The Alphabet Blog: G is for Gums

The Alphabet Blog: G is for Gums

Your gums are probably more important than you think.  Dentists refer to the gums as “gingiva,”  “attached tissue,”  and “soft tissue.”

Your gums serve an important purpose:  they warn us that problems are starting.

Warning signs from your gums that tell you there are problems include redness, swelling, sensitivity to touch, sensitivity to cold, and bleeding easily.

Your gums react to local irritants such as plaque, food debris (pop corn kernels are famous for causing gingival irritation), hot foods, scratchy foods, and hardened plaque called calculus or tartar.

Irritation around your gums is very similar to having a sliver in your finger.  It might not hurt until you touch it, but it will be irritated until the sliver is removed.

In the case of your gums, prolonged irritation leads to recession of the gums.  When gums recede, or shrink downward, the very sensitive root surface of the tooth is exposed.  Many people experience cold and touch sensitivity due to gingival recession.  Treatment options include application of fluoride, phosphates, calcium and other minerals and gum grafting.

Dentists who specialize in the gums are called Periodontists. Periodontists are specialists in the gums and the bone that support the teeth.  They may recommend deep cleanings to remove debris (plaque, calculus, and food debris) below the gums that you can’t reach with floss.

You may have had your gums measured at the dentist.  We do this with a periodontal probe that is marked in three millimeter increments.  The gums surround each tooth and leave a pocket around the tooth the way a turtle neck sweater fits around your neck.  In health, the pocket around a tooth is 1mm-3mm deep.  Anything deeper than 4mm cannot be cleaned with floss.  If you have measurements of 5mm or deeper, you will be referred to a periodontist for evaluation.  If plaque or other debris is not removed, the gum tissue becomes red, sore to the touch, puffy, and bleeds easily.  Over time, the gums will let go of the place where they attach to the teeth and irritants will migrate downward and eventually destroy bone.

Healthy gums do not hurt to be flossed and do not bleed.  If it is uncomfortable for you to get your teeth cleaned at the dentist, you need to floss more and deeper.  Red, bleeding gums that hurt to touch are not being cleaned well enough daily.

Gums that are not kept clean will contribute to receding gums, overall sensitivity, cavities at the gumline, and bone loss.   Such irritation is called gingivitis  (inflammation of the gingiva).  While the gums are irritated, flossing may be a little uncomfortable and may cause bleeding but with persistent daily flossing, the gums will improve.

Colored lesions on the gums can be a sign of a problem.  However, the most common abnormal colors are due to harmless causes.  Here is a list of a few conditions that dentists can see on your gums:

White spots are often a sign of trauma to oral soft tissues and are commonly caused by:

  • biting the area
  • burning the area with hot foods (hot cheese on pizza is the #1 culprit!)
  • alcohol-containing mouth washes
  • smoking
  • smokeless tobacco

White spots can also be a sign of:

  • yeast infection (candidiasis)

Redness of soft tissues can be a sign of:

  • yeast infection (candidiasis)
  • thermal burn
  • anemia
  • leukemia
  • allergic reaction
  • Brush, floss, and be healthy

-Dr. Cook

The Alphabet Blog:  F is for Fluoride

The Alphabet Blog: F is for Fluoride

Fluoride has become a controversial topic.  Here are some quick facts about fluoride:

The Centers for Disease Control and Prevention calls fluoridation one of the 10 great public health achievements of the 20th century.

Water fluoridation reduces cavities by at least 25%.

Fluoridated water began in Grand Rapids, Michigan in 1945.  A 15-year study of 30,000 children in Grand Rapids was conducted to reveal results of fluoridation.  Results of the study:  decay in children born after fluoridation was reduced 60%.

Studies on fluoride for 60 years have consistently indicated that fluoridation is safe and effective.  It is the most efficient way to prevent one of the most common childhood diseases – tooth decay.  Tooth decay is 5 times as common as asthma and 7 times common as hay fever.

Most bottled water does not have enough fluoride to help prevent cavities.

Nearly all tap water contains some fluoride, but can range from 0.2 mg/L fluoride to 2.0 mg/L fluoride.

Approximately 70% of all public water systme are optimally fluoridated (between 0.7 and 1.2 mg/L fluoride.

Every $1 invested in water fluoridation saves communities $38 in dental treatment costs.

Most home water filtration systems do not remove fluoride.

Water filtration by reverse osmosis and distillation does remove fluoride.

Water fluoridation is considered safe and affective by the Centers for Disease Control and Prevention, the American Academy o fPediatrics, the American Medical Association, the World Health Organization, and the American Dental Association.

Dental fluorosis is a cosmetic condition in which injesting too much fluoride before age 8 causes white spots on the enamel.

The best source for information about your home water supply is your water utility.

Love your smile,

Dr. Cook

Sources:  The American Dental Association, The Centers for Disease Control and Prevention, the National Institutes of Health.

The Alphabet Blog:  E is for Enamel

The Alphabet Blog: E is for Enamel

Enamel is the hard, outer layer of your teeth.  It is fairly transluscent with a high gloss.

