Monday, July 30, 2012


The implant restoration above the gumline that appears natural
It wasn't too long ago that when teeth were lost, only less than ideal options were considered. Even today, in many parts of the world, the only dentistry that is performed is the removal of teeth. Even in advanced societies including the United States, less than ideal options are only considered.

For roughly the last 20 years or so, dental implants have been placed at a higher rate each and every year. Fortunately, there are now many more practitioners placing dental implants.

Basically there are several options for a missing tooth.These are listed from worst to best.

1. Do nothing. Just leave the space
2. Restore with a removable partial denture
3. Restore with a bridge
4. Place a dental implant

Teeth drift toward the space

The worst option is to just leave the space. This isn't merely a cosmetic issue, it's a functional issue. Firstly, there are fewer teeth to perform the function of chewing. The remaining teeth must bear more force than they are designed to. This will obviously cause problems with the remaining teeth. This situation is similar to ripping out studs from the framework of a house. The remaining studs must now carry a greater load. Secondly, when teeth are missing, the remaining teeth move. Teeth posterior to the missing tooth tend to tilt forward. This will create forces that are not in alignment. Just as if the studs of a wall are placed at odd angles. Another issue is that the opposing tooth will drift into the missing space and further malign the teeth. This is similar to a situation when gears have teeth that do not line up properly. How many miles would you get out of a car that has gears with teeth not only missing, but out of alignment? Not many I'm sure.

Partial dentures

The second option is obviously much better than the first. A partial denture will distribute the forces and prevent movement of the remaining teeth. The disadvantage with this option is that it must be taken out nightly. It does not remain in the mouth permanently.


The third option is a more permanent option. However, I still don't like this option for two reasons. First, the teeth adjacent to the space must be cut and shaped even if there wasn't a problem with them to begin with. So now we compromise two additional teeth to replace a missing tooth. The second reason I don't like this option is that hygiene is significantly compromised. It is much more difficult cleaning under the bridge. The supporting teeth are now more susceptible to recurrent decay. In fact the average lifespan of a bridge is only eight years.

The implant option is by far the best way to restore a missing tooth. Depending on which studies are cited, the success rate is approximately 95%. They will outlast a person life-span. I don't know if my assurances to my patients are true because we haven't done them for five thousand years, but I often joke and tell them that they will still be in place in 5,000 years. I guess archaeologists will confirm my outrageous assurance to my patients. Even if I'm wrong and they only last 100 years, I'd still consider it a success.

Missing tooth replaced with an implant
Not everyone is a good candidate for dental implants. If you have a missing tooth, your dentist should be able to determine if you are a good candidate. I will discuss implants in more detail in a future blog.

Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit

Monday, July 23, 2012

Floss Floss Floss

Only about 5% of the US population will floss their teeth on a regular basis. In fact, before I became a dentist and didn't know any better, I rarely flossed either.

People frequently tell me they don't floss and don't want to floss. They often state that they don't want to because it requires too much effort. Yes, it is a pain to floss your teeth, but it's even more of a pain to have to wear dentures. They also state that they don't like to floss because their gums hurt or bleed. The truth of the matter is that they hurt and bleed because they don't floss regularly. This will be explained shortly.
Once when I was serving at Camp Lejeune Marine Corps Base in North Carolina, I worked alongside dozens of dentists. One day I heard the periodontist (a dentist specializing in the supporting structures of teeth) and a Marine have a discussion in the room next to me. The Marine asked the periodontist if flossing was really necessary. The periodontist replied, "you only need to floss the ones you want to keep". That statement made me laugh for quite some time. I often use that line with my patients. My team is  probably tired of hearing that joke by now.

So, why is it necessary to floss? I often explain it this way. If you lined up numerous cars front to back and ran them through a car wash, only the top, right and left sides would get clean. The front and back however would not get clean. The same is true for teeth. The surfaces you do not have access to will not get clean. Any surface that isn't cleaned regularly is significantly more at risk into developing into a carious lesion (a cavity). Therfore, when flossing is not done regularly, cavities will form in between the teeth.

Many believe that flossing makes their gums bleed and hurt. Well, that is partially true. Only unhealthy gums will bleed and hurt. The reason they bleed and hurt is because they are inflammed. Debris that is left below the gumline is similar to having a splinter in your finger. If you don't remove the splinter from your finger, it will get inflammed and eventually infected. This is precisely what happens when debris is left below the gumline. If the inflammation and infection persists for extended periods of time and becomes chronic, then tissue destruction occurs. In other words, the gums and bone pretty much are destroyed. So initially gingivitis (inflammation of the gums) occurs. If allowed to progress, it will become periodontitis (inflammation of the supporting structures of teeth--gums and bone). Periodontitis can lead to tooth loss or even worse medical conditions that are life-threatening (read the blog on periodontitis).

