Sunday, December 1, 2013

Table of Contents

I've known for quite some time that searching for a particular blog was difficult. The blog is setup so that they are listed by date. This is the only way that the blog site allows. 

I've listed my blogs alphabetically to make a search much simpler. Just click on the desired blog and it will navigate directly to it. Please excuse the white font which may be a little difficult to read. The site only allows it to be white.

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

Friday, November 15, 2013

Why Does a Tooth Hurt After a Root Canal?

In many cases, root canals are performed on teeth that are either dying or are already dead. Many of these teeth are incredibly painful. Root canals are performed to eliminate pain and infected tissue within the tooth. Fortunately, pain after having a root canal is uncommon. The literature shows that approximately 95% of the time there is little to no discomfort.

If you are one of the unfortunate few that does experience discomfort, there are several potential reasons why this could occur. The tooth is not the source of the discomfort after a root canal. It is the surrounding structures of the tooth that is the source of the pain. The tooth itself does not hurt because there are no longer any nerves within the tooth.

Here are some potential reasons why:

1. Inflammation

Inflammation may be present at the tip of the root. This may occur for a number of reasons. Once the inflammation is resolved, the discomfort will dissipate. NSAIDS such as Ibuprofen will usually resolve the inflammation.

Infected tooth. A root canal is indicated
2. Infection

When a root canal is performed, the inside of the tooth is completely cleaned out of any bacteria and diseased tissue. However, a root canal does not clean past the tip of the root. In order to remove any infection past the root tip, we rely on the immune system and antibiotics.

While the infection is still present, it is not uncommon for the bone surrounding the tooth to be tender. This is exacerbated whenever the tooth is pushed on or bitten into. A round of antibiotics will most often resolve the infection.

3. High bite

After a root canal is done, a temporary filling or temporary crown is placed. If too much material is placed, then a high bite can result. This will cause the opposing tooth to hit the treated tooth prematurely. The result is excessive force and pain on the tooth every time the teeth come together.

When a patient is numb, sometimes it is difficult to assess the bite. After the numbness wears off, it is much easier to assess the bite. If the bite feels funny after the numbness wears off, do not assume that you will get used to the bite. You won't. It will start to hurt and cause bigger issues. Fortunately, a high filling is easy to correct. All that is necessary is to grind the filling down slightly.

4. A fractured tooth

Sometimes a fracture can be incrediblydifficult to see even with high magnification. An x-ray most often will not reveal a fracture either.

When a tooth has a fracture that extends into the nerve or all the way through into the root, it will die. The treatment for a dead tooth is to remove the dead tissue within the tooth. The problem with a fractured tooth however is that no matter what is done, the tooth will eventually fail and the only thing we can do to correct the problem is to extract it.

5. Persistent infection

The goal of a root canal is simple…..remove all dead and infected tissue within the tooth and seal it so that it doesn't get recontaminated.

If the canal(s) is not cleaned thoroughly, then the root canal will eventually fail. Bacteria will remain within the tooth. Antibiotics will not be able to reach the site because there will no longer be a blood supply to the tooth to carry the antibiotic to the infected site.

Accessory canals can be difficult and sometimes impossible to clean and seal.

If you experience pain after a root canal is performed, call your dentist to determine why.

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

Thursday, November 7, 2013

Why Does a Tooth Hurt After a Filling?

It's not normal for a tooth to hurt after a filling is placed. Unfortunately, it does occur on occasion. When this happens, there is almost certainly something that has caused the discomfort. We have to put on our detective hats and figure out the true cause of discomfort. There are many potential causes of tooth discomfort after a filling is placed. Here are a six potential reasons:

1. A "high" Filling

This just means that the bite is too high. In other words, there may be too much filling material that causes the opposing tooth to hit the filling prematurely. This causes excessive pressure on the tooth and can certainly cause discomfort. Usually, this is quite simple to diagnose. If the pain is elicited by biting into the filling, then it is likely that the filling is a little too high. You may also experience cold sensitivity on the tooth.

When a patient is numb, sometimes it is difficult to assess the bite. After the numbness wears off, it is much easier to assess the bite. If the bite feels funny after the numbness wears off, do not assume that you will get used to the bite. You won't. It will start to hurt and cause bigger issues. Fortunately, a high filling is easy to correct. All that is necessary is to grind the filling down slightly.

