1. Children's Dentistry
Introduce children to dentistry early to give them a positive start to dental care. Your child's first tooth appears at around 6 months and can quickly decay without proper home care or supervision. Bring your child for a check-up between ages 1 and 2 as all their milk teeth will already be in place before they reach 3 years of age. At age 6 the permanent teeth will emerge and replace the milk teeth progressively. As your child grows, it is also important to assess jaw development and plan for braces if needed.
Importance of your child’s first set of teeth?
Many parents assume that because their children’s first set of teeth will be replaced, it is less important. However, the “milk” teeth are vulnerable to tooth decay which can lead to severe pain and infection of the underlying permanent tooth which is already in the jawbone at a very early age. In addition, if the milk teeth are lost early on, it may cause the permanent teeth to be out of alignment when they finally appear in the mouth. In severe cases, these permanent teeth have no space to enter the mouth and remain buried in the jaw bone and require surgical removal at a later stage.
Is thumb-sucking detrimental to a child’s dental development?
Many children have a habit of thumb-sucking. In addition to concerns over hygiene, if this habit persists beyond age 4, it prevents the normal growth and development of the permanent set of teeth and the jaws. This may result in the child’s permanent front teeth being unable to meet leading to speech impediment and difficulty in biting with the front teeth. This condition, known as an “anterior open bite”, persists even into adulthood and is difficult to correct without surgical intervention. As such, it is important to try to avoid the condition from happening.
At what age can children look after their teeth independently?
Parental care is necessary as all milk teeth are already in place by the time the child is 3 and may not have the ability to adequately clean his/her own teeth. A quick brush with or without toothpaste and even a wipe-down after milk or meals is adequate to prevent tooth decay. It is important not to allow the child to bring a milk bottle to bed as this can lead to massive decay. We recommend parental supervision until age 7 or when they have understand the need to clean their own teeth and have sufficient manual dexterity.
Fissure sealants and fluoride treatment
Our teeth have natural pits and grooves and there is a tendency for food debris and germs to accumulate on them causing decay. In addition, our teeth are in close contact with each other, and are difficult to reach for a thorough cleaning. The use of a thin plastic layer to seal the grooves, and the use of fluoride to strengthen teeth will help reduce the likelihood of tooth decay. These procedures are quick, painless and effective. We recommend sealing the first adult molar when they emerge between 6 and 7. The other back teeth should also be sealed if necessary
What to do if your child’s permanent tooth is knocked out?
Find the tooth, rinse it lightly for 10 secs & wrap it in a damp tissue or cloth
Call the dentist immediately and try to arrive at your dentist within an hour
Your dentist will check your child to ensure that:
a. he does not have any other serious injury
b. if the tooth is suitable for re-implanting
Only adult teeth can be re-implanted. In many cases, it may not be possible to do so.
At what age do children need braces?
Most children with crooked teeth start on braces at around age 12 after all their milk teeth have been replaced and their second permanent molar comes into the mouth. However in some children, the jaw is too small to accommodate all the permanent teeth and may benefit by having early treatment to expand the jaws. This involves wearing a simple removable or fixed device which stimulates the jaw to grow. Children who have long lower jaws may also benefit though these devices, termed “functional appliances” or “orthodontic trainers” are less successful than those used to expand the jaws.
Do we need to extract teeth before wearing braces?
If there is insufficient space in the mouth to accommodate all the adult teeth, the first premolar (4th teeth from the front) are usually removed as that allows enough space for all the teeth to fit into position cosmetically and with a proper biting relationship. However if we can intervene early enough, jaw expansion rather than extraction is preferred. In cases where the crowding is extreme, we may even extract the milk teeth early to encourage the 4th tooth from erupting early. This special treatment method, termed “serial extraction” is done less frequently and only if necessary.
Your child’s dental development...
1st tooth appears at months 3-6.
Do not allow your child to bring a milk bottle to sleep
All 20 “milk” teeth will be in the mouth. Thumb-sucking habits should be stopped by age 3
HOW CAN A DENTIST HELP?
First dental visit at 12 months
6 monthly dental check-up
Diet advice and analysis
Get child used to dentist
Simple dental cleaning
Adult back teeth appear even before all milk teeth are lost.
