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We are devoted to your safety

safe orthodontics

There have been some recent news reports about people contracting infections in certain medical facilities due to improper sterilization.  These reports, understandably, have made some people concerned about infection control.  Here at Kellerstein Orthodontics, we believe that proper sterilization procedures are critical and we adhere to the protocols of the Ontario Dental Association (ODA) and the Canadian Dental Association (CDA).  We take every possible precaution to ensure your safety:

  • First, used instruments are cleaned and disinfected in an ultrasonic bath with an enzymatic detergent to remove any debris or contamination
  • Then, the instruments are rinsed in a bath of distilled water to remove any contaminants and soaps
  • Then the instruments are packaged into cassettes and sterilized in a steam-pressure autoclave.  This autoclave is checked frequently to ensure that not even the toughest microorganisms can survive in it.
  • Cassettes are wrapped and not uncovered until ready for use.  This prevents any microbes from getting to the instruments while they wait to be used

With all of these protocols in place, patients can be certain that the instruments used in their mouths are safe.  But safety does not end with our instruments.  All of our countertops are disinfected between patients with a high-level surface disinfectant.  Chairs, counters, sinks and handles are wiped down and disinfected before each new patient is called in.

We use gloves and masks for each patient, and disinfect hands with hand sanitizer before gloves are put on.  We use disposable barriers on all surfaces that cannot be wiped down, and change these between patients.

When you come to visit us for any reason, whether it be an adjustment to your braces, or a new aligner or retainer is being fitted for your use, or whether you are having your teeth scanned with our iTero 3D scanner for an Invisalign case, you can rest assured that all of our instruments are always properly sterilized before use and because we use a cassette system, each tray which contains the instruments is also wrapped in plastic to minimize any accidental exposure to any foreign contaminant.

Our office also takes care to run tests on our sterilization machines to be 100% certain that any bacteria or virus is killed ensuring that you may rest easy knowing that your visit is not only comfortable but safe.

News reports about infections are disturbing, buy you can rest assured that at this practice your safety is our top priority.

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How the selfie is impacting Orthodontics

Selfies and invisalign

The selfie – love it or hate it, there’s no denying it has had a major impact on the dental world.  It has become a go-to form of expression for many people, almost as socially acceptable as a handshake!  People will snap dozens of shots, cherry pick the one they like the best, and share it with the world.  In the course of taking multiple selfies you get to see your smile up close and zoom right in.  In the industry, this is referred to as “Photographic self-assessment”.

As a direct result of selfies we see many patients come to our door with specific concerns or requests about how to align their teeth just right for that perfect look!  That is great from my perspective, since the more specific patients are about their concerns, the better I am able to tailor a specific treatment plan to address them.
And this type of specific planning is where our new software for Invisalign treatment really shines.  First, we create an individualized smile-plan by taking a 3-dimensional scan with our state-of-the-art ITero Element scanner.  We then create a computerized simulation (called a “Clincheck”) of how the teeth will move from the start to the end of treatment, taking care that the final result addresses all of the patient’s concerns.  The Clincheck simulation also includes views of how the teeth should look at each week of the treatment, allowing us to monitor how well the teeth are responding to treatment and whether things are proceeding on schedule.  And, for patients who love to take selfies along the way, they can compare their selfies to the simulation to reassure themselves that everything is on-track.

Now, one final note about selfies – we definitely want to create a plan that addresses all of our patient’s esthetic concerns.  But we also have to keep in mind the health of the teeth, gums, and jaws.  This is why we always create plans that not only address the appearance of the front teeth, but also the back teeth and the bite, which you can’t see on the selfie.   Without doing so, the teeth may straighten but may develop gum disease, jaw aches, and may not be stable in their new position.

So take a selfie and make a list of your goals….and realize that as your orthodontist, I will likely have important input to modify that list to get you a smile that is not only dazzling, but also will last for the long-term.  And realize that obtaining that perfect smile will likely take some time, but short-cuts often end up costing more time and money in the long-run.  As the old expression goes,  “There are no short-cuts to anywhere worth going.”

