Drilling Down

A guide to the mysterious world of dental procedures.

 Illustration by Andrew Joyce

Like most people who grew up in the ’70s and ’80s, we thought dentists were all about routine cleanings and fillings, and little more. 

Today, dentists have so much more in their repertoire, from invisible braces and implants to same-day crowns and porcelain veneers. Often, they will tell you about these things while you’re reclined in a dental chair, which is not ideal. You’re too focused on the bright light, the dental professionals in surgical masks hovering over you, and the cooking show on TV.

To find out what’s really going on, we’ve talked to a few dentists around the state. We asked them to tell us what they did besides cleanings and fillings, and what questions their patients had, when they weren’t too busy staring into the light or learning how to make a soufflé. Here’s what we found out.

Getting to the Root of It

For those of us getting to a certain age, we may hear more about root canals. It turns out they’re not as scary as their name implies.

“When you have a root canal, the nerve in your tooth is removed, not the roots of your tooth,” says Dr. Kelly Bussey, a Virginia Beach endodontist. “I get that question a lot: ‘If you remove the roots of my tooth, is my tooth going to fall out?’ The answer to that is no. When you have a root canal, the outside of the tooth still stays alive, so it’s still held into the socket.”

Patients need a root canal when the nerve in a tooth is starting to die or has died and is abscessed, she says. Some of the causes can include an area of decay that reaches the nerve tissue or a crack or a fracture in a tooth. Teeth with multiple fillings are also vulnerable to decay.

The pain of all this death and decay soon makes itself known. “A dying nerve is typically sensitive to cold, pressure, and sweets,” she says. “A dead nerve is typically an abscess, so that has symptoms of infection: pain to pressure, swelling, and some heat sensitivity.”

Every tooth that undergoes a root canal requires the placement of a crown. “And the reason being is, the whole point of a root canal is to seal up the system, so the root canal filling material that the endodontist places seals the root structure and then the crown seals the crown part of your tooth, the part that shows in your mouth,” Bussey explains. BusseyEndo.com

Plant One On 

Implants are titanium screws that are placed in the jaw to hold dental prosthetics, which can range from single restorative crowns to full, permanently affixed dental arches. 

“Implants are for tooth loss, whether it’s loss of one tooth or all of your teeth,” says Dr. Vincent Coviello, an oral surgeon in Winchester. Tooth loss can occur over time, due to decay, or as the result of a sudden, traumatic injury.

Sometimes patients refer to the crown as the implant, instead of the screw. In addition, “I’ve had patients tell me they have a post—thinking they have an implant—but it may be something like an embedded post in a root-canal-treated tooth,” he says. “When they see pictures of the implant driven down or screwed into the jaw itself, they understand [the difference].”

The process of getting an implant can take several visits over the course of months. “The first is a surgical phase, which can take a few appointments. It could be just the placement of the implant and the follow-up for the implant. Then there is the prosthetic phase, which is usually rendered by the dentist, where the crown or denture is affixed to the implant,” says Coviello.

While they are waiting for their final product, patients can be fitted with a temporary prosthesis for aesthetic reasons. The temporaries are premade and applied to the implants at the time of surgery. In addition, “I would say a majority of patients need some type of ancillary grafting to make the implants happen because they may not have a good enough bone foundation,” Coviello says.

While most dentures may cost a few thousand dollars, a fixed upper or lower arch—secured by four to six implants—can cost around $25,000 per arch. At Coviello’s office, the cost is all-inclusive, including the lab fees for the dentures, the implants, and the dental and surgical fees. Many of these dental arches are made from porcelain and have a more natural appearance than acrylic dentures. From a functional standpoint, “They’re closer to your regular teeth and are not taken in and out of your mouth. They’re also less bulky than conventional dentures,” says Coviello. 

“The only complaints I’ve really had are about cleaning. You have to be a little agile to clean around the implants themselves. Overall people are pretty happy with it,” he says. WinchesterOralSurgeryCenter.com

Fill Me In

Dr. Deidra Kokel

While the whir of a dental drill is one of the most memorably chilling sounds of childhood, right up there with the squeak of chalk on blackboards, some dentists now offer a quieter alternative known as laser dentistry. The method channels the power of water, air, and laser light to easily strip away dental decay, thoroughly clean the area, and create fillings. 

Because it pulses instead of grinds, the laser does not agitate the nerves. “Seventy-five percent of laser patients do not need to be numb. There’s no shot, there’s no needle, and they walk out with a white filling,” says Dr. Deidra Bird Kokel, a Leesburg general and cosmetic dentist. 

In addition to fillings, the laser can be used for biopsies and other procedures. Kokel can set the laser’s wavelength to address either the teeth, which are composed of hard tissues, or soft tissues, such as the tongue, cheeks, gums, and lips.

