My Blog

Posts for: June, 2017

By Scott A. Allegretti, DDS Provincetown Dental Arts
June 19, 2017
Category: Oral Health

Can you have healthy teeth and still have gum disease? Absolutely! And if you don’t believe us, just ask actor David Ramsey. The cast member of TV hits such as Dexter and Arrow said in a recent interview that up to the present day, he has never had a single cavity. Yet at a routine dental visit during his college years, Ramsey’s dentist pointed out how easily his gums bled during the exam. This was an early sign of periodontal (gum) disease, the dentist told him.

“I learned that just because you don’t have cavities, doesn’t mean you don’t have periodontal disease,” Ramsey said.

Apparently, Ramsey had always been very conscientious about brushing his teeth but he never flossed them.

“This isn’t just some strange phenomenon that exists just in my house — a lot of people who brush don’t really floss,” he noted.

Unfortunately, that’s true — and we’d certainly like to change it. So why is flossing so important?

Oral diseases such as tooth decay and periodontal disease often start when dental plaque, a bacteria-laden film that collects on teeth, is allowed to build up. These sticky deposits can harden into a substance called tartar or calculus, which is irritating to the gums and must be removed during a professional teeth cleaning.

Brushing teeth is one way to remove soft plaque, but it is not effective at reaching bacteria or food debris between teeth. That’s where flossing comes in. Floss can fit into spaces that your toothbrush never reaches. In fact, if you don’t floss, you’re leaving about a third to half of your tooth surfaces unclean — and, as David Ramsey found out, that’s a path to periodontal disease.

Since then, however, Ramsey has become a meticulous flosser, and he proudly notes that the long-ago dental appointment “was the last we heard of any type of gum disease.”

Let that be the same for you! Just remember to brush and floss, eat a good diet low in sugar, and come in to the dental office for regular professional cleanings.

If you would like more information on flossing or periodontal disease, please contact us today to schedule an appointment for a consultation. You can also learn more by reading the Dear Doctor magazine article “Understanding Gum (Periodontal) Disease.”

By Scott A. Allegretti, DDS Provincetown Dental Arts
June 11, 2017
Category: Dental Procedures
Tags: teeth whitening  

Bright, naturally white teeth are a key component in a beautiful smile. But the opposite is also true: nothing diminishes an otherwise attractive smile more than stained or discolored teeth.

There is good news, however, about tooth staining: it can be greatly reduced with the right whitening technique. But before taking action we need to first uncover the cause for the staining — whether from the outside or inside of the tooth, or a combination of both.

If it’s an external cause — known as extrinsic staining — our diet is usually the source. Foods and beverages that contain tannins, like red wine, coffee or tea fall in this category, as do foods with pigments called carotenes as found in carrots and oranges. Besides limiting consumption of stain-causing foods and maintaining daily oral hygiene, you can also diminish extrinsic staining with a bleaching application.

There are two basic ways to approach this: with either a professional application at our office or with a home kit purchased at a pharmacy or retail store. Although both types use similar chemicals, the professional application is usually stronger and the whitening effect is obtained quicker and may last longer.

Discoloration can also occur within a tooth, known as intrinsic staining, and for various reasons. It can occur during tooth development, as with childhood overexposure to fluoride or from the antibiotic tetracycline. Poor development of enamel or dentin (the main sources of natural tooth color), tooth decay, root canal treatments or trauma are also common causes of intrinsic discoloration.

There are techniques to reduce the effects of intrinsic staining, such as placing a bleaching agent inside the tooth following a root canal treatment. In some cases, the best approach may be to restore the tooth with a crown or porcelain veneer. The latter choice is a thin layer of dental material that is permanently bonded to the outer, visible portion of the tooth: it’s life-like color and appearance covers the discoloration, effectively renewing the person’s smile.

If you’ve been embarrassed by stained teeth, visit us for a complete examination. We’ll recommend the right course of action to turn your dull smile into a bright, attractive one.

If you would like more information on treatments for teeth staining, please contact us or schedule an appointment for a consultation. You can also learn more about this topic by reading the Dear Doctor magazine article “Teeth Whitening.”

A growing number of dentists are now providing botulinum toxin, otherwise known as BoNT-A (Botox®), treatment for their patients for both oral and maxillofacial cosmetic and therapeutic use. It has been estimated that up to 16% of North American dentists now use BoNT-A in their practices for cosmetic and therapeutic uses . While the use of BoNT-A for cosmetic purposes has gotten a lot of attention in a number of dental journal articles, BoNT-A products are excellent products to use for dental therapeutic uses in a number of areas.

BoNT-A works by inhibiting the release of acetylcholine at the neuromuscular junction. Acetylcholine, as you well may remember, depolarizes the motor end plate of the muscle and will cause a muscle contraction. By inhibiting the release of acetylcholine, BoNT-A effectively will either reduce the intensity of the contraction of the muscle or will eliminate the contraction altogether, depending on the dosage used. Essentially, BoNT-A neurotoxin interrupts the contraction process of the muscles and causes a temporary muscle paralysis. This can last usually anywhere up to three months as the muscle initiates new acetylcholine receptors and the growth of branches from the neurons to form new synaptic contacts. Gradually the muscle returns to its full function and with no side effects whatsoever .