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Invisalign Promotions or “cheap” invisalign. Buyer Beware.

Cheap invisalign

Let’s face it – everyone loves a good deal. That’s why, when people search online for Invisalign, their eyes are often drawn toward the ads for cheap promotions. $1800 Invsialign! $2500 Invisalign! Given that the average orthodontist’s fee for Invisalign is $6000-$7000 in Toronto, these deals seem almost too good to be true. And, as a general rule, if something seems too good to be true, it probably is.

Imagine, for a moment, seeing an online ad for plastic surgery – “Nose jobs, normally $8000, now only $1999.99.” Seems like a good deal, right? But almost too good to be true? Why would a qualified plastic surgeon lower the fee so much? Now imagine reading the fine print and discovering that the sale price was not actually for a procedure that would fully correct the nose, just alter the appearance very slightly.  And imagine finding out that the doctor performing the procedure was not actually a plastic surgeon, but just a family doctor who took a few weekend courses.  Would the deal still seem as enticing at that point, or would alarm bells be ringing in your head?

Most of the online deals for Invisalign are very similar to our imaginary plastic surgery ad.  The treatment offered at the low price is usually a product called “Invisalign Express,” vs  “full Invisalign”.  The Express product was designed for patients with the most minor dental problems, and is totally insufficient for the vast majority of patients. In other words, this cheap product is unlikely to give you the results you want, and is not the same as full Invisalign.  Furthermore,  most of the doctors offering these promotions are not orthodontists, but general dentists with much less training – similar to family doctors offering surgery.  So even when full Invisalign is used, it is not used as expertly or with the same results that an orthodontist could provide.

There is nothing wrong with wanting to save money, and some promotions are legitimate.  but before you go for that online promotion, here are some tips to be sure of what you are getting:

    1) Be aware that there is a difference between orthodontists and general dentists, and that not everyone who does Invisalign is an orthodontist.   Remember that Invisalign is just a tool and, like any tool, the results you get depend on the skill of the user.  If you aren’t sure whether your doctor is an orthodontist or a general dentist, just ask!  And beware of un-regulated terms like “cosmetic dentist” or “invisalign expert.”

    2) Make sure that the product you are buying is full Invisalign, not Invisalign Express. This will ensure

    that you will get as many aligners as you need, as well as a 5-year warranty on the results.  Ask your doctor if they are using iTero 3D scanning to help map out your treatment plan?  Our office is equipped with this exciting technology you can learn more about and watch a video about iTero here and read more in this article about it’s key benefits and why you will benefit from working with an Orthodontist that works with this technology.

    3) Ask the doctor what happens if the results are less than perfect. Will more aligners be ordered at no extra charge?  Will braces be provided at no additional charge to correct the problem? Or will you need to be referred elsewhere and have to pay again?

    4) Ask the doctor whether the goal is simply to straighten the teeth or also to correct the bite. You, as a patient, may not care much about your bite, but the doctor performing Invisalign on you should.  Without taking your bite into consideration, the results may cause you more harm than good.   

    Most of us wouldn’t shop for bargain basement medical care because we want the best for our health. Let’s not forget that our dental health is part of our overall medical health. Don’t settle for less than the best.

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Why should I care about my bite?

Most people understand why they should straighten their teeth – straight teeth are better-looking, they provide a more esthetic smile, and are more conducive to hygiene and dental health.  Less understood, though, is why it is important to have a proper bite.

The reason that most people are not concerned about their bite is that it has never bothered them in the past – they are not in pain and have no difficulty chewing.  So when an orthodontist tells them that they need their bite corrected, they wonder why it is necessary, and whether it would not be faster and cheaper to just straighten their 6 front teeth.  Frankly, there are products on the market (such as Smile Direct and 6 Month Smiles) designed to do exactly that.  But these products are very dangerous and are not offered by most orthodontists – because your bite matters, even if you’re not aware of it!