Amongst the people that do floss regularly, I find that many aren't flossing correctly. They are also confused by the choices of available floss. There are many different types on the market. Ask your dentist or hygienist to determine which type is best for you and to demonstrate the proper way to floss.

Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit

Wednesday, July 18, 2012

Dental Insurance

I don't pretend to understand dental insurance fully. There is so much variability with insurance plans that it boggles my mind. Fortunately, I have team members that help me decipher these plans.

Many people are able to maintain adequate oral health care that they would otherwise not if it weren't for their insurance plans. However, dental insurance does present many issues for the patients and the providers. Dental insurance issues is one of the greatest sources of frustration for patients and providers.

My greatest concern is that insurance will  often dictate treatment. Yes, patients are ultimately responsible for making choices and the dentists are responsible to act in their best interest. However, insurance will play a major role in the decision making process.

Insurance premiums and coverage vary widely. Many of the contracts are not in the best interest of the patient. I may get the insurance industry angry with this statement, but it is a fact that they dictate treatment.

First of all, most insurance plans have a maximum benefit of $1000 dollars per year. Some of the better ones may have $1,500  or more per year. Back in 1967, the average coverage was $1,000 per year. It pretty much has gone unchanged. The kicker is that with inflation, there is significantly less coverage today. Premiums have also significantly increased since then. In otherwords, it costs the patient more for the insurance while getting less from it. What if the indicated treatment costs go well beyond these limits? The patient must decide  to pay all of the fees over the limit or only have $1,000 of treatment performed while neglecting the rest. In this scenario, the indicated treatment will never be completed because things don't get better on their own. They obviously get much worse, more expensive, less predictable and less ideal. Their oral needs will never be met.
Another way treatment is dictated is that only certain procedures are covered. There are many clauses in the contracts that exclude even covered procedures. If a procedure is covered, in many cases, they may only cover 50% of the costs.

Provider choice can also be severely limited. Your dentist of choice may not be on their provider list. You will therefore have to either go to one on their list, or you may have to go out of network.

From the dentists perspective, some of the reimbursement rates are so low, that if they were to be in network, it would actually cost more to perform a procedure than to not do anything at all. This is precisely why so many dentists do not take certain insurances.

Many employers simply choose a plan for you. If given the opportunity to choose, review carefully what each plan offers. I know this can be an overwhelming and confusing endeavor. Fortunately, many dental offices have personnel that are very well versed in this area. Discuss your plan with your provider if necessary to determine what plan if any is in your best interest. 

Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit

Monday, July 9, 2012


I am often asked, "Doc, which toothbrush should I use?". Well, for me the choice is rather simple.

I prefer electric toothbrushes over manual toothbrushes.

Soft bristle toothbrushes are as effective at removing plaque and debris as hard bristle toothbrushes, but soft bristle brushes don't cause damage to the soft tissue in the mouth.
If a manual toothbrush is used, it is best to use a soft bristled toothbrush. Many people believe that a firm toothbrush will remove plaque and debris much more effectively than a soft bristled toothbrush. That is debatable. What is certain though is that hard bristles cause more trauma to the soft tissues and gum recession is much more likely.

Electric toothbrushes remove plaque significantly better than manual ones. Now people may ask which electric toothbrush is best. Well, there are numerous companies that produce numerous models. There are some inexpensive choices and some expensive choices. There are rotating, oscillating, vibrating and combination types. There are many different sizes and different shapes. Each have their advantages and disadvantages.  I can see why the consumer can be incredibly confused with the apparently endless choices.

Sonicare is a great example of a vibratory toothbrush.
Now, which electric brush is best? Personally, I like the Sonicare line of brushes. Oral B brushes are also very good brushes. I prefer the vibratory types because they not only clean the areas that make contact with the bristles, but actually clean several millimeters beyond the point of contact. This is incredibly important in removing debris from below the gum line decreasing the chances of gingivitis and periodontitis from developing.

These brushes can range in price from 15-200 dollars. Very good brushes can be found around the 60-140 dollar range. They can be found at places such as Walmart and Walgreen's. One may argue that they are expensive. Well, yes they are. However, restorative dental work is considerably more expensive and more importantly, it is priceless to maintain natural teeth for life.

Discuss your options with your dentist to determine which may be most suitable for you.

Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit