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Questions about Fillings when there is no Decay
- My dentist says I need a filling on the outside of my tooth near the gumline – but he says there is no decay there – what is going on?
- When do I really need to fill those wedge-shaped notches on the outside of my teeth that I can feel with my fingernail?
- What causes those notches that do not involve decay?
- What are the choices of materials that an be used for filling those notches?
- How long should the fillings in these areas last?
- Are fillings in these areas difficult to do well?
Answers about Fillings when there is no Decay:
- My dentist says I need a filling on the outside of my tooth near the gumline – but he says there is no decay there – what is going on? There are two possibilities, one far more likely than the other. When a lot of dentists were trained, there was a term in common usage, “toothbrush abrasion”. The term found popularity in the 50s as the profession couldn’t explain why some people, actually many people, have such lesions on their teeth without any sign of decay. The only explanation we had for decades was that the toothbrushing was done too aggressively and too horizontally, and possibly with a paste that was too abrasive. This entire scenario has not been all but completely ruled out. VERY FEW people have any toothbrush abrasion showing on their teeth. IF they do, the shape of the lesion is “bowl-shaped”, very rounded and broad. The far more COMMON lesion is “wedge-shaped” or notch-shaped, very triangular from the outside inward, sharp on the edges and often positioned near the CEJ, where the cementum of the root meets the enamel. These latter lesions are called ABFRACTION LESIONS, based on the engineering term which means that when something is bent repeatedly enough times, it will break. Think of bending a paper clip. They may well need to be restored, but not necessarily…………………BACK to questions
- When do I really need to fill those wedge-shaped notches on the outside of my teeth that I can feel with my fingernail? There are specific instances where these lesions need to be restored: 1. When they are deep enough so they are threatening to expose the pulp; 2. They are deep enough so they actually threaten the strength of the tooth, it might actually break off; 3. The lesion shows up in the mouth when you talk or smile, creating an esthetic concern; 4. The dentin that is exposed by the lesion is very sensitive to cold or touch, causing frequent pain. In all four of these instances restoration is a reasonable option………………… BACK to questions
- What causes those notches that do not involve decay? They are caused by the BENDING of the teeth, and this is NOT the same as tooth mobility. When teeth are held firmly in the bone socket, if you push on them from the side, as rigid as they SEEM, they can actually flex or bend a little bit. When I was in dental school I lived in a house with a mailbox in front, which was sitting atop a metal pole which was cemented into the sidewalk in front of the house. As I came home every day I would pull the door of the mailbox down to check for mail, and there would be a slight flexure of the pole. Of course, the place where the pole bends the most is where it is connected to the concrete – and, sure enough, after some years the pole BROKE right there! The same thing happens in the patient’s mouth. When their teeth grind on each other, applying a lateral force, the tooth will bend and start to break down near where it is supported by the bone. I’ve actually tested this in a patient’s mouth, by cementing a strain-gauge to a tooth and measuring the deformation of the surface of the tooth during lateral movement. It really happens!……………….BACK to questions
- What are the choices of materials that can be used for filling those notches? There are a couple of choices, but all will tend these days to be tooth-colored. Before we had composite resin restorations the tooth was prepared carefully and gold was actually pressed into the preparation – my mother had several of these done in 1942 and she always called them “golden gumline fillings”. They actually use a form of gold foil to build up the final restoration. Those fillings in her were seen by me when I first opened my eyes after birth, and were seen by me on the day she died 68 years later! These days we might use a typical composite resin, or my favorite, the flowable composite resin (because it tends to be more flexible, moving with the tooth as it continues to be bent), or glass ionomer cement, or a combination of glass ionomer and composite resin, called a compomer. Many dentists tend toward glass ionomer material for restorations near the gums because they think the fluoride release of that material will help avoid recurrent decay. But, first, for non carious lesions, there was no decay to start with, and second, in my experience, local fluoride release or not, there can still be recurrent decay around this material. So, I’m sticking with flowable…………………BACK to questions
- How long should the fillings in these areas last? If they are done well, many years. Of course the gold foil I mentioned in answering question 4 lasted over 7 decades, but there is no reason a well done composite shouldn’t last 20 years. If done well! That means that the tooth is prepared so that the restoration is likely to remain in place and not fall out. Now – you also have to realize that the problem that caused the wedge lesion in the first place is still there – the tooth is still flexing. If the dentist cannot figure out how to prevent these lateral forces on the tooth, another lesion may start to form. I have seen many instances where another abfraction lesion actually forms at or near the filling, once I saw another lesion forming WITHIN the prior restoration!………………..BACK to questions
- Are fillings in these areas difficult to do well? The mostchallengingthing about doing these fillings is that they are near, and generally running below the gunline, down into the pocket to some extent. Composite restorative materials require that the preparation at the time of filling be totally free of contamination with blood or saliva or any moisture. Since we are looking for adhesive bonding between the composite and the tooth structure, especially the dentin which is at the gingival margin, this contamination must be avoided. The only sure way to accomplish this isolation is to place a rubber dam (a 6 x 6 inch square rubber sheet) over the tooth (holes are punched for the teeth), and push the rubber under the gumline, below the place where the margin of the preparation is located. Some dentists try to pack some yarn into the pocket in this area to soak up the saliva, but the presence of the gingiva over the level of the preparation makes contamination likely. A dentist that is really looking to optimize the results for you knows how to isolate easily and quickly and comfortably with a dam so you will get the best, long-term results. Dentists that care enough to do this are becoming more rare these days…………………BACK to questions