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April 29, 2009

Tooth decay -how preventable is it?

Blogged under Dental Education,Oral health care by DrJean on Wednesday 29 April 2009 at 4:58 am

Dental caries or tooth decay is a disease.It involves a process where the enamel of the teeth loses minerals( a process called demineralisation) due to an acidic environment in the mouth causing the surface to become more permeable to bacteria. (Our mouth is loaded with them,if you are not aware!) .Once bacteria gains entry into the tooth structure,they continue to proliferate by metabolizing the sugar (glucose,sucrose,fructose,lactose etc) in our diet.The by-product of this process is more acid that continues to destroy more tooth structure.
To treat tooth deacy,you basically need to have fillings done.

However,we are now looking at diagnosing a pre-decay condition and taking steps of prevention.
Before that,just a bit of chemistry of the disease:-
Acid dissolves tooth structure.The source of acid can be extrinsic (bacterial and deitary/environmental) or intrinsic(stomach acid reflux) or a combination of both.
A process called demineralisation occurs.What is seen on the tooth surface is white patches called white spot lesions,which when left unattended ,will deteriorate to a cavity.
Now we are looking at how to neutralise the oral environment and remineralise the tooth surface.
As long as the tooth surface is still intact ,bacterial molecules are too big to penetrate enamel layer,therefore there is the opportunity to remineralise.
Firstly,we have to stop the demineralisation by raising the pH in the oral cavity.

Normal salivary flow is usually sufficient as a buffer to neutralise the normal acid levels in the oral cavity.In situations where salivary flow is reduced due to certain reasons(consumption of certain medication/post radiotherapy/certain systemic diseases),some form of ph-raising oral rinse is required.There are also some products that stimulate salivary flow.
Personal habits like use of nicotine,alcohol,caffiene etc can also cause lower salivary output .These substances act as a diuretic .Our body’s natural reaction is to conserve fluid,therefore it will produce less saliva in the presence of high levels of these substances.

We start by eliminating sources of acid in our mouth.
Dietary habits need to be noted and changes made where necessary ,for example,we should halt consumption of food and drink that have high sugar content and with low pH/how acidity.
If there is a problem with instrinsic acid where gastric reflux is a problem,then one should seek the advise of a physician.
For bacterial acid,there are antibacterial treatment options that your dentist can recommend.

Of absolute importance is of course ,good tooth brushing with a fluoride-containing toothpaste and proper flossing .
In conclusion,we should aim to modify the chemistry of the oral cavity to one of non-acidic nature.

March 1, 2009

Teeth Whitening options

Blogged under Dental Education,Tooth whitening by DrJean on Sunday 1 March 2009 at 9:22 am

I have always wished that teeth whitening was more affordable so that it is accessible to most people.The fact of the matter is that most of us wish we had whiter and brighter teeth but the main damper is the cost of the whitening.

I have been doing in-house professional whitening for my patients for more than 2 years now and yes,we do get satisfying results,in various degrees.However,in Malaysia,any kind of in-house or chair-side whitening will cost quite a bit ,especially where light-activation whitening is involved.

When I went to US last October to listen to some of the gurus of whitening, they were talking about whitening treatment that is growing exponentially in the US over the last 2-3 years.And interestingly, the type of whitening they talk about is that of dentist-supervised take-home whitening.

Take-home whitening as opposed to in-house whitening is where your dentist makes custom trays to fit your teeth and dispenses whitening gel for you to wear the trays with the gel in it overnight.The downside to this is ,you have to be compliant in wearing your trays and to do it as instructed by your dentist.And it takes at least 2 weeks or more before you see good results.Now,if you REALLY want whiter teeth,and you do not want to pay a lot for it,you would be compliant and you would be patient,right??

Well,here was an option to whiten at a much lower cost and most importantly,it works.In fact, more than that,the product that was presented to us contained PF,a term used to describe a combination of potassium nitrate and fluoride.(Potassium nitrate is the ingredient used in desensitizing tooth pastes and fluoride in safe amounts, has been proven to reduce tooth decay when used in tooth pastes as well as when it is topically applied on the teeth by your dentist.) So here we have not just a product that whitens but also reduces tooth decay and provides desensitizing effect during the process of whitening.It has also been proven to harden the enamel of the teeth over the period of use.

Take-home whitening is something that has been around for a long time.However it has obviously not lost its effectiveness with the development of newer and more superior products.

In this society where everyone wants things FAST,it may not sound very appealing.However,it is most definitely an option and take-home whitening has been proven to give better results when used long term because the rebound (to the oirignal colour) is a lot slower compared to chair-side whitening.