An improper bite is unlikely to cause acute pain, but is very likely to cause long-term problems to the teeth and gums, and possibly the jaw joints.

Here is a short list of some common bite problems and how they can affect your dental health:

Overbite (where the upper teeth overlap the lower teeth too far vertically)

  • Leads to chipping/damage to the edges of the teeth
  • Can wear away the backs of the upper teeth making them prone to fracture
  • Can lead to gum recession and periodontal bone loss

Overjet (where the upper teeth protrude too far ahead of the lower teeth)

  • People with overjet are far more likely than average to injure their upper front teeth, and any injuries to the teeth are more traumatic than usual, often leading to tooth loss or need for root canals
  • Can also lead to speech problems such as lisps
  • Can lead to damage to the gums behind the upper front teeth

Underbite (Where the lower teeth bite in front of the upper teeth)

  • Can lead to chipping/wear of the teeth
  • Can lead to jaw pain (TMJ disorders)
  • Can lead to speech problems such as difficulties pronouncing fricative letters (such as “f” of “v”)

What are the benefits of having a good bite?

Having a good bite maximizes the chance of your teeth, gums, and jaw joints remaining healthy for your lifetime.  It also will provide you with the most esthetic smile possible.  It can even improve the appearance of your face, both from the front and side views.

Straightening the teeth without correcting the bite is a bit like painting a damaged wall without fixing the sub-structure.  It will look okay for a while, but eventually problems will occur.

How do orthodontists correct bites?

Orthodontists train for 3 years beyond dental school, specifically learning how to correct bites.  We can often correct bite problems with braces or invisalign, using techniques that most general dentists lack the training to perform.

Occasionally we need to augment the treatment to obtain proper bite correction.  Sometimes it is necessary to have patients wear elastics, stretching from the upper teeth to the lower teeth to guide them to a correct bite.

Less commonly, it may be necessary to extract teeth, or in rare circumstances perform surgery on the jaw.  Having said this, most patients do not need such invasive treatments, and we only recommend them in cases where the benefits truly outweigh the risks.

One of the most crucial steps in the orthodontic process is formulating a treatment plan that takes both the alignment of your teeth and your bite into consideration.  It is only by correcting both of these things that we can obtain the best results for your smile and dental health.

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When should I bring my child to see the orthodontist?

kids and braces

One of the most common questions people ask me is when they should bring their child for an orthodontic consultation.  The American Association of Orthodontists recommends that children should be seen for a consultation at age 7.  The reason for this is that most children begin to get their first few permanent teeth by age 7, and so should be seen at that time to make sure they are coming in properly.

Having said that, I do not believe that most children need to be seen by an orthodontist at age 7 unless either a parent or the general dentist suspects a problem exists.  I generally recommend that kids be seen by age 9.  Frankly, there are few orthodontic problems that cannot be treated as effectively at age 9 as age 7, and there is generally a big difference in psychological and emotional maturity between those ages.

Now, the fact that I recommend children be seen at age 9 does not mean that I generally treat most kids at that age.  Many orthodontic problems are best treated once all of the permanent teeth have come in, which may not be until age 12-14.  However, there are some problems that are best treated early so as to avoid worse problems down the road.  These include crossbites, underbites, and habits damaging to the teeth (such as thumb sucking).

I generally tell parents that our consultation appointments are free of charge, so bringing their child to see me won’t cost them anything.  I may tell them that no work needs to be done and that they should return in a year, or I may identify a problem that requires immediate attention.  Either way, it is to the child’s benefit to know.

It is never too late for orthodontic treatment – I treat many mature adults in my practice.  But treating at earlier ages often makes the treatment faster and easier.  So bring your child for a consultation by age 9, or even as early as age 7 if you or your dentist suspect something might be wrong.

