Dental Topics

Dr. Josephs provides information on dental topics of interest.


You will find brief information on common dental related topics I have addressed.  Each of these topics can take up a book on their own.  The goal here is to give you a brief answer, but as coherent an answer as I can in this format.  I have left much of the technical jargon out to make it simple.  Over time, I will add more topics.  (These topics, and these short articles are meant only as general information and should not be used to diagnose you in any way.  Always see your dentist or medical doctor regarding a problem or symptoms you may be having.)

Dr. Edwin Josephs

Do not use the information in these articles, or any information on this website to diagnose yourself.  Consult your physician, or dentist. 


Do cavities cause pain?  Will I feel pain if I have cavities?

Over the years, I have found this common misconception, that if teeth are not hurting this must mean the absence of cavities.  You don’t necessarily feel pain if you have cavities.  Sometimes it may cause a sharp sting upon consuming sweets, but not always, and most cavities do not cause noticeable symptoms at first.  In fact, it is important for any dentist to review the X-rays, and exam results with patients.  The fact that cavities in general are silent in the beginning makes routine dental exams of great importance.  Small cavities have to be detected with visual exams and X-rays.  Without X-rays it is nearly impossible to know if cavities exist between the teeth or not.  Some patients may have a lower risk for cavities and may not need regular x-rays, but there are those who are at higher risk.  The risk level must be established by your dentist, and you and your dentist must take many other factors into account in determining how often you should have x-rays done.  You may not need to take x-rays every 6 months.  If you are maintaining a good home care, and a regular dental exam and cleaning schedule, and you have not had a cavity in several years, then your dentist may modify your X-ray requirements so that you only need them once a year, or possibly even longer.  But I advise you to not make this decision based on what you may read about X-rays online.  Always discuss risks and benefits of X-rays.  There cannot be one general rule for everyone. (from WebMD archives)


I only want a cleaning, why do I need an exam when I have no pain or discomfort?

(Int J Health Sci (Qassim). 2017 Apr-Jun; 11(2): 72–80.

Prevalence of periodontal disease, its association with systemic diseases and prevention

(Muhammad Ashraf Nazir)

Short answer is that both cavities and gum disease are silent, at least during early stages.  Gum disease is shown to be linked to other systemic diseases.  I have attacked a journal article which goes into detail explaining the relationship between various diseases and periodontal disease.  

Here are some reasons why everyone needs dental exams:

  • Many people wonder about this because they feel no pain. When it comes to gum disease, it is often silent, as are cavities.  It is only at a more advanced stage in the disease that patients begin to notice something is not right.  But months and years will go by before any of these initial signs are noted by the patient.  Cancer in the mouth is also often times painless.  It begins with a small spot, or a lesion.  Even if you are not a smoker, you will need routine oral cancer screening by your dentist. 
  •  To be safe, you need a full exam every 6 months to one year depending on your specific oral health needs.  This may or may not include X-rays.
  • As a restorative dentist, I want the best for my patients. But regardless of how well I do the restorative work if the gums are not healthy then I have failed right from the start.  It does not matter much what the house looks like if it is built on a weak foundation.  With healthy and stable gums, I can then do what I do best and rebuild and restore teeth structurally, and restore bite, and esthetics.
  • Gum disease may affect your heart and other organs. It has been linked to other systemic diseases. Although more research is needed in this regard, it may be safe to assume from the data at hand that systemic disease and gum disease are linked.

I hope this helps you understand why we recommend that you see a dentist for regular exams.

What is a root canal? 

Pictures of what a root canal is

Above photo taken from Encyclopedia Britannica, Inc.

(The below information is my own explanation and not in any way affiliated with Encyclopedia Britannica, Inc.)

I believe as more people search internet for answers, more than ever before the dental community will face patients who are misinformed.  It is not a good idea for patients to diagnose themselves.  Patients must speak about their oral health concerns with their dentist, and hygienist.  And it is the job of your oral care providers to take the time to educate you.  We do have the background training, and foundation to sort through all the clutter online, and present to you the relevant information.  A root canal is basically a last effort to save a tooth from extraction. 

I would like to explain the basics of root canal to you in simple words.   

Inside every tooth there is a chamber like a room.  This chamber or room is in the center of tooth.  What lies below the gum, we call the root or roots depending on the tooth.  This chamber inside the tooth has extensions that look like canals which follow the roots all the way down to the end of the root.  These are called canals.

The Chamber and the canals are filled with soft tissue such as blood vessels and nerve bundles.  Like electrical cords wrapped in a soft sheath of tape, they are neatly placed inside the center of the tooth in this chamber and along the canals inside the roots.

This bundle of nerves and blood vessels run through this long canal and connect to the rest of the body.  When we get a cavity, it is usually from the outside, and it grows inward towards the center. If it reaches this chamber where the nerve bundle lives, the tooth needs the nerve bundle removed.  This is because a cavity is caused by bacteria, and bacteria entering into this chamber may continue down into the canals and finally out into the bone, causing jaw infection.

At this point the infection is in the bone, and you begin to feel swelling, and even pus draining out of the gums.  This is a very basic description and not very scientific. It is just to give you a general idea of what a root canal treatment is.  Basically, a root canal treatment is done by opening an access to this central room.  The goal is to disinfect the chamber where the bacteria has accessed, and also the canals that are connected to this central room.  Once we reach the room, we remove the affected bundle of nerves and vessels in the room, and canals, and we try to scrub the canals clean to disinfect them. The scrubbing continues until we reach the end of the canals which is at the tip of each root.  This is the root canal space and after we have scrubbed it clean, we will fill it up using a rubberized filling material.  Then the access hole is filled, and typically the tooth gets a crown placed over it.

Unfortunately, root canals do fail from time to time.  The failed root canal can be retreated and redone. Or, the patient may decide to have the tooth extracted.  What a root canal treatment does is repair/disinfect the roots which are housing bacteria in order to prevent infection and save the tooth in process.  But this is not a perfect treatment.  If it is done well, and tooth is sealed so that new bacteria cannot gain access to the chamber, and if patient takes good care of their teeth, you can expect the newly root canal treated tooth to last a long time. 

Without a root canal, the tooth will need to be pulled.  People must understand that root canals are not appropriate in every case or for every person.  Patient’s health history, history of previous dental work, and history of the tooth in question must be all considered in deciding between a root canal or extraction of the tooth.  It is also important that what you read on internet is not taken as a diagnostic tool, rather it is to be used as information to be discussed with your medical doctor, and your dentist.  Your dentist has a duty to discuss this with you, and to sort through the information and present you with facts and use this information to steer you towards the best possible treatment.  Sometimes this may mean not doing the root canal but doing the extraction.

Patients must be given alternative options and not only focus towards root canal.  It is important that you know all your options and these options should be discussed with your dentist.  Alternative treatment to any root canal treatment is extraction and implant.  At times, even bridge may be more appropriate.  Each case is different, and must be approached individually. 

(The below article was not quoted in my answer, but I provided this article for your information)

Can Fam Physician. 1988 Jun; 34: 1357–1365.

PMCID: PMC2219109

PMID: 21253195

Root-Canal Therapy: A Means of Treating Oral Pain and Infection

Mitchell Levine

Copyright and License information Disclaimer

Why does my tooth need a cap, or crown?

I will keep this one concise.  Crowns are generally done to restore function back to the tooth, to prevent a weak part of the tooth from breaking down, and/or to alter the shape or esthetics of teeth.

Teeth are required to undergo very heavy pressures in the mouth during chewing.  A tooth may be too weak to handle these high pressures in the mouth over time, and if dentist diagnoses this to be the case, he or she will recommend a crown to protect the tooth from breaking down.

What can cause weakness?

  • Old fillings which are failing and are too large to be replaced with another filling.
  • Teeth with cracks in them which threatens to cause fracture.
  • If a tooth has had a root canal treatment, most of the time a crown is recommended since after root canal these teeth are generally more brittle and prone to fracture.
  • Esthetics are a major reason for crowns.  We have beautiful porcelain crowns which mimic natural teeth.  If a tooth has gaps around it, or broken down, or if discolored beyond the help of bleaching, then a crown may be considered.