December 31, 2008

Direct veneers

Blogged under Aesthetic Dentistry by DrJean on Wednesday 31 December 2008 at 12:51 am

I am not too fond of showing “before and after” pictures as they inevitably give the very wrong impression that with a snap of the finger and “Tada!”,you get an instant makeover.I am merely showing them because I want to get the message across that more often than not,we can use direct veneers as an alternative to crowns.

Direct veneers are composite material bonded directly on to the enamel of the teeth.It is unlike indirect veneers which is usually done with porcelain which is fired in the laboratory and then bonded onto the tooth with a bonding agent or luting cement.

Direct veneers are actually a very good and far more economical option when correctly indicated.However,as I said,the indications has to be right ie it is nor a magic potion for every and anyone.

I do quite a bit of veneers because there is minimal removal of tooth structure as compared to full coverage crowns where a lot of tooth structure has to be take off in order for the crown to be fitted on to the tooth.

This is a simple case where the patient has fractured his front tooth and there was no pain nor sensitivity over a long period of time.I did some tests to ensure the tooth is still healthy and proceeded to do a veneer for him.

The following person had whitening done followed by veneers over his 2 front teeth which had brown streaks on them since they came out in the mouth.

This other individual had very heavily restored 4 front teeth and the restorations tend to discolour and chip off every now and then.Instead of crowning them,I just placed some veneers over them and at the same time giving them a whiter shade.

This is a young person who has small front teeth and some of them pegged shaped.As a result,she has spaces between her front teeth.I just bonded the veneers on to make her teeth look wider and longer without removing any tooth structure at all.

They are really quite nice and durable.Again,I want to stress that it is not THE solution for everyone.

October 23, 2008

“Climbing the invasiveness ladder”

Blogged under Dental Education,Personal by DrJean on Thursday 23 October 2008 at 12:38 am

I just came back from Salt Lake City,Utah in the United States of America after attending the Asia Pacific Key Educators Conference hosted by Ultradent Products Inc,a leading dental manufacturer in the US.

What a timely reminder for me personally,that we have only that much of tooth structure in our oral cavitites! How invasive do we want to be as dentists,in the name of practising modern,high-tech dentistry? Are we destroying more tooth structure than necessary or are we going all out to preserve as much of it as we can? 

This conference covered many topics,including latest updates and trends on whitening,root canal treatment,bonding technology in tooth restorations,aesthetic dentistry and tissue management in dentistry.However,my main take-home point was this -it confirms my conviction about wanting to keep as much natural tooth structure as possible in the mouth.Hence my occasional reluctance and refusal to do certain procedures for my patients is justified.

The man behind Ultradent is the incredibly smart yet amazingly warm and friendly Dr Dan Fischer.He started the company almost 30 years ago in the basement of his house and today it is an establishment with more than 700 employees and sits on a sprawling piece of land in Salt Lake City with a 220,000 square-foot building.

We had the privilege of hearing Dr Fischer share his passion about preserving tooth structure and how we should,as dentists be committed to respecting the tooth structure and educating our patients about it.



Ultradent was such a wonderful host to all of us delegates from Malaysia.India,Philippines,Hong Kong,China and Mongolia.We were made to feel so much at home right from the moment we arrived .The hospitality was genuine and warm,the food was great and plentiful, the programmes were authentic and fun.They even arranged a day of sight seeing for us down to the canyonlands of Southern Utah.



Great trip!! ..except for the lonnnggggg journey and the horrendous jet lag that followed…… 🙁


October 9, 2008

Cosmetic Dentistry-current trends and options

Blogged under Aesthetic Dentistry,Dental Education by DrJean on Thursday 9 October 2008 at 8:17 am

The “in” thing currently on teeth appearance in the US is long,squarish and white,BO shade(aka toilet-bowl white) teeth.

Who knows,in a couple of years,this may change to the small,oval and not-so-white look.

This is what trends are all about.They change.Whatever it is,most Hollywood celebrities are sporting this kind of teeth.


And,I can assure you that many who are non-celebrities aspire to do likewise.

So.what are the options for a lady to look like Halle Berry or Jessica Simpson?Oops sorry,I mean to have teeth like them.What would it take for the men to have Tom Cruise’s set of pearly whites? Or even Shrek’s Chiklets teeth?

Teeth whitening,be it the one-hour professional whitening or the take-home DIY whitening kit,is a good start.As I have mentioned previously,if you are not contra-indicated for teeth whitening,then you would be able to achieve a reasonably brighter smile.

Other options include porcelain or resin-bonded veneers to change the shape and colour of your teeth.However,these treatment options may not be appropriate for everyone.Sometimes,other treatments are required as an adjunct treatment.For example,one may need some sort of gum surgery to improve the shape of the teeth.Orthodontic treatment is often a treatment of choice for poorly aligned teeth.Other lesser known options include corrective jaw surgery and more extensive gum surgery to lengthen the teeth.