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Self Care Program for Temporomandibular Joint Disorders (TMJD)

The joint that connects the jaw with the skull is called the Temporomandibular Joint (TMJ).  The initials refer to the joint itself, and do not refer to a diagnosis. (Everyone has two “TMJs” but no one has “TMJ”). 

Like any joint (hip, shoulder, and wrist), the TMJ can be strained or injured.  The injury can be the result of a specific trauma to the jaw or can result from prolonged low level trauma from oral habits such as night-time tooth grinding.  Stresses (physical or psychological) can also result in tensing of the joint, which can result in jaw pain or clicking. 

Once a joint or muscle is strained, it can be easily re-injured – like a sprained ankle which is subsequently more prone to injury.  Because we use the jaw for so many activities including talking, eating, yawning, and laughing, the joint and the muscles are constantly moving.  Therefore, TOTAL relaxation of the jaw joint and surrounding muscles is difficult.  However, allowing the jaw muscles and joints to be in a relaxed position is very manageable with practice.  Regular attempts to relax the jaw muscles, and avoidance of activities that would overwork the area, will be helpful to reduce the pain and prevent additional strain to the area.  The following suggestions should help:

  1. Eat a PAIN-FREE diet.  Do not chew gum – the repetitive chewing motion involved with gum chewing places a great deal of activity on the TMJ(s).  Avoid hard foods, such as French bread or bagels.  Avoid chewy foods, such as steak or candy.  Cut fruits into small pieces and steam vegetables.   Cut up food with a fork and knife if biting into food hurts.  Chew with your back teeth.  Eat anything you want as long as it does not cause pain or locking in your jaw.  If “soft” foods cause pain, put any food you like into a blender and start on a grind setting.  Blend the food into the chewiest consistency that does not cause pain or locking in your jaw.  Do not stay on a soft diet too long by periodically increasing the consistency of your diet as tolerated.  Discuss the details of your diet with your doctor periodically. 
  2. Apply moist heat for 15-20 minutes two to four times each day to the painful area.  For example, microwave a gel pack or hot water bottle and a wet towel until they are very warm.  Wrap the towel around the gel pack/hot water bottle and put it on both sides of your jaw going under your chin, or treat one side and then the other side of your jaw.  This heat treatment should feel very warm but comfortable.  Some people respond better to cold treatments.  Try using ice wrapped in a very thin cloth (or no cloth) for 5-10 minutes two to four times each day over the painful areas of your jaw muscles and/or TMJ(s).  The ice may initially give you a “burning” sensation – this is normal.  Keep the ice on the painful area only until you first feel some numbness, and then remove it.  Heat or ice can reduce joint or muscle pains and relaxes the muscles.  You may also find that cold followed by heat is useful.  Experiment. 
  3. Chew your food on both sides at the same time to reduce strain on one side.  Specifically, cut your food into its normal size and cut that piece in half.  Then put one piece on both sides of your mouth and chew.  This will take practice.
  4. Avoid caffeine.  Caffeine is a “muscle tensing” drug and can make your muscles feel tighter.  Caffeine or caffeine-like drugs are in coffee, tea, soda, chocolate, and some aspirins.   Decaffeinated coffee typically has half as much caffeine as regular.
  5. Avoid oral habits that put strain on the jaw muscles and joints.  These include teeth clenching, teeth grinding, touching or holding the teeth gently together, biting cheeks/lips, pushing your tongue against teeth, or jaw muscle tensing.  Also avoid biting on objects like pens or pencils.  DO NOT CHEW GUM.
  6. Avoid resting your jaw on your hand.
  7. Avoid activities which involve wide opening of the jaw such as yawning.  When you feel like yawning, put the tip of your tongue hard against the top of your mouth and let your mouth open as far as it can without letting your tongue off the top of your mouth.  You can also put your hand under your jaw to limit the opening.  Prolonged dental treatments with your mouth open should be avoided, if possible, until the pain has been reduced or eliminated.
  8. Avoid stomach sleeping since this puts strain on the jaw and neck muscles.  Sleeping on your side is ok as long as you do not put a force on your jaw.  Sleeping on your back is best. 
  9. Use anti-inflammatory and pain-reducing medications like ibuprofen, Tylenol, and aspirin (without caffeine) to reduce joint and muscle pain as per your doctor’s suggestions.
  10. Calcium is very important for the healing and health of your TMJs and jaw muscles.  Calcium comes in many sources including dairy products and certain vegetables.  Supplements can be used in the 1200 mg per day range.
  11. Tongue up on your palate, teeth apart and jaw muscles relaxed.
    The teeth should not be touching/resting together except occasionally they would touch     lightly with swallowing.  We suggest that you closely monitor your jaw position during your waking hours so that you maintain your jaw in a relaxed, comfortable position.  This involves placing the tongue lightly on the top of your mouth wherever it is most comfortable while allowing the teeth to come apart, relaxing the jaw muscles.  Often putting your tongue gently on the top of your mouth where you softly say “n” is a comfortable position. 