Why are primary teeth (baby teeth) important?

Primary teeth are extremely important.  These are some points to keep in mind about baby teeth;

  • Nutritional needs of the baby are met through proper chewing. Missing or painful teeth will hinder this
  • They act as an aid in the development of a child’s speech, and word pronunciation
  • Esthetics of a smile are important even in children and affect how they feel about themselves.
  • One of the most important roles baby teeth play is as space savers for adult teeth.

These are a few yet important roles that primary teeth play.


How should I prepare for my child’s first dental visit?

Arrange your child’s first appointment on a day when you have plenty of time, and don’t have to rush.  Do not rush.

Leave the house early, and avoid stressful situations on the way to the dentist.  This may put the child in a stressful state which may cause anxiety right from the start.  Do not talk about shots, or pinch or needles just yet.  Be calm on the way to the dentist, and project a relaxed and confident energy to help your child relax.

The first appointment should be calm and all threatening instruments and demeanors should be avoided.  Not much should be done on the first few appointments if possible.  Cleaning, if done, should be a very light instrumentation and polish.  Not much can be done, or should be done on that first day, unless there is an emergency.  It is sufficient that the child gets familiar with a calm and friendly environment.  Usually, first impressions will have lasting effects.

Why is one of my teeth turning brown? 

There are several reasons why one tooth alone may get darker when previously it had normal color like the rest of the teeth.  The discoloration or staining may be extrinsic or intrinsic in nature.

Extrinsic factors are usually surface stains.  This happens to one tooth only if this tooth is not in the same plane as the rest of the teeth. For example, if one of the front teeth is slightly pushed back towards the tongue or palate, it creates a space where food and stains collect.  Over time, this tooth will get darker as the bristles of the toothbrush do not always make full contact with the tooth in order to clean it adequately.

The intrinsic factor which may cause darkening is a dead pulp or nerve bundle which includes nerve and blood vessels inside the tooth.  This occurs due to a trauma in the past to the tooth in question.  Sports accidents, airbag accidents, bumping of the face against a hard surface, any trauma may eventually cause the darkening of the tooth over time.  This does not happen right away.  It may take months, even years before the shade changes are noted.  Trauma to the tooth causes the blood vessels and the nerve inside the tooth to break.  Just as blood turns brown in color over time when exposed, the bleeding pulp inside the tooth turns the tooth brown to gray in color over time since the blood gets out of the blood vessels and into the tooth structure over a long period of time. Usually there are no symptoms, but over time patients may feel pain due to pressure on the tooth in question.   This is considered a necrotic pulp, or a dead tooth, and root canal treatment is typically advised.

Discolored teeth may also be due to certain medication, excessive fluoride intake as the tooth is forming prior to eruption, and also developmental anomalies that affect the formation of dentin or enamel. 

Usually after a root canal, these teeth are covered by a porcelain crown to restore the color of the tooth back to normal.  It is difficult to diagnose these teeth by just looking at them.  Most of the time they may just be stains, especially if there is crowding involved.  Only a dentist should diagnose your tooth.  This requires testing of the tooth with instruments for surface stains, polishing, testing the tooth for any pain response, radiographs, and most importantly, a comprehensive dental history.


Is it safe to use mall kiosks or other none accredited dental spas to do professional teeth whitening?

I cannot recommend a strong bleaching agent to be handled in the oral cavity by someone other than a trained staff member under supervision of a licensed dentist.  It may be damaging to enamel and soft tissue, if it is allowed to rest on soft tissue, and it may not be right for you as a patient.  Everyone must be evaluated on an individual basis by a dentist who takes the time to familiarize themselves with your overall health and the health of your teeth and gums.  Tooth sensitivity is always a risk even if you are doing whitening at a dental office, but it cannot be mitigated or treated at these whitening kiosks. There are individuals who may have a thin layer of enamel, especially at the edges of their front teeth.  Typically, we don’t recommend whitening for these individuals without proper remineralization support.   

Remember also, that if you have fillings, veneers, crowns on front teeth, these will not whiten, and you will end up with different shade of teeth if whitening is performed.  A professional strength whitening also requires gum protection.  Gray colored teeth also do not respond well to whitening. 

I don’t dispute the results some achieve, but so will an ordinary toothpaste or whitening gel over the counter.  The public holds us to a high standard, and rightly so.  When you have individuals in white coats masquerading as health care providers you get a sense of trust and this is intentional on their part.  But I would advise you against it.  See your dentist first. He or she knows your teeth.  If you are determined to use their services, please first speak to your dentist.  You must be diligent and careful.  Not everyone should get bleaching done the same way. Only you and your dentist can come up with a plan of action taking into account your dental history, proper material, dose, and time for appropriate bleaching of your teeth. 


What kind of toothbrush should I use?  Hard, medium, soft, or ultra/extra soft.

When it comes to toothbrush, we advise our patients to skip all the mediums, and hard bristled brushes.  If your dentist recommends a medium or hard bristled brush, then discuss your concerns with them.  There may be a specific reason you are recommended a medium bristled toothbrush.

We are always worried about the permanent mechanical damage these hard brushes can cause to the thin gumline and the tooth structure at the gumline. Some say this is only due to abrasive nature of over the counter toothpastes.  I agree with the fact that toothpaste generally has an abrasive effect on teeth in the long term, but it helps to use an ultra-soft bristled brush in either case.  But my advice to you the reader is, ask your dentist before you make the change.  As for my own patients, I recommend ultra-soft and soft bristles.  None of our patients are given mediums, or hard bristled brushes. Again, this is our specific setting, and this may not be right for you.  Speak to your dentist first.

The job of a brush is to remove as much soft plaque as possible, and in the process even remove some of the newly formed stains.  Typically, medium or hard bristles are not needed for this.  Let’s face it, most of us are heavy handed when it comes to brushing.  I have seen otherwise healthy teeth with mechanical damage from years of hard brushing, and not to mention some gum recession.  Therefore, even if the heavy-handedness habit is not mitigated, at least an ultra-soft, or extra-soft toothbrush will slow the damage.

Why do you find these brushes on the shelf then?  The reason you see so much medium and hard bristled brushes on the shelf is probably due to consumer demand for them.  So, manufacturers and stores simply oblige and feed the demand.  I am glad there is that option, as I said over and over, there may be a situation where hard bristle is warranted.  But we see mechanical damage, and soft tissue impact as a good enough reason to advise our patients against them. I much rather avoid fillings and gum grafts to repair damage done by hard bristles years down the road. Again, speak with your dentist if you have not had this conversation with them yet.  Your hygienist, and dentist will be your best source of information.  Also, pick a brush you are comfortable using.  Rounded bristle-ends afford better reach in tiny grooves.  Size of the head of the brush is also important, especially for those who can’t open wide, or have smaller arches.  Use a brush that you can use to easily reach the last teeth. Add-ons on the brush heads are becoming the common sight on many toothbrushes. These plastic or rubber projections, the manufacturer claims, enhance the cleaning power of their brushes over against their competitors.  Ask your dentist what he or she thinks.  Personally, I recommend a simple, extra soft bristled toothbrush that allows you easy access to all your teeth surfaces.   

Whether you use manual brush, or electric brush, make sure you don’t place heavy pressure on the brush.  Lightly hold it against your teeth, and use short and concise circular motion to brush.  Do this twice per day unless told by your dentist otherwise, and floss once at least.

I’m afraid of going to the dentist.  What do you recommend for someone like me?

You are not alone.  Many people remember one or multiple unpleasant experiences in the past which started this fear of the dentist in them.  You may have many good experiences, but unfortunately, often times this fear develops during childhood and stays with us for a very long time.  Plus, horror stories under the dental genre are very popular and this too can paint a scary image in our minds, thus causing fear.

