Dr. Melanie Holden, DMD

Your mouth is a window to your body and your entire health. We take this seriously, and we will show you how to thoroughly clean your mouth in a way that lowers the overall amount of bacteria.

Periodontitis is a serious gum disease that can cause you to lose your teeth. Two factors decide gum health: plaque and bacteria, which we can all remove daily, and genetics — some of us inherit a tendency to gum problems and may need more visits even with meticulous oral hygiene. If we find bone loss, we may recommend scaling and root planing, a deep cleaning: with your mouth numb, plaque and tartar are removed from below the gum line, and the root surfaces are cleaned, smoothed and disinfected.

Digital x-rays let us look closely at the teeth and surrounding structures with nearly 80% less radiation than a standard x-ray. During your dental exam we also check your entire mouth and oral tissues for irregular lumps, red or white patches or recurring sore areas — screening for early changes at a stage when they are easier to treat.

If you are missing some teeth, you have three choices: implants (a titanium root with a porcelain and/or metal crown, permanent and treated as a natural tooth — usually a 6–8 month process, depending on grafting and how long the implant takes to integrate), a bridge (cemented to the prepared teeth on each side of the space), or a removable partial denture (metal and acrylic, or flexible plastic, held by small clasps and removed daily for cleaning).

If you are missing all of your teeth: implants with fixed bridges (6–8 implants per arch), implants with a removable denture that snaps on (2–4 implants per arch), or traditional acrylic dentures made from impressions over several try-in visits.

Each option involves different procedures, time frames and life spans, and every option needs maintenance and may need replacement during a lifetime. We want our patients fully informed about each one, so that the choice is theirs.

A natural tooth has a root below the gumline and a crown above it. A dental implant replaces the root; once it has healed, a porcelain and/or metal crown is placed on it and used like a natural tooth. Implants can also secure dentures so they do not move, slide or cause sores.

1. Extraction of the tooth, with a bone graft if needed. A temporary flipper may be used meanwhile for chewing and appearance.
2. A dental cone-beam CT scan 3–4 months later, to plan the placement in three dimensions around sinuses, nerves and blood vessels. Sometimes the scan shows that a case should be referred to a specialist for grafting.
3. Surgical placement under regular dental anesthetic, 1–3 hours depending on the number of implants, followed by 3–6 months of healing while the bone grows around the implant.
4. Uncovering the implant, placing an abutment and taking an impression for the lab.
5. Trying in and cementing the final crown or bridge. A denture that snaps onto implants involves a couple of extra visits for fit.

Teeth wear as we age, and stress lines become cracks — especially in teeth with older fillings. A crown rebuilds and protects a tooth to prevent a full fracture, and is needed after a root canal. Cared for correctly, crowns can last for decades; decay can still form at the gum line, so brushing and flossing continue as before.

The options are a full porcelain crown, porcelain fused to metal or gold, or a full gold crown. We determine which options suit your tooth, and you make an informed decision on the material. On the first visit the tooth is reshaped, the old filling and any decay are removed, a core is placed, an impression and colour match are taken, and a temporary crown is cemented. On the second, the crown is tried in, adjusted to your bite and cemented permanently. A slight sensitivity to cold for a short time is normal.

A bridge uses your existing teeth to cross the space where a tooth is missing. Bridges are made from gold, other metal alloys and/or porcelain.

Normally two visits: first, the adjacent (abutment) teeth are shaped, an impression goes to our lab, and you leave with a temporary restoration that resembles your natural teeth — roughly a two-hour visit. Second, the temporary comes off, the bridge is tried in for fit and appearance, and cemented — roughly 45 minutes to an hour. Occasionally the temporary is re-cemented while the bridge is altered.

Dentures are removable appliances that replace missing teeth: full dentures when all the teeth in an arch are removed, partials when only some are missing. In the first weeks to months most patients need several adjustments, and most problems are fixed in the office with simple adjustments. Over the years a denture or partial will need adjusting, repairing, relining or remaking as your mouth changes; see your hygienist every 3–6 months and your dentist annually.

A conventional full denture is made after the tissue has healed, with one or two try-in visits over 4–6 weeks. An immediate full denture is made before the teeth are removed and placed the same day, then relined or remade after 6–8 months of healing. Partials come in acrylic, cast metal (strong, long-lasting and repairable) or flexible acrylic (strong and more aesthetic than cast metal, but it cannot be repaired or added to).

