Restorative Dentistryin Fort Worth, TX
Treatment options come in the form of how we treat the specific teeth in need and how we ensure your child’s comfort. The restorative options address the teeth, and the sedation options address how to complete treatment safely, effectively, respectfully, and humanely. First, we will address the restorative options. Scroll down for sedation options.Contact Us
The restorative options for teeth due to decay or hypoplasia are dictated by the size of the lesion and the strength of the tooth once the cavity is removed.
Sealants are an elective preventive procedure. They coat the deep grooves of the teeth and facilitate better hygiene. They do not cover in between teeth. However, they provide significant preventive benefit regarding the avoidance of cavities on the chewing surfaces of back teeth. All our sealants are placed with BPA-free material.
Fillings are intracoronal restorations. They are a good option when restoring smaller cavities. We depend on the strength of the remaining tooth structure to provide strength for the filling when restoring form and function to the tooth. In our practice, we only place white fillings with BPA-free material.
We do not place silver fillings.
When there are cavities in between anterior teeth, the more predictable restoration is a crown. Fillings do not tend to retain well in this area due to the force exerted during function and the anatomy of anterior teeth. In our practice, we only place white crowns on anterior teeth. There are two types of white crowns:
Strip crowns are composed of filling material. The tooth is reshaped to remove the cavity and allow for the crown to fully cover the remaining tooth structure. A clear former is sized that will most closely match the existing teeth. Then that former is filled with filling material, and the crown is placed on top of the tooth. The excess filling material is removed, the filling material is set with a curing light, and the clear former is stripped off, which is why they are called strip crowns. These crowns look very natural and can also be prone to fracture, just as white fillings are. Care must be taken to keep the gum line very clean around these crowns because they can also be prone to stain, just as white fillings are. These crowns are stock crowns and come out of a box, and while care is taken to match existing dentition, it will not result in a perfect match. It is rare that anyone other than the parent and the dentist will recognize a difference or that the tooth is not a natural tooth.
Zirconia crowns are white, rigid, and the tooth must be shaped to a very particular preparation to accommodate their fit. They are very technique sensitive, and often our little patients must be asleep for the placement of these crowns. They are very durable and extremely natural-looking with high esthetic quality. These crowns are stock crowns and come out of a box, and while care is taken to match existing dentition, it will not result in a perfect match. It is rare that anyone other than the parent and the dentist will recognize a difference or that the tooth is not a natural tooth.
Crowns are a good option when the cavity removal will result in loss of 1/3 of the tooth structure or more. This can happen quickly in baby teeth because they are so small. Also, if the cavity approaches or involves the nerve and a nerve treatment is required, a crown is indicated to seal the tooth from bacteria and prevent infection of the nerve space.
Stainless steel crowns are silver, extremely durable, and studies have shown they are the restoration most likely to stay in place until the tooth falls out naturally. They are malleable and can be contoured to fit for better retention. They are composed of surgical grade stainless steel and are different than the silver filling material (known as amalgam.) They do not contain mercury. They are stock crowns and come out of a box. No temporary restoration is needed.
Pulpotomies or “nerve treatments” are sometimes called “baby root canals,” but that is a misnomer. A pulpotomy is a vital nerve treatment where the top part of the nerve is removed, and the nerve in the roots of the tooth is left alone. A medicament is placed on the exposed nerve, and the nerve chamber is filled with a soothing material called IRM. A crown is then placed over the tooth. Pulpotomies are indicated when removal of the cavity will involve the nerve.
Indirect pulp caps are medicaments placed when the cavity is deep, and removal is close to the nerve. The medicaments used are biomimetic and help the tooth protect the nerve from sensitivity.
Extractions are indicated when the tooth is non-restorable due to the extent of decay or infection. Sometimes we elect to remove baby teeth with cavities when the tooth is expected to fall out naturally within the year, and thus the extraction is less invasive than a filling or other restoration.
Ectopic permanent teeth can result when baby teeth aren’t lost naturally. Sometimes a baby tooth is “over retained,” and the permanent tooth is coming in in front or behind the baby tooth, aka an “ectopic eruption.” In that case, extraction of the baby tooth is indicated.
If a tooth is extracted within two years of when we would otherwise expect it to fall out naturally, we will see the permanent tooth come in more quickly. If we lose baby teeth due to extraction (or trauma) very early, or greater than two years before it would fall out naturally, typically, we will see delayed eruption of the permanent tooth. This is because the permanent tooth loses the path of the roots of the baby tooth, the path fills in with bone, and it takes a while longer for the tooth to move through the bone.
Space Maintainers or “spacers” are placed when a tooth is extracted to hold space for the permanent tooth. They are made of surgical grade stainless steel. Depending on the space preservation needed, we can make these at the time of the appointment or take an impression and have the appliance custom made by our lab.