2. Uncured filling material

A special light hardens the filling material.
Tooth colored fillings usually have a paste like consistency until it is "cured" with a special light. This light initiates a reaction and causes the material to become very hard. If for some reason, there remains material that hasn't solidified, the tooth will become sensitive to cold and biting. You may now be thinking "hey, those are the same clues as the "high filling". You're absolutely right...they are the same. There are ways to distinguish between the two. In this case, there may also be unprovoked pain. In other words it just hurts even when not biting or eating/drinking something cold. Fortunately, this is easy to correct as well. Applying the special light to the filling will usually resolve the problem. If it doesn't, then replacing the filling should solve the problem.

3. Trauma from the procedure

When any work is done to a tooth, it is a traumatic experience for the tooth. Sometimes the nerves inside the tooth get irritated. When this happens, the tooth becomes hypersensitive to cold. Again, you may wondering "hey, just like the previous two problems". Again, you are absolutely right. In this case though, there should not be any discomfort when biting. The good news is that this problem will usually correct itself within a few days. An anti-inflammatory medication such as Ibuprofen will reduce the inflammation within the tooth and will therefore also reduce any discomfort.

4. Exposed Root Surfaces

Exposed root surfaces on multiple teeth.
When the gums recede past the necks of the teeth and exposes the root surfaces, there can be some cold sensitivity. In many cases, this can be resolved with a desensitizing toothpaste such as Sensodyne.

If you have exposed root surfaces that weren't cold sensitive prior to the filling being placed, but now are, then it is likely that the inflammation caused by the procedure on the tooth will make the tooth very sensitive to cold. Just like in the previous example, Ibuprofen can help. Even if medications aren't taken, this problem will usually resolve itself within a couple days.

5. Open Margins

Open margins
This means that there is a gap between the tooth and the restoration. because of this, there is exposed tooth structure. Exposed tooth structure tends to be very hypersensitive to thermal changes. If this is the cause of the sensitivity, then by simply filling in the exposed tooth structure should resolve the problem.

If the margins are left open, then the tooth will develop decay again right at the interface between the tooth and restoration. It is imperative that the margins are completely sealed.

6. Cracked Tooth

Obvious fractures.
I've mentioned in previous blogs that I don't place any metal fillings. I haven't placed one since 1997. I've seen countless teeth that have fractures that are directly attributable to these metal fillings. Read my blog on metal fillings. A cracked tooth is sometimes a death sentence for a tooth. If the fracture stays above the gumline, then we could most likely save the tooth. However, if the fracture has spread below the gumline, there is nothing we could do to salvage the tooth.

In many cases, we often can't even see a fracture but know it is there. A good clue is that the tooth hurts only when biting a certain way. It doesn't always hurt when biting, but when the direction of the force is applied in such a way to spread the fracture, pain is elicited.

There are more reasons than these six, but these are the most common. If problems persist for more than a few days, have the tooth evaluated to determine what the problem is.

For more information on a wide variety of subjects, please visit our website at

Wednesday, October 30, 2013


Since we are about to amass large caches of candy, we can't fight the candyfest. We all know that candy can be detrimental to our oral health, but what we don't all know is that some candies are much worse than others.

Which candies are the worst? 

In general, candies that have the consistency of taffy or caramel are particularly bad. The reason why is that these types of candy adhere to the teeth. The exposure time of the sugars being metabolized by bacteria is dramatically increased. This predictably leads to a much higher incidence of decay.

Another major generalization or categorization of the type of candy is one that is in the mouth for prolonged periods of time. Some examples include suckers, hard candy and gum. Prolonged sugar exposure as we now all know is particularly bad for our teeth.

I can't reasonably believe that I can convince anyone including myself to not eat candy. Our kids will definitely be much more difficult to convince. Try to pry the Holloween booty from your kids fingers.

Since we're going to eat candy anyway, consider brushing and flossing within a reasonable amount of time. Brushing and flossing within the first 5 minutes will go a long way towards the prevention of tooth decayIf you cannot brush for some reason, then rinsing with water will provide some benefit.

To summarize, avoid or decrease the consumption of sticky candies and candies that sit in the mouth for extended periods. When consuming these types of candies, make every effort to remove the sugars from your teeth as soon as possible since most of the damage will occur with the first 20 minutes.

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

Tuesday, October 22, 2013

Oral Health for Your Pets

All of my blogs so far have been about the oral health of humans. I'm gonna change things up a bit this week.

It should not come as a surprise to know that animals also have oral health issues. The good news is that the oral health issues of animals are also preventable and treatable.

