Interview with Dr. Anthony Ceccacci

Originally from Toronto, Canada, Dr. Ceccacci studied at the University of Toronto (B.Sc.) and the New York University College of Dentistry where he received his D.D.S. On the Dean’s List at N.Y.U., he followed graduation with a General Practice Residency at Oral and Maxillofacial Surgery King’s County Hospital in Brooklyn, N.Y. From 1991-1998, he served as Associate Clinical Professor at New York University's College of Dentistry. He has been in private practice since 1988.

Q: What have been the most exciting and interesting advances in dentistry in the last 10 years?

DR. CECCACCI: Several exciting developments occur to me:

The first is bleaching and whitening -- procedures have improved dramatically in just the last few years.

The second is the diagnostics, in the diagnostic tools we use -- particularly advances in the use of digital films to detect cavities.

A third is implants -- the techniques have evolved to a point where everything is highly predictable, to the order of 95% or greater. And the materials used in doing implants have vastly improved.

Q: Tell us first about advances in teeth bleaching and whitening.

DR. CECCACCI: In the past, whitening was a time consuming process, one part of which was take-home gel trays that the patient did at home over a period of weeks to achieve results. BriteSmile is a whitening system that is only one 90 minute appointment and brightens your teeth 5, 6, 7 sometimes 12 shades brighter than the shade you currently have.

BriteSmile combines a whitening gel with a special blue plasma arc light. This procedure is done in-office. Results are immediate.

As a clinician, it’s very fulfilling for me to see a patient’s reaction to their teeth whitening experience. Its usually one of renewed confidence and excitement, which in our profession we don't see a lot of. Whitening is a harmless procedure in which you can walk out in 90 minutes and feel better about yourself. It’s a fun problem to solve as a dentist. It's a positive experience on both sides.


Q: Some people wonder whether bleaching is completely safe.

DR. CECCACCI: Safety in tooth whitening is a number one priority. It has been studied extensively for the past 5-7 years. The BriteSmile procedure does not have any deleterious effect on the hard tooth substance or any irreversible effects on the soft tissue as best we know.

The concentration of solutions in the BriteSmile procedure is equal to the products used for the take-home tray kits. BriteSmile uses 15% concentrated peroxide. It is the combination of the gel with the blue plasma arc light that makes whitening extremely effective.

With whitening, the teeth themselves are not "eaten away" by the acidic nature of the peroxide. The surface is only affected in that the stains which are existing on the surface area are allowed to be bleached out by the effervescence of the peroxide that is activated by the proprietary blue plasma arc light.

I, myself, have been a BriteSmile patient and am very happy with my result. My shade difference was 9 shades. I went from a B3 to an A1.


Q: What about the effects of BriteSmile on fillings and other dental work?

DR. CECCACCI: BriteSmile whitening will only lift off surface stains. It will not change the inherent color of the tooth restoration.

If you come to us for a brighter smile and you are happy with the end result of the whitening, that may perhaps prompt you to make changes in your existing dental restorations. In most cases, restorations last about 10 years. If a restoration is reaching the outside edge of that time period, you may want to change it.

But a lot of restorations are in the back regions of the mouth and if you don't have an extraordinarily wide smile, you won't see them. If the restorations can be seen when you talk or smile, ideally you should change them out once your tooth shade has been whitened.

As far as the filling restorations are concerned, if you have tooth colored fillings, you might get them to be a little bit lighter. However, they are susceptible to re-staining again. You may want to change them to porcelain inlays and onlays, which are lab-fabricated restorations. They would replace the existing fillings to match your tooth shade exactly.


Q: How do porcelain veneers work and what are their advantages?

DR. CECCACCI: Veneers are made of porcelain and are of eggshell thickness, anywhere from 0.3 to 0.5 millimeters in profile. They are positioned over the facial surface of the tooth, or what you see as tooth when you smile (the front parts of your teeth). They are fragile when they are not cemented in place, but once they are cemented to your teeth, they are very resilient to fracture.


Q: They look exactly like natural teeth?

DR. CECCACCI: Yes. The reason that people do them is to enhance their appearance so they look better than your natural teeth or your previous dental work. Many people get them for cosmetic reasons, others because they are not willing to go ahead with adult orthodontics. Let's say the patient had a rotated or malaligned tooth. That malalignment can be remedied using the prosthetic procedure of porcelain veneers rather than sit through years of orthodontics.

With properly placed veneers, you cannot detect the margin (where the tooth ends and the gum begins) of the veneer. They are strategically placed 0.5 mm below the gumline so they are not detectable. The cement used when the veneers are permanently placed is the same color as the tooth. You will not, as a lay person, be able to detect them.


Q: Are veneers always done for several teeth?

DR. CECCACCI: No, a veneer could be done for one tooth. For example, if you have particular staining or a malalignment of a tooth a veneer can be matched with your surrounding natural teeth.


