Wisdom teeth do not always emerge (erupt) into the mouth properly because there may not be enough room in the mouth for them to fit. Sometimes, a part of the tooth may remain covered by a flap of gum. Food particles and bacteria can get trapped under this flap and cause a mild irritation, a low-grade infection called pericoronitis and swelling. This usually happens with the lower wisdom teeth.

What You Can Do

You cannot treat pericoronitis at home. Do not use warm compresses on your face. If you recognize the symptoms, get treatment right away. The symptoms may include:

  • A bad taste in the mouth — This often happens when there’s an infection.
  • Bad breath (halitosis)
  • Pain in the area around your back teeth — Pericoronitis usually occurs around the wisdom teeth.
  • Swelling behind the very back teeth — If you have pericoronitis, you’ll notice that the gum tissue in the back of your mouth is swollen. This swelling may not allow you to bite comfortably without pinching the swollen tissues between your teeth.
  • Not being able to open your mouth fully

What Your Dentist Will Do

Pericoronitis can be tricky to treat because the overlying flap in the tissue won’t go away until the wisdom tooth fully emerges naturally — which is unlikely to happen — or is removed by an oral surgeon.

Your dentist, however, may try to treat the problem without extensive procedures. He or she will clean the area thoroughly to remove damaged tissue or pus. If the area is infected, you’ll be given oral antibiotics as well.

Your dentist will tell you how to keep the area clean, which is the best way to prevent the problem from coming back. You will have to brush and floss every day and also rinse your mouth with water several times a day. This will help to prevent food particles from building up in the area.

If the condition returns, your dentist probably will send you to an oral surgeon, who will remove the tooth. Once the tooth is out, you should not have the problem again. If the problem is caused by an upper wisdom tooth biting the gum covering a lower wisdom tooth, the upper one may be removed first.

Please call Dr. Jeffrey Fester in Roswell, GA, 770.587.4202 to schedule a free consultation.


Why Should I Whiten My Teeth?

Why Should I Whiten My Teeth?

Maybe you’ve always wanted a beautiful white smile. Or your teeth have yellowed over time. Or you’re not happy with the staining that results from drinking coffee, tea or cola. Whatever your reason for wanting whiter teeth, you’re not alone.

Just like we all have different hair and skin color, people also have different tooth color. Some teeth are more yellow than others, while others yellow with aging. Your natural tooth color can also be affected by many factors.

Surface stains and internal discoloration can be caused by:

  • The natural aging process
  • Using tobacco (smoked or chewed), drinking coffee, tea,
    colas or red wine, and eating pigmented foods such as
    cherries and blueberries
  • Accumulation of plaque and tartar deposits
  • Ingesting too much fluoride (more than 2 parts fluoride per million
    parts water) when teeth are forming, which gives teeth a “mottled” look
  • Treatment with the antibiotic tetracycline during childhood
  • Trauma to the teeth that may cause a brown, gray or black color

There are many reasons for whitening your teeth, including:

  • The boost to your confidence and self-esteem that comes from a great smile
  • A younger appearance
  • A special event such as a wedding, job interview or class reunion
  • To make a positive first impression on others
  • To simply reverse years of everyday staining and yellowing

Before beginning any whitening procedure, be sure to consult with your dentist. Only he or she can evaluate whether you’re a suitable candidate for a particular treatment.

Please call Dr. Jeffrey Fester in Roswell, GA, 770.587.4202 to schedule a free consultation.


How Do I Know What Shade My Teeth Are?

How Do I Know What Shade My Teeth Are?

There’s no one standard system in the dental field to measure and determine tooth color. Nor is there an exact answer to how white your teeth can become-every person’s situation is unique. One commonly used reference tool, however, is a shade guide.

One of the more common shade guides divides tooth color into four basic shade ranges:

Tooth Shades

  • A (reddish brown)
  • B (reddish yellow)
  • C (gray)
  • D (reddish gray)

Within each range are different levels of darkness — which results in a chart detailed enough for almost everyone to find their exact tooth color on the guide.

To use such a guide, simply match your current tooth color to the corresponding color on the chart. This gives you a starting point as you determine how much whiter you’d like your teeth to be.

How white should your teeth become? That depends.