I'm borrowing some information from the ASPCA. They came up with "Ten Steps to Your Dog's Dental Health". The information is applicable to all animals. Here are ten ways to optimize your pet's oral health:

1. The breath sniff test

It's expected that your dog's breath may not be pleasant. If however your dog's breath is especially offensive, it could be a sign of disease.

2. Lip Service

Lift up on your dog's lips and observe his mouth. You may not know canine oral anatomy, but you don't need to. Just observe for things that don't look normal. If there are any questions, have your dog evaluated.

3. Signs of oral disease

Again, you may not know the anatomy, just observe for abnormalities.

4. Removal of plaque and tarter

Just like humans, have your pet's teeth cleaned at least annually. Failing to do so can lead to bigger issues.

5. Canine tooth brushing kit

Taking your animal to the vet is great, but that would at most only be twice per year. What about the rest of the year? Many dentists joke around and tell their patients to brush the ones they want to keep. So brush your pets's teeth as frequently as possible. Preferably daily.

6. Daily hygiene

Initially, this could prove challenging. You may want to start when your pet is still a puppy. This way they get used to the idea of having their mouths handled regularly.

7. Brushing technique

You want to use a brush and toothpaste that is designed specifically for your pet. The brush heads are smaller than adult human brushes. Brush using a small circular motion. Also, you don't want to use toothpaste designed for humans because your pet may swallow too much fluoride. In small quantities, fluoride is perfectly safe, but too much fluoride is actually poisonous.

8. Know your mouth disorders

This is one of the ASPCA's recommendations. Although I agree that knowing oral pathology is helpful, it isn't practical or necessary. You don't have to be an expert in the abnormal, you're already an expert in the normal. As long as you can spot if something doesn't look right, you're fine. Have a professional evaluate any concerns you may have.

9. Chew on this

Chewing on toys can help remove plaque build up. Your vet can help you choose a toxin-free rawhide or toy.

10. Diet

Ask your vet to recommend a food specifically for your pet. Each animal will have different nutritional requirements throughout their life-time. In general, hard foods are better than soft foods. The hard foods help remove debris from the surfaces of the teeth. Soft foods encourage the accumulation of plaque and tarter.

Keeping your pet's oral health at optimal levels improves overall health and potentially increases the number of years the family pet will remain in the family. Speak to your dentist or veterinarian if there are any questions or concerns regarding your pet's oral health.

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, October 9, 2013

Out of Network !?!? (Part 2)

In my last blog I discussed being out of network from both the patient and provider's perspective. I failed to present one other perspective. I should have included the perspective of insurance companies.

Insurance companies may not like what I have to say, but facts are facts.

Insurance companies, like any other business are in business to make money. How do insurance companies make money? Well, they make their money in the premiums they receive from employers and the insured. They keep this money by paying out as little as possible in insurance claims. So in a nut shell, to make money, they must have as many people paying premiums as possible but must also deny or lower as many claims as possible.

There is a major conflict of interest. They are in the business of helping maintain the health of their clients, but in order for them to be profitable they must deny services or dramatically reduce the covered benefit to be profitable.

This is true regardless of the type of insurance. It could be fire insurance, life insurance, auto insurance and countless other types of insurance. The same business model exists. Bring in as much money as possible and pay out as little as possible.

You may ask how I can make these allegations against insurance companies. Well, you may have some stories of your own where you may have felt that you've been mislead or given the run around by an insurance company.

We are in the trenches where we see this activity everyday. They put up as many road blocks as possible for my patients (and for me) as they possibly can. I can't even say how many times an insurance company has sent a denial back to us stating that they need x-rays. But on the returned claim, you see where the x-ray was ripped off of the claim as evidenced by the ripped paper from where it was stapled.

Okay, I guess I've vented enough on insurance companies.

Do your own research on your insurance. If you cannot get the care you need and deserve, you may have to be prepared to get as active in the process as possible. You may need to fight them on occasion. There are government agencies where you can report insurance abuse. In Illinois, there is the Illinois Department of Insurance. You may have to figure out who to file with in your own state.

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, October 2, 2013

Out of Network !?!? (Part 1)

Since Obamacare is now upon us, I thought I'd write something about insurance to shed some light on the subject. More specifically, the nuances of being out of network. There are some implications to both patients and providers.

 Let's first start with the implications of being out of network from the patient's perspective:

People often have difficulty finding "in-network" providers. They can simply go to their insurance company's website to locate a nearby provider. A nearby provider could be difficult to find. Especially when the reimbursement rates are so low that most offices would go out of business if they accepted the  deeply discounted insurance plans.