To this, I can’t give you a short answer.  It is a complicated topic.  This has to do with patient management more than the needle and the drill. But you can try breathing exercises and a good night sleep.  Plan on leaving your house a little early.  The stress of traffic, and not making the appointment on time will only add to the stress.  Speak either in person or over the phone with the staff, and with the dentist about your fears prior to the appointment. Bring this concern up to your dentist’s attention.  Let him, or her prepare for your visit.

 There are options, in case the fear does not subside.  Nitrous oxide gas administered at the dentist office has a great safety record, and it is effective in reducing anxiety.  There are also medications available by prescription.  This must be determined on individual basis, and prior to the appointment.

But one of the ways to manage a patient’s anxiety is behavioral in nature.  I’m not talking about your behavior as a patient, but that of the dentist and the dental team.  For this reason, what I have to recommend in this regard will take up several pages, and I can’t include that here.  But here is the short summary of it.

A good connection with the patient, through genuine and friendly conversation, helps establish a starting point. We strive to get to know you, and for you to know us.  Only then, health history, patient’s medical, and dental treatment history are reviewed.  Radiographs should be discussed with patient, and we do this routinely.  X-rays used during treatment planning phase to educate patients are a great tool to inform the patient.  Patients have responded positively to this, in a surprising way.  It is very satisfying to us when patients begin to understand their own X-rays and feel included in the discussion. 

Gentleness, light-handedness, and patience employed in all aspects of dentistry tend to calm a patient’s anxiety.  Explaining the procedures and reasons for the procedures are all part of this stress reduction technique.  Once a patient sees and understands what area of their mouth is in need of attention, and once they understand the nature of treatment, it removes a lot of the fear which comes from not knowing what is going on.

A conservative treatment plan is also reassuring. And when the time comes for actual treatment, we need to get to know one another again.  Treatment day not only teaches the dentist how the patient does but also teaches the patient about the behavior of the dentist at work.  For this reason, if possible, it helps to start with a simple procedure, like one or two simple fillings in order to introduce the patient to treatment under a new dentist and the new style of dentistry.  A good rule of thumb is to never let patient walk away with more questions than they came in with. Proper information about patient’s treatment, and about the way the dentist and staff are prepared to help an anxious patient are critical. 

But when we do all the we are able to do, and the results are still less than satisfactory, then other options of mitigating fears and anxiety must be considered, including referrals to sedation dentists.


Is oil pulling effective in improving health of your gums and teeth? 

This is a question most dentists today will face and will need to answer at some point.  By now, I have been asked this question three or four times, and I know I should be prepared to give an answer.  As a dental professional, “I don’t know” is not good enough.  Evidence is emerging that oil pulling may have some positive benefits to the oral health.  But there are too many factors to consider like: type of oil, your medical history and appropriateness of using specific oils, and etc.  I cannot condone the practice for someone in my position due to scarcity of long-term studies on this subject.  I can however evaluate individual patients, their medical history, their oral history, and their oral health, and establish certain safety guidelines for that individual patient to use oil pulling safely, and appropriately, if that patient is determined to pursue this practice.  But I also have to warn that patient of potential down side of oil pulling as I see it.  We just don’t have long term studies to refer to. 

Generally, what someone needs to do to achieve healthy teeth and gums is to brush twice a day with a soft or ultra-soft bristled toothbrush, and floss at least once per day, and visit a dentist regularly.  We also need to see our dentist or hygienist in order to remove calculus in hard to reach areas that cause gum disease.  This hard substance cannot be removed with toothbrush. 

This is why hygienists are a critical part of maintaining your oral health.  They are specially trained to remove this harmful substance from teeth surfaces and often times from under the gums. 


Oil pulling must not be a substitute for brushing, flossing, and regular dental check-ups/cleanings by your dentist. 

It may be used as a supplement to the traditional oral health care, if deemed safe for you by your health care and dental care provider. The practice of oil pulling is an old eastern practice, mainly Indian in origin. I like to include for you a helpful study to review.  The links are below this article.  

  So, when you brush, do it with soft bristles, and in a circular motion, with light pressure.  Back to oil pulling, and what I see as benefits of oil pulling.

  • due to viscosity of oil, swishing it will physically remove the harmful soft film we call plaque off your teeth without the need to use bristles. This may take longer however, for the same reason that it is the softest possible way to remove plaque.
  • A study showed that oil pulling, using coconut oil can in fact reduce the number of S. mutans bacteria which is considered the bad bacteria. J Int Soc Prev Community Dent.2016 Sep-Oct;6(5):447-452. Epub 2016 Oct 24. Comparison of antibacterial efficacy of coconut oil and chlorhexidine on Streptococcus mutans: An in vivo
  • According to this study, it is as effective as Chlorhexidine mouthwash, which is an effective antimicrobial. This really surprised me.
  • Coconut oil contains vitamins and antioxidants, which may be of some benefit
  • Since it can reduce some of the harmful bacteria in the mouth, it may act as an effective bad breath remedy.

I can understand the benefits of oil pulling. But at the same time, I am not sure I can guarantee it will not cause other problems.  Here in the west, we just don’t have a long-term study on this subject.  Oil pulling is an ancient technique which was practiced in parts of the East, mainly from India.  But for us in the west it is new.  Studies are mostly short term, and they are few and far in between.

What are my concerns about oil pulling?

These are just some things that come to my mind.  I do not have a study to back these points.  This is just my concern as a dentist which I feel I need to share with my patients.

  • The amount of work you are putting your facial muscles, and masticatory muscles through may cause inflammation in these muscles. This may lead to more developed facial muscles which could cause enlargement of the muscles.  (my speculation)
  • forces the jaw joint to perform far more strenuous movements which may have negative effects on the TMJ in long term. Popping, pain on opening and closing, inflammation, and limited range of opening.  All these things come to my mind as possibilities knowing about the anatomy and physiology of this joint.  I have not observed any of these effects on the TMJ as a result of oil pulling.  But it is fairly a new phenomenon in our society, and we have not had enough time to evaluate its effects.
  • It may cause complacency regarding brushing and flossing. This will lead to major oral health problems.
  • American Dental Association does not approve of this for good reasons.  Everyone including dentist look up to their association for journals, tests, and studies.  Imagine if they told everyone to do oil pulling without proper clinical studies, and long-term studies at that.  They cannot make such recommendations, and I completely understand.  I too cannot make that recommendation for the same reasons.  I need long term clinical studies, and proper standard procedure.  Not every patient may be safe doing oil pulling, and not every compound should be used.  So, I make no recommendation except that be careful, do your research, and discuss this with your medical doctor, and your dentist first.  Make sure your hygienist is also informed. 


I cannot encourage you to do oil pulling as a health care provider.  But I will warn anyone who thinks this is a substitute for brushing and flossing, don’t be so sure.  What 20 minutes of oil pulling does for your teeth and gums, 3 minutes of flossing and brushing does, albeit with no vitamins and antioxidants.  I have not seen someone who started oil pulling at a young age, but I have seen plenty of 97, 98, even 100 years old patients who maintain their oral health and have kept their teeth brushing twice, flossing once, and seeing a dentist twice per year.

That said, there is an area of oral health which I think oil pulling may help.  I have treated many elderly men and women who suffer from dry mouth, and cavities which form on the roots of these patients. This affects those of us who suffer from dry mouth for any reason, and any age.  These patients suffer from very aggressive forms of cavity that target the roots of the teeth, and it has been a frustration for patients, and for dentists for a long time.  I need a preventative, at home remedy to reduce the rate of cavities forming on roots.  Often times, patients also lose some of their dexterity, and are unable to effectively brush and floss.  An agent which can be used for 5 minutes or less via swishing, which would reduce harmful bacteria, remove plaque, and coat root surfaces with a little fluoride (optional) would be a good start for what it is I wish to see out there.  A type of oil infused with antioxidants, calcium phosphate substrate, and natural antimicrobials, along with salivary enzymes would be wonderful, especially if it helps replenish  lubricity of the soft tissue.  I hope and wish those with the ability to study this would spend the time and resources to conduct a proper multi-year study using natural oils for oil pulling on geriatric patients suffering from root decay and dry mouth. 