Care for them like real teeth: brush them, store them in room-temperature water or a denture solution, never in hot water except for flexible partials, and never try to adjust them yourself.

Reasons for an extraction include pain, infection, deep decay, fracture, bone loss or an impacted tooth. In most situations a tooth can be extracted at a same-day emergency visit without antibiotics; exceptions include impacted wisdom teeth, severe swelling that prevents opening the mouth fully, or an inability to get numb. Extractions are simple or surgical — in a surgical extraction the gums may be opened and the tooth sectioned into smaller pieces.

Wisdom teeth, or third molars, usually begin to erupt at 18–21 and are often impacted. We do not provide general anesthesia in our office; for patients who prefer to be sedated, we refer to the oral surgeon of your choice.

Root canal therapy removes infection and the nerves from the roots of a tooth, and is often necessary to save an infected tooth — left alone, an abscess forms, which is bone loss in the jaw. Reasons include a very deep cavity that reaches the nerve, trauma to the tooth, or a crack that extends into the nerve.

For most front teeth and premolars the treatment is done in our office; molars are referred to an endodontist. It takes one or two appointments — sometimes medicine is placed inside the roots and the root canal is completed two weeks later. Anesthesia comes first; a rubber dam isolates the tooth and a mouth prop lets you rest. The canals are shaped and sterilised, sealed with gutta percha, and a core filling is placed. A crown follows, usually within two weeks, because a tooth that fractures after a root canal must be extracted.

Coffee, wine, smoking and other foods stain teeth even with proper care. We use a tray whitening system in two steps: an impression of your teeth, then custom whitening trays you can use over and over with the whitening gel over a few days.

At home: brush, place a dab of gel in each reservoir on the front of the tray, seat the trays and gently press them back against your teeth without squeezing the gel out. Leave them in for two hours and do not eat or drink for 30 minutes after. Some sensitivity to cold is temporary; use a toothpaste for sensitive teeth and call the office if it lasts.

Fluoride is essential for the health of your teeth. We offer fluoride varnish or silver diamine fluoride (SDF) applications, and custom fluoride trays for use at home — see the instructions under After your procedure.

• Protect the blood clot. Bite gently but steadily on the gauze for 45 minutes. A small amount of blood looks like a lot when it mixes with saliva. If you need more gauze, wet it first and keep firm pressure for another 45 minutes — never place dry gauze over the area, it removes the clot. If true, excessive bleeding persists, bite firmly on a wet tea bag for another 45 minutes, without chewing.
• No mouthwash for 2 weeks. After 12 hours, rinse with warm salt water (½ teaspoon of table salt in 8 oz of warm water) every 4–6 hours or as needed, for 1–2 weeks.
• Discomfort after dental surgery is normal. Take any medication given or prescribed as instructed, and ibuprofen (Motrin) or Aleve, if you are able, as directed for swelling and pain.
• Brush carefully and regularly without touching the extraction area — a clean mouth heals faster.
• Eat soft foods and drink plenty of water; supplement with liquids such as Ensure shakes. You may not be able to chew solid food for several days.
• Sutures, if used, dissolve on their own.
• Control swelling with ice packs on your face over the area, 20 minutes at a time, for 72 hours.
• Signs of an allergic reaction (generalised rash, itching): call your dentist immediately or go to the E.R.
• Extraction wounds take 7–10 days to close and may stay painful for 2 weeks.
• For at least 72 hours: no excessive activity, bending over or heavy lifting; do not pick at the area; no straws; no carbonated or alcoholic drinks; no sharp or hot foods; no smoking until healing is well established; no spitting; do not lick the extraction area.

• Take all prescribed medications exactly as directed; call the office immediately with any questions or problems. Take Tylenol or Advil as soon as possible to avoid soreness, then as needed.
• Gently rinse with warm salt water (½ tsp salt in 1 cup of warm water) as soon as you return home, then every 2–4 hours, to promote healing and reduce pain.
• Some discomfort is expected and should be mild. If it is not subsiding, or you have prolonged pain, tingling or numbness, call the office.
• Clean the implant and gums gently with a toothbrush and toothpaste. Avoid hot or spicy foods for one week or until the gums have healed. Do not lick or feel the area with your tongue, fingers or any object — it is a wound and must heal.
• You may have sutures to be removed in 1–2 weeks.
• If a denture, partial or flipper has been placed, leave it in for 24 hours unless you are in significant pain; if so, remove it and call the office. If a temporary has been placed, do not chew gum or hard or sticky foods on it. If it comes off, it can be re-cemented — it is not an emergency. Clean it as you would a normal tooth, threading floss out from the side.
• Brush implants as you would teeth, and keep regular check-ups: implants must be cleaned at home and professionally every 4–6 months.
• From extraction to finished product, healing takes roughly 3–8 months. After the implant has healed, an impression is taken for the crown or denture; the lab needs about 2–4 weeks for a crown and 4–6 weeks for a denture, with 2–3 try-in visits.