In many cases people opt to visit a provider that is not in-network for a variety of reasons. This can add some confusion to the already confusing world of insurance. In some cases, there is no difference to the patient's out-of-pocket costs. However, in some cases the out-of-pocket costs can be more than what they would pay at an in-network provider. This is perhaps the biggest disadvantage of going to an out-of-network provider.

It can be a challenge getting an accurate estimate since insurance companies don't make things clear and simple. So try to eliminate as much guesswork as possible. If you opt to go out of network, make sure you get an estimate of your insurance coverage prior to any treatment being rendered.

Now let' look at it from the provider's perspective:

Many of these providers are business owners. A business can only compete in two of the following three areas: 1. Quality 2. Service 3. Price

To illustrate this point, let's take a look the restaurant industry. Keep in mind that this applies to every industry.

If we examine the business model of a fast food restaurant, we know that they compete on price. They also compete in either quality or service, but not both. A high end restaurant will compete on service and quality, but not price.

Here are some examples of contrasting businesses: McDonalds vs 5 star hotel restaurant; Starbucks vs gas station coffee; WalMart vs Nordstrom; Hagen-Das ice cream vs store brand ice cream. It doesn't matter what type of business, they can only compete in two areas. They all of course try to compete in all three areas, but one of the areas is severely compromised.

How does this specifically apply to a dental office? Let's look at two extreme's.

Dental office focused on quality and maybe even service.

Dental office focused on price.

The first is an office that deals with a high volume of patients that accepts deeply discounted insurance plans and government reimbursements. These offices certainly provide a valuable service to as many people as possible. However, given the low reimbursement rates, these offices must see a large volume of people to just break even. Quality or service will have to take a back seat. In order to be profitable or to stay in business, they must make a decision on which corners to cut. Perhaps it could be cheaper materials, cheaper labs, cheaper employees or any other corners that can be cut. Since they need to see a high volume of patients, either quality or service must be compromised.

The second office sees fewer patients but provides much better quality and service. In this type of office, the provider is able to provide much better care and service. However, price is compromised and the expense can be higher.

The first example is not much different than Walmart. The second is not much different from Nordstrom. Of course there is quite a bit of variation from business to business and many fall somewhere in between.

As you may have already figured out, I choose to focus on quality and service. I also try to keep the costs as affordable as possible. However, I cannot compete on price as effectively as a low reimbursement office or a government aid clinic.


So which one is better? Depends on what you value most. There is no wrong answer. Sometimes I want to have a quick and inexpensive meal and will choose to go to McDonald's. Sometimes I want a nice relaxing meal where I can enjoy the entire culinary experience. You must determine which of the two factors are most important to you--and then seek a provider that shares your philosophy.

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

Addendum: The next week I felt that this blog was incomplete, so I wrote a bit more on this subject from the perspective of insurance companies. Click on the following link:

Tuesday, September 24, 2013

Loose Dentures

Unfortunately, many people do not keep their teeth. They most often get dentures to improve function and aesthetics. There are many potential problems that occur with dentures. The ability to keep them in place is one of the most common problems. There are many more, but at this time I will only discuss the looseness of dentures and some solutions.
 Let's describe what typically happens. When teeth are lost, the bone resorbs (disappears; melts away). In many cases dentures are fabricated prior or shortly after the teeth are extracted (removed). Most of the dramatic changes of the bony architecture occur within the first six months after having teeth extracted and will continue at a slower rate throughout life.
So what is the significance of the bone loss? Initially, the recently fabricated dentures will fit. However, after approximately the first six months, you may notice that the dentures have significantly loosened up.
Initially denture adhesives may not be necessary. Over time you may find that more and more adhesive is required to keep the dentures in place.
There are many types of adhesives.
This is just one example.
There will be a point where no matter how much adhesive is used, adequate or satisfactory retention cannot attained. At this point, we can reline the denture. We simply add material to the internal surface of the denture where the bone and gums have pulled away.
A denture being relined.

After  a while, relines will not help the denture and a new one should be fabricated. On average, a denture should be replaced after about 5 years.

Notice the muscle attachments are at the same level
 as the bone. Also notice that the tongue sits higher than the bone.
As time passes, there will be so much bone loss, that a conventional denture will not stay no matter how much adhesive of reline material is used. Take a look at the picture on the right. Here we see that the musculature of the face will dislodge the denture anytime the muscles contract. The floor of the mouth and tongue will also displace the denture.