J Tradit Complement Med. 2017 Jan; 7(1): 106–109.

Published online 2016 Jun 6. doi: 10.1016/j.jtcme.2016.05.004

PMCID: PMC5198813

PMID: 28053895

Oil pulling for maintaining oral hygiene – A review

Vagish Kumar L. Shanbhag

Are dental X-rays safe?  How much radiation am I being exposed to by taking dental x-rays? (some figures are estimation)

Dental x-rays have some of the lowest radiation levels registered. This is not to promote careless use of dental x-rays, but to help you understand the dose compared with other sources of radiation you may encounter. 

Today, 2 single dental x-ray films are about 0.002-0.005 milli-Sieverts (mSv).  For comparison, radiation from the background we encounter through an average day, sun, food, soil, building, is about the same.  A typical flight from Los Angeles to New York is approximately stated at around 0.030-0.040 (mSv).  Often times these are the types of comparisons you will note on the internet.  It is important to note that even though the overall amount of radiation dose may be similar, especially in background exposure in comparison to dental X-rays, one must not forget that a dental X-ray concentrates that energy on a small point in the body, in one second.  The background radiation takes all day, spreading that energy over the entire body.  So, it is correct as far as the dose charts are portraying the numbers, the effect is different in practice.

There are many varied charts and colorful pictorials all over internet trying to promote safety of dental x-rays by comparing them to bananas, buildings, and airplanes.  Although I appreciate someone trying to alleviate concerns of patients, it is crucial that patients understand that effects of radiation are cumulative.

Each patient must be evaluated carefully. For example, if you are undergoing cancer treatment with multiple CT scans and more radiation to kill the tumor, your dental x-ray requirement will change.  I need to take this into account.  I must take the back seat to cancer treatment when it comes to X-rays.

But you have to understand my dilemma as your dentist.  Without x-rays, I’m diagnosing partially blind which means I may not be able to diagnose the problems adequately.  But I do understand the situation you are in.  I have to do the best I can with what I have to come up with a treatment plan and not expose you to more radiation than needed, even in best of times, let alone when you have undergone urgent medical treatment which has exposed you to more than usual radiation.

As far as dental x-rays are concerned, the new digital units have many improvements over the old system in many ways, radiation levels being the main one for patients. A typical 4 bite Wing x-rays taken annually for exam and cleaning is roughly about 35 mSv  This is F speed film.  This means a single x-ray is about 0.005 milli-sieverts. By comparison: (estimates)

Flight from L.A to N.Y.———–0.040 millisieverts (mSv),

4 Bite-wing dental X-rays +2 Anterior——–0.035 millisieverts (mSv)

Mammograms———————-0.40 millisieverts (mSv)

Single Chest X-ray——————0.10 millisieverts (mSv)

CT scan of head———————2 millisieverts (mSv)

CT scan of Chest——————–7 milliSieverts (mSv)

CT scan of Abdomen—————8 millisieverts (mSv)

Use this as a very generalized guide, not as definitive numbers.  This is just to give a very rough estimate of what dental x-rays produce in radiation compared to some other ways one is exposed to radiation.  Again, this is not to give a dentist license to take x-rays with slight regard.  Each patient must be evaluated individually according to their medical history, and this is where a good conversation is vital between patient and dentist.

A couple of examples: (this is a general guide we use, and it is not meant to be a solution for all scenarios.  This should not be taken as standard guideline)

  • if a patient has a very good home care and is diagnosed as low risk for cavities, it is best to avoid unnecessary exposures every six months. 
  • A patient may have undergone radiation treatment, and multiple CT scans, which may make them prone to root decay. On such, one must perform a thorough visual exam and consider localized areas which pose a high risk for tooth loss or infection to be x-rayed.  This is just a general example of what we do in our own practice daily.  Also, a well-informed staff who knows the patient well, who works as a team with the doctor to tailor an x-ray schedule to reduce patient’s exposure to unnecessary radiation is vital.

What can we say to our patients to alleviate their fear of dental X-rays?  Well, besides what was already discussed above, let me refer you to an expert physicist, Adam Evearitt.

(Adam Evearitt is the owner of Atom Physics and is a board-certified medical physicist.), Mr. Evearitt states, in an article written for Colorado Dental Association:

· What we know is that radiation from dental exams has never been scientifically proven to raise the risk of cancer incidence.

  • We know that the human body is used to getting bombarded with x-ray radiation from cosmic rays from space and radon gas in the air constantly from the moment we are conceived to the moment we die, so our bodies are used to repairing the damage caused by low amounts of radiation.
  • We know that dental radiation has always been considered safer than other forms of medical radiation because it is directed to areas of the body that just aren’t radiosensitive. And if we shield the areas of concern—like the thyroid—and make sure that the lenses of the eyes and are kept out of the x-ray fields, then we are helping the patient to feel safe and protected.”, Adam Evearitt

Are dental x-rays safe during pregnancy?

Dental x-rays are considered safe during any stage of pregnancy.  The American College of Obstetricians and Gynecologists note that delaying X-rays may cause further complications such as infections.  (ref from Journal of American Dental Association, July 2019Volume 150, Issue 7, Page 636.  Dental x-rays, by Anita M. Mark), also ADA.

That said, each pregnancy and each patient must be evaluated individually.  The patient’s history of dental caries, and need for X-rays prior to pregnancy must be taken into consideration.  If you are evaluated as a high-risk person for cavities, then postponing X-rays may cause more harm than good. Even then, I would not proceed with my X-rays unless I have consulted patient’s M.D first. Then we follow standard precautions of taking X-rays of isolation of neck, and organs with lead shields, thyroid collar.  As a general rule, at our office we try to limit invasive restorative dental treatment in the first and third trimesters to absolute minimum.  And restore when postponement may pose a higher risk to patient.  We do recommend regular cleaning to avoid further gingival complications. 

Are silver, or amalgam fillings bad for your health?

This topic will continue to be controversial due to the presence of mercury in these fillings.  As a dentist, I can vouch for their mechanical effectiveness in being able to withstand pressures of the bite and acidic environment of the mouth, and appreciate their longevity.  Yet, they do contain mercury as one of the main ingredients which makes them come under scrutiny by many who advocate for alternative treatment.  This is why we have made the decision to exclude them from our list of procedures.  But not because we have proof of their toxicity to our patients.  Any assertion should be backed up with proper facts generated by a reliable long-term study.  And as far as we can tell, studies have failed to show any concrete link between amalgam fillings and systemic disorders.  However, there are studies that show higher mercury in the tissue of individuals with numerous amalgam restorations.

Int J Environ Res Public Health. 2019 Sep; 16(18): 3283.

Published online 2019 Sep 6. doi: 10.3390/ijerph16183283

PMCID: PMC6765786

PMID: 31500155

Exposure to Dental Filling Materials and the Risk of Dementia: A Population-Based Nested Case Control Study in Taiwan

Natalia Mikhailichenko,1,2 Kimitoshi Yagami,3 Jeng-Yuan Chiou,4 Jing-Yang Huang,5 Yu-Hsun Wang,5 James Cheng-Chung Wei,1,6,7,* and Te-Jen Lai1,8,*

It is imperative that dentist, and medical professionals keep up with the current data available as a result of long-term epidemiological studies.  

The alternative to silver/amalgam fillings are various composites which are not based on metal and mercury. These are the white fillings and work by a bonding principle.  They have made much advancement in almost every respect, and I don’t see a good reason to use amalgams.

This is my own opinion on this matter, another dentist may disagree.  The presence of mercury in silver fillings, even though it is bound and not readily released in large quantities, is good enough reason for me to abandon their use, especially when composites have improved so much.  Many papers have been published, and studies have been made.  Yet, it is difficult to be able to link their presence to various ailments which may affect us many decades later


What if I already have amalgam fillings?