Upper 2 front teeth appears and next to front teeth erupt by age 8
From age 9-12, the other 12 milk teeth are replaced by adult teeth.
HOW CAN A DENTIST HELP?
Assessment for teeth eruption and position
Caries risk assessment
Seal fissures on adult back teeth to reduce risk of decay
Check jaw growth & development
Custom made sports mouthguard
The second last adult molar tooth erupts
Decision on braces
“Wisdom teeth” appears - often in poor position and may need surgical removal
HOW CAN A DENTIST HELP?
Full dental assessment with 6 monthly check-ups and cleaning
Orthodontic referral if necessary
Assess / extract wisdom teeth
Scaling & Gum Treatment
2. Scaling & Gum Treatment
Scaling is the term used by dentists to remove the hardened deposits that form on your teeth. These deposits, known as “calculus” or “tartar”, form when the natural calcium in our saliva mixes with the bacteria in our mouth and food debris. Starting off initially as a soft mix called “plaque”, it hardens over time and becomes difficult to remove, causing our gums to bleed and teeth to become shaky. At that point “root planing” is required. This more focused procedure to remove the hardened deposits on the root surface below the gum margin is commonly referred to as gum treatment.
How Does Tartar Form?
Tartar begins to form within minutes from the last time you brush your teeth.They first appear as a thin layer of soft deposits known as “plaque”, which is a combination of small residual food particles and your saliva, along with the bacteria found naturally occurring in your mouth. As they accumulate, they harden causing a bad taste and the breath to smell less fresh. If left unchecked, it will lead to bleeding gums, loss of the bone surrounding and supporting the tooth leading eventually to tooth loss.
What is the Process of Scaling (Tooth Cleaning)
The procedure takes around 30 minutes. A vibrating device known as an ultrasonic scaler is used to loosen the hardened deposits. Though generally painless, you may experience sensitivity during the procedure. Sometimes, the dentist uses an instrument known as a hand scaler to manually remove the deposits of calculus (tartar). This is done if the deposits are below the gums to enable a more thorough, yet gentler clean. After scaling, the surface of the tooth is polished to remove stains and to smoothen the surface. An air jet is then used to spray off residual soft deposits below the gums.
Why Does Your Dentist Sometimes Apply Fluoride to Your Teeth?
Fluoride has long been known to prevent tooth decay and is added into toothpaste as well as to our water supply. However there is a second major use of fluoride, and that is to desensitize teeth. While scaling is very important in removing the bacteria plaque which adheres to the tooth, it exposes the underlying “scrubbed” surface which feels raw due to the presence of nerve endings. The use of fluoride to cover these surfaces will reduce post-treatment sensitivity and assist the tooth to regain a natural barrier.
What is Gum Treatment (Root Planing)？
In order to remove the adherent deposits which lie below the gum line, a more thorough or forceful effort may be required. As most adults have 28 teeth in our mouth, the procedure is usually divided into 4 separate seatings to enable the dentist to carefully clean each tooth . For patient comfort, a local anaesthetic injection is given to numb each tooth and the surrounding gums before proceeding. While this will completely stop the pain during the procedure, you may still feel the pressure as well as the accompanying high pitch sound and scratching of the tooth surface.
Can I have Gum Treatment in comfort
Yes, it is possible for thorough cleaning of our teeth (and gums) to be carried out painlessly through the use of intravenous sedation.
This is an increasingly popular option as many patients prefer to have the treatment done in a single seating and without feeling the multiple injections required. In this case, a single injection with a small needle is first given on the hand by a Specialist Medical Anaesthetist. He will then attach a small tube from which he can administer a mixture of drugs to calm you and ensure that you are pain-free during the subsequent treatment.
Why do spaces appear in between my teeth and what can be done?
Our teeth are in general shaped like a “spade”. As such there is usually a triangular or pyramidal space between two teeth which are filled with gums that when healthy appear light pink. If we do not clean our teeth sufficiently, the deposits of soft bacteria plaque and hardened calculus will cause the underlying jawbone to be lost (resorbed), and the gums to recede. In this case we will need to either grow back the gums (which is not an easy task) or to mask the appearance by slightly trimming the sides of the teeth followed either by using a clear aligner or veneers to close the gap.