Fortunately, we can help these people with an implant supported denture. In this case, the implants hold the denture in place. No adhesives nor reline materials are required. In addition, the denture doesn't have to be anywhere near as bulky as a conventional denture which enables better comfort and function.

Implant supported denture
The last option is by far the best option. However, it is also the most expensive option. Implants are also placed. In this case, many more implants are placed and are restored as either individual teeth or as bridges as in the picture below. 
Upper teeth restored with implant crowns and bridges

If you have loose dentures, discuss your concerns with a dentist to help you decide which option is best 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

Wednesday, September 11, 2013

Question and Answer About Partial Dentures

I just recently received a question online from the Q&A Panel at I thought that since this is a common problem, that I would share the question and answer here.

Here is the question:

"About two years ago I got an upper denture. The dentist left some top teeth in for support (I guess) of that denture. However, because of this, the denture extends out like an awning above my lower teeth, and looks terrible. All you see coming at you is big teeth on top. Now it doesn't even fit well, and I would like to get it re-done. I wonder if I should have those 5 remaining upper, natural teeth of mine removed before trying to re-do it? Is there really such a thing as a "natural" looking denture? Sometimes you can spot them a mile away, but on others you are surprised to find out they are wearing dentures. What makes the difference exactly in a natural look VS I'm wearing dentures and hate that you know. I can afford a "good" denture, but cannot afford implants unfortunately.
Thank you,
L. Burns

Here is my answer:

Hello L. Burns,

I'll answer as best I can with the information I have. Trying to assess a condition without actually seeing it is like diagnosing a car problem over the phone.

If the remaining teeth are in good shape, you certainly want to keep them. This will enable the preservation of bone and will certainly help keep the partial denture in place.

As far as the fit is concerned, over time, the bone and gums will resorb away from the denture. When this happens, there will be spaces between the denture and the soft tissue of the mouth making retention much more challenging. Either a new partial denture will need to be fabricated to fit better, or you can also reline the internal surface of the denture to improve the fit. In your case since you don't like the appearance, I suggest you get a new one so that you can have a more aesthetic prosthesis.

I certainly hate dentures that you can spot a mile away. I want things to look completely natural. When you get a new partial denture, have a discussion with your dentist on how you want them to look. This will eliminate the guesswork. The position, shape, color and overall aesthetics can be changed to get the look you're looking for.

Hope this helps!

Dr. Martin J. Cisneros

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, September 4, 2013

Is Excessive Gum Chewing Bad?

I'm certainly not going to make the case that one should never chew gum. However, I will certainly try to discourage excessive gum chewing.

Now what is excessive gum chewing? There is no precise answer for this. The good news is that there are some indicators that might give you some clues. For example, sore muscles, joint pain and tooth decay.

Four things immediately come to mind:
  1. More cavities
  2. Excessive tooth wear
  3. Decreased facial dimensions
  4. Joint and muscle issues (TMD--temporal mandibular disorders)

When chewing gum that is loaded with sugar, the results are very predictable. More sugar equals more cavities. However, chewing sugar-free gum can actually decrease the potential for cavities. If after eating a meal you find that you don't have a toothbrush readily available, I recommend rinsing with water. If water is not available, then sugar-free gum can be helpful in removing debris from the teeth thereby decreasing the potential for cavity formation.

Excessive tooth wear
Excessive chewing will lead to excessive tooth wear. Take a look at the picture on the right. You can see that it appears as though someone has taken a file to these teeth and have made them completely flat. This likely wasn't the case. It's more likely that other issues such as clenching/grinding may have been the primary cause of wear in this particular case.

This next picture demonstrates TMD and a decrease in the vertical dimensions of the face. Notice the size of her jaw muscles. They are incredibly well developed. Overuse will lead to muscle/joint pain, damage and dysfunction. 

Also notice that her teeth have worn down and her face has gotten shorter. Cosmetically, it makes people appear much older. In this case, Dr. Sam Muslin improved her overall appearance by not only fixing her teeth, but by increasing her vertical dimensions.

Courtesy of Dr. Sam Muslin

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

Friday, August 23, 2013

Just Lost a Tooth? Now What?

When a tooth is lost, there are several options to replace it. You can have something that is permanent or something that is removable. There are four main options: 1. implant 2. bridge 3. partial denture and 4. nothing.


The best option is to replace it with an implant. Implants are very predictable and have a very high success rate. Once they are integrated into the bone, they can pretty much last forever. I joke around and tell my patients that it will still be in there 5,000 years from now. The disadvantage is that it is the most expensive option. Typically the implant and crown can range between $3500-4500.