There’s no one right way to whiten your teeth. Some people want an instant and dramatic change, while others prefer more gradual whitening such as the type that results from a whitening toothpaste or gel. Final results depend on your natural tooth color, how stubborn any stains are and the treatment you choose. Keep in mind that:

  • A change of just two or three shades can make a noticeable difference in just about anyone’s smile
  • While whitening can occasionally change tooth color nine or more shades, the majority of people who whiten their teeth see a change of between two and seven shades
  • Each procedure has its advantages and disadvantages. Laser whitening and other in-office bleaching procedures, for example, may produce the most dramatic results, but cost significantly more

Please call Dr. Jeffrey Fester in Roswell, GA, 770.587.4202 to schedule a free consultation.


How Does Tooth Whitening Work?

How Does Tooth Whitening Work?

There are many ways to whiten your teeth — from whitening toothpastes and other products that can remove many surface stains for very little cost, to light-activated whitening techniques in a dentist’s office that cost up to $1,000 and can produce dramatic results.

All whitening techniques work in one of two ways:

  1. Bleaching removes both deep & surface stains.Bleaching removes both deep & surface stains.Bleaching procedures change your natural tooth color, usually anywhere from five to seven shades brighter. In-office (chairside) whitening and at-home (tray) whitening both rely on bleaching. Bleaches contain an active ingredient, most often carbamide peroxide or hydrogen peroxide in concentrations of 10-22%, which helps remove both deep and surface stains. There are significant cost differences between different bleaching procedures:
    • A light-activated whitening session in a dentist’s office, sometimes called chairside bleaching, can cost $500 or more and results in instantly and often dramatically whiter teeth. However, after a year or so of eating and drinking normally (coffee, tea, soft drinks), your teeth become slightly discolored again and develop new stains. With chairside bleaching, you have to pay the $500 to have white teeth again.
    • A custom mouthpiece created by your dentist for in-home bleaching costs around $300, and you typically wear it several hours a day or overnight for two weeks. When you notice new staining, you just wear the mouthpiece again for a night or two to take the stains off.
    • Over-the-counter products for whitening teeth (those found in a drugstore) include boil and bite tray application, whitening gels applied with a brush, and whitening strips in a price range of $10.00 to $45.00.
  2. Abrasion removes most external stains.Abrasion removes most external stains.Non-bleaching procedures work by physical and/or chemical action to help remove surface stains. All toothpastes rely on mild abrasion to remove surface stains between dental visits. Whitening toothpastes have special chemical or polishing agents that provide additional stain removal. A professional cleaning by a dentist or hygienist also uses abrasion and polishing to remove most external staining caused by food and tobacco.

Everyone responds differently to different whitening procedures. Some people respond well to whitening toothpastes, while people with gray teeth or other serious discoloration may require porcelain veneers or bonding (discussed elsewhere in this section) to achieve the smiles they’ve always wanted. Only your dentist or hygienist can determine what’s right for you.

Please call Dr. Jeffrey Fester in Roswell, GA, 770.587.4202 to schedule a free consultation.

Fluoride Supplementation: The Ongoing Debate

Fluoride Supplementation: The Ongoing Debate

Diane L. Markowitz, DMD, PhD

Fluoride: Striking a Balance

Along with vaccination, control of infectious diseases, and motor vehicle safety, adding fluoride to US drinking water is considered one of the greatest public health achievements of the 20th century.[1] Fluoride was first added to water in 1945, a measure that was followed by a dramatic 50%-70% decline in the incidence of decayed, missing, or filled teeth (DMFT) in the United States.[2] Fluoridation was considered a safe and inexpensive way to prevent tooth decay, regardless of socioeconomic status or access to dental care.

The success of supplemental fluoride in reducing tooth decay and loss led to a search for additional modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, drops, and professionally applied fluoride treatments.[2] More than 65 years after fluoride was first added to community water supplies, the outcome of the “more is better” approach is an inability to accurately quantify the population’s exposure to fluoride. Is it enough? Is it too much?