Enamel is the hardest substance in the body and scores a 5 on the 1-10 Mohs Hardness Scale:

Mohs Hardness Scale


Talc                      Pencil lead 1.0-2.0

2 Gypsum               Fingernail 2.5

3 Calcite                  Copper penny 3.5, brass

4 Fluorite                Iron

5 Apatite                Tooth enamel, knife blade, glass 5.5-6.0

6 Orthoclase         Steel file 6.5

7 Quartz                Scratches glass

8 Topaz                   ——

9Corundum           Saphire, ruby

10 Diamond           Synthetic diamond

In dentistry, enamel is important to bonding fillings and crowns onto teeth because bonding agents bond much better to enamel than they do to dentin.  Often, when placing a filling on a front tooth, I place a bevel around the edge of the filling to increase the surface area of the bond. 

Here is a photo of a bevel:

Bevel Example

The small rainbow-shaped reflection on the lower right corner of the upper middle tooth is the bevel I cut into the tooth.

After restoration:

Enamel on baby teeth begins to form by a process called amelogenesis during the third month of fetal development and is completed around one year of age.  Enamel develops from the tips of the teeth toward the roots, laying down one layer each day corresponding to the Circadian rhythm.

In my practice, I often describe enamel to patients as similar to a brick wall.  The wall is made up of minerals such as Calcium, Phosphates, and Fluoride.  When acid (plaque) sits on enamel, it removes minerals/bricks.  This is called demineralization. When enough bricks are missing, a hole is visible either in x-rays or upon clinical examination. That is a cavity.  Mineral “bricks” start to leave the enamel surface in an acid that measures 5.5 or smaller on the pH scale.  Examples of pH in acidic fluids:

Water   7.0  (remember, anything over 5.5 is ok)

Diet Coke   3.39

Diet Pepsi  3.05

Hawaiian Fruit Punch  2.82

Coke Classic   2.53

Pepsi  2.49

Battery Acid  1.00

Fluoride is a naturally-occurring substance that happens to fit into the space of missing bricks and leaves the enamel stronger than it is without it.

Dental materials manufacturers continue to create products that mimic enamel in every way:  hardness, wearability, how it wears opposing teeth, flexibility, and translucency.  Dental filling material is often layered to achieve the best esthetic outcome possible.

Here is an example of enamel replaced with porcelain in my office:



The Alphabet Blog: B is for Botox

Botulinum toxin is used to treat patients with certain neuromuscular conditions. In the 1950s, scientists discovered that botulinum toxin can reduce muscle spasms that cause chronic muscle cramping, pain, and wrinkling of skin.  The solution prevents some of the muscle fibers from contracting. One of the most researched medicines in the world, BOTOX® treatment is approved for medical uses across the world. BOTOX is one of three brands of botulinum toxin.  The other two are Dysport and Xeomin.  Dentists have started offering botulinum therapy for patients who clench their jaws so much that even the use of a protective mouth guard does not prevent them from breaking teeth and causing headaches and migraines.  Some dentists also offer the treatment for wrinkles.

 BOTOX® is the first medicine to be studied and then approved by the FDA specifically for the prevention of headaches in adults with Chronic Migraine who have 15 or more days each month with headache lasting 4 or more hours each day in people 18 years or older.

At Cook Family Dentistry, we recommend a removable oral appliance (“night guard”)  as the first line treatment approach for patients who exhibit signs and symptoms of chronic clenching and grinding.  Although it is commonly referred to as a “night guard,” patients benefit from wearing the appliance any time that they clench and grind. Many patients report clenching and grinding at work or while driving and notice a correlation between clenching/grinding and stressful times.  If the patient wears the guard but continues to experience fractured teeth, fillings, and crowns, headaches, or migraines we discuss botulinum therapy.

In addition to tooth problems, some patients report problems with their jaw joint (the Temporomandibular Joint, or TMJ) such as pain, limited opening, and lock jaw. For these patients, we first recommend gentle, conservative home remedies such as soft foods, warm compresses, stretching exercises anti-inflammatories (ibuprofen).  If home remedies fail to give relief, we often recommend a night guard and may refer them to an Oral Medicine specialist.

We have administered bilateral injections of the botulinum toxin neuromodulator Xeomin.  Xeomin is a brand name that is administered in the same dose as the Botox brand with the same efficacy and duration.  Xeomin has been studied and used extensively and has been proven to be exceedingly effective and safe.  For patients who clench their teeth, the benefits of Xeomin include reduction of:

  • tooth fracture
  • tooth loss
  • toothache
  • jaw ache
  • muscle soreness

  • headaches

  • migraines

Injection of Xeomin for clenching involves easy, gentle injections into the masseter muscles and in some cases, additional injection into the temporalis muscles.  Masseter injections are administered from the outer surface of the face near the lower border of the jaw bone.  Temporalis injections are administered into the bulk of the muscle above the temple area around the hairline.   Although neuromodulators for esthetic (upper face) areas often take days to take effect, my patients who have received the injections for clenching report relief within 24 hours, and sometimes immediately.  The effect typically lasts 4 months.  My patients have reported lasting effects of from 2 to 4 months.  Every patient in my office who has received botulinum therapy has raved about the relief that they finally achieved from chronic pain.