The next best option is a bridge. However, I personally don't like this option for a couple reasons. First of all, if the teeth adjacent to the missing tooth are "virgin" teeth (perfectly sound teeth with no decay), then we would end up damaging them as well by cutting them down. The average lifespan of a crown or bridge is approximately eight years. That means that in eight years, we may likely have issues with the adjacent teeth. The reason this is the case is because decay can sometimes form at the junction between the tooth and the crown. Many people do not floss, so the surfaces that aren't cleaned regularly will have recurrent decay. Even if a person flosses, it is a challenge to floss under the bridge unless a floss threader is used. The cost of a bridge can range between $1000-1300 per unit. A bridge always has three or more units. The cost of a three unit bridge is comparable to an implant, so the implant to me is the only logical choice unless the adjacent teeth have significant decay and need to be restored anyway.

Partial Denture

The next best option after a bridge is a partial denture. A partial denture is the most economical choice ranging between $500-2000. It works......but I don't like this option either. As far as the patient is concerned, it is very inconvenient to always have to remove the appliance. For me, I don't like it because in many cases, the partial denture is retained by other teeth. Over time, the other teeth are damaged or compromised. It is an option though.

Do Nothing

By far this is the least expensive option. However, it is also the worst option. The remaining teeth shift and create problems. Teeth are like gears. They need to match up properly. For example, if the gears in a watch or engine don't match up, in a relatively short period of time the watch or engine will fail. In addition, the jaw bone will develop defects.

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, August 14, 2013

Minimally Invasive Dentistry

What exactly is minimally invasive dentistry? There is much written on this subject.

The device shown above is a cavity detector. It's a nice piece of technology that allows dentists to assess cavities more accurately. The technology is far more precise than visual or tactile inspection.

Even though we have and use many different tools and techniques, minimally invasive dentistry is not a collection of procedures, techniques or treatments. Minimally invasive dentistry is a concept. Basically, it can be summarized as doing the most conservative possible treatment to maintain optimal oral health.

There are three main advantages to this approach:
  1. We avoid unnecessary tooth destruction
  2. We minimize expense
  3. Results are more predictable
Let's look at a diagram on the right to demonstrate an example. Here we see that in the early stages of a carious lesion (a cavity), it is confined to the outer layer (enamel) of the tooth. As it advances, it penetrates into the inner layer (dentin) of the tooth. Once this happens, the progression of the carious lesion is accelerated. In other words, it gets bigger faster. If allowed to progress into the pulp of the tooth, now a root canal is required to salvage the tooth. If enough tooth structure is destroyed, then the tooth may not be salvageable.

How do we minimize expense and unnecessary tooth destruction? Easy, just treat at the earliest time possible. I often tell my patients that it's much better to change your oil than to change your engine; or change your car;  or simply stop driving. I know, crazy analogy but it makes sense. With the progression it gets more 20 fold or more. 

Let's look at some costs of possible treatments:
  • Treat early--cost of a filling: $100-200
  • Treat later--cost of crown or onlay/inlay: $1,000-1400
  • Treat much later--cost of root canal, build up and crown: $2,200-2800
  • Treat much much later-- cost of extraction $100-200 + bone graft $300-600 + implant $3,800. Alternatively a bridge $3,000 or partial $1,800 can be made to replace the missing tooth.
If we opt to wait, what are we waiting for? For things to get worse?

Unfortunately, most people will wait. Approximately, 80% of the population does not see a dentist on a regular basis. Most in this group will only address their issues when it is blatantly obvious or when they are in significant pain. The entire experience can however be much more pleasant while at the same time being easier on the pocketbook and psyche if a proactive approach is taken.

Here some examples of potential scenarios:

Small lesion treated very conservatively
Much more extensive decay. The restorability is questionable because it is impossible to determine
the extent of the vertical fractures.

In summary, addressing issues in the earliest stages possible will enable the conservation of tooth structure, will reduce costs, will increase predictability and decrease physical and/or emotional distress.

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 31, 2013

Invisalign vs Wires and Brackets

I frequently get some variation of the question "Doc, is it better to do braces or invisible braces?"

I'll briefly discuss the advantages and disadvantages with each of these options. For this blog, braces are wires/brackets and invisible braces are Invisalign aligners.

Wires and brackets


In some difficult cases, certain tooth movements are only possible with wires and brackets. Invisalign cannot work in every case.