Sensational headlines, and opinionated articles tend to attract more public attention than journal articles stating the results of long-term studies done on this subject. 

The studies show that more mercury is found in people who have several amalgam fillings than those who have no amalgam fillings.  But these studies as far as I can glean their data, fail to establish concrete link between let’s say dementia and the presence of amalgam fillings. Another fact to keep in mind is that we are exposed to the mercury in these fillings the most during their placement and then during their removal. While it is set in the tooth, the amount of mercury released is the lowest unless the filling is compromised by decay, fracture, etc.   Again, modern techniques can reduce exposure to mercury in both instances, but it can’t eliminate exposure completely.  If you are like millions who have them, speak to your medical doctor and your dentist.  Do some research as well.  While the filling is in the mouth, the mercury is blended with other metals, and it is bound.  Exposure however is still possible via amalgam vapors during chewing.

What I do with them is what most dentists do, remove them if the patient is concerned but only after they have been well informed. Or, remove them when signs of failure are noticed.  Fracture lines in the tooth seem to be common with aging amalgam restorations.  They do have a tendency to resist cavities due to their expansion inside the tooth, but this same expansion may play a role in formation of hairline fractures in the teeth after several decades.  The fracture lines may cause more mercury release, and this is my own speculation.  The fracture lines will at times weaken the structure and in some cases they will need a crown to restore the tooth structurally.

This is my observation over the years. When we see discoloration of the tooth, decay, fracture lines, or leakage of the edges of the filling, we propose replacement.

Another reason we will replace a silver is if patient decides to have them removed for esthetics reasons. This is a legitimate reason, but like any other time, patient must be well informed prior to replacement.  

Use of modern dental equipment and rubber dam isolation will certainly lower the exposure to mercury vapors, but may not totally eliminate it.  So, an honest discussion with known facts must be started with patients.  Facts based on studies will better inform you of your decision to remove or not.  Sensational articles and assertions are plenty online.  This is even more the reason that you should discuss them with your dentist.

Yet again, this is my personal view on this matter.  If you are concerned about their long-term effect on your body, don’t be silent.  Talk to your dentist, hygienist, and your medical doctor.  The dentist is your best source of information on how to safely remove them, if you have decided to do so. 

Refer to this journal article for further information on amalgam/mercury fillings. 

Toxicol Int. 2012 May-Aug; 19(2): 81–88.

doi: 10.4103/0971-6580.97191

PMCID: PMC3388771

PMID: 22778502

The Dental Amalgam Toxicity Fear: A Myth or Actuality

Monika RathoreArchana Singh,1 and Vandana A. Pant


How can I stop snoring?

Most people have heard of C-pap machines.  But there are other alternatives which may help also.  The reason for most snoring is the backward sagging of relaxed tongue into the airways and causing turbulent flow of air or even blockage of air flow.  This also can be caused by relaxation of soft tissue which may flutter in the presence of airflow.

To achieve their objective, some appliances work by simply moving forward the mandible which moves the tongue forward also, clearing the air passageway. Talk to your dentist about this.  Some of the appliances resemble trays which go over the entire arch on top and bottom that are connected with bands.  These are prescribed by dentist, or medical doctors, therefore they must be custom made to fit your teeth and mouth.  C-Pap has been a wonderful device and will continue to help many, but alongside C-pap there are other devices which may help alleviate the problem of snoring as well.

What are the symptoms of Snoring?  How would I know if I am snoring? 

Aside from a family or friend informing you of your snoring, there are also symptoms you may notice.  Do not self-diagnose, as these symptoms are common to other illnesses which may become serious and life-threatening if ignored.

If you have any of these symptoms, see your doctor right away.

  • Daytime sleepiness, and excessive yawning
  • Headaches during the early parts of the day, mornings.
  • Lack of, or difficulty concentrating during the day.
  • Sore throat.
  • Chest pain, similar to heart burn. (do not ignore chest pain, it could be heart related)
  • High blood pressure

Nighttime signs, usually reported by spouse, or a family member:

  • Labored or forceful breathing.
  • Gasping for air.


Do I have Acid Reflux (heart burn), and does it damage my teeth? 

Acid reflux also commonly known as heartburn, is when the stomach acid repeatedly flows backwards into the esophagus.  It may not be noticeable in the beginning.  If this condition goes on regularly, or if it takes place twice or more weekly, it is diagnosed as GERD, Gastro Esophageal Reflux Disease.

Most of us have experienced a mild episode of this condition.  Acid reflux is also linked with obstructive sleep apnea. This study has valuable information for those who want to read more about it.

 J Neurogastroenterol Motil. 2010 Jan; 16(1): 22–29.

Published online 2010 Jan 31. doi: 10.5056/jnm.2010.16.1.22

PMCID: PMC2879818

PMID: 20535322

Gastroesophageal Reflux Disease and Sleep Disorders: Evidence for a Causal Link and Therapeutic Implications

Contributing factors to acid reflux, or heart burn:

  • Eating a big meal before bed
  • Eating certain foods regularly such as: fatty foods, spicy foods, acidic foods.
  • Drinking alcohol, coffee, soda and caffeinated beverages in general.
  • Some medications will also do this, but discuss these with your doctor.
  • Pregnancy-this is common, and discuss this with your medical doctor and your dentist.
  • Overweight – this is a factor for heart burn, but people of normal weight experience acid reflux as well.
  • Smoking

There are more factors which give rise to heart burn which I have left out.  Some of the symptoms may mimic a heart attack.  Please, do not assume you are having acid reflux when you get chest pains.  This pain can move up to the throat even, and often times feels like the symptoms of heart attack.  So, do not dismiss any chest pain as mere heart burn, always seek immediate medical help.  In fact, all symptoms listed in this article, may be associated with other illnesses, or conditions. Do not self-diagnose.

  • Burning sensation or pain around chest, or throat. (do not dismiss this symptom, call your doctor right away, as this could be a sign of heart attack)
  • Sour taste in your mouth
  • Burping, and persistent hiccups
  • Sore throats that occur often
  • Persistent dry cough
  • Difficulty swallowing

Observing the signs of acid reflux (heart burn) by dentist.

Your dentist may be the first person to spot the presence of this condition by the signs visibly left behind by the presence of excessive acid on teeth.  In most cases that I have encountered, the patient is not aware of this.  Your medical doctor may also not readily spot this problem if you are not complaining of any symptoms.

But the dentist is in the right position to spot the signs, which appear on the teeth. Prolonged exposure to stomach acid will damage the lining of your teeth, and these are the signs that a dentist looks for to find out if you have an ongoing exposure to acid potentially caused by heart burn.

These signs are usually seen on chewing surfaces of molars and premolars.  In certain cases, even the side of the teeth is affected.  They look like cupping or holes usually on the tip of the cusps, or in advance cases, grooving begins to appear around fillings.  These can cause sensitivity to temperature, but often times come with no symptoms at all, at least not in the beginning.

The acid erosion on the teeth can be seen in kids and in adults.  When I tell my patients of the signs present for acid reflux, they are usually surprised to hear this.  But it is very important for the dentist to keep their eyes on the signs and symptoms of acid attack on the enamel of the teeth and to alert the patient right away.  We must refer the patient to the medical doctor for further evaluation.

My biggest concern for my patients, when seeing these bowl-shaped indentations on the molars, is not the molars but the esophagus.  I can repair the acid erosion of the teeth, but the esophagus can be seriously inflamed and eroded in the presence of chronic acid reflux.  This can have severe health implications.  So, when we see these signs, we inform the patient and ask them to see their medical doctor for further evaluation.


Tooth sensitivity


This condition affects many of us in the U.S, and around the world.  Most of us will at some point experience a temporary period of tooth sensitivity, and some of us are prone to it more than others.  When a dentist talks about tooth sensitivity, he or she is talking about pressure changes occurring outside of an exposed dentin, which is the sensitive part of the inner tooth.  When a section of the enamel is broken or missing, it exposed the inner layer of tooth called dentin.  This is how a tooth becomes sensitive.