Every day

• Rinse after meals. Leave your denture or partial out at night while you sleep — your gums need a chance to breathe for a few hours each day.
• Use denture adhesive only if necessary.
• Brush denture teeth with a toothbrush and denture cleaner — no toothpaste. Dentures can be soaked in plain water or denture cleaners. Do not bleach. Keep out of reach of pets.
• If an ulcer or sore spot occurs, leave the denture out as much as possible and rinse with warm salt water (½ tsp salt to 8 oz of warm water). If it is not healing, call for an adjustment. Several adjustments may be needed while your mouth gets used to the appliance.
• If you have a flexible partial, soak it in hot water for 2–3 minutes before placing it in your mouth.
• Most dentures and partials require relining every 3–5 years.

Immediate dentures or partials — the first week

• Do not remove the appliance, if possible, for 24 hours. After 24 hours take it out and rinse with salt water (½ tsp in one cup of warm water).
• For 4–5 days remove the appliance only to clean it or to rinse, unless the doctor or staff instruct otherwise: if it is out too long in the first days, swelling may keep you from putting it back in.
• Eat small portions of soft foods; use instant or canned protein drinks to keep up nutrition.
• After each meal rinse the denture well and brush it with a toothbrush and denture cleaner — no toothpaste.
• After the first week, start leaving the denture or partial out at night and follow the everyday care above.

• Brush immediately before placing the whitening trays, then rinse.
• Place a dab of whitening gel in each reservoir — only on the part of the tray that covers the front of your teeth.
• Seat the trays and gently push the front of the trays back against your teeth so the gel makes contact. Do not squeeze the gel out; wipe any excess away with a cotton swab.
• Leave the trays in for 2 hours. Do not eat or drink for 30 minutes after use.
• Slight sensitivity to cold water or air is temporary; use a toothpaste formulated for sensitivity if it occurs. Call the office for any prolonged sensitivity or gum irritation.

You will most likely feel soreness in the area and pressure when you bite down; this should decrease within one to two weeks. Take over-the-counter pain medication such as Advil (ibuprofen) or Aleve (naproxen) for the soreness. Avoid chewing on the treated side, both to avoid irritating the area and so that the temporary restorative material sets properly. You may need an antibiotic for any remaining infection; your dentist will decide. If pain or tenderness increases, you react to a medication, or the temporary filling comes out, call your dentist immediately.

Before your permanent crown or bridge you will wear a temporary restoration. It is not as sturdy as the permanent version, so brush the area gently, do not pull up on the tooth when flossing, and avoid hard, sticky and chewy foods. If the temporary comes off between appointments, call the office so we can re-apply it.

Some sensitivity and irritation after the temporary or the permanent is placed is normal and subsides as the soft tissue heals; a warm salt-water rinse helps, and Advil or Tylenol can be taken if the pain does not go away. The permanent crown or bridge may feel a little awkward for a few days and should feel like one of your natural teeth within a week. If your bite feels abnormal in any way, let your dentist know. Care for it like your own teeth: brush and floss regularly.

After the anesthesia wears off your teeth will likely be sensitive — from the numbing, from the removal of the decay, and from the conditioner used. All of the decay has to be removed, which irritates the nerve inside the tooth, much as a sore on your arm becomes sensitive when it is cleaned and then rapidly gets better. Avoid hot and cold food or drink for the next few days. Continue your normal cleaning, brushing and flossing so that your fillings last.

Your gums will probably be slightly sore and irritated for a few days. Rinse with warm salt water (1 tsp salt in 8 oz of water) two or three times a day to relieve the pain and cleanse the area. Continue brushing and flossing right after the procedure, but brush gently. For swelling or stiffness, use a cold compress and a pain reliever. Avoid hard or chewy foods for 2–3 days. If pain or swelling continues after a few days, contact your dentist.