Sometimes filling patients worry about what happens if the laser were to strike an area beyond the tooth. “They think it’s like a Buzz Lightyear laser. They’re afraid it will cut or burn their gum,” she says. “As long as you have a proper setting for the wavelength, which we have been trained to do, it’s a very, very accurate process.” LeesburgDentist.com

Getting Deep

Routine dental cleanings usually take place every six months. Sometimes, though, a dentist will refer a patient to a periodontist for a more intensive cleaning.

“Scaling and root planing is a nonsurgical periodontal therapy that involves careful cleaning of the root surfaces to remove plaque and calculus from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins,” says Dr. Priya Acharya, a periodontist in Roanoke. “Patients are given local anesthesia for comfort.”

According to Acharya, patients require the therapy when they have an excess pocket depth in the groove between their gums and teeth. The area is measured with a dental probe in a periodontal exam, which also includes a full mouth series of X-rays. “In a healthy mouth, the pocket depth is usually between 1 and 3 millimeters. Pockets deeper than 4 millimeters may indicate periodontitis,” she says, referring to the serious gum condition that can harm soft tissue and lead to bone loss. 

Says Acharya, “The main side effects are the soreness of the gum tissue for two to three days and tooth sensitivity, which usually resolves after seven days.” AcharyaPeriodontics.com

Hollywood Smiles

Dr. John Kling II

If you’re wondering why so many people have such flawless white teeth these days, take a virtual stroll to the smile galleries of Kokel and Dr. John Kling II of Alexandria. Both dentists have achieved dramatic results through the application of porcelain veneers.

“Many people come in and either they’ll have older filling materials in the front teeth, discolorations or chipping, or just don’t like the looks of their teeth, and they ask about the possibilities of veneers,” says Kling, an accredited member of the American Academy of Cosmetic Dentistry. 

During a consultation, Kling will advise them about the various types of products, which include traditional and the more expensive prepless veneers. Both are made of layers of porcelain. “When light hits the porcelain, it transmits all the way through the tooth, the colors come back as natural colors,” he says. “The thing about veneers is, they can be made so you just can’t tell that they’re there—and that’s what you want.”

Traditional veneers require the removal of a small amount of tooth structure from the front of the tooth, “around maybe .5 millimeter to 1 millimeter,” according to Kling. The newer, thinner veneers, such as DuraThins, require even less preparation. “If I can avoid taking away tooth structure, I’d always rather do that,” he says.

During the first visit, “you take photo-graphs, check shading, and then we take impressions or molds of those areas, and the patient will leave with temporary veneers that I fabricate,” says Kling. Once the veneers return from the mill, he removes the temporary veneers and bonds the permanent ones to the patient’s teeth. “Although they are made of very, very thin porcelain, they are exceptionally strong once they’re chemically bonded,” he says. 

According to Kokel, who is also an AACD member, veneers can change the color and contour of teeth, as well as the width of the smile. “The number one question is, ‘If I do a veneer, is it going to look like I had braces?’ And a lot of times, the answer is yes,” she says.

Kokel says patients will pay from $900 to $2,000 for a single veneer from a master ceramist; most patients end up having eight to 10 placed to achieve a broader, Julia Roberts-style smile. “It’s a big investment,” she says, “but once they get them, they say, ‘I wish I would have done this 20 years ago.’” DrJohnKling.com 

Crown Me

The crown is the visible, white part of the natural tooth that shows through the gumline. There are also restorative crowns, also known as caps, which cover a tooth. Dentists may recommend these when the tooth structure has been compromised, due to a root canal or a large filling that has fractured. Other times, a patient may want a crown for cosmetic reasons, such as to cover a discolored tooth.

Following an examination, a dentist will file down the tooth to prepare the crown. Sometimes the dentist may add bonding materials to make the tooth area large enough to support the crown. Next come impressions. Afterward, a temporary crown is attached to the tooth to protect it until the next visit, when a permanent crown is placed.

Some dentists, like Kokel, also offer same-day crowns, which are milled right in the office. The convenient one-stop approach holds special appeal to her patients, which include many commuters fighting Northern Virginia traffic. Usually it takes about 90 minutes for her to mill a crown. Whether they choose the same-day route or come back another day, the price is the same.

The results are especially dramatic in the replacement of front-teeth restorations. “The materials have really, really changed a lot in 25 years,” says Kokel. “The older crowns had some metal in them. So, at the top of the tooth, a lot of times you will see this little gray line that goes right around the gumline. But really, that’s not a line in the tooth—it’s the cold grey metal shining through.” Today’s porcelain restorations blend more naturally into the gumline, she says.

This article originally appeared in our August 2019 issue. For more on dental health, click here.

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