What happens if my gums get worse
Some patients leave it till late before seeking treatment or are either genetically prone or faced with an aggressive form of gum disease. While dentists will still try to help you keep your teeth through more aggressive cleaning, sometimes “gum surgery” is required to clean the roots or the teeth may need to be stabilised through a procedure termed “splinting”. Note that in some cases, extraction may be the only choice but rest assured, with modern scientific knowledge and technology, the bone that has been lost can be regenerated and the missing teeth replaced with implants.
3. Dental Fillings
Fillings are specially selected dental materials used to fill cavities or defects in teeth as the result of either tooth decay or damage by excessive force. Different types of materials including metals, composite resins, porcelain and zirconia have been used. As the strength, durability, biocompatibility and aesthetic properties are vastly different, the choice of filling material depends on clinical and patient factors including cost. The decayed portion is first removed and the remaining tooth structure then prepared by shaping the cavity and refining the margins before inserting the filling.
Types of Dental Fillings
01. Traditional Filling Materials – Amalgam
The commonest filling used was amalgam, which is a mix of silver, other metals and mercury. It has been in use for more than 100 years as it is a low-cost option that is both strong and durable. However, its use has been reduced due to concerns over the mercury content and the poor cosmetic outcome. While we do not advocate routine replacement of these fillings, we have not used amalgams in the clinic for more than 30 years. The substitute for amalgams when the fillings are small are tooth coloured resin materials. For large cavities, crowns may be required.
02. Conventional Tooth Coloured Filling Materials - Composite Resins Composite resins are mouldable plastic materials placed to repair cavities in teeth It is today the mainstay for most fillings as it closely matches the colour of teeth. The procedure involves removing the decayed portion of the tooth followed by roughening of the sides of the cavity. An acid is used to gently etch the tooth surface to create micropores on the tooth surface. The resin is then bonded to the tooth and hardened by shining a blue light. However, they are not as strong and are less suitable for larger fillings. In general they last between 2-3 years.
03. Adhesive Filling Material - Glass Ionomer Cement
Another common material, “glass ionomer” cement, is used to seal the sides of teeth which have become sensitive as a result of abnormal shearing off of outer enamel near the gum margins of patients who grind their teeth. Minimal tooth preparation is required and the tooth lightly cleaned with a special liquid to condition the tooth surface.
These fillings are simple to use and are effective but seldom last for more than 2-3 years.
04. Metal Fillings
Gold and non-precious metals have also been used to replace parts of teeth which have fractured off. They are stronger than silver amalgams and plastic materials and are suitable for use on patients who grind their teeth. Two visits are required. In the first visit the tooth is prepared and a mould is made and sent to the laboratory for processing. The metal is then melted at high temperatures to the desired share and form required. Also termed an “inlay”, they are cemented in place on the second visit. Their use has been superceded due to the patients preference for porcelain fillings.
05. Porcelain Fillings
Porcelain fillings are a popular option due to its strength, relative durability and cosmetic appearance. However, it is a more costly option. As with traditional fillings, the decayed section of the tooth is first removed and cleaned. A mould is made of the remaining tooth and sent to the laboratory for processing. Using modern computer-based techniques, a filling can be made within hours. These fillings last longer than composites but do not as long as full metal filling. On the balance however, it is the preferred material of choice today. The average lifespan is 7-10 years
06. Zirconia Fillings
Another material commonly used is Zirconia which is even stronger than porcelain but is opaque and less aesthetic. However, recent developments in material science has resulted in newer zirconia products which are a compromise between strength and appearance and can nearly match the cosmetic result of porcelain while retaining significant strength. These fillings are preferred in patients with high biting forces or who grind their teeth. They are preferred in areas where the filling is visible. It should be noted that the last molar teeth in the lower jaw are visible when one smiles.
What do the terms inlay and onlay mean?
An inlay is a tooth filling which is made in the dental laboratory to fit the mould of a tooth cavity. It is then returned to the clinic for the dentist to cement. As the filling fits within the boundaries of the tooth it is termed an inlay. An onlay is a type of inlay where the underlying tooth structure is more extensively broken down and a much larger part of the tooth needs to be covered or overlaid by the replacement filling material, hence the term “onlay”.
How are Computer designed and manufactured fillings made?