One year ago, after extensive review of the available evidence, the US Department of Health and Human Services (HHS) and the US Environmental Protection Agency (EPA) recommended that the maximum level of fluoride in drinking water be lowered to 0.7 mg/L (currently the minimum of the optimal range, 0.7-1.2 mg/L).[3] This step was taken to balance the benefits of supporting dental health in all children by preventing dental caries while limiting the risk for inducing fluorosis because of the unknown, and possibly excessive, exposure to fluoride from multiple combined sources.[4] Still, the practice of adding any fluoride at all to municipal water supplies has vocal opponents.

What Is Fluoride?

Fluoride is the reduced form of fluorine. It can occur as fluoroacetate, which is a fluorinated calcium phosphate that is common in silicates found in bedrock. Depending on the bedrock’s mineral content and climate factors, rainwater filtration through these geologic formations can result in unsafe levels of naturally occurring fluoride in aquifers used for municipal drinking supplies.[5] Naturally occurring fluoride in ground water is not found in significant amounts in the overwhelming majority (96%) of US communities.[6]

Fluoride is incorporated into the mineral portion of tooth enamel, hydroxyapatite, as it develops. Hydroxyapatite becomes fluorapatite, which is more resistant to demineralization caused by bacterial acidification in oral plaque. Dietary fluoride incorporated in plaque has an antibacterial effect, slowing the growth of Streptococcus mutans, the primary cause of dental caries.[7]

Supplemental Fluoride: Benefits and Harms

Evidence for a population level benefit of community water fluoridation is extensive and has been well-reviewed elsewhere.[8-10]The overarching conclusion from this evidence is that fluoridation is effective in reducing the prevalence and severity of dental caries across the lifespan, even after the expanded exposure to fluoride from toothpaste and other nondietary sources.[4]

However, closer inspection of subpopulations of minority children demonstrates that although the DMFT index has declined in the general population, it has remained stubbornly high in some areas. Subgroups of children in the top tertile for the DMFT index include those who are[11]:

  • Black or Hispanic;
  • Living in poverty;
  • Lacking access to dental care; and
  • Living in areas with a nonfluoridated water supply.

Lack of fluoridation has been found to have the greatest influence on high DMFT index, but as children get older, race, poverty, and lack of dental insurance outstrip the effects of nonfluoridation. In other words, although drinking water fluoridation is beneficial, it cannot completely overcome the deleterious consequences of social inequality.[12]

Claims of Harm

Despite substantial evidence for benefit, healthcare providers often find it challenging to convince parents that no harm will come to them or their children from recommended amounts of supplemental fluoride. These parents may be aware of the views of contemporary “antifluoridationists” who believe that water fluoridation is a vast conspiracy among scientists, health professionals, and industry (such as aluminum mining and pharmaceuticals) to dump an unnecessary and dangerous waste product into public water supplies. Fluoride has been blamed for allergies; goiter; chronic fatigue syndrome; hip fractures; Down syndrome; and many types of cancer, most notably osteosarcoma.[13,14]

Fluoride’s detractors insist that fluoride has no public health value and that no clear scientific evidence proves that fluoride actually reduces tooth decay or is harmless to humans. Some have even claimed (incorrectly) that the American Dental Association can arbitrarily revoke the licenses of dentists who voice disapproval of fluoridation.[13]

Objections to community fluoridation are based on poorly designed studies whose conclusions are quoted repeatedly and without objective analysis. Critics who cite these studies often do not distinguish correlation from causation. The most often cited harms from fluoride involve intelligence, bone health, reproductive health, and cancer.

Fluoride and intelligence. A study widely cited for fluoride’s deleterious effects purports to show that fluoride impairs intelligence in children.[15] The study compared 118 children in 2 Chinese villages: one with high and one with low naturally occurring fluoride levels in the water supply. Group comparisons were made on 7 categories of the intelligence quotient (IQ) in these 2 villages. The investigators found that IQ was significantly lower in the high-fluoride village and that IQ was inversely related to urinary fluoride levels. However, this study has major limitations. Without elaborating on the criteria for inclusion or exclusion, the researchers stated that they used a “cluster” sampling method to choose the children from each village. This technique resulted in fewer than 5 children in some cells, eliminating the possibility of determining significance. The fluoride level in the drinking water of the high-fluoride village was up to 4 times the amount recommended by US standards. Other environmental sources of fluoride exposure, including the use of coal with high fluoride content in poorly ventilated home stoves, was not taken into account. Furthermore, the village with high fluoride levels also had low iodine levels, a potentially confounding variable. Insufficient maternal, fetal, and childhood iodine intake is associated with low intelligence.[16]

Fluoride and reproductive health. Much of the research on the biological effects of fluoride has been conducted using rat and mouse models. A study at the National Institute of Environmental Health Sciences found no deleterious reproductive effects in animals given drinking water with 100-400 times the concentration of fluoride recommended for humans.[17]

In the early 1990s, researchers demonstrated chromosome damage in vitro in great ape cells, but not rat cells, exposed to artificially high fluoride levels.[18] The results of this study have not been replicated in human or nonhuman primates. Fluoride critics have speculated, on the basis of this study, that humans are more sensitive than rats to fluoride. However, no evidence thus far suggests that recommended amounts have a similar effect in humans.

Fluoride and bone health. Ingested fluoride is sequestered in bone as well as teeth.[19] The long-term effects on bone of low-level exposure to fluoride, however, are unknown. A study in Finland that examined hip fractures in elderly women who drank well water with high concentrations of fluoride found that higher fluoride levels were associated with increased risk for hip fractures in women aged 50-64 years.[20] However, this study did not control for physical activity or other factors that affect the likelihood of hip fracture, such as small body size, smoking, and alcohol use. In a multicenter study, bone density and bone fractures in more than 9000 healthy women older than 65 years — women who were continuously exposed to fluoridated water for at least 20 years — experienced significant increases in bone density and a concomitant reduction in fractures.[21] In a more recent study of elderly women living in 3 communities with varying fluoride water levels, serum fluoride concentrations were not associated with bone mineral density or osteoporotic fractures, regardless of water fluoride levels.[22]

Fluoride and cancer. A study conducted in the 1970s, the only one to demonstrate a significant association between fluoridated water and cancer, did not control for the industrialization more prevalent in fluoridated cities.[23] By contrast, age- and sex-controlled studies of osteosarcoma frequency and fluoridated drinking water have demonstrated no significant association.[24,25] Osteosarcoma is rare and occurs most often in growing children.[26] Still, the low frequency in this population makes it difficult to draw statistically significant conclusions about the relationship of osteosarcoma to drinking fluoridated water.[27]


With little concrete evidence for harm, how can the practice of adding fluoride to drinking water reasonably be questioned? The answer, it seems, is the only documented risk of excessive amounts of fluoride supplementation: fluorosis.

Fluorosis is hypomineralization of the dental enamel, resulting in higher surface and subsurface porosity than normal enamel. Fluorosis is caused by excessive exposure to fluoride during the early stages of enamel development. The condition is characterized by a range of defects seen as white bands and white islets in enamel as seen in Figures 1 and 2.

Figure 1. Dental fluorosis (white opacities), severe.
Image courtesy of John Warren, Iowa Fluoride Study, University of Iowa

Figure 2. Dental fluorosis (white opacities), mild.
Image courtesy of John Warren, Iowa Fluoride Study, University of Iowa

How Does Fluorosis Occur?

Structural enamel matrix proteins in mice, normally expressed during the secretory phase of amelogenesis, are stimulated by very low concentrations of fluoride but inhibited by concentrations above 2.25 ppm.[28] Although it is unknown whether a mouse model is relevant, this may be the way in which dental fluorosis occurs in humans.

Alternatively, the primary mode of action at the enamel/plaque interface may be topical exposure to fluoride, rather than systemic incorporation.[29] If this is the case, then fluoridation of drinking water should have little or no effect on primary teeth but could cause fluorosis in permanent teeth.

How Prevalent Is Fluorosis?

Mild fluorosis has been found in more than one quarter of US children.[30] Since the widespread practice of fluoridating water supplies began, the prevalence of fluorosis has risen in children, in proportion to the level of fluoridation in the water supply.[31]In communities with high natural fluoride levels in drinking water, the prevalence of enamel fluorosis is directly related to the level of fluoride in the water source.

Fluorosis estimates from a recent National Health and Nutrition Examination Survey reveal that 23% of individuals aged 6-39 years have mild fluorosis, 2% have moderate fluorosis, and less than 1% have severe fluorosis (Figure 3).[30] The highest prevalence (41%) of fluorosis was in adolescents and may reflect an increase in fluoride exposure in this age group.[4] When these data were compared with an earlier survey of fluorosis in children, an overall increase in dental fluorosis among the population was evident, including increases in moderate and severe fluorosis.[31]

Figure 3. Prevalence of enamel fluorosis in person aged 6-39 years, by age and severity of fluorosis — United States, National Health and Nutriton Examination Survey, 1999-2002. From Beltrán-Aguilar ED et al.[30]

Is Fluorosis Significant?

The significance of fluorosis has not been definitively established.Almost all cases of fluorosis (97%) are mild, are not visible to the naked eye, and have no documented effect on the risk for caries or on quality-of-life self-assessments.[32] Although fluorosis does not induce tooth decay, moderate to severe forms of fluorosis can be considered unattractive.

Most experts consider mild to moderate fluorosis to be a cosmetic concern only. A low prevalence of mild fluorosis has been accepted as a reasonable and minor consequence when balanced against the substantial protection against dental caries afforded by the fluoridation of drinking water and use of other products containing fluoride.[30] Still, the risk for fluorosis was the impetus for government agency recommendations that fluoride levels of public drinking water be lowered.[4]

How Much Fluoride Does This Child Need?

Monitoring fluoride exposure in childhood is important in preserving the effectiveness of fluoride in caries prevention while limiting the risk for fluorosis.[33] Only fluoride ingested while enamel is forming (between birth and 8-9 years of age) will affect permanent teeth and potentially cause fluorosis. The Centers for Disease Control and Prevention (CDC) recommend that children younger than 8 years of age not be exposed to more than 1 mg of fluoride per liter of fluid from combined sources.[34]In assessing a child’s need for supplemental fluoride, the clinician must consider all of the child’s dietary and nondietary sources of fluoride.

Drinking water. The greatest contribution to an individual’s fluoride exposure comes from drinking water, either as a beverage or in food preparation. Therefore, the first question to be answered by the clinician attempting to determine whether a patient is receiving adequate fluoride — or too much fluoride — is what the fluoride content of the family’s water supply is.

This question can be answered by consulting the local public health department or water utility to inquire about the concentration of fluoride in the drinking water source. This information also can be accessed at the CDC My Water’s FluorideWebsite. Most US municipalities with negligible natural fluoride in their water sources currently add fluoride to drinking water at 0.7-1.2 ppm.

Fluoride supplements. Current American Academy of Pediatric Dentistry guidelines for supplemental fluoride in children, according to the fluoride content of their drinking water, can be found in the Table.

Table. Dietary Fluoride Supplementation Schedule[35]

Child’s Age Fluoride Content of Drinking Water Supplya
< 0.3 ppm 0.3-0.6 ppm > 0.6 ppm
Birth-6 mo None None None
6 months-3 yr 0.25 mg/day None None
3-6 yr 0.50 mg/day 0.25 mg/day None
6-16 yr 1.0 mg/day 0.5 mg/day None

aThese guidelines may need to be revised if the recent HHS recommendation to reduce fluoridation in drinking water to 0.7 mg/L is adopted.

Fluoride is absent from most bottled water. Families who obtain water from a well should have it tested periodically to determine its natural fluoride level. Currently, the American Dental Association recommends that children older than 3 years living in households with well water with a concentration of fluoride less than 0.6 ppm be given a supplement in the form of drops or lozenges. Children in homes with adequate natural fluoride levels greater than 0.6 ppm should not receive supplemental fluoride.

Infant formula. Ready-to-feed liquid infant formulas contain less than 0.21 ppm of fluoride.Infants 3-9 months of age who drink reconstituted infant formula from powdered formula (which includes fluoride) prepared with fluoridated water containing more than 1 ppm of fluoride seem to be significantly more likely to develop dental fluorosis in developing permanent teeth.[36]

Because fluoride supplementation is not recommended for infants younger than 6 months of age and commonly used sources of water may be fluoridated, parents may wish to consider nonfluoridated sources of water when mixing infant formula. No fluoride is necessary in exclusively breastfed infants younger than 6 months.

