Friday, August 16, 2019

Honesty is the Best Policy

        I have found my ability and the need to relate honestly is both a virtue and a curse. People who know you well may tend to trust you more if you are known for your honesty, since what they see and hear is what they get.

         People who meet you for the first time, not so much. Often people meeting someone new tend to "judge a book by it's cover, even when the cover doesn't project what's really inside. Personally I prefer to be truthful in my interactions with others. I may sometimes not tell others my every thought ( a sin of omission) but I really try to be truthful in my communications. This has for the most part worked out well but not in every instance.

             My patients who know me well, tend to know that I give them my best and most honest advice. I don't always paint an overly optimistic picture, but they can rely on me to be truthful and they know if I recommend a procedure, I truly believe it is their best option.

                  Sometimes this trait doesn't sit well with new patients who sometimes are hoping for a particular treatment plan that can be accomplished fast and good, in the most economical manner. This can at times happen, but some patients have unrealistic expectations and I will not mislead them into starting treatment with me without a discussion of what is their best option. I may include a second and even third option, but if what they want is something I can't in good conscience offer, I won't do it. These patient's either adjust their expectations or go somewhere else.

                 Sometimes  they tell me how a previous dentist was able to accomplish some dental magic, but to my mind the way that that dentist handled their treatment is not how I want to approach their treatment. Personally I enjoy sleeping soundly at night and dislike treatments that seem to be temporary in nature and may lead to worse problems. After all teeth don't grow on trees and implants are expensive replacements.

Thursday, January 5, 2017

Why do my teeth keep breaking?

Some of my patients do seem to break a number of their teeth. There are probably a number of factors in involved. 
        First lets look at back teeth that break or crack. Often the teeth that break have fillings that undermine the existing tooth structure. Even a small filling placed close to the edge ( the mesial or distal of the tooth) can make a crack more likely to develop. Many of these teeth really should  have onlays or crowns placed to protect them.

             Another factor is the occlusion and frequency of night time clenching and bruxism ( many people do this at times while sleeping). Patients that have worn their teeth flatter so that there posterior tooth surfaces meet quite broadly during excursions often apply more force to their posterior teeth. These are people who have "cow bites" (Dentists term). Often when I examine these peoples teeth they have multiple posterior broad wear facets from their forceful grinding and chewing.

                Destructive habits , such as chewing on ice cubes, bones and other hard substances can also cause teeth to break. I had one teenaged patient who had no fillings in her teeth but kept breaking her teeth. It turned out she had a habit of chewing on to a pen top (kids do the darnedest things!)

              I have also observed that older patients, whose pulps have receded (no pulps in their clinical crowns) seem to be more likely to experience tooth fracture. This is especially true if the have a deep overbite involving their anterior teeth.

                Some dentists advocate changing the occlusion of patients by extensive tooth equilibration or by reconstructive dentistry. My solution is simpler.  For  most of these situations is to recommend that my patients wear a nightguard while sleeping that will protect their teeth and help eliminate destructive tooth to tooth contacts at night. This seems to be the least invasive choice and to my mind it is a "DO NO HARM" solution to the problem.

Monday, May 30, 2016

Growing Need for Cosmetic Dentistry

                 With the constant growing phenomenon that includes social media, TV, magazines, evolution of technology, more patients think about their image. It results in an extreme desire to have great selfies and an overarching desire to look younger.
For Example when a picture is posted on any social Media, no one wants to look bad. If someone scrolls through their pictures and feels that they have some extra kilos to lose; the individual will feel more pressured and motivated to lose weight to show the world that they look better than before.
This is happening all around us and is being reinforced by the cultural and societal norms of the twenty-first century. Celebrities in magazines and on TV have the desired look of tall and slim, with beautiful features, including their teeth.
          Its said that 47% of the people notice the smile first in a photograph or while talking to a person.
When a photographer takes a photo and asks the subject to smile, people don’t want to be embarrassed or ashamed of their teeth. Nowadays, the average person is more likely to invest in teeth whiteners, as well as cosmetic dentistry for the constant search of perfection.
When someone trips and cracks a tooth, their first instinct is to go running to the dentist in order to fix the broken tooth. In addition, coffee addicts are buying teeth whiteners to remove the unwanted stains on their teeth.
Everyone wants to feel and look beautiful within the definition set by the world around them. Brushing and flossing is not satisfying anymore because individuals do not believe that it does a sufficient job cleaning their teeth. Patients want bright, white, and flawless teeth, and are willing to pay extra to get them.
          Each year, the cosmetic dental industry has an increase in patients and revenue, making it a great option for individuals who have an interest in joining the dental field.