Although the teeth are straight, the inability to maintain
 adequate hygiene has resulted in discolored and decayed teeth.
  • Unpredictable final outcome.
  • Oral hygiene is compromised.
  • Treatment time on average is 2-3 years.
  • When brackets are removed, there is often some decay or discoloration of the teeth. Also, during bracket removal, tooth structure is often inadvertently chipped off the tooth surface.
  • Food restrictions. Some foods are off limits.
  • Wires and brackets often poke the soft tissue and sore irritated areas often develop.
  • More discomfort when teeth move.



  • Final outcome is more predictable.
  • Better oral hygiene.
  • Treatment time is much faster. On average, treatment is typically about a year.
  • Invisalign aligners are nearly invisible
     and are very tolerable to wear.
  • No food restrictions.
  • Less discomfort as teeth move because of the predictable and precise movements.
  • More aesthetic.


If not compliant with wearing the aligners, then the teeth will not move to the desired position. In other words, if you don't wear them, the teeth will not move.


In conclusion, I prefer Invisalign (when feasible to treat with this modality) over wires/brackets. However, I have friends and family that prefer to have wires. I don't understand why. I think for school age kids, it may be a status symbol to have brackets. I don't get it.

Feel free to visit the Invisalign website ( for more information.

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

Thursday, July 18, 2013

Is there a difference between a DMD and a DDS?

Over the years, I've been questioned many times on what the difference is between a DMD degree and a DDS degree. There is much confusion over this.

Some believe that a DMD degree is the better degree because it is a variation of the MD degree. Some believe that the DDS degree is better because, the " S" in DDS indicates that they may be more competent in surgery.

The only real diference in these two degrees is simply one different letter in a different order. That is the only difference. The training and credentialing process is exactly the same. Most have undergraduate degrees in the hard sciences such as biology, chemistry and physics. Once accepted into dental school, the first two years are mostly shared with medical students in a lecture setting. The third year of school is when the clinical training really ramps up. Dental students diverge from their medical counterparts at this stage. To graduate and get licensure, we all take the same National, Regional and State Boards (clinical and written), have the same requirements to maintain our continuing education, and are regulated by the same agencies.

Here is a little historical perspective:

  • Baltimore College of Dental Surgery was founded in 1840 and was the first dental college. It is now known as the University of Maryland. They awarded a DDS (Doctor of Dental Surgery) degree.
  • It wasn't until 1867 when Harvard opened up a dental school when a DMD (Doctor of Dental Medicine) degree was awarded. At the time, they felt that the DMD degree as a more accurate description of the profession.
  • We now have over 60 US dental schools. Approximately 2/3 of the schools offer the DDS degree; 1/3 offer the DMD degree.

The ADA (American Dental Association), is well aware of this mass confusion. Many discussions have been held. Some have proposed that we eliminate the DDS degree. Some have proposed that we eliminate the DMD degree. Some have proposed that we come up with an entirely new degree. There has not been any consensus or resolution up to this point.

So, in conclusion, the only difference is one letter. Everything else is exactly the same.

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 10, 2013

Top Ten Ways To Keep Your Teeth

Most people want to keep their teeth for life. Teeth are not only important for chewing our food to initiate the digestive process. Teeth are also important for overall health and well being. Having teeth can also benefit your pocketbook and your love life. The power of a smile is immense.

Here are ten things (in no particular order) to consider if you want to keep your teeth for life:

10. Brush

This is obviously an important factor. If possible, use an electric toothbrush. It will clean plaque off of teeth more efficiently while at the same time being gentler on the gums and teeth.

9. Floss

If you don't floss, you're only cleaning part of your teeth. Floss the ones you want to keep.

8. Frequent hygiene

Brushing and flossing is only part of the battle. It is vitally important that good oral hygiene is performed frequently. Preferably after each meal, after awakening and prior to bed.

7. Keep sugary snacks down to a minimum

I'm not suggesting that you not eat any sugary snacks, but keeping it to a minimum will improve your chances of keeping your teeth.

6. Visit your dentist regularly

Visit your dentist regularly so that you can catch problems earlier. The sooner you address any problems, the better off you'll be from an oral health perspective; and from a financial perspective.

5. Wear an athletic mouthguard when participating in contact sports

Many teeth are lost unnecessarily every year in athletic events. Even sports that are not considered contact sports such as basketball cause a tooth to be knocked out. Wear the athletic mouthguard if you value your teeth.

4. Maintain good overall health

There are many oral manifestations that are evident in many diseases. Poor overall health will oftentimes lead to poor oral health. For example, diabetics tend to have a higher incidence of periodontitis.

