Surprising Sources of Sugar
Most people know about the common sources of sugar in their diet but don’t realize that a huge number of products have additional added sugar that can complicate their plans to reduce sugar intake. It’s not just those sugar donuts (as good as they taste!).
Common Sources of Sugar:
- Soda
- Sports Drinks
- Energy Drinks
- Fruit juice
- Iced tea
- Candy
- Cakes, cupcakes and other desserts
- Ice cream
- Fruits
- Breakfast cereals
Tricky Sources of Sugar
- Carbohydrates including bread, pasta, potatoes, chips – In addition to many products having added sugar, your body immediately starts breaking this down into sugars in your mouth with an enzyme known as amylase.
- Many different sauces including ketchup, BBQ sauce, and spaghetti sauce. A lot of the commercial products include this in the form of high fructose corn syrup which is even worse than regular sugar
- Most yogurt brands
- Canned soups
- Salad dressings
- Granola bars
- Alcoholic drinks
- Certain gums and mints
I know when most people look at this list they think, “Wow that is everything I eat.” It is a huge problem in the western diet that so many foods have sugar. This has led to skyrocketing levels of obesity, heart disease, diabetes, and cancer, and what we’re especially concerned about, cavities.
Work to reduce how much of these foods you consume as well as how often! Limit them to mealtimes if possible to reduce your risk of tooth decay.
My Tooth Is Gray!
What Causes Gray Teeth?
There are several different reasons why teeth may show up as gray.
- An accident with the tooth. This is most common with kids where they are running around and bump one of their front teeth. This trauma causes some bleeding within the tooth which stains the tooth from the inside out. It is very similar to a bruise.
- Amalgam fillings. An amalgam filling on one portion of a tooth can create a situation in which the entire tooth looks gray.
- Decay underneath. If only a portion of the tooth has turned gray and not the entire tooth, it is very likely there is some large decay underneath. Get to a dentist ASAP!
- If all your teeth are gray and have been for as long as you can remember, it may just have been how they came in. Certain medications taken in childhood can cause this as well.
What To Do About Gray Teeth?
- With baby teeth, grayness is not a cause for concern. Generally these teeth do just fine until they come out on their own.
- Teeth stained with amalgam would need removal and replacement of the amalgam filling. Sometimes this will make the grayness go away but other times it has stained deep within the tooth and can’t easily be removed.
- Teeth with decay will need the decay removed and a filling or crown placed. Once the decay is removed, it will no longer appear gray.
- Permanent teeth that have turned gray from an accident are difficult to change the color because they are literally stained from the inside out. Oftentimes these teeth end up needing a root canal or have already had one. For teeth with root canals a procedure known as internal bleaching can be done to help whiten the stain from the inside out. Results are mixed with this procedure.
- Teeth whitening with the KOR Deep Bleaching system can oftentimes create good results in reducing the grayness.
- The last option for gray permanent teeth is to have a veneer or crown done to mask the gray on the tooth.
Dental Calculus Build-Up Linked To Heart Disease
Many previous studies have found a link between periodontal disease and heart disease. The exact link between the two still isn’t entirely clear but it is thought that the constant low level inflammation in the gum tissue raises the level of certain inflammatory chemicals throughout your body. This can be a significant contributor in the development of various types of heart disease. It is also linked to a variety of other health problems. See our section on the mouth-body connection for more information.
In a long term observational study published in PLOS ONE in June of 2016, researchers found that high calculus scores (heavy, hard build-up on teeth indicative of long term poor oral hygiene) were highly correlated with the development of angina pectoris (chest pain indicative of heart disease). Interestingly plaque scores (soft build-up on teeth), gingival index scores, and the number of periodontal pockets did not increase the risk of developing chest pain associated with heart disease. A high calculus score increased the risk of developing angina over a 26 year period by over 2 times!
So what does all this mean for you?
If you’ve got bleeding and inflamed gums, please go see the dentist!
If the dentist diagnoses you with periodontal disease get it treated!
Spend a little extra time every day working on your oral hygiene, especially flossing! Not only will you protect your teeth but possibly your heart as well!