Using the trays

• At bedtime, remove any partial or full dentures. Brush thoroughly with a soft toothbrush and regular toothpaste, and floss each side of each tooth — food and plaque can keep the fluoride from reaching the tooth surface.
• Place a thin ribbon of fluoride gel into each upper and lower tray so that every tooth space has some. Either 0.4% stannous fluoride (Gel-Kam) or 1.1% sodium fluoride (PreviDent) may be used; spread it into a thin film with a cotton swab, a finger or a toothbrush.
• Seat the trays on the upper and lower teeth for 5 minutes. Only a little fluoride should come out at the base of the trays — otherwise there is too much in them.
• Remove the trays and spit out the residual fluoride thoroughly. Do not rinse, drink or eat for at least 30 minutes.
• Head and neck radiation patients: begin using fluoride in the custom trays no later than one week after radiotherapy is completed, and repeat daily for life — tooth decay can occur in a matter of weeks if fluoride is not used properly.

Caring for the trays

• Rinse and dry the trays thoroughly after each use, and clean them with a toothbrush and toothpaste.
• Occasionally disinfect them in a solution of one tablespoon of household bleach (Clorox) in about half a cup of water, for about 15 minutes.
• For hard-water deposits, soak them in white vinegar overnight and brush them the next morning.
• Do not boil the trays or leave them in a hot car — they may warp or melt.

The jaw joint just in front of the ears is the TMJ, the temporomandibular joint. Anyone with orofacial pain (pain in the head and neck) should have a thorough examination to identify the source, which may be the joints, muscles, nerves or other structures. Noises in the jaw joints are very common. Like any joint, the TMJ and the jaw muscles can be strained or injured, most commonly from overuse — clenching, nail biting and gum chewing add loads that leave no time for rest and healing. These suggestions are designed to reduce injury and discomfort.

• Heat. Apply heat to the area of discomfort 2–4 times a day for 10–20 minutes — never more than 20 minutes, as excessive heat may cause swelling. A microwave gel pack, water bottle, heating pad or moist heated towel all work; some people find alternating heat and ice brings more relief. Apply ice only until numbness is felt.
• A pain-free diet. Avoid hard or chewy foods such as bagels, gum, caramels, raw carrots, hard breads, steak and candy. Blend foods, cut fruit into small pieces and steam vegetables. Chew with the back teeth, avoid opening wide or biting into large portions, and do not stay on a soft diet for long — increase firmness as tolerated. Chew on both sides at once: cut each bite in half and place half on each side.
• Teeth apart, jaw muscles relaxed. The teeth should touch only when chewing and swallowing; the rest of the time they should never touch, not even lightly. Rest the tongue on the floor of the mouth behind the lower front teeth, or lightly on the roof of the mouth, but do not press it firmly against the palate.
• Avoid caffeine. It is a muscle-tensing stimulant found in coffee, tea, soda, chocolate, diet aids and many pain medications; even decaffeinated coffee carries about half the caffeine of regular. Regular use — as little as 1–2 cups a day — may lead to persistent headaches.
• Watch for straining habits: clenching or grinding, biting lips or cheeks, chewing pens, pencils or toothpicks, nail biting, pushing the tongue against the teeth, holding the jaw tense. Do not chew gum.
• Avoid stress on the jaw. Do not lean on it. Support the chin with a hand when yawning. Until the pain has eased, avoid prolonged dental appointments with the mouth open wide, and ask for frequent breaks during treatment.
• Sleep posture. Avoid stomach sleeping, which loads the jaw and neck for hours. On your side, position the pillow so it does not push on the jaw and keeps the neck aligned.
• Diet, exercise, rest and calcium all matter for the health and healing of the joints and muscles; 900–1,200 mg of calcium a day is recommended (a glass of milk is about 300–400 mg; yogurt, cheese and vegetables also contain calcium).
• Medication. Anti-inflammatory and pain-reducing medications such as ibuprofen (Motrin) and aspirin without caffeine, per a doctor's recommendation. Over-use of these frequently leads to headache disorders, as does regular caffeine use.
• Relax. A quiet room, soothing music, a warm bath or shower and slow deep breathing — techniques you can also use while driving, working or studying. High-stress jobs, legal action, life changes and relationship problems can all increase or cause jaw pain.
• This is not life-threatening, even though it can be very uncomfortable. Discomfort of the jaw joints and muscles is extremely common, and locking is not uncommon. Most often the symptoms improve over time by changing habits, relaxing the jaw and neck, avoiding further strain and following these instructions.