**  RECOGNIZE THAT THIS IS NOT A LIFE-THREATENING SITUATION, EVEN THOUGH IT CAN BE VERY UNCOMFORTABLE.  INJURY TO THE TMJ AND JAW MUSCLES IS EXTREMELY COMMON, AND LOCKING OF THE JAW IS NOT UNCOMMON.  MOST OFTEN THESE SYMPTOMS WILL IMPROVE OVER TIME.  CHANGING HABITS, RELAXING THE AREA, AVOIDING ADDITIONAL STRAIN OR INJURY, AND DOING THE ABOVE SHOULD SPEED UP YOUR RECOVERY CONSIDERABLY. 

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What is ITero 3D Scanning and why it matters to you.

3D Scanning iTero

Recently, our office decided to invest in an ITero machine. Traditionally, when orthodontists needed 3-dimensional models of teeth (either to measure the teeth or to make braces or retainers), we took dental impressions. This involved mixing a goopy, rubbery material, squishing it in place over the teeth, and holding it there for 1-2 minutes while waiting for it to harden.

Although I have developed several techniques for making dental impressions less unpleasant for my patients, many have told me that having dental impressions taken was their least favorite part of the whole orthodontic process. I found that, more than any other fear that new patients had, they feared the dental impressions – having been told stories of gagging and vomiting by their friends and relatives. Well, the times have changed. ITero is a new system which uses a 3-dimensional scanner instead of dental impressions. We simply run a scanner (looks like a thick pen) over your teeth to capture the 3-D image. We can take as many breaks as you need, and no goop goes into your mouth. Say goodbye to gagging and horror stories about orthodontists! And the measurements and appliances that we make are more accurate than ever before.

As an added bonus, once we’ve scanned your teeth, we can immediately show you the scan on a monitor and do a mock-up of what your teeth will look like once they’ve been straightened – all at your first consultation visit, free of charge! We stay on the cutting edge of technology to give you innovations to make your treatment better and more comfortable than ever before. That is our commitment to you!

We invite you to visit our web page here for more info on how the ITero machine works and to watch a video.

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Halloween Candies – Which treats are OK if you have braces?

halloween braces

Let’s face it – most children and teenagers are going to eat sweets on Halloween, and an occasional indulgence won’t be the end of the world for their teeth.  But some Halloween treats are better than others, especially if braces are being worn.

With any sugary snack, the longer it is present in the mouth, the greater the potential to cause cavities.  That is why the worst things for teeth are hard candies designed to be sucked for a long time.  Things like lollypops, hard candies, and jaw breakers are among the worst culprits for causing tooth decay, whether or not braces are present.  Similarly, sticky sweets like taffy, caramel, tootsie rolls and bubble gum are difficult to remove from the teeth and can remain in the mouth for minutes or hours, leading to cavities. They also tend to get stuck under the braces and are difficult to brush away.