Why Are My Gums Receding?
This is a patient of mine. He’s about 30 years old and as you can see has severely receded gums. This is probably one of the worst cases I’ve seen in several years. His receded gums are a result of brushing too hard. The root surfaces of all of his teeth have some level of exposure. Receded gums can cause a multitude of different issues over the years.
- Root surfaces of teeth tend to be quite a bit more sensitive than the enamel that covers the crown of your tooth.
- Root surfaces also tend to develop cavities at a much higher rate than enamel surfaces. The material isn’t as hard and is more susceptible.
- As gums recede, the bone around the teeth tends to recede as well. This can hurt the foundation of the tooth and eventually lead to loose teeth.
What Causes Receding Gums?
- Brushing too hard, especially with a hard toothbrush. Always use a soft toothbrush. If you notice yourself brushing hard and developing some slightly receded areas consider investing in a nice electric toothbrush. Many of the higher end models have a pressure sensor that will light up when you are using too much pressure. Check out our recommendations here.
- Periodontal disease. Poor oral hygiene along with some other risk factors can lead to gum disease, also known as periodontal disease. This causes both the bone and gum tissue around your teeth to recede.
- Genetics. Some people are just more predisposed to receding gums.
- Grinding. Teeth that get too much pressure, generally from grinding, have a tendency to develop receding gums. A nightguard will distribute this pressure more evenly and help reduce the effects of this. I recommend either having a nightguard made or using our guide on creating your own custom mouthguard at home.
- Teeth out of alignment. Severely crowded teeth or teeth pushed out in different directions have a tendency to develop more recession. Orthodontics is your best option in these cases.
How to treat receded gums?
There are a couple of different treatment options depending on why you have receded gums.
If you have periodontal disease this needs to be treated at your dentist’s office and then you will need to work extra hard on your oral hygiene to include better brushing techniques and flossing. The first line treatment for periodontal disease is scaling and root planing.
For minor recession from brushing, oftentimes no treatment is needed as long as you adjust your brushing habits.
For more major recession or recession that is severely sensitive, you can consider having surgery to graft tissue over the receded areas. Generally this is done by a periodontist (gum specialist) who will take some tissue from the roof of your mouth and transplant it over the root surface of your tooth.
Why Do I Have Sensitivity After Fillings?
One of the common questions I get asked is why do some people get sensitivity after having fillings. Sensitivity after fillings can be very frustrating and challenging. Many times you didn’t have any problems with the tooth before the fillings and now the dentist went and messed with it and it hurts! He or she must have done something wrong, right? Not always Let’s take a look at some of the different factors that go into sensitivity.
- Sensitivity in the first several days to weeks after a filling is done is oftentimes a result of the drilling done on the tooth. When a tooth is drilled on it causes a reversible inflammation in the nerve which makes the tooth sensitive. When the inflammation settles down the sensitivity usually goes away. For some people this period of time is extremely short and other people it can take weeks and weeks. Generally, larger cavities tend to have more sensitivity than smaller cavities.
- Teeth filled with amalgam (metal) fillings can develop some sensitivity as a result of the metal conducting temperature through them. This metal conducts changes in temperature far more quickly than your natural tooth enamel.
- Your bite is high. If your bite is high it also causes that reversible inflammation of the nerve which can lead to sensitivity. Usually an adjustment of your bite by the dentist will solve the problem within a couple of days.
- Bonding systems for white fillings are extremely complex. Even with perfect techniques some of the older systems still cause some sensitivity as a result of the chemical bonding process. There are steps dentists can take today to reduce this.
- Bond failure of white fillings. In rare causes the bond of the filling material to the tooth doesn’t set up quite right. This can be a result of moisture getting onto the tooth surface during the process, oil contamination, and old or defective bonding agents. This happens to every dentist at some point even with the best techniques. If the dentist removes the filling and places a temporary filling material the sensitivity resolves and then a new filling can be placed.
- If the sensitivity is severe (pain that starts on it’s own and is bad enough to wake you up at night) it can mean that the nerve is in the process of dying and needs a root canal.