Toothpaste. Toothpaste (usually containing 600-1000 ppm fluoride) should not be used during infancy, an age when children are liable to swallow it. Instead, only water and a soft, age-appropriate toothbrush should be used for oral hygiene. Once children are able to expectorate, typically by 3 years of age, they should brush with a toothpaste containing fluoride, using only a pea-size dollop. Some local absorption of fluoride will occur into the slightly porous enamel of newly erupted teeth, and most children at this age will not swallow the toothpaste. However, if the child swallows only a tiny amount, it should not cause harm. After the age of 8 years, there is little to no risk for dental fluorosis because all of the tooth crowns anterior to the 12-year molar are already mineralized.

Topical fluoride treatments. Topical fluoride treatments used by dentists (sodium fluoride 2.26% or difluorosilane 0.1% fluoride) are administered to prevent caries.[37] These products can increase ingested fluoride levels, but because these treatments are applied infrequently and are professionally supervised, they are unlikely to contribute greatly to enamel fluorosis, even in young children.[38] With a growing population of patients lacking dental insurance and the difficulty of finding dentists who will take Medicaid patients, many children are going without regular topical fluoride applications.[39]

Other sources of fluoride. A minor source of fluoroacetate is produced naturally by a few plants, in sulfur vents, and by volcanic eruptions, exposures that the average American is not likely to confront. Environmentally delivered fluoride from groundwater (possibly incorporated in agricultural products) and air pollution may be responsible for exposing the growing child to uncertain, fluctuating, and possibly excess amounts of fluoride. Exposure to certain other pollutants, such as lead, with fluoride has been associated with fluorosis in rats.[40] Measurable blood lead levels occur in some children living in old houses with peeling, lead-based paint, placing these children at greater risk for fluorosis in addition to the other deleterious effects of lead.

The American Academy of Pediatric Dentistry encourages pediatric providers to assess children for caries risk (including the level of protection afforded by fluoride exposure) and provides an online tool.[41] In addition, the American Academy of Pediatrics recommends that pediatricians consider applying fluoride varnish for patients at risk for caries during well-child visits between 6 months and until the patient is able to access a dental home. An online tutorial is available.


As a public health measure, community fluoridation improves caries resistance among all individuals without respect to economic or social circumstances. It diminishes the risk for pain, disfiguring tooth decay, and tooth loss and decreases the cost of restorative dental care and the serious health consequences that may result from dental neglect, especially in persons with chronic illness. Optimally fluoridated water has been shown repeatedly to be safe and effective in preventing these outcomes.[42]

Since public water fluoridation was first introduced in the United States in 1945, a nationwide decline in the DMFT index, a standardized way of gauging the ravages of caries, has been evident. Opponents persist in seeing fluoridation as unrelated to this decline and maintain that water fluoridation is no longer necessary.[43]

To date, no evidence proves that optimally fluoridated water in municipal water supplies is harmful to human health. Evidence does show, however, that the recommended level of fluoride in drinking water dramatically reduces the prevalence of dental caries. Claims by those who oppose community water fluoridation have been carefully examined and are not supported by current evidence. Healthcare and dental professionals should be confident in explaining to patients that fluoridated water is a danger neither to themselves nor to their children.


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Mouth Guards and Maintenance

Once you have had your mouth guard adjusted to fit your teeth you must learn to properly maintain your mouth guard. A mouth guard should only be worn during sport practices and games. Do not chew on the mouth guard because you could weaken the effectiveness of the plastic or laminated material.

Your dentist should make sure that your mouth guard does not have sharp edges

because it could irritate or damage the gum tissue or cheeks. After wearing your mouth guard, check it for damage. If your mouth guard is damaged, replace it so it doesn?t irritate the gum tissue. Your mouth guard will last longer if you properly care for it.

After wearing your mouth guard, you should clean it with cool water and use your toothbrush and toothpaste to eliminate bacteria that may develop during usage. Rinse your mouth guard and place it in a container to keep it until the next practice or game at room temperature.

Be sure to visit your dental professional for regular dental appointments and to discuss any concerns or questions you have regarding mouth guard usage in sports.

Please call Dr. Jeffrey Fester in Roswell, GA, 770.587.4202 to schedule a free consultation.