3. Avoid bad oral habits

Habits such as chewing ice or biting on fingernails will increase the chances of early tooth loss.

2. Do not smoke

Smokers tend to have a significantly higher incidence  and severity of oral diseases.

1. You must really care about keeping them

This is probably the most important factor. If your teeth are not a priority and are not that important to you, then you will likely not even worry about the previous nine ways to keep your teeth.

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 1, 2013

Reconsideration of Tooth Removal in Orthodontic Cases

We (dentists) have all learned that the primary problem in orthodontics is either too much or too little spacing between teeth. When there is inadequate space, teeth come in crowded and crooked. When there is too much space, the teeth will have gaps between them.

Small arch size resulting in crowding
Large arch size resulting in spacing

All dentist to some extent have been trained in  orthodontics. Many general dentist perform orthodontic procedures in their offices. Some refer to orthodontists if they don't enjoy this part of their practice.

When we encounter crowded teeth, we need to create space. There are several ways to create the necessary space. One way is to pull some teeth. Many adult teeth have been pulled with the intent of straightening teeth. While this may solve the patient's primary concern and give them a straight and beautiful smile, we have inadvertently create another problem. That problem is obstructive sleep apneaSleep apnea is very serious and will take 12-15 years off of a typical life-span.

I have spoken to some of my orthodontist friends and discussed this issue. Years ago when I was in dental school (1993-1997), we were taught that this was a good way to create space. This is still being taught. However, as the medical/dental community has learned more about sleep apnea, we have discovered that a narrowed arch will push the tongue upward and/or posteriorly. In either case, the airway is compromised. This will only exacerbate the problem of sleep apnea.

I have been a member of the American Academy of Sleep Medicine for nearly two years. In the last year and a half, I have been trying to educate my general dentist and orthodontic colleagues on this issue. Advancements in medicine and dentistry occur very rapidly these days. As we make new discoveries, we must modify our old ways of thinking. We must consider alternative ways to straighten teeth without narrowing the arch size. Fortunately there are ways to accomplish this. The details are beyond the scope of this blog.

So the message here is this: if you or someone you know will be undergoing orthodontic treatment, carefully evaluate all of your options before having teeth extracted. Your dentist/orthodontist may not yet be fully aware of this issue. They certainly will be soon. But if they aren't aware of this yet, ask questions. Specifically, ask if the arch size will become more narrow and if there is a potential for obstruction of the airway thereby exacerbating obstructive sleep apnea.

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

Thursday, June 20, 2013

Age When Children Should See a Dentist

There is much variability in the recommended age of when children should start visiting a dentist. There are many experts offering their opinions on this subject. Some of these experts are dentists, physicians, children's psychologist, early childhood experts and more. Their expert opinions range from newborn to the age of four. That's quite a range!

There are three main variables to consider.
  • Child Variability
  • Parent Variability
  • Dentist Variability
Teeth eruption times vary with each child. The first teeth may start to come in at 6-10 months of age. There is much variability in maturity levels as well. The more mature a child is, the easier the dental visit will be. Another consideration is the child's anxiety level. When the child isn't fearful, the appointments tend to be pleasant for them. This certainly isn't the case for the extremely fearful child.

Child with extreme apprehension of dentistry
Child with a positive dental attitude

The parents play a major role in shaping the child's first dental visit. If the parent has a positive view of dentistry, then the child will also more often than not have a positive experience. If the parent is highly dental phobic, then the parent will inadvertently transfer their fears onto their children. This can occur without the parent even uttering a word to their child. Children are highly intuitive. They can sense the emotions of others by mere observation.

The age at which my fellow dentists start seeing children varies greatly as well. We all have slightly different philosophies as to when we start seeing children in our offices. For me, age is not really that important. What is important for me is the child's level of cooperation. If they aren't fearful, then it's never a problem. When they are fearful, it makes it rather difficult to assess and treat any problems they may have. The single most important factor in my opinion is the parent's feelings about dentistry in general.

The sooner a child starts visiting a dentist, the better. If we can see them for a routine exam on their first visit, it makes future visits much simpler. If however the first visit is an emergency visit, it will almost certainly be a stressful event for the child and will therefore set them up to be dental phobic for their entire lives. Another reason why you should get them in sooner than later is that any potential treatment will be less expensive, less extensive and more predictable.

The American Academy of Pediatric Dentistry recommends that a child make their first visit when the first tooth comes in. Usually around six months of age. The bottom line is to get them in as soon as you can--preferably by their first birthday.

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