- Cracked tooth. In rare cases a tooth can crack shortly after the the filling process through no fault of the dentist. This generally leads to sensitivity as well as sharp pain when biting.
So what do I recommend doing when you have sensitivity after fillings?
- If your bite feels high, go back to the dentist for a bite adjustment. This will not go away on it’s own.
- If the pain is severe, go see the dentist. Severe pain isn’t normal after fillings.
- Otherwise, give it some time. Everyone heals at different rates and oftentimes your teeth just need some time to settle down.
DIY Dry Socket
One of the most common complications of having a tooth taken out is developing a dry socket. A dry socket is when the blood clot that is supposed to be in the extraction site either doesn’t form or is displaced. This exposes the bone in the area causing a severe toothache type pain. Many of my patients have told me that the dry socket pain is worse than the toothache that caused the tooth to need to be extracted! This pain can last anywhere from a week up to 5 weeks. Most dry sockets resolve in the shorter end of that range and will always resolve on their own whether you seek treatment or not. Some types of treatment will actually extend the healing time so keep that in mind.
So how do you know if you have a dry socket? Most dry sockets follow a relatively predictable pattern.
- Tooth pain from an extraction generally peaks and starts to quickly decrease within 24-48 hours after the extraction. A dry socket on the other hand usually starts 3-5 days after having a tooth taken out.
- Dry sockets have a much higher incidence after removal of impacted wisdom teeth (especially bottom wisdom teeth) as well as after difficult extractions.
- Risk factors include smoking, using straws, spitting, taking birth control medication, and the intake of hot liquids and foods in the first day or two after the extraction.
- Oftentimes you’ll see a hollow area where the tooth came out and sometimes you can see or feel the exposed bone.
- If you notice pus coming out of the area, it may be infected rather than a dry socket. This is much less likely than a dry socket but can cause similar pain and in a similar time frame. See your dentist for sure if you are concerned it may be infected.
It is important to realize that while a dry socket can be miserably painful, there are no health consequences associated with it. All treatment seeks to manage the symptoms until the area is able to heal on it’s own. Studies have been pretty inconclusive as to what treatment, if any, is best for managing dry sockets. Let’s take a look at some of the things you can do at home.
- Practice prevention. Avoid smoking for as long as you can manage after the extraction. 3 days minimum and longer is better. Don’t use straws or spit. Avoid hot foods for the first day or two after the extraction.
- Take 600-800 mg of Ibuprofen every 6 hours on the dot. If you only take it when it hurts you’ll get into a bad pain cycle that is hard to get out of. Staying ahead of the pain is important.
- Rinse any debris out of the socket. Food tends to get trapped down in there and can cause problems. The easiest way to do this is with a curved monoject syringe. Your dentist usually has these or you can sometimes get them at a pharmacy. An alternative would be a standard oral medication syringe (like you’d use to give medications to kids). As long as you reach the tip into the socket, it’ll work fine. Put some water in it and gently rinse the socket out. Don’t be forceful as this can also displace blood clots.
- DIY Dry Socket Medications – Most medication materials that dentist’s use for dry sockets have some combination of eugenol (oil of cloves) and an anesthetic such as benzocaine as well as some other minor ingredients. Oil of cloves and benzocaine (like in Anbesol) are both medications you can purchase over the counter. The best thing to do is make a 50/50 mixture of these two things and dip a piece of cotton in it. Take a pair of tweezers or something similar that can hold the cotton and push the cotton into the socket. Make sure your cotton piece is big enough that when you push it into the socket you have enough sticking out the top to remove it. Leave it in for a couple of minutes and then remove. You don’t want to leave this in the socket long term as it will slow/stop healing. This combination of medications will help relieve some of the pain and you can do this several times a day.
- If all else fails, remember that the pain will go away on it’s own.
Oil Pulling In Dentistry
Oil pulling is the concept of placing a small amount of oil in your mouth (generally sesame oil but many others have been tried as well) and swishing, “pulling” it through your teeth, and holding it in place for some time. This oil is then spit out.