Whatever the treatment of choice,my stand as a dental care-giver is that one should not attempt to have healthy tooth material removed extensively just for the sake of aesthetic and beauty.We need to manage our expectations.We are after all only blessed with one set of permanent teeth which is to last us the rest of our lives.




September 11, 2008

Teeth erosion

Blogged under Dental Education,Oral health care by DrJean on Thursday 11 September 2008 at 7:13 pm

A commonly seen condition these days is erosion of the enamel of teeth,especially among the youth and young working adults.

This is usually seen at the outer surface of lower teeth particularly the premolars and the molars,at the gum margins.The erosion can range from mild to very severe with decay.They start with whitish patches,when enamel begin to leech its minerals due to constant and long term contact with acidic elements.They then begin to turn light brown as the enamel layer breaks down and eventually as decay sets in,the initial lesion cavitates deeper.

The most common cause for this condition is high consumption of carbonated drinks.They are not only highly acidic (ie corrosive),they also contain high sugar content.The common practice among young people these days is to sip on a can of carbonated drink throughout the day,sometimes several cans in a day.The oral cavity is constantly flooded with acid and sugar,which is a potent combination for decay to form.The cariogenic( decay -causing )bacteria in the mouth are having a ball with these individuals!

So,do be aware that not only are you heading for an early-age diabetic condition,you are also destroying your teeth unneccesarily.As my parents’ generation would advise,and wisely so,”Limit your consumption of carbonated drinks to Chinese New Year(or Hari Raya Puasa or Deepavali or other festive seasons)!”

August 7, 2008

Cosmetic Dentistry-what’s that all about?

Blogged under Aesthetic Dentistry,Dental Education by DrJean on Thursday 7 August 2008 at 9:10 am

In the Oxford dictionary,the word “cosmetic” is defined as relating to treatment intended to improve a person’s appearance.”Cosmetic Dentistry” then refers to branch of dentistry dealing with the apearance of teeth.

What exactly is cosmetic dentistry? This term has been made even more popular by the various reality TV shows with “Extreme Makeover” theme.A common scenario is where a person,usually a young working adult or a middle age woman,would tell me “I don’t like the appearance of my teeth” or “I feel ashamed to smile widely because I do not have nice teeth” or “I wish to have nicer looking teeth”.

I remembered many years ago,a lady in her 50s came to see me and in her hands she had a photo.She said,” I would like to have teeth like that” and she shoved the photo into my hands. It was a photo of Faye Wong,the Hong Kong artiste,fllashing her celebrity smile.I didn’t know whether to laugh or to cry!!

I think it is perfectly fine to want a set of teeth that is pleasing to look at.

Asthetic is definitely a very important feature of dentistry. But what is more important to me is the foundation under that beautiful set of straight and sparkling white teeth.

I constantly remind my patients that if they do not have underlying healthy gums and teeth,whatever “cosmetic” job that is done will usually not last.

In the next part of this topic we will look at what aesthetic or cosmetic dentistry constitutes and what are the current trends in cosmetic dentistry


April 15, 2008

All-ceramic crowns

Blogged under Dental Education by DrJean on Tuesday 15 April 2008 at 10:34 pm

In the advent of new developments in material for dentistry,one of the things that we are moving more towards is the use of metal-free resotrations.

We have moved increasingly from using amalgams to resin materials like composite and glass ionomers .These new materials are not only more aesthetic,the newer reinforced ones have very superior strength.

Where crowns( and bridges( are concerned,there is an increasing shift to use non-metal-based prostheses.

In a very simple way,these all-ceramic crowns are classified into low-strength and high-strength ceramic restorations.

Low strength ceramics are leucite-reinforced pressed porcelain and these are used only in very specifically indicated cases.They have very good aesthetics but low impact-strength.

High-strength ceramics are categorized based on the coping used and these copings are referred to as the core.These core material now replaces metal,hence the all-ceramic,metal-free restoration.

Alumina-core ceramics have aluminium oxide as its core material under the pressed porcelain which is fused to it.Zirconia-core ceramics will have zirconia as its core material.

Some of these crowns are done using the CAD/CAM technology.This method is capturing the photographic image of the prepared tooth model using computer technology ,a 3D restoration design is crafted to conform with all the detailed specifications,the computer will then send infomation to a milling machine where a block of core-material/ceramic will be milled to the specification.

Now,with the CEREC CAD/CAM machine,a crown can be constructed within an hour while the patient waits on the dental chair.However,there is extremely high cost involved as the CEREC machine and the material used are pretty costly 🙁


March 5, 2008

More about tooth whitening

Blogged under Tooth whitening by DrJean on Wednesday 5 March 2008 at 6:55 pm

There are some facts that you may need to know before deciding on whether you are a suitable candidate for tooth whitening.