Q: Why do they look better than bonding and caps?

DR. CECCACCI: Veneers look better because there is no metal substructure behind it which gives them a natural refraction of light, just like natural teeth. There is no opacity (flatness) in color as there is in bonding materials. Also, typically, with crowns or bridgework, once you have a little recession of the gumline, you see that black line at the gumline from the ceramic-metal, which, for most people, is unsightly. So veneers are a lot better from a cosmetic point of view.


Q: What are people most often seeking when they come in for cosmetic dentistry ?

DR. CECCACCI: Most people's concerns have to do with color of their teeth and typically once they've had tooth whitening, then they become concerned about an area or tooth that has not responded to bleaching, perhaps a preexisting crown, in which case we change it. They are encouraged to make changes based on their whitening results.


Q: How do digital imaging and the advances of imaging help your work? How exactly do you use them?

DR. CECCACCI: These diagnostic tools ultimately mean quicker and more efficient treatment for the patient. The accuracy of digital film reduces guesswork significantly. Treatment outcome is more predictable and thereby successful thanks to these advanced diagnostic tools.

Digital films replace old fashioned film x-rays. They are quicker to develop and need 90% less radiation to expose the digital sensor (which has replaced the x-ray film). I then bring the image onto a computer screen where the patient and I can discuss the diagnosis together. These images can be magnified, colorized, and we are able to measure exactly the amount of decay.

I also use an imaging system called Columbia Scientific SIM/Plant™ Treatment Planning software. In combination with a digital CT (CAT scan) scan, the software presents a 3-dimensional representation of the patient’s facial aspects, more importantly the jaw area. Treatment, such as dental implant surgery, can be done on a computer model prior to working on a patient. I can test various scenarios and actually perform them on the computer model (a 1:1 ratio actual size model of the patient), allowing me to consider all the options in an effort to find the optimal treatment for the patient. I engineer a treatment plan from that model and make a blueprint of the case.


Q: For what type of treatment do you most often use the planning software?

DR. CECCACCI: Dental implant surgery. It’s important to know what the jawbone structure is. The program gives us an accurate 3-dimensional picture of what the jawbone is like. This allows us to know where we need to do any enhancement, augmentation or building of jawbone structure before we perform any type of treatment. Ordinary x-rays do not suffice for this type of treatment. The software optimizes treatment plans, reduces risk and promotes successful treatment outcomes.


Q: What exactly is a dental implant? How does it work? Many people have heard the term but don't know the details.

DR. CECCACCI: A dental implant is an artificial titanium tooth root placed into the jawbone. When the implant is healed, an implant crown is screwed on top of it or cemented on top of it. It is non-removable and can support the load of a biting force just like your natural teeth.

Your natural teeth are held by alveolar bone. This is the type of bone from which the jawbone is made. The implant needs the support of that bone just as a natural tooth does. When teeth are missing, over time, bone in that area becomes lost. We need that residual, alveolar bone to place an implant into. If that alveolar bone is not there, then we place synthetic bone, prior to placing a dental implant.

Alveolar bone is not just of medical concern. It is of cosmetic concern as well. If the bone is not there, the face may have a tendency to have a sunken-in look.

The imaging diagnostics I spoke of before allows me to see what condition the jawbone is in for placing dental implants. I am able to see situation at hand, determine the various options, and choose optimal treatment for the patient, all before initiating treatment. The patient then is confident about treatment and enthusiastic about the results, because the ultimate judgment a patient makes, aside from pain, is whether or not the outcome is esthetically pleasing. Fine practitioners recognize the importance of allowing these diagnostics tools to help them. This is an important adjunct to the doctor’s skills.


Q: Have the methods of doing implants changed?

DR. CECCACCI: The technique and the implants we are using today are far superior to what we had 15 years ago. There have been remarkable refinements. The design and surface texture of the implant has been treated. Historically it was never treated.

You want the implant to stick to the bone. This phenomenon is called osseointegration. You don't want any other type of tissue, other than bone, around the implant, and so the dental industry has gone through different ways of increasing that surface area. We are up to acid etching the implants to a certain level or surface blasting the implants to increase the surface area with calcium phosphate. That seems to have an advantageous effect in that the implants can now be loaded (meaning the artificial tooth can be placed on the implant) sooner than they normally would have in the past.

We are now loading implants after about two months as opposed to before, where we had to wait 6-9 months before they were loaded. The patient that comes to us now may not know the difference, that it once took 6-9 months, but he or she certainly benefits from improved procedures.


Q: You take on complex and difficult cases. It's something of a specialty for you. How do you approach treatment for such a patient?

DR. CECCACCI: Many disciplines may need to be involved. Complex work is necessary when a patient has many different dental issues. For complex problems, you need a treatment plan to define the appropriate mode of treatment, which may or may not include dental implants. But diagnostic imaging definitely helps us map out a plan, much like an architect would, a foundation for something to build on.