Oil pulling isn’t necessarily a new concept but has recently become popular in the west due a surge in homeopathic remedies for various types of health problems. Oil pulling originated in India and has been practiced for centuries. Traditionally it was thought to help with a wide variety of health problems including inflammation, headaches, diabetes, and even thought to whiten teeth.
While it likely isn’t dangerous, there have been no studies that have proven any benefit to oil pulling. There have been a variety of different studies that have measured the ability of oil pulling to reduce bacteria growth in the mouth or decrease inflammation. None of these studies have shown any benefit at all.
I recently had one patient come in with a cracked tooth that was abscessed and causing pain. She had tried oil pulling for several weeks and was confused as to why it wasn’t helping! Please don’t be this person! The biggest danger I see in oil pulling is that people turn to this method of dealing with an abscess or gum disease and don’t actually take care of the problem at hand. As I’ve tried to make clear on this site, I think you should do everything you can to reduce your reliance on the medical and dental profession, including using home remedies that work. This is a home remedy that does not work and these types of dental problems are absolutely ones that should be treated specifically by a dentist.
Oil pulling = Definitely Not Recommended
Implants
Updated March 11th, 2017
A dental implant is a titanium screw that is placed in the bone to replace missing teeth and are the best option for most people for replacing missing teeth. Dental implants are probably one of the most exciting developments in dentistry over the last several decades. Success rates with dental implants are in the high 90’s making them more successful than most other types of dental treatment. Dental implants can be used to attach single teeth, bridges, or dentures. So let’s take a look at the procedure for a dental implant…
The Surgery
The dentist or surgeon first evaluates the area to make sure that an implant will work. Sometimes a 3D CT scan is completed for accurate planning. If a tooth needs to be extracted first, they will do that and place some bone grafting material where the tooth came out in order to maintain the bone in that area. This area is usually allowed to heal for several months so that bone can fill in the area. If there was no tooth to be extracted, the surgeon can simply proceed with the implant placement.
During implant placement the surgeon drills a hole in the bone slightly smaller than the implant which it is inserted into. The tissue is closed over the implant and allowed to heal for 3-6 months depending on the area. Once the bone has healed around the implant, it is finally ready to put a tooth on it. Your dentist takes several impressions of the implant and a dental lab creates several pieces that will screw into the implant and hold the crown in place.
There are some situations where this surgery goes a bit differently.
- If the sinus is in the way, a sinus lift is needed to make room for where the implant will go.
- If the implant can be inserted securely sometimes a temporary tooth can be placed on the implant immediately. This ends up being especially helpful for front teeth.
- Dentures can also be attached immediately if the implants have been placed securely.
Restoring An Implant With A Crown
This is a picture of an actual implant ready for an impression to make the permanent tooth.
This is what the cross section in the bone looks like where an implant has been placed. As you can see the implant replaces the root of the missing tooth.
The part on top of the implant that sticks out above the gum tissue is known as the abutment. This is what the crown will be attached to.
Here we have a crown in place over the abutment. The tooth can function like a normal tooth again.
Benefits to a Dental Implant Instead of a Bridge or Partial Denture
- They function just about as well as a regular tooth. A well done implant should feel like a normal tooth to you.
- They are fixed in place. You basically just have to take care of them like a regular tooth.
- It is one tooth solution to a one tooth problem. You don’t have to compromise other teeth to make them work like you would with a bridge or partial denture.
Downsides to Dental Implants
- Cost and Time – One of the biggest downsides to dental implants at this point is the cost and time involved in making them work. It can take typically anywhere from 3 months to a year to complete the process.
- Having to go through a surgery – The surgery itself is usually pretty minor and heals quickly.
- Financial. They end up up costing anywhere from $2000-$5000 per implant when everything is said and done.
How to Take Care of Your Dental Implants
- You’ll want to brush and floss your implant just like the rest of your teeth. Implants can develop infections around them just like your other teeth can leading to loss of the implant. Good oral hygiene and avoiding smoking will minimize this risk.
- Don’t pick at the gum tissue around your implant. This can introduce bacteria around the implant leading to an infection.