The tooth is scanned and a filling custom designed using digital technology. Pre-fabricated blocks of filling materials such as porcelain, zirconia or plastics are trimmed to exact specification in a laboratory using precision tooling in a “milling” machine. The process is highly automated. The end-product is then heat treated to harden it and produce a smooth or glazed surface. The dentist then attached the fillings using a special biocompatible cement. Porcelain and plastic fillings can be made within hours while Zirconia fillings will need an extra day to process.
When are fillings required?
Fillings are required when teeth are decayed, or when a part of it has chipped, worn down or broken off. In general, composite resin fillings are useful for smaller chips and cavities while metal, porcelain or zirconia are more suitable for larger fillings or when the tooth is badly broken down. Tooth coloured restorations are usually used to restore our front teeth or the back teeth which are visible when we smile. Adhesive fillings are used to prevent teeth sensitivity. If the cavity or defect is too large, a crown may be needed.
What is Tooth Decay (Dental Caries)
Tooth decay is the result of the action of acids produced by the bacteria which accumulates on teeth which are not thoroughly cleaned. These penetrate the tooth surface causing cavities. If this lies within the outer enamel layer, there is little pain. When it reaches the second layer (the dentine), the pain begins. If it reaches the innermost part of the tooth (the pulp) that houses the nerve and blood supply of the tooth, the pain is usually severe and the term “pulpitis” is used. Infection can then spread from the pulp to the jawbone through narrow passages within the root called the root canals.
How do you fill or repair a fractured tooth?
Teeth may fracture following a traumatic injury or as a result of strong bite forces over time. Depending on the extent of damage, the tooth can either be repaired or removed. The tooth is assessed and the smaller portion of the cracked tooth is removed. If the remaining tooth structure is sound, the tooth can be filled. The tooth is first roughened and a liquid (an acid) used to create micro-pores on the tooth surface. A thin layer of a special bonding agent is applied before a resin filling is attached and hardened using a special blue light source. Larger fractures may require a crown.
4. Root Canal Treatment
Root canal treatment is the procedure which removes the injured or infected tissues from within the central core of the tooth, known as the pulp chamber and root canals. This is then followed by disinfecting and reshaping the canals before sealing them off from the rest of the body using an inert material and cement. Unlike fillings or crown which repair tooth structure, the objective of root canal treatment is to stop pain and infection. As the canals are fine and require careful manipulation, the use of a special microscope to ensure adequate visualisation during treatment is useful.
What is the procedure like?
Root canal treatment usually requires two 1-hour visits to complete though it can sometimes be combined in a single session. On the first visit, the contents of the pulp chamber and root canals are removed and cleaned. A disinfectant is used and if there is an infection, a medication is placed and the cavity sealed for a week to allow the infection to clear. At the second visit the canals are cleaned once again and shaped to receive the sealant which is a type of rubber which is lightly heated and placed together with a cement to create a barrier between the tooth and the rest of the jawbone.
What to expect
A local anaesthetic injection is required and the dentist will place a rubber sheet around the tooth. This is to reduce the risk of the disinfectant entering the mouth or irritating the surrounding gums. There is no pain after the anaesthesia though some patients may find it uncomfortable to keep the mouth open for the full hour with the attached rubber and frame over their lower face. If the tooth affected is a back tooth, the procedure is usually longer as premolars have 2 roor canals and most molars have 3 root canals.
How will I feel after the procedure?
There may be some discomfort when biting on the affected tooth for the first 2-3 days after the procedure but the discomfort should be far less than before the treatment. If necessary take the painkillers prescribed. Root canal treated teeth are weaker and will eventually darken in colour over time even though the pain may have gone. It is recommended that a crown be used to protect the root canal treated tooth. This will also help restore appearance though it should be noted that the tooth will eventually still get darker.
What is Root Canal Surgery
Root canal surgery is an alternate method of treating an infected tooth by directly approaching the affected tip of the tooth through a minor surgical procedure. A small incision is made and the infected root tip removed. The end of the tooth is then filled with a biocompatible cement to achieve a seal. This approach is favoured if a crown has already been placed over a root canal treated tooth as it is difficult to access the affected root tip through the usual approach. The medical term used is apicectomy or apex resection surgery.