Nitrous oxide, or laughing gas, is a light anxiolytic agent. It is not sedation. The gas is exchanged in the alveoli of the lungs, and it is not metabolized by the body. When we breathe in the laughing gas, it takes a few minutes to work. The effect may be a tingling in the fingers and toes and a relaxed feeling. It can help our patients sit in the chair a little longer and help them focus on the movie playing on the overhead TV during treatment. Laughing gas makes shorter appointments easier to tolerate and promotes a positive outlook regarding dental treatment. Laughing gas will not make children fall asleep or sedate them. It will not change their behavior and make an extremely anxious child tolerate dental treatment. The best candidates for laughing gas are patients who are familiar with dental treatment or who have treatment needs that will require limited, short, straightforward appointments.
Oral Conscious Sedation
Oral conscious sedation is performed for patients who are determined to be good candidates based on their medical history and ability to tolerate treatment.
The medications used are determined by the level of sedation necessary to complete treatment, the patient’s age, and medical history.
The medication is a liquid oral suspension that our patients drink. Depending on the medication, it can take anywhere from 15 minutes to an hour for the onset of the sedation. During oral conscious sedation, the patient may be drowsy but not asleep. At the onset of the sedation, the patient is placed on monitors that include blood pressure, pulse oximetry, and we constantly monitor the rise and fall of the chest. Nitrous oxide is typically administered during oral sedation unless the patient is too young to tolerate the mask or there are other considerations that negate its use.
During oral conscious sedation, we may have up to one hour of working time, depending on the type of medication used. It is particularly important to be aware of the amount of local anesthetic used during treatment. Often the limiting factor for treatment will be the safe administration of local anesthetic. For this reason, treatment is often limited to one half of the mouth.
The patient is less sensitive to stimulation during this time, and it typically allows our team to complete more treatment in one setting, i.e., the right half of the mouth. In contrast, with nitrous oxide/laughing gas we can often treat one quadrant before the patient becomes restless.
During oral sedation, patients will still be aware of what is happening, and we need them to be willing participants in treatment. Typically, our patients who are able to tolerate x-rays and cleaning and who have treatment needs in multiple areas of the mouth (i.e. upper right, upper left, lower right, lower left) are good candidates for oral sedation. Children typically do well for treatment if it is completed in 1-2 visits. At the 3rd visit, we see behavior deteriorate. If children have treatment needs in all 4 quadrants of the mouth (as is common), it is not reasonable to expect them to maintain good behavior over 4 separate treatment visits. For this reason, it might be prudent to consider limiting treatment to 2 visits with oral sedation. We can get more treatment done as the child is less sensitive to the stimulus of treatment, and we can preserve the developing psyche. For many, it is a more kind, respectful, and humane way to complete treatment.
Before oral sedation, the patient should not have anything to eat and drink after midnight unless otherwise instructed by Dr. Laborde. Upon arrival at the office, weight and vital signs will be recorded. Dr. Laborde will listen to the child’s lungs and check for oral airway obstruction like large tongue and tonsils. After this assessment, the medication will be measured based on the patient’s weight and administered.
After oral sedation, the patient may be numb for a few hours. The first drink should be water, and it is important to advance the diet slowly. The most common post-op complication is lip biting due to a numb lip. It is important to give your child constant reminders to “keep your lip outside your mouth.” This is more instructive than “don’t bite your lip,” which often results directly in lip biting. If lip biting occurs, call our office, and we will work through it together.
During IV sedation or deep sedation, the child is completely asleep for treatment. Children who are good candidates for IV sedation have significant sensitivity and/or anxiety that makes stimulation like dental treatment intolerable and traumatic. Children who demonstrate this level of sensitivity often are not able to stand on the scale to be weighed, cannot tolerate x-ray examination, often cannot sit alone for an exam without their parent holding them, have tears for any dental instruments, including the mirror, or have a history of a traumatic dental experience. Sometimes children do not demonstrate overt anxiety about dental treatment, but they have a tooth that is difficult to achieve profound anesthesia, often called a “hot tooth,” history of an unsuccessful oral conscious sedation, or reactive airway disease that contradicts the use of oral sedation medication.
During IV sedation, we work with a dental anesthesiologist who monitors the sedation. The child breathes a mask to fall asleep, and then the IV is started when the child is unconscious. Since the anesthesiologist can mitigate pain and discomfort through the IV, we aren’t as dependent on local anesthetic for the procedure, and we are typically able to complete all necessary dental treatment in one sitting.
We take deep sedation of children very seriously. We work with the same team each time. We use time out procedures and are familiar with emergency protocol. We use state of the art monitors and equipment, and most importantly, we do not start another child’s treatment before the previous child meets discharge criteria. The most important emergency readiness protocol is in patient selection for the procedure and occurs before IV sedation is discussed with the family. Stringent checks are in place to determine who is an appropriate candidate for IV sedation.