potential oral surgeon or dentist whether the hardware he or she uses has been accepted by the American Dental Association. To gain ADA acceptance, manufacturers must conduct two five-year clinical studies to show the hardware holds up in real use. Not all implant systems have ADA acceptance.

• Removable dentures can be hard to eat with because they provide only a fraction of the chewing force of natural teeth.
  
  
• A full lower denture can be dislodged by jaw and tongue movement.
  
  
• Ill-fitting dentures can be irritating and painful with hard plastic riding atop a thin layer of gum tissue over bone.
  
  
• Partial dentures, which replace a few missing teeth, can also promote tooth decay around their clasps and, by mechanical action, weaken the surrounding teeth.

What is a veneer?

Porcelain veneers are ultra-thin shells of ceramics, which are bonded to the front of teeth. Increasingly popular since the late 1980's, porcelain veneers have been used to improve the appearance of the front teeth.

What are veneers used for?

Veneers are used to correct many of the same things as bonding. Veneers may be an option instead of a crown in covering a partially broken front tooth. They are much stronger and last longer than bonding does but are more expensive and time consuming to have done. Veneers can:

• cover up discoloration and stains in front teeth
• brighten teeth
• repair a damaged (chipped) tooth
• change the shape or size of your teeth.

What are the advantages of veneers over bonding?

• They are much stronger than bonding.
• They will not pick up stain like bonding does.
• They do not become dull over time like bonding does.
• Veneers last longer than bonding.

Most people should get at least 4-5 years from a veneer with reports of veneers lasting more than 10 years. How long they last will depend on how a person uses their teeth.

What are the disadvantages of veneers?

• They are more expensive than bonding (typically $400-$600 per tooth).
• They are more time consuming to prepare and cannot be done in one sitting.

Are they a substitute for braces?

Porcelain veneers are not "instant orthodontics," and in most instances, they are not a substitute for braces. Patients with very crooked teeth should consider braces first. However, patients with teeth that need minor movement may be suitable for porcelain veneers. The appearance of crowded front teeth can be corrected with porcelain veneers when the back teeth have a good bite.

Who should not consider veneers?

Patients must have fairly sound tooth structure. Persons who are not good candidates for veneers include those with:

• periodontal disease
• teeth that are severely broken down
• little or no enamel remaining

What happens during the procedure?

Persons will require 2 or 3 appointments to have a veneer inserted.

• The first appointment may consist of an initial consultation. The consultation includes an evaluation of the present conditions, a visual examination, and sometimes X-rays. Some dentists take color photographs to show other patients or colleagues the "before-and-after" results of this procedure.
  
  
• During the second appointment (lasting 1-2 hours) the teeth are prepared by essentially sanding off a small amount of enamel, making a mold of the tooth and sending it to a lab to make the veneer.
  
  
• During the final appointment (lasting 1-2 hours) the veneer color is first adjusted. Once the final decision on color is made, the tooth is cleansed with specific chemicals to achieve a bond. A special cement is sandwiched between the veneer and tooth. Then a visible light beam initiates the release of a catalyst to harden the cement. Excess cement is removed.

It's critical that you take an active role in the smile design. Spend time in the decision-making and planning of the smile. Have more than one consultation if necessary to feel comfortable that your dentist understands your objectives.

How do I care for my veneers?

You will go through an adjustment period of a week or two as you get used to your "new" teeth. Follow normal hygiene procedures by brushing and flossing daily. At first, flossing may seem "tight" because of tiny amounts of excess cement that may remain. After one or two weeks, you may return for a follow-up appointment for minor adjustments of the veneers and additional cement removal, if necessary.

Questions to ask your Dentist- be informed!

Before choosing the dentist to place your porcelain veneers, request information about the dentist's experience. Before-and-after photographs of previous treatment will give you an idea of the dentist's esthetic skill. Ask your dentist about the laboratory technician's expertise with porcelain veneers. Other questions you might ask are:

• Is there any way to preview what I will look like?
• What if I don't like the results?
• What complications do you foresee?
  

Have realistic expectations

There is no such thing as perfect with veneers. It's not uncommon to see slight variations in the color of porcelain veneers upon close inspection, as this occurs even in natural teeth.