Success Rates of Root Canal Treatment
In competent hands, the success rate exceeds 90%. However if the infection is extensive, or in back teeth where the canals are much narrower and curved, the success rate lowers. It is also more difficult to redo a previously root canal treated tooth and success rate drops to around 70% regardless of whether a conventional or surgical approach is used. It should be noted that the lifespan of a root canal treated tooth is usually shortened as it is usually compromised structurally by decay, cracks or by the need to remove the internal core of the tooth in the process of saving it.
5. Wisdom Teeth Extractions
Wisdom teeth are the last teeth to erupt in our mouths and only appear between ages 16-24 years of age. As most of our jaws do not have enough space for it, they often do not come fully through and are not functional and may cause pain and infection. The term used to describe this situation is that the teeth are “impacted” and the resultant infection is termed “pericoronitis”. In most cases, a surgery is required as the tooth is usually partly covered by the overlying gum and partially buried within the jawbone.
Do wisdom teeth always need to be removed?
No, it is not always necessary to remove wisdom teeth if they are in a functional position, are well cleaned and not causing any pain or infection. However, as most patients have jaws that are too small to accommodate all their teeth, wisdom teeth being the last tooth to erupt often emerges in an awkward position and are difficult to keep clean. This results in food residue being trapped below the overlying gum leading to infection of the surrounding gums as well as decay of the molar tooth in front of the wisdom tooth. In this case, it should be removed.
What to expect
The procedure takes around an hour and is performed under local anaesthesia though many patients prefer the comfort of being either sedated or to be completely asleep under general anaesthesia.
A surgical procedure is usually required and the gums covering the buried tooth pushed back to expose the tooth.
As the angle of the tooth is usually unfavourable, it cannot be easily removed. A dental bur is used to divide the tooth to enable it to be removed in 2 or 3 sections.
The gums are then stitched back into position.
Is Wisdom Teeth Surgery Painful?
Is Wisdom Teeth Surgery Painful? You may feel some minor discomfort during the procedure as even though the local anaesthetic that is given blocks pain pathways, you will still be able to feel some pressure and hear the sound of the drilling and the instruments. You will also need to eep your mouth open during the duration of the surgery. In most patients, the lower wisdom teeth may take longer to remove and require more manipulation. This sometimes leads to cracks in our lips or the corner of your mouth. You will usually be given painkillers to take before the procedure so that you will be comfortable after the surgery.
Can the surgery be Completely Pain-free?
Yes, you can have a complete pain-free experience as the surgery can be performed under intravenous sedation in the dental clinic or under general anaesthesia within an operating theatre. For most patients, intravenous sedation is preferred as it is comfortable and the recovery is fast. The mix of drugs given will help you relax, sleep and eliminate pain. The anaesthetist will give you a small injection to numb your hand before inserting a tube through which the medication will be dispensed. Our centre has all the requisite equipment to monitor you during the entire procedure.
How long does it take to recover from the Surgery?
After the operation, you may feel uncomfortable but this can be contained with the prescribed painkillers. Expect some oozing from the surgical site which can be controlled by applying direct pressure with a clean gauze. Some swelling and bruising is also to be expected for a few days after the surgery and you will be given 3-5 days off work. You can resume normal activity within a day but should avoid exercise and swimming. A soft diet is advised and can commence after the numbness from the local anaesthesia wears off, usually after 2-3 hours to avoid biting your lip or tongue inadvertently.
Is the Procedure Safe
The surgery is safe as there are no major blood vessels in the oral cavity. However your dentist will still exercise the utmost care during the surgery. The only major complication is possible damage to the nerves which supply the lips, cheek, teeth and tongue. Most other problems are temporary and reversible. It is also safe to undergo sedation and general anaesthesia as it is always carried out and supervised by experienced specialist medical anaesthetists and trained nurses. Our operating theatre also meets international recognised safety standards of air exchange and quality.
6. Mouthguards, Jaw Pain and Headaches
Mouthguards are plastic shields which fit over your teeth to act as a cushion or shock absorber in order to protect your teeth from injury. While most understand the need to wear these protective guards during contact sports, damage to our teeth also occurs slowly over time as a result of either habitual clenching of our teeth during the day, or subconscious grinding of our teeth when we are sleeping. This habit, termed bruxism, will over time cause damage and pain to our teeth and jaw joints and may even lead to frequent headaches.
What are Sports Mouthguards?