If you have significantly large fillings or crowns on your front teeth(this includes all the teeth that can be visibly seen when you smile widely,the you have take into consideration that these will need to be redone after tooth whitening as they WILL NOT be whitened along with you natural teeth.I am stressing on this because,most of the time we budget for something only to find out that the final cost is more than expected.So,it is vital that you check with your dentist who is going to do the whitening procedure for you.


Pigments from our food and beverages( and nicotine from cigarette smoke ,for smokers)will get absorbed into our teeth. The peroxide in the whitening gel releases oxygen ions in our teeth and these ions chemically alter the stains and eliminate them.However,our teeth will continue to absorb stains.So,tooth whitening of any kind is not a treatment that has a permanent effect .

Some professional tooth whitening systems like Britesmile have their own follow-up maintenance products.These products are to be used regularly after the chairside procedure to counter and delay the relapse process .If you want to maintain bright teeth at all times,then you may have to consider repeating the whitening procedure every 2 years or so.


Most of us do not have teeth that are even coloured where every single tooth and tooth surface is of the same shade.More often than not,we have the canines more yellowish ir darker.Some of us have a band of transluscence at the biting edge of our teeth,others have a darker band nearer to the gum margin.All these are due to the difference in the thickness of enamel and dentin on each individual’s teeth.

Therefore,in cases like these,in total effect,your teeth will become a lighter colour but you cannot expect the entire surface to be of one shade ,or all your teeth to be of the exact same shade.This is because it is mainly your enamel that gets whitened by the peroxide in the whitening gel.


I would like to mention tetracyline stains again. Depending on the severity of these stains,which are intrinsic in nature (ie,these are stains that were deposited when your teeth are in their developemental stages), your teeth can only be lightened to a certain degree and you probably have to repeat the treatment several times (ie escalated cost for you)in a short period in order to get substantial results.Even so,the brownish/greyish hue which comes from the inner dentin layer cannot be fully masked.

So if you have tetracycline stains and you still want nice white teeth,tooth whitening is really not the treatment of choice.You would have to have ceramic crowns made for all the front teeth that are visible when you smile widely.


Having said all that.most of us want a brighter smile,so if you have a reasonably healthy set of teeth n gums and you want your teeth to look brighter and whiter,then,tooth whitening is definitely an option.

January 31, 2008

Xylitol and oral health

Blogged under Dental Education by DrJean on Thursday 31 January 2008 at 11:16 pm

Last weekend,I spent 2 full days at the Istana Hotel in downtown Kuala Lumpur,attending a dental conference along with several hundred other dental professionals.It was the 15th FDI-MDA Scientific Convention and Exhibition.

I must say that the lecture topics and the speakers were pretty good.I personally learnt quite a bit from the lectures.The organising commitee did a commendable job in this area.

One of the topics covered over 3 lectures was regarding caries(tooth decay) management.We are moving into the age of minimally invasive dentistry(MID) and this terminology is actually very well accepted by the general public.It gives a very non-threatening feel to your dental treatment.

We are talking a lot about prevention and arresting dental diseases in its early stage.

One of the substances that is relatively unknown but has great potential for use in preventive dentistry,is xylitol.

Xylitol is a natural sweetener.A natural sweetener (as opposed to artificial sweeteners which can be purchased to be used as a sugar substitute) is found in fruits and vegetables.It is mainly harvested from the bark of a tree found in Scandinavia.Well,you can imagine that it is not something you can find sold off the racks of your local Tesco or any of your neighourhood supermarket.Yes,it is a rather expensive substance to produce.And the nearest thing you can get hold of that contains xylitol(in small amounts) is actually some brands of sugar-free chewing gum.

So what’s the big deal with  xylitol? Studies done on it has shown that xylitol has protective action against tooth decay.It is the only sweetener that does not produce acid in oral plaque(which contains decay causing bacteria).Xylitlo also prevents bacteria from sticking to the tooth surface ,prevents growth and metablolism of the these bacteria.Basically it has a suppressive action against decay-causing bacteria in the mouth.On top of all that,it has also been proven to reverse early processes of tooth decay on enamel surfaces by reversing the loss of minerals from our tooth surface due to acid activity.

Based on these infromation,dentists are beginning to prescribe xylitol-containing chewing gum to some patients who show early signs of loss of mineral form their enamel surfaces,and to those who are relatively more prone to tooth decay.

Chewing on gum will increase salivary flow,and that acts as a buffer to the acidity as well.Therefore,the action of xylitol is enhanced. However,they are  not to chew a stick of gum for more than 10 minutes because our salivary glands stop producing saliva after 10 minutes of stimulation.


My dear friends,Dr Amy and Dr Amy and I posing for a photo.

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