The schooling that is necessary to become a cosmetic dentist may be long and difficult, but the success afterwards makes it worth the while. Cosmetic dentists help patients feel more confident about them, which is something each dentist should pride themselves on.

Friday, January 15, 2016

Do I really require twice a year cleanings?

            This is a question asked sometimes by "self paying " patients. They are worried bout the costs of two check ups and cleanings per year. Although no one "needs" two cleanings a year ( I mean, after all it's not a life or death decision), most dentists recommend this as our standard recall schedule.                     
                That's because we feel this schedule allows us and our patients a good chance of avoiding many dental problems and helps prevent bone loss that if left unchecked can cause their patients to lose teeth. With the cost of a single tooth implant somewhere between 20000 to 50000 , not going twice a year to your dentist might not save  money over the long haul ( Sometimes cheap is expensive and expensive is cheap?).

          Most people understand the importance of having oil changes at the frequency their car manufacturers recommend but sometimes this same logic isn't as convincing  where their teeth are concerned. It should be pointed out that taking care of ones teeth is probably more important than car maintenance. A  car can be replaced with a newer and better model, but really teeth really can not.                     Fortunately  missing teeth can be replaced with dentures, fixed bridges and implants, but these approximations  are not truly as versatile as ones own teeth .

                      Teeth that are well cared for both at home and by the dentist can last a lifetime! Why not "get with the program" and have twice a year cleanings? 

Wednesday, December 2, 2015

Why does my crown keep falling out?

Maybe it's not that into you.....? :)
              Being rejected by your crown hurts, especially when it was recently made and cost some serious money. Why does it happen? Usually either it has to do with the shape of the prepared tooth holding it or because the crown is ill fitting.

                For a crown to be retentive (resist the forces that may tend to remove it) the preparation has to be smooth and only SLIGHTLY tapered. It also has to be long enough to provide enough surface area to grab the cement. If the prepared tooth is too irregular, too short or too tapered, it may not have the proper shape to hold onto its crown.

                 Also, another possibility is that the crown can be cemented with a poor fit. In this case the crown does not hug the tooth well enough for the crown to stay put and since the crown is completely dependent on cement to stay. An analogy would be found in furniture making where most good furniture is made with dovetails, that increase the ability of the furniture to hold the wood together. Without dovetails, the pieces tend to work themselves loose more quickly. 
                The same can be true with crowns, since their success is dependent on having a properly shaped tooth holding them and an intimate contact with it. The space between the crown and the tooth should be minimal (20-40 microns) in order for the cement achieve maximum holding power.

                   Most dentists faced with a permanent crown that comes out will first try to re-cement it. In my practice, I upgrade to a different permanent cement with more holding power. Unfortunately these cements do not always offer a long term solution and I am faced with the option of making the crown over.  When I do so I pay special attention to correcting any shortcomings in my tooth preparation and making sure that I take a perfect impression.

                  I should add a few  additional reasons that crowns can come loose. If the bite is high or just unfavorable, crowns can be more likely to come loose. Crowns do better when most of the occlusion is experienced along a  mostly vertical force vector and without much  of a horizontal component. Anterior teeth with deep over bites can experience a lot of horizontal forces on them and can sometimes be challenging to crown. Also some patients do have habits that are just not that friendly to crowns such as eating stale tootsie rolls or very hard and sticky candies. When chewed often these sweets tend to loosen even well fitting crowns

Dr. Pankaj Malhotra is a Periodontist & Implantologist in DELHI NCR region of INDIA, who maintains a practice in Noida. For more information about his Dental Practice please visit his website at 

Tuesday, June 2, 2015

Do You Shop For your Dentist?