Sports mouthguards are plastic shields which can be bought off the shelf, or custom made in the clinic to cover our teeth and protect them from injury. In addition to wearing them during contact sports like rugby, hockey or boxing, there is a tendency to grit our teeth during active exertion such as weightlifting or competitive distance running. It is also useful in sports where there is a risk of falls such as skateboarding or off-road cycling as the cushioning effect of these guards can protect teeth from fracture and also prevent us from biting our cheeks and lips during falls.
What are Nightguards?
Night Guards are custom-made plastic shields that cover our teeth to cushion them when we grind our teeth. It has been documented that around 15% of the population grind their teeth when sleeping. While the actual cause is not known, it has been associated with stress, anxiety and sleeping disorders. Night grinding can lead to excessive teeth wear, or to teeth becoming sensitive, loose or even cracked. In addition, excessive wear leads to shortening of the face and increased facial line which affect facial proportion and aesthetics. In some patients, it can also result in headaches.
How do we get a custom-made mouthguard?
While mouth guards can be bought over-the-counter, these do not fit accurately. Our clinic is able to fabricate a custom-made mouthguard within an hour as we have our own laboratory. A mould of your teeth is first taken and a mouthguard made by heating a special plastic material to fit accurately around the model of your teeth. The mouthguard is firm enough to resist your grinding forces yet soft enough to prevent tooth wear. Mouthguards should be worn during the night if we have a known habit or during the day during sports or if we clench our teeth habitually at work.
What Other Types are mouthguards are there?
Mouthguards can also be modified to help manage snoring. These devices are specially designed to help keep our lower jaw and tongue from falling backwards when we sleep, thus preventing our airway from being compromised. Mouthguards can also be used to straighten teeth or help keep teeth in alignment after braces. These are usually thinner and are termed retainers. Mouthguards can also be modified to be used to hold a tooth bleaching agent in order to whiten teeth.
For more information, please consult the clinic.
- J Oral Rehabil. 2019 Jul; 46(7): 617–623.
What has a toothache to do with jaw pain and headaches?
Pain arises either as a result of irritation of our nerves or the effect of chemicals our body produces in response to injury or infection. It is made worse by stress and underlying emotional factors. As the nerves in our mouth, face and head lie close together and even share some common pathways when sending signals to the brain, it is sometimes hard for us to determine where the source of pain is from as it may come from the tooth itself, from surrounding structures such as the maxillary sinus or the jaw joint, or if could be from central causes such such as migraines and tension headaches.
How does the dentist differentiate one pain from another
An accurate history is important as it helps the dentist pinpoint the cause and severity of the problem. Questions will include the nature, frequency and intensity of the pain, whether there are factors which provide relief or make it worse, and also whether the pain is periodic, cyclical or spontaneous. A self assessment scale of pain levels is useful so that you can provide feedback if the pain or the treatment given is helping. If the source of the problem cannot be identified, further investigation with an MRI and consultation with a Neurologist may be required to determine the underlying cause.
Pain from the jaw joint (TMJ)
The joint which connects our lower jaw to our upper is called the temporomandibular joint or TMJ for short. It is a common cause of jaw pain or headache in patients who grind their teeth while sleeping or who have a strained biting relationship due to crooked teeth. Some patients may also experience a clicking sound from the joint when opening. In severe cases, it may limit the ability to open one’s mouth fully without pain or the joint may even be dislocated or get stuck in an awkward position when opening or yawning.
How to treat TMJ pain
As in all injuries, rest and a cold compress is the best management though an anti-inflammatory painkiller and a muscle relaxant in combination is sometimes required. In some cases, an injection to the jaw muscle using Botox provides relief as this reduces the bite forces generated. On the longer term, the use of a passive mouthguard and a warm compress helps. If the pain recurs frequently and increases in intensity, a therapeutic device or splint, similar to a mouthguard may be required to change the biting position. Braces or even crowns may also be needed to provide long-term stability.
Headaches are a part of life and something everyone has experienced. However if it occurs more frequently than twice a month, it requires further investigation. Though a tooth is often the source of the problem, we need to also exclude other causes including sinusitis, nerve pain, jaw joint pain, migraines, tension headaches and even high blood pressure or other medical conditions which may require referral to a specialist. It should also be noted that headaches are often related to stress and anxiety and these factors should also be addressed as part of a long-term plan.