The National Institutes of Health recognizes this safe and effective treatment.  See  and  for more information.

The following is a link to two studies demonstrating the safe and effective use of neuromodulators for clenching.

The Mayo clinic statement on the use of neuromodulators to reduce muscle overactivity:

In addition, see this link from Pub Med, titled Interventional neurology: botulinum toxin as a potent symptomatic treatment in neurology.

To reduce the chronic, severe clenching forces that have caused you tooth pain, tooth fracture, filling and crown fracture, tooth loss, and headaches, I recommend masseter injections of Xeomin neuromodulator every four months.  It is hoped that in reducing muscle activity, the muscle will retrain itself, through atrophy and decrease the need for treatment over time.  This is not guaranteed, but has been reported.

I hope this information has made your life a little better.


Dr. Amy Cook


The Alphabet Blog: A is for Amalgam

The Alphabet Blog: A is for Amalgam

Bevel Example

Amalgam is what dentists call silver filling material.

At Cook Family Dentistry in Auburn, Washington, we stopped placing amalgam fillings in 2006 because newer composite material is better for the tooth in the long-run.  Composite requires much less tooth structure to be cut away, creates a seal to the tooth, and is more supportive to the tooth.  Occasionally, concerned patients ask about amalgam, and here is our reply:

Do you use mercury?

We do not place silver or mercury fillings anymore.

Silver fillings were developed in Europe in 1812 and have been used in America since 1833.

While some people may have sensitivity to certain metals, silver fillings in general have been proven to be safe.

Silver fillings last a long time but in order to place them, the tooth has to be cut more severely.  The bottom of the hole has to be wider than the top of the hole in order to hold the silver filling in place.  This undermines the tooth structure and contributes to future breakage.

Tooth-colored (composite) fillings do not require as much tooth removal.  They are bonded to the tooth and provide a seal and some support to the tooth.  Like any material, composite material can chip and wear.  Unlike amalgam/silver, composite can be repaired instead of cutting out the entire filling as long as the rest of the seal is intact and there is no decay. 

I want to take out my mercury fillings.

We do not recommend removing silver fillings unless there is decay or fracture.  Anytime we drill on a tooth, we risk irritating the nerve inside the tooth.  An irritated nerve can get better on its own but if it doesn’t, the nerve will need to be removed and replaced with a rubbery sealing material.  (This is a root canal.)  Also, removal of silver fillings creates a fine metal dust and vapor that exposes the patient.  We use a rubber dam and high volume suction to minimize exposure as much as possible when we have to remove any old materials.

The reason that mercury was added to metal powder in making silver fillings is that mercury is liquid at room temperature.

FDA has reviewed the best available scientific evidence to determine whether the low levels of mercury vapor associated with dental amalgam fillings are a cause for concern. Based on this evidence, FDA considers dental amalgam fillings safe for adults and children ages 6 and above. The amount of mercury measured in the bodies of people with dental amalgam fillings is well below levels associated with adverse health effects. Even in adults and children ages 6 and above who have fifteen or more amalgam surfaces, mercury exposure due to dental amalgam fillings has been found to be far below the lowest levels associated with harm. Clinical studies in adults and children ages 6 and above have also found no link between dental amalgam fillings and health problems.   (   March, 2014)

I hope that reading this information makes your life a little better.


Dr. Amy Cook

A Word About Tooth Brushing

We all learned how to brush as toddlers, right?  Then why do most people miss plaque?  In reality, we live busy lives.  We brush once, hopefully twice a day and if our mouth tastes minty we assume we’re clean.  Here’s what you could be missing:

Current tooth brushing info and recommendations:

Brush in the morning, after meals, and before bed.

Brush with the softest bristles you can find.  Medium and Hard bristles abrade away enamel and gums causing grooves, dark tooth structure, recession of the gums, sensitivity, higher risk of decay, and the appearance of long teeth.

Mechanical (battery-operated or plug-in) toothbrushes clean better because they provide more bristle movement.

DO NOT scrub side-to-side.  This causes horizontal grooves in teeth which lead to sensitivity, recession of gums, and exposure of softer, more vulnerable parts of your teeth.  Instead of scrubbing side-to-side, gently brush in circles, aiming the bristles toward the gumline and cleaning the gumline, too.

Because soft tissue acts as a reservoir for bacteria and odor, remember to brush tongue and cheeks.  Better yet, clean the tongue with a tongue cleaner.  In my office, we give patients the Discus Dental brand tongue cleaner.  Made of flexible plastic with two sides of gentle serrations, this tongue cleaner will remove an unbelievable amount of plaque (full of bacteria!) and odor even after brushing your tongue.  I always recommend regular cleaning of soft tissues when patients complain of chronic halitosis (bad breath).

After brushing, rinse and dry bristles before storing.

Two minutes is the recommended amount of time to brush your teeth.  Remember to brush the tongue side, cheek side, and chewing surfaces of every tooth.

Happy Brushing!

Dr. Cook

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