Almost every day my dental office gets a call from a potential patient shopping for a dentist. They ask for fees for certain procedures and often that is the end of the conversation. 
             I should note that my fees fall within the usual and customary range considered reasonable but for some persistent shoppers are too high. It seems that the internet has become the new Yellow Pages and potential patients are letting their fingers do the walking. It's not that hard calling a number of dentists and get a sense of the fees for the procedures that they will need. 
          Unfortunately, no information on the quality of the dental work can be gotten from these phone calls and shopping for dental work for some may be similar to shopping for furniture or other consumer goods. However teeth are not disposable and even implant replacements will not last forever.

         When I buy a piece of furniture, if I go to Ikea or any Local store, I expect to get a good price for what I buy, but I do not have the expectation that my purchases will last a lifetime or even ten years. It is asumed that there is a trade off involved with the inexpensive price paid but most of the time shoppers are  happy with their purchases . Many people like buying new furniture and actually like buying new pieces when they either tire of, or have to, replace them as they age.

            Teeth shouldn't be compared to furniture and restorations that are durable and preserve teeth for long periods of time are not always easily accomplished by dentists whose fees are the most reasonable. Although a higher price does not guarantee quality, it does tend to allow a dentist to to spend the time needed to create a thoughtful treatment plan and also the time to execute excellent restorative dentistry.
            I would like to quote a few examples here.. 
People dont mind paying 300 for Rs 30 popcorn in a theatre, but have reservations paying Rs. 300 consultation to a Dentist..
Also people dont mind paying 4000 bucks for a pair of jeans which shall last for 4-5 yrs and being worn for probably 100 times. While a crown of approximately the same value which you wear everyday and use it thrice daily lasts much longer than that..
             I guess the point of this post is to explain that price of services should not  be the primary method in choosing a dentist. Other attributes are quite important including but not limited to  recommendations from their patients, their skill level and their character.

Please contact me at

Friday, May 2, 2014

Sensitivity after a Crown placement

              There are two types of sensitivity that can commonly experienced after a crown is cemented. One is sensitivity to biting pressure and the other is sensitivity to cold (and or hot) liquids. If a patient is  experiencing either of these after a permanent crown is placed, then probably the best thing to do is to let their dentist know.

                  Sensitivity after a permanent crown is placed is not that uncommon. If a patient reports sensitivity, I check their bite, since a high bite can be irritating to the ligaments holding a tooth and can even cause pulpal sensitivity. A patient should be able to close there mouth comfortably without feeling any pain. If when they close their mouth (without chewing any food) they experience pain from a new crown, the bite should be adjusted.

              If a patient can comfortably close their mouths, but does experience pain on heavy chewing, I usually ask them to wait and see if the pain gets better with time. A crown cementation can sometimes irritate the pulp and with time this irritation can diminish. This can take months to go away and if a patient is willing, its usually best to wait. If I see them at their next recall, the tooth is still sensitive to chewing or when drinking cold liquids, I take a radiograph and if no pathology is evident, I usually try to get the patient to wait longer, since the only real other options are to perform a root canal on the tooth or to cut off the crown and place a temporary crown with a sedative filling. Which of these I would choose, if I feel the need to treat the tooth, is dependent on whether I believe the pulp has a reversible or irreversible pulpitis.

              Deciding whether a pulpitis is reversible is not always easy, but the prior history of the tooth has a lot to do with the decision. If a tooth was assymptomatic prior to me working on it initially, I am more likely to choose to remove a crown and place a temporary. If a tooth had a pre-existing crack in it or was symptomatic prior to me preparing it for a crown, I am more likely to recommend the patient visiting an endodontist and have a root canal done through the crown.

               I feel that the pulp is still vital and not infected, there is usually no harm in watchful waiting, since with enough time sensitive crowned teeth can calm down. I explain this to my patient and if the symptoms are bearable we often wait for the symptoms to slowly go away. If the symptoms are worsening instead, we can always choose the root canal option.
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Sunday, March 16, 2014

Why Dental Diagnosis are sometimes In-Exact.