What things cause pressure changes, which cause tooth sensitivity? 

  • cold, heat.
  • Sweets
  • Acidic foods
  • Mechanical objects rubbing on the defective region
  • Gum recession. (gum shrinking away, or down from the enamel)
  • Dental filling, or crowns.

Why does tooth sensitivity happen?

Broken, or missing enamel is usually the reason you feel temperature sensitivity.  But to delve deeper, we must be familiar with tooth anatomy.  I will attempt to keep the answer as simple and basic as I can.  I also ask that you refer to the photo I painted to show different anatomical structures.  Please excuse the art work.  I drew this myself as an illustration for you.  I did not want to download a copyright photo from the internet.  My photo of the dental anatomy is not a copyrighted image, so feel free to use it.   Also, understand that the answers here are purposely kept simple.  The information here is just for general information.  The topics discussed in these articles are intentionally kept at a basic level to hopefully give you some information.  But be sure to discuss any of your symptoms with your dentist.

Enamel, Dentin, pulp, and dentinal tubules.

Tooth is covered by a thick layer called enamel.  This layer is inorganic, and hard.  It functions as protection to the tooth, and it is the visible covering of the tooth.  When you look at your teeth in the mirror, this is what you are seeing.  This layer is about 1mm to 1.5mm thick. This enamel covering ends at the gumline.   Just under it is the organic layer of the tooth called dentin.  Dentin contains millions of tunnels we call dentinal tubules.  These tubules traverse the entire thickness of dentin.  The dentinal tubules reach all the way out to enamel.  Therefore, enamel acts as a hard cover for dentin tubules, sealing the contents of the tubules.  What is in the tubules is of great interest to our discussion regarding sensitivity.

One end of these tubules reaches the enamel cover, but the tubules starts way deep at the central chamber of the tooth, called pulp chamber.  What’s pulp?  It is a living tissue made up of nerve, and blood vessels.  So, from outside to inside we have 1) enamel, 2) dentin, 3) pulp chamber, where the nerve and blood vessels reside.

Back to the tubules;

These tubules extend from the pulp across dentin and reach all the way out to enamel.  They don’t penetrate enamel.  Instead, enamel act as cover that seals the contents of the tubules.

Inside these tubules is liquid, and inside the liquid filled tunnel is also a strand of nerve which enters into the tubules from pulp.  These strands of nerve which enter the dentin tubules extend part of the length of the tubules.  The stands of nerve are suspended in the liquid filled tunnel.  (Refer to the photo, the blue lines are the liquid filled tubules, and the yellow lines represent nerve).  Every tubule contains a neutral PH liquid, and strands of nerve. What keeps the liquid from moving or evaporating is the enamel covering.  When the enamel covering is missing or damaged, it exposed the dentinal tubules and the liquid inside the tubules begins to react to outside pressures.  When the liquid reacts, the nerve that is suspended inside also reacts, and this is how you feels sensitivity.  Bottom line is, there is a section of your tooth that has lost enamel covering, and exposed dentin is reacting to the outside environment.  So, imagine drinking cold water.  As the water moves past this defective region, it causes pressure changes to take place inside the dentinal tubule and the liquid in the tubules begins to move.  The nerve that is in this tubule now becomes reactive, and pain is felt.  (this discussion can get very technical, I have tried to keep it as simple as possible)

What regions of the tooth are more prone to sensitivity?

Any areas that are more subject to enamel loss, are also more prone to sensitivity.  Enamel is thinnest at the gumline.  it is usually on the gumline facing the cheek, or lips that we often see most of the sensitivity.  Sensitivity can also occur on the chewing surfaces if acid has eroded, or thinned enamel, anatomical grooves have opened a cavitation into the dentin layer below, or a filling with open or leaky margins, and so on.

What can you do at home?  There are products and toothpastes over the counter that contain potassium nitrate 5%, which can help reduce sensitivity.  I do not advise you to purchase any product that your dentist has not recommended.  Before you buy any over the counter products, please speak with your dentist first.  Some of these products may not be right for your situation.  Tooth sensitivity is a complicated problem that needs to be diagnosed by a dentist first.  Additionally, you may have allergies to any of the ingredients listed on these products.  Again, speak to your dentist first. For our patients whom we know, we are comfortable to advise ProNamel toothpaste in most cases.  I don’t represent their company, and all these comments are not written on their behalf.  But I do use their products since this particular toothpaste has shown to be effective in some cases.

Normally if the sensitivity is high, we recommend professional product that we apply on the affected areas.  If none of these are working, then a filling may be used to function as an enamel repair, or replacement.  All this must be determined by your dentist.   It is vitally important to identify the cause of the damage to the enamel, or the cause for sensitivity.

My advice to my patients is usually to use the OTC products which we deem safe for that individual. If They have not done so already, we advise switching to a soft or ultra-soft toothbrush, or modify their brushing technique.   We may provide samples of OTC fluoride rinse if appropriate for that individual.  We ask that they avoid junk foods, sodas, and rinse mouth right away after consuming certain foods containing high acidity.  This is usually the first phase.  If this does not work or if the symptoms are moderate or severe, then we recommend a professionally applied non-invasive products not available over the counter.  This is usually effective for few months, and may need to be reapplied.  But in case this does not produce the desired effect, then we advise composite fillings.

What can cause teeth to become sensitive?

  • Hard brushing– this is one of the most common causes of temperature sensitivity. We have a habit of brushing in a straight line, and using too much pressure.  This problem is exacerbated by using hard bristled toothbrush.  The abrasive nature of most toothpastes also contributes to this problem.  This causes a type of lesion (enamel defect) that is often located at the gumline, where the gums and the tooth come together, and it is often times on the cheek facing side.  This is because we are able to put more pressure on the outside then we are able to put on the tongue side of the teeth.  This vigorous brushing over the years removes the thin enamel from gumline and creates a wedge-shaped lesion called abrasion, mechanical abrasion to be specific.  With the enamel gone, dentin is exposed and with this, the tubules inside the dentin are now open and readily react to the pressure changes outside.

Prevention of the mechanical abrasion caused by toothbrushing- you can help the situation first by getting rid of your hard toothbrush.  Always try to use a soft or ultra-soft brush unless instructed by your dentist to do otherwise.  Before you make any changes to your brushing, speak with your dentist.

The second, and most important thing you can do is stop brushing in a straight line.  Begin brushing using light pressure in circular motion.  Be gentle, and brush in circular pattern.  If you are using electric tooth brush, it is even more important that you do not brush vigorously in a straight line.  The electric brushes are wonderful tools, and they do an amazing job cleaning.  But they tend to have medium to hard bristles.  It does not matter much in this case, since you don’t rely fully on the hand movement to clean the surfaces.  What you should do is lay the bristles gently over the teeth, and begin slow circular movement, allowing the automatic movement of the bristles to do the job.  So, in either case reduce pressure, and move in circular pattern over the teeth.  I know it is a hard habit to change, but it will pay off in the long run.

  • Acidic foods/acid reflux– This is becoming more and more common, at least as far as we can observe. Acid attack usually will affect the gumline and the chewing surface of the tooth.  When acid is the cause of enamel loss, we call this chemical abrasion or acid attack.  The result is the same as mechanical abrasion; loss of enamel, and uncovering of the sensitive layer of the tooth, the dentin.

Prevention is normally achieved by first speaking to your medical doctor.  Often times, dentists are the first ones to detect this.  Acid erosion may be due to foods, or acid reflux.  Obviously if it is from food, then the best thing to do is to make some changes to the diet.  If the source of acid is from healthy foods, or those foods that you rely on for a healthy lifestyle, then a dentist will not be justified in asking you to stop eating them.  In these cases, please use some water to quickly wash away acid build-up on your teeth, immediately after consuming acidic fruits and spit the water out.  The amount of acid has a less significant effect on the teeth than the duration of time acid is allowed to dwell on the tooth.  By immediately washing your mouth with water, it lessens the time acid stays on the tooth.  Usually, I don’t advise patients to use fluoride each time you eat acidic foods.  This would lead to over exposure to fluoride.  I don’t recommend this.  If the acid is due to acid reflux, then your dentist should recommend that you speak to your medical doctor first.