When you think about this clearly, and when one learns how to use BoNT-A neurotoxin properly, it can be used for a number of dental therapeutic procedures that can relieve pain and can retrain muscles which can certainly enhance dental treatment plans as well as help some serious disorders that have been frustrating to the dental practitioner for many years. TEMPOROMANDIBULAR JOINT DISORDER (TMD)

I have personally treated patients for temporomandibular joint disorder in my practice for the past 30 years. It almost seems as if temporomandibular joint disorder is some kind of fad in dentistry that has gone in and out of style during my career. We have been told that 80% of patients have some sort of TMD and need treatment, then it is something that you just don’t hear about for awhile. TMD is almost like a black box that sits somewhere in the middle of medical and dental healthcare professionals with neither profession having a decent treatment plan for relieving its symptoms. Often, TMD is just a clinical label for any pain of the jaw and facial muscles, which can be associated with headaches, earaches, cervical spine disorders, and general facial pain.

Often, with TMD cases, there may be one or multiple trigger points in muscles that a patient points to. Palpating these areas immediately sends a cascading pain along muscle or neuronal tracks that radiate from the trigger point outward. Many agents have been used and injected directly into these trigger points to treat these areas, including sterile saline and local anesthetic. The theory of trigger point injections is that the disruption of the trigger point may be enough to bring some relief, either short term or long term. The success of these treatments have been limited, primarily because the effect of sterile saline or local anesthetic lasts from a few minutes to a few hours.

Other treatments have been used for TMD disorders over the years which include psychological therapy, maxillary or mandibular repositioning, orthotic devices, neuromuscular therapy, drug treatments such as anti-inflammatory agents, non-narcotic and narcotic pain medications, muscle relaxants, chiropractic therapy, massage, acupuncture, and even antidepressants.

There are many schools of thought in dentistry that an orthognathic approach will work the best with occlusal equilibrations and full mouth reconstructions, which will absolutely relieve facial pain.

The use of BoNT-A therapy for TMD symptoms has been in use for many years , . For trigger point injections, it makes much more sense to use BoNT-A products because the effects will last for three months and you are actually helping relieve the intensity of the contraction of the muscle, which is usually in spasm. Many times we, as dentists, have developed tunnel vision and believe that just by fixing the dentition that it will solve all of the other problems. Many dentists completely ignore the fact that the muscles themselves may be in spasms and need the relief in order to allow us to achieve the right occlusal equilibration and end-point for our full mouth reconstruction. In other words, what I would like you to think about is this progression – let’s treat the muscle spasm symptoms first and then build our occlusion to the relieved muscles so that the facial pain will be eliminated. Studies clearly show the relief of painful symptoms in facial muscles with BoNT-A of up to 90% of patients who had not responded to traditional treatments .

For facial pain and TMD cases, BoNT-A neurotoxins can be generally applied to a number of muscles of facial expression and mastication, including the masseter, temporalis, frontalis, procerus, corrugator, orbicularis oris, orbicularis oculi, mentalis, depressor anguli oris and pterygoid muscles.

The use of BoNT-A products in TMD therapy can give us a totally new insight as to helping these patients who have had a lot of trouble getting relief before.


Bruxism is the general term that refers to both clenching and grinding of the teeth. There have been numerous theories as to why this occurs and certainly most bruxism will manifest itself nocturnally. Certainly, there are components of psychological stress that may cause it. No matter what the theory is that causes bruxism, there is no question that it leads to the destruction of otherwise healthy dentition, exacerbates periodontal disease, either causes TMD and is the cause of headaches and facial pain. Traditionally, intraoral appliances have been the treatment of choice for bruxism with good success as to relieving some or all of the symptoms.

We use BoNT-A products routinely in helping patients with bruxism. Here is where proper training in the use of BoNT-A neurotoxins is really essential. We would typically treat bruxism and TMD patients with bilateral injections of BoNT-A into the masseter and temporalis muscles. A practicing clinician must have a good feel as to what the proper dosage is because too much of the BoNT-A will paralyze the muscles of mastication and interfere with the patient’s ability and confidence in chewing and talking. Too small of a dosage will not have any effect at all. Using the right amount of BoNT-A will reduce the intensity of contractions of these muscles of mastication as well as give your patient full competence for chewing, eating properly, and speaking. The relief afforded to patients by BoNT-A neurotoxins can help eliminate facial pain, grossly reduce their TMD symptoms and can significantly help the other associated treatments of periodontal disease by removing the bruxism element.

As an example of BoNT-A treatment for both TMJ and bruxism, figure 1 shows a patient who has experienced facial pain and has significant bruxism, so much so that she has had to have significant dentistry repeated because of restoration breakage. You can see just be looking at this patient that her masseter muscles are in spasm even at rest and gives her a very square look to her face. This is not skeletal but is purely a result of masseter hypertrophy. Figure 2 is a close up view of the masseter muscle in spasm. You can see the result of BoNT-A therapy two weeks later in figure 3 – the masseter muscles are no longer in spasm and the patient’s face is much more rounded at the corners of the mandible. We were not interested in the cosmetic effects of this treatment even though the patient was thrilled. Her facial pain had disappeared and she subsequently has had successful long term dental treatment with BoNT-A injections repeated approximately every 4-6 months to maintain her comfort.