Crunchy treats are not necessarily bad for teeth, but they are bad for braces. Hard pretzels, nuts, and potato chips can break your braces if not eaten carefully. Similarly, candies with a hard shell that are designed to be crunched can break your braces (this includes smarties and M&Ms).

So which treats are acceptable for those with braces? Plain chocolate bars (no nuts or caramel), or chocolate bars with wafers are less likely to break braces and cause cavities. Examples of these include Kitkat bars, Aero bars, Coffee crisp bars, and others. These treats are less likely to cause problems (provided they are eaten in moderation and are followed by good brushing and flossing).

So for those of our patients who celebrate Halloween, we hope you have a great time trick-or-treating! Go ahead and enjoy some delicious treats, but please choose them wisely. And if you do accidentally crunch on something you shouldn’t, we are open the day after Halloween ☺

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Invisalign from your Dentist: What Could Go Wrong?

As an orthodontist, people are always telling me about their friends who are getting Invisalign, and often it is being done by a general dentist.  Whenever I hear such a story, I mention that I hope the person at least got the opinion of an orthodontist before starting treatment.  And my question usually elicits surprise – what’s wrong with a dentist doing Invisalign?  What could go wrong?

A lot can go wrong, actually. Invisalign is just a tool to straighten teeth and, like any tool, what matters is the skill and training of the user, not the tool itself.  Many people don’t realize that in order to become a certified Invisalign provider, all a dentist needs to do is complete a single, 10 hour course.  That’s it!  And even if dentists take a few continuing education courses in Invisalign, they still have nowhere near the training of an orthodontist, who has trained for over 3000 hours in the use of braces and Invisalign even before graduating!

“Ok”, you might ask, “dentists are not as trained as orthodontists.  But Invisalign is Invisalign, right?  What’s the difference if I get it from my dentist or my orthodontist?”  And the answer is that there is often a huge difference in the quality of the result, depending on who does the treatment.  Because in order for Invisalign to properly correct your teeth and bite, the treatment needs to be planned by a doctor who understands orthodontics.  If not planned properly, the Invisalign will not move the teeth as predicted.  What could go wrong?  Patients can end up with un-esthetic results – protrusive teeth, asymmetric teeth, teeth that won’t fully straighten, etc.  Patients can end up with gum disease, jaw aches, and unstable results.

I’ll give you an example from my own practice.  I recently got a referral from a general dentist who offers Invisalign to his patients.  He had been treating this particular patient with Invisalign for almost 2 years, and he told me that somehow the teeth were just not behaving.  He had taken multiple moldings of the teeth over the years, and asked Invisalign for corrections, but the teeth were just not getting any better.  He hated how his teeth looked, and had difficulty chewing because his back teeth did not bite together properly.  This was how the patient’s teeth looked after 2 years of Invisalign.

Crooked upper teeth.
Slanted lower teeth.
Back teeth don’t touch when biting, patient had trouble chewing.

I told the dentist that this patient would require 1-2 years of braces to correct the problem, and that it was not correctable by Invisalign.  And the dentist was shocked.  He asked me “if this case was not treatable with Invisalign, why did Invisalign accept the case?” And my reply to him was, “because Invisalign is not the doctor, they are just the manufacturer.  They rely on us to tell them what to do, not the other way around.”

And this is what is so crucial to understand about Invisalign –

it is not a magical solution for effortless tooth-straightening.  It requires the skill and training of an orthodontist to tell the Invisalign company how to move the teeth.  Otherwise, the plan that Invisalign generates might not be realistic.

What can go wrong if your treatment is not done by an orthodontist?

You can potentially waste 2 years of your life, thousands of dollars, and end up with a worse problem than you started with, as this patient learned to his dismay.

Look on every street corner and you will find a general dentist with an Invisalign sign in the window.  But if you are hoping to get Invisalign, make sure that you choose an orthodontist.  Because Invisalign doesn’t straighten your teeth.  The doctor using the Invisalign does.  Your dentist is not an orthodontist….even if he does Invisalign.