  • Grinding and clenching at night– The lesion or enamel defect this leaves due to over-pressure is very unique. This too is noted on the cheek side of teeth, at the gumlines.  It resembles lesions made by mechanical abrasions, but more irregular in shape.  This too ultimately results in loss of enamel and exposure of dentin which is the sensitive section of the tooth.

To remedy this problem, we usually advise nightguards.  Custom made nightguards spread the force across the whole arch, and provide a flat glide surface which further minimizes pressure on individual teeth.

What about over the counter nightguards, do you really need an expensive custom made nightguard?  I don’t recommend over the counter nightguards to be used for more than a week or maximum two weeks.  We often recommend the use of OTC nightguards to use as a test to see how well can patient tolerate wearing an appliance at nights.  This is helpful to see if patient is able to keep the nightguard in the mouth and still fall asleep.  However, given that these nightguards are meant to be universal in fitment, they are made of soft rubberized substance.  We have noted in the past that a soft nightguard acts as a stress relieve appliance, at times making grinding worse, and creates more tension on the jaw muscles and the TMJ itself.  Second, remember that what helps reduce pressure is also a flat glide surface.  Well, a rubber material does the opposite.  It creates strong traction and prevents gliding.  This places more pressure on the TMJ.  So, we recommend a thin and hard nightguard custom made to fit your arch properly.  You must be diagnosed properly as well.  Please don’t diagnose yourself and always consult with your physician and dentist about your jaw pain, or tooth pain.

  • Gum recession– this can also happen due to mechanical means, such as aggressive brushing, or brushing using hard bristles. Recession will sometimes occur due to heavy grinding as well.  Another reason for recession is due to plaque build-up, and chronic periodontitis.  These conditions must be diagnosed by a dentist.  This is why your specific condition must be diagnosed properly.  The best treatment for this is often (not always), gum graft surgery.  This is a common procedure, a well-documented procedure which works.  It is often done by a specialist in the field of periodontology, or by a gum-specialist.  Your dentist will examine the reason for sensitivity, and if gum recession is the reason, he will recommend a list of recommendations.  This may be a treatment option for your condition.  Speak about your sensitivity to your dentist, and let them consult you about your specific situation, and what can be done about it.

Do not ignore tooth sensitivity.  Sometimes it is benign and temporary.  At times it is more involved.  There are many variables to be considered.  Therefore, one solution will not work for all cases.  This is why it is important to not self-diagnose or self-medicate.  Consult your dentist.

Ultimately, one of the most common treatments is to place fillings where the enamel is missing, or chipped.  The filling is a good option, but only after a thorough exam, and often it isn’t the first option.


Sensitive Teeth

(no copyright applied)

Tooth sensitivity after fillings, crowns. 


Another major cause of tooth sensitivity is after a new filling is placed, or a new crown is performed. There are few factors involved in this that I should touch on.  The difficulty with this topic is how technical it can get.  I will try to simplify my explanation to make sense of this.

When a tooth is diagnosed with a cavity, the treatment is usually a filling.  If a tooth is shown to be structurally weak and at risk for fracture then a crown is diagnosed.  Sensitivity after dental treatment is referred to as post-op sensitivity.  Let’s briefly discuss some factors which lead to post-op tooth sensitivity.

  • Depth, or severity of decay– this will usually be one factor contributing to post-op sensitivity. While the decay is present in the tooth, patient may not have any symptoms.  In fact, often times this is exactly the case.  As a cavity progresses deeper into the tooth, the structure it leaves behind is demineralized and soft in nature and it acts as an insulation layer for the sensitive dentin.  A cavity also approaches the nerve slowly and without changing temperature, and quietly without vibration.  Typically, it has to get pretty close to the pulp for tooth to begin to feel sensitive.  This is not always the case, but it is a common observation.  When the dentist begins cleaning and removing this decayed portion of the tooth, there is water, cold temperature, vibration, and sometimes some heat.  This may cause the nerve to become sensitive and react more readily to stimuli.  So, often times the size and depth of the cavity in question may be a factor.
  • Cavity preparation by the dentist– Once the cavity is removed, next few steps are critical. As we saw from the description above, dentin is filled with fluids which contains nerve endings.  These are the dentin tubules containing the liquid, and nerve. While the dentist is working directly in this sensitive environment, some precautions must be taken to ensure this delicate system is not disturbed beyond what is unavoidable.  The liquid inside these tubules cannot be disturbed too much, or caused to be evaporated.  Since the nerve inside these tubules reacts to changes of pressure and PH of the liquid, it is important to not cause evaporation, or drastic PH changes.  We avoid desiccation of the dentin by not holding the air source over the dentin when drying the surface.  In order for the dentist to place the bonding agent which holds the filling in place, he or she needs a somewhat dry surface.  But it is crucial to note that most of these bonding agents do not require the surface to be completely dry, and in fact they bond better if the surface is moist.  So, preserving the moisture of the tooth is probably the best defense against long term post-op sensitivity.
  • The nature of the bonding agent (what glues the filling to the tooth) is acidic. It must be acidic to allow for better bonding.  We need a microscopically rough surface.  And remember teeth are made of calcium.  Therefore, to roughen the surface a very weak acid is utilized to achieve this objective.  Without this step, fillings would leak, or come out soon after placement.  Yet, this very aspect of bonding agents can cause a temporary PH drop in the liquid of the dentin tubules and make it acidic.  This in turn, may contribute to nerve irritation.  Unfortunately, not a lot can be done about the bonding agent.  But there are few steps that can be taken to minimize the effects of these materials on the PH of dentin.  Careful application and delivery of the steps for filling usually avoids most of the problems.  In majority of cases there are no post-op symptoms.  In some cases which exhibit post-op symptoms, these tend to be temporary.  Following a specific set of procedures, avoiding over drying, strategic application of acidic agents, and placement of filling material in small units and multiple steps instead of one large step of bulk filling placement, has been very effective in averting long term post-op sensitivity.
  • Ultimately, the filling itself may not be sealed due to bulk filling, or shrinkage. Or there may be some air bubble trapped between the tooth and filling.  In this case, filling should be redone.


I have tried to minimize any technical information to avoid confusion.  I hope the above explanations were not too difficult to understand.


I will try to add more information to this series.  Remember that these statements are my own opinion based on my own professional observation in clinical settings.  These are not laboratory tested and may not be the opinion of your dentist.  Please do not use them as a means of diagnosing yourself.  Always, talk to your dentist or medical doctor regarding your symptoms. My aim here is to offer more information to my own patients knowing how much information there is out there and how confusing it can get for someone with little expertise in a field such as dentistry.  I also welcome any of you to suggest topics that you would like me to post on. See you soon.


What causes bad breath, and what can I do?


Bad breath It is generally caused by the bacteria deposited on the tongue, between teeth,  gums, and any other areas that can act as pockets for germs. But it could also have a more significant cause.  If you are experiencing persistent bad breath, it may indicate a more serious underlying cause.  Please speak to your medical doctor, and dentist about this problem. 