This "blueprint" that is created from the software is vitally important because you want to try to mimic nature. If you consider that a patient has lost his/her own natural teeth, you’d be foolhardy to believe that you can do a whole lot better than nature did, so you aim to replicate what nature would do in terms of engineering.


Q: How has dealing with complex procedures changed for patients that have a multitude of problems?

DR. CECCACCI: When a person has a whole series of problems, we implement all of these wonderful new advances in diagnostic imaging and call on other colleagues who specialize in other branches of dentistry to help the patient.

There are complex cases that may require root canal therapy, periodontal therapy, implant therapy as well as cosmetic and crown and bridge therapy all at the same time. We must devise a plan that makes sense for the patient, one that will be efficacious and highly predictable because patient is going to have a lot of "chair" time.

Yes, we do those long, complex cases. We hope we don't have to, but it is an event that occurs on a regular basis, more often than I would like to see. If the preventative measures were truly effective, if people visited the dentist on a regular basis, they could perhaps prevent a lot of complex problems.

Most people try to avoid the dentist because they think it will be a painful experience. I believe strongly that we have learned to deal with pain management in a much more prudent fashion.

People do themselves a disservice by waiting to come to the dentist until let they end up with a series of problems. By that time, pain is usually what provokes the patient to make an appointment. They have avoided visits because of the pain fear and now they are in pain when they come to us.

We have the ability to restore them and manage their pain, but they have to be willing participants during the course of treatment to have their proposed outcome come to fruition. It is very important to win their confidence to do so. Therefore, I feel strongly about all of the technology I use, it gives me more information to be very sure about a patient’s case.


Q: What advances do you think we'll see five years from now, and what about ten years from now?

DR. CECCACCI: As far as restorative materials, what your crowns, veneers, inlays and onlays are made of, I think we are going to take leaps and bounds to create better materials that will be less problematic to the patient once they are inserted in the mouth.

Hopefully in the future, I don't know how soon, we will be able to generate enamel and dentin, which is what tooth is made of. Potentially we could replace teeth with tooth substance rather than with a foreign substances we now use. Rather than do a filling with porcelain or gold alloy materials, we will do a filling with bioengeneered enamel.


Q: Fillings would have then evolved from metals, glasses and ceramics to bioengineered enamel?

DR. CECCACCI: We're replacing bone, why can't we replace tooth substance? Or the whole tooth? Why not develop a whole tooth for that site? That is further down the road than five years. In the near future, I do believe we will have computer generated restorations that are done chair side. Rather than taking a goopy, foul-tasting dental impression, we will be able to put a scanner in your tooth, (incidentally we are doing so right now, however, not to the level of degree of success that we'd like), an infrared scanner would take an impression of the tooth or teeth in your mouth, and an hour later, the computer would generate or make a restoration out of porcelain.

That is already here and it will be refined to the point where every dental office should have one in place within five years.

What that means to the patient is less waiting. You would theoretically sit for an hour, go have lunch, come back and your restoration will be done, rather than coming back a week from now, while the technician in the lab creates the restoration and you get the final restoration back in two or three visits.

I think that is where the direction of dentistry is going. The preventative measures in dentistry will improve a lot more than they have in the past. Perhaps etiology may have a part to play because we are dealing with microbes. If we could get a handle on the microbes that are attacking our dental structures and apparatuses (the gum tissue and bone), and attacking enamel through decay, we would then become "molecular biologists." We would control and manage the habitat that these microbes live in (our mouth). We would no longer be "dentists." That would certainly be an interesting paradigm shift.


Q: What other advances have there been?

DR. CECCACCI: Other advances have been in pain management. The anesthetics we are using today, the small gage needles and the use of topical anesthetics have vastly improved. The way that we manage the patient from start to finish is a lot different than years ago where a person would have to sit "white-knuckled" in a chair to have a procedure done.

I strongly believe that a patient should not feel anything during the course of the procedure. That is the worst thing I remember when I had my own dental work done. I keep that in mind, because I don't want my patients to have the experiences I had when I went to the dentist.

Pain management has been developed to the point where very little pain is experienced at all. As with anything, there is always a risk you take with any procedure that you do and we try to minimize that risk. Pain management has improved vastly and I’m very pleased about that.

Q: How did you become interested in dentistry as a profession?

DR. CECCACCI: Like a lot of people, who become dentists, I was influenced by high school guidance counselor who helped me to set up a program leading to the profession. And I've always had scientific and technical bent.

It seemed like an interesting profession when I was high school.... and it has been. I'm constantly attending conferences here and abroad, taking continuing education courses, reading dental journals, talking to my colleagues who are still in academia (I taught for eight years at N.Y.U.) to find new ways to help my patients. It helps keep me interested.

Dentistry is a social and educational experience. I am privileged to be able to be a part of this. I am passionate about performing to the best of my ability.