- Keep up with regular dental visits. It is important that your dentist check the implant at each visit in order to catch any problems early.
- Consider investing in a Waterpik Dental Flosser. A Waterpik cleans off plaque around your teeth and implants far better than any other option including floss or interproximal brushes. A Waterpik has also been proven to be safe for use with dental implants.
- Use a low abrasiveness toothpaste. See our list here. Highly abrasive toothpastes can scratch the surface of the implant and cause it to build up plaque more quickly.
- Use a rubber tip stimulator on the gum tissue around the implant. This helps build a special type of tissue around the implant known as keratinized tissue. The presence of the this type of tissue is critical for maintaining a good seal around the implant and avoiding infection.
Most Common Complications of Dental Implants
- Infection around the implant. If caught early your dentist or surgeon can clean this out and often save the implant. If let go too long, the bone can be destroyed all around the implant and you’ll end up losing it.
- The screw inside the implant can break or loosen. If you start to notice the tooth moving at all, contact your dentist for them to evaluate and see what needs to be done. If the screw is loose they can usually just tighten it up again. A broken screw is a bit more difficult to fix.
Dentures
Dentures are likely the most difficult part of dentistry for both patients and dentists. The reason why most dentists don’t like them is that they are a compromise in every single way and despite doing everything right, many times patient’s struggle to adjust to dentures. They oftentimes blame the dentist for the problems, not realizing that the problem is the simple fact that dentures aren’t easy to get used to. Dentures are NOT a replacement for teeth. They are replacement for no teeth. Let’s take a look at the different types of dentures…
Complete Dentures
Complete dentures are made after you have had all your teeth removed. Complete dentures for your top teeth generally do pretty well as they develop suction that keeps them in place. Complete dentures for bottom teeth are FAR more challenging than top dentures. They do not develop suction and simply sit on the tissue. Anytime the tongue moves it tends to pop the denture up.
Here is a set of dentures made for a patient of mine. This is pretty typical of what you’ll see for a set of dentures. The gums and teeth are usually both made of an acrylic material (yep, same kind of stuff used on fake nails).
This is what the inside of a bottom denture looks like. As you can see there is very little to a bottom denture to allow it to stay in place.
And this is the inside of a top denture. Top dentures tend to stay better because they are able to develop some suction when the borders of the denture all the way around fit well.
Partial Dentures
Partial dentures are made when someone is missing multiple teeth but have some remaining teeth that are strong enough to anchor a partial denture. Partial dentures work far better that complete dentures because the remaining teeth give the denture something to anchor onto. The two main types of partial dentures are cast metal frame partials and flexible partials. The cast metal frame partials have a metal substructure and acrylic tissue and teeth bonded on top. Flexible partials are made of a nylon type material that is flexible and uses the gum tissue to create retention for it to stay in place. Cast metal partials are heavier and don’t look as good but are much easier to repair. Flexible partials look better and weigh less but are more difficult to adjust and repair.
Implant Retained Dentures
For people who aren’t able to adjust to complete dentures, we recommend having implants placed that the dentures attach to. Attachments are placed in the denture and it can be snapped in and out. Implant retained dentures do far better for people than traditional complete dentures. Below are a couple of pictures of clear model of a lower jaw with implants placed. As you can there are two implants right around where the canine teeth should be the bottom denture has several attachments that will allow it to snap on to these implants. This provides much better function than a regular bottom denture.
Fixed Hybrid Denture
A fixed hybrid denture is the Cadillac option of dentures with a similar price tag. Four to six implants are placed in each arch and a denture is made that is attached to the implants. It stays in place and can only be removed by your dentist. It restores your ability to function and chew as closely as possible to what you would have with your own teeth. As you can see from the pictures, the denture really only extends far enough to hold the teeth in place, unlike a traditional denture that has to extend much further. This makes it much less bulky and much more comfortable. You can see the screw holes that attach the denture to the implants in these pictures. Your dentist would cover these areas after tightening everything down so that you wouldn’t feel them. This type of denture can be more challenging to clean since you can’t take it out yourself. Usually we recommend a Waterpik as the easiest way