Reasons for bad breath, and what you can do:

  • Tongue– due to its unique anatomical features, and large surface, it harbors much of the bacterial deposits that cause bad breath. SOLUTION- brush your tongue twice per day, or use tongue scraper twice per day.  You may also choose an over the counter mouthwash and follow instructions on how to use it.
  • Between teeth– one area that is sometimes ignored is between teeth. If you are not flossing daily, then your fight against bad breath is on losing ground.  In fact, bad breath may be the least of your problems. So, floss once or twice per day. 
  • Gum pockets, jaw bone disease, or periodontitis– Even healthy gums have a pocket that forms around every tooth. These pockets hold bacteria.  A healthy gum pocket is measured to be around 2mm to 3mm.  But these pockets can grow deeper with worsening oral health, inadequate or lack of oral hygiene.  More bacteria is found as the gum pockets get deeper, and also the type of bacteria tend to change from more beneficial ones to more disease causing ones. Eventually, the bone under the gum is affected.  At this stage, the condition is called periodontitis.  SOLUTION- good oral hygiene at home, regular dental check-ups with cleanings, and making sure you don’t have any faulty dental fillings, crowns affecting these areas.  So, please see your dentist regularly. 
  • Faulty crowns, fillings which may become bacterial breathing grounds- keep a good oral hygiene regiment at home, and see your dentist. This is the only way to find out which dental work needs replacing, and when. 
  • Dry mouth– This is also a very important factor that may cause bad breath. Saliva is one of our most important natural defenses against bacteria that causes dental problems such as tooth decay, and gum disease.  Saliva helps by washing away the bacteria that causes bad breath, and other oral problems.  So, anything that causes saliva to slow down, or stop can cause not only bad breath, but also other oral health problems.  What can cause this:  mouth breathing which can cause dry mouth, and worsen bad breath.  Salivary gland dysfunction, chemotherapy, medication that may affect your saliva level.  Please see your medical doctor about this and do not diagnose or treat yourself.  
  • Respiratory tract infections, Sinus infection, lung infection– contact your medical doctor, or your specialist like ear, nose, and throat doctor, or pulmonologist.
  • Tonsils– our tonsils have many crevices where food debris can get lodged. At times, this soft food debris may harden into a tonsil stone.  These, and also the cryptic surface of the tonsil can harbor bacteria that causes bad breath.
  • systemic illnesses such as diabetes, kidney disease, liver disease may also cause this problem. This is also why bad breath must be discussed with not only your dentist, but also with your medical doctor to rule out any uncontrolled systemic diseases.



Can you fix cavities at home? 


The answer to this is not simple.  Most cavities that can be helped naturally without fillings are those that are extremely small.  The problem here is that when they are this small you won’t be able to spot them, especially between teeth.  Even if you were told they were there, how will you find out if your treatment is working? So, a better question is this:


Can a dentist help you use natural ways to remineralize your tooth without the use of fillings?


The answer to this is yes, but it depends on size of cavity, dental history, oral hygiene habits, and diet.  These factors tend to make the results vary once treatment starts. 

Fluoride has shown to help with remineralization of enamel.  In my own clinical experience, I have seen cavities that are really small respond to fluoride treatment.  Even this has been challenging due to the fact that we cannot control patient’s sugary and acidic food intake, salivary flow, and oral hygiene at home. 

But despite this, we have used this approach with many of our patients, and the results are more than gratifying for me as a dentist.  When we see a cavity that is small, (incipient decay), we use fluoride and give home care advice and monitor the lesion during the next several exam appointments.  And this is only done on patients with good home care and those who keep their 6-month prophy/exam appointments.  This is important because it give us a chance to monitor the cavity and make sure it is not growing bigger.  Under some circumstances  we may see remineralization of a lesion that is less than 50% the depth of enamel if patients follow the recommendations.  Smaller the lesion, the better the chance.  But only a dentist can do this because they have to see it with an X-ray when it is between teeth, and monitor its progress.  Over the counter fluoride mouthwash, and in office varnish is a good approach.  For those who have a high risk for caries, geriatric patients, or those who suffer from dry mouth, we often advise prescription strength toothpaste with much higher levels of fluoride.  This tends to help reduce rates of tooth decay.  At times, we have also advised sugar free gum with high xylitol contents to be used by patients who are accustomed to gum chewing.  This recommendation of course must be in the absence of TMJ disorders.


Community Dent Oral Epidemiol. 2014 Aug; 42(4): 333–340.

Published online 2014 Dec 20. doi: 10.1111/cdoe.12090

PMCID: PMC4282025

PMID: 24354454

High-fluoride toothpaste: a multicenter randomized controlled trial in adults

Murali Srinivasan,1 Martin Schimmel,1 Martine Riesen,1 Alexander Ilgner,2 Michael J Wicht,3 Michael Warncke,4 Roger P Ellwood,5,* Ina Nitschke,2,* Frauke Müller,1,6,* and Michael J Noack3,*


Does oil pulling get rid of cavities?  It will not reverse an already existing cavity, but it may help with decay prevention.  We have not observed  cavity reversal in those who perform oil pulling.  But I must admit, we have a very small group of patients who do oil pulling.  A proper study should be done on oil pulling and its potential benefits or otherwise.  There is nothing in these oils that can help rebuild or replace the missing calcium crystals  of the tooth. Talk to your dentist about oil pulling, and if you have not had an exam in over 6 month. 

Canker Sores

Canker sores, which are also called aphthous ulcers, are a round or oval white lesions with red borders that occur on the soft tissue of the mouth.  Typically found on the base of the gums, inside lips, cheeks, soft palate, and under the tongue.  They do not occur outside of the lip like a cold sore.  Minor canker sores have a limited duration of up to 2 weeks.  If they persist longer than that, inform your medical doctor or your dentist.  This is because there are minor canker sores, and then there are major canker sores.  Major ones, unlike the minor canker sores, tend to be larger and deeper.  Sometimes they have irregular borders, and tend to be much more painful.  They tend to last longer than minor canker sores and they should be examined.

There is another form of canker sore that looks more like a minor canker sore, and that is herpetiform canker sore.  Unlike the minor canker sores which affect the young adults, herpetiform canker sores occur later in life.  They are small lesions that occur in clusters. These are called herpetiform, only because they resemble herpes lesions hence, “herpetiform”. They are not caused by herpes virus.  The herpetiform lesions also last up to 2 weeks, like the minor canker sores.

Causes of canker sores

We don’t know exactly what causes these sores, but we know there are factors that may trigger their onset.  At times, multiple factors may be involved.

Stress, injury to the soft tissue of the mouth by mechanical means such as hard foods, brushing hard, trauma from cheek biting, highly salty or acidic foods, allergies to certain foods, vitamin deficient diets which are low in iron, B12, folic acid may also be a contributing factor.  Body’s reaction to certain oral bacteria could cause this reaction as well.  Some people may be sensitive to sodium lauryl sulfate, a compound found in some toothpastes, and mouthwashes. The origin may also be due to a change in body hormones.  All of these can trigger these lesions. H. pylori bacteria may be another cause of canker sore. Inflammatory bowel disease may be linked.  If you have any concerns, or if they persist longer than 1 to 2 weeks, or if they are very painful, please contact your medical doctor or your dentist.



What is enamel, and why it is not possible to fix large holes in the teeth with home remedies?

It is a nanocrystalline structure made of hydroxyapatite crystals.  This crystalline structure makes up 96% of the enamel.  The other 4% is the organic material left over from the process of enamel generation.  The process of enamel formation called amelogenesis takes place in the jaw by a layer of epithelial cells called ameloblasts. These cells are lost once that tooth erupts. The enamel generation is so complex, and so regulated by these cells, that the slightest misfire, so to speak, leaves a large and noticeable defect in the enamel with varying severity.  Some teeth have missing enamel as they erupt, and some have brittle and discolored enamel.  The process is so intricate and complex that it boggles my mind that most of the time it is able to create spotless enamel.  It is unthinkable that it would regenerate on its own without these cells, in an acidic environment, using home-made remedies.  This is like claiming one can regenerate the missing body panels on your car by washing your vehicle with certain home-made soaps.  Yet, many people fall for these claims.

There is research currently being conducted which looks at stem cells containing the enzymes needed and ways of delivering these cells to the right spots for amelogenesis.  All this is only to deal with enamel. We should also consider dentin.  Which is just as complex.  There is also the presence of bacteria, and already decayed dentin.  This must be removed and dealt with.  So, if you have a hole in your tooth please see your dentist before it causes pain and infection.

I’ve lived in this area for 25 years and this office provides the best service. I felt that my best interest was in mind, that’s the most important thing to me. The staff is always very friendly and in a good mood, always happy to see you.

Aldrin Yousefian