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When should I ask my Dentist for a Referral?

The other day I was talking with a friend, and he told me, “I have a great dentist.  He does EVERYTHING – root canals, orthodontics, gum surgery, even wisdom teeth.”  I’ve heard comments like this before, and they make me realize that there is a misunderstanding among the public when it comes to dentistry, which does not exist in medicine.
No one would ever say “I have a great family doctor.  He does EVERYTHING – brain surgery, appendix removals, even liposuction.”  Most people understand – at least in medicine – that no one can be an expert at everything.  Family doctors have their areas of expertise, but what makes a family doctor truly great is in knowing when to refer you to a specialist to get the best possible care.  The same is true in dentistry.
Many people are unaware that specialties exist in dentistry.  Dental specialists are:
  • Orthodontists (experts in straightening teeth, correcting bites, aligning jaws)
  • Oral Surgeons (experts in removing teeth, surgery on the jaws)
  • Endodontists (experts in root canals)
  • Periodontists (experts in treating gum disease)
  • Pediatric Dentists (experts in treating children, patients with behavior problems)
  • Oral Radiologists and Pathologists (experts in diagnosing complex problems of the jaws)
These specialists are dentists who, after finishing dental school, completed another 2-4 years of additional training, specifically in managing their area of expertise.  Thus, an orthodontist has MUCH more training than a general dentist in using braces and Invisalign.  An oral surgeon has MUCH more training at removing wisdom teeth and performing surgery on the mouth.  And so, patients who require these procedures would be well-advised to seek a referral to a specialist.
So why don’t dentists automatically refer patients to specialists?  Well, many of them do exactly that.  But some dentists take continuing education courses, training to perform procedures previously only done by specialists.  And with their additional training, they don’t always see the need to refer patients elsewhere.  Or sometimes they know that a specialist will charge a higher fee for a given procedure, and they will offer to do the procedure themselves to save the patient money.  It becomes difficult, from the patient’s perspective, to know whether to ask for a referral or not in such cases.
To help with the decision making, here is a short (and by no means comprehensive) list of problems for which I would recommend that you seek a referral, no matter how much continuing education your dentist has done:
  • Extraction of impacted wisdom teeth (or any complicated extraction)  (Oral Surgeon)
  • Gum surgery, including grafts and crown lengthening (Periodontist)
  • Gum disease with 5mm or more of pocketing or recession (Periodontist)
  • Root canals of molars (Endodontist)
  • Bone grafting surgery prior to implants (Periodontist or Oral Surgeon)
  • Implant placement where more than 2 implants are to be done, or where the implants are not in the front of the mouth (Periodontist or Oral Surgeon)
  • Orthodontics of any kind, whether braces or Invisalign (Orthodontist)
Although there are general dentists who offer the above procedures in their offices, I think that in a city as well-served by specialists as Toronto, there is no good reason not to see the best-trained person for these highly complicated procedures.  Doing so will give you the best chance for an excellent result and the lowest chances of failure or complications.
You see, a dentist might pull wisdom teeth, but if something goes wrong during the procedure the patient will be sent to an oral surgeon who is trained to handle complications.  Would it not be wise to see that oral surgeon right from the start, knowing that the procedure is a complex one?
A dentist might be a certified Invisalign provider (all that takes is a single, 10 hour course), but if something goes wrong and the teeth or bite do not align, dentists often lack the training to correct the problem.  At that point, they will refer you to the orthodontist you could have seen to begin with, and perhaps avoided the problem altogether.
Dentists are your first line of defense against problems of the teeth and mouth.  They are an integral part of your health-care team, and are the people best suited to help you with cavities, mild-to-moderate gum disease, dealing with missing teeth, and handling esthetic concerns in your mouth.  But for patients with more complex problems of the mouth, seeking a referral to a specialist is just as advisable as seeking a referral to a medical specialist for any other part of your body.