              Even after after taking x-rays and performing a thorough clinical examination of a patient in pain, it is not always possible to make a definitive diagnosis in just one visit. Sometimes there are multiple possible causes for a patients discomfort. Often a patient having pain originating from one quadrant has multiple restorations and more than one can be  experiencing pain.

             Just last week a patient came in after a trip to Chennai complaining of pain. She hadn't slept all night. My clinical examination showed that the pain was coming mostly the area around lower back tooth , which had previously had a root canal, post and crown. The mesial papilla of the tooth  was swollen and painful. It had a pocket of 5-7 mm, and No drainage.  Clearly her pain could be due to a failing root canal or a fracture of one of her roots or also because of side teeth fillings. The x-rays taken were non conclusive.
                     To make the diagnosis more complicated the Patient had a bad cold and throat infection and fever. So the pain could have been worsened by Sinusitis or general malaise of the patient, which would definitely get better within 2-3 days with medication.

             I placed the patient on Antibiotics and it was decided that the best course of treatment was to do nothing more for the present but to speak with her in the following week to see if she was experiencing any improvement. If there was no improvement he could then check her again to see whether there was an actual tooth problem that required treatment.

                  Although patients in pain often want immediate relief, sometimes the best way to handle  a problem is to do nothing. This is especially true when the dentist is not sure what is causing the problem and there is a possibility that the symptoms will go away if the patient is given enough time. If the problem persists for more than a week or two , the patient should come back to the dentist in order to have him better diagnose the cause of the symptoms and often the source of the problem may become more apparent if given additional time.
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Wednesday, February 12, 2014

What Should you do if your Filling Falls off...

If your filling falls off it is generally the time to call and schedule a dental visit. If your tooth is not hurting, it usually not so important to call your dentist, but you would be wise to seek an appointment within a week. Absence of pain is not a reason to delay seeing a dentist, since patients who report that a filling has fallen out can often have decay present or may have a piece of the tooth broken as well.

Once you visit your dentist, he will most likely need to take a dental radiograph or two so that he can diagnose the extent of the problem. If there is no decay present your tooth may just require a new filling. If decay is present, the dentist will need to clean it out prior to refilling the tooth. Bear in mind that in the event that the decay  has compromised the pulp, your tooth may require a root canal procedure and teeth with extensive missing tooth structure may be candidates for a crown instead of a filling.

Wednesday, May 1, 2013

Toothaches : What to do..?

English: Aching tooth: This statue is in the w...
Aching tooth

Although there are many causes for "toothaches", the correct procedure is to call your dentist. If you do not have one, call a friends dentist. If its after hours, call and take the appointment. Ok, but what to do until then?
The first thing to try is to take a pain killer such as Ibuprofen (Combiflam or Flexon) or Crocin. Both of these medications are not only good at cutting down inflammation but also provide pain relief for mild and moderate pain. Both are excellent to be used as first line medications for tooth pain. Do not take a stronger narcotic medication without trying one of these two. The sole exception would be for someone who  has a bleeding  problem or an allergy that can be caused by either of these drugs.

              It is not advisable to place tablets or clove inside the mouth in an attempt to alleviate the pain. Some patients try and holding this against the tooth in an attempt to stop the pain, but the medicines can cause burns in the gingiva. Rinsing frequently with warm saline solution can help in the event that a patient has a swelling in the gum.  It is not advisable to place a hot compress on the outside of the face, since this can draw an infection toward the skin of the face and can cause more swelling.

              Sometimes patients experience toothaches immediately after eating. Usually these people have a tooth or teeth with deep caries and eating can cause the teeth to throb. For these patients I advise not letting food come in contact with the painful tooth (teeth) since it can cause a worsening of the tooth ache. Often teeth with deep cavities and vital pulps will calm down on their own if left alone for a short period of time (an hour).

            If you are experiencing an "after office hours" tooth ache and cannot reach your dentist, a trip to the hospital emergency room is an option, since many emergency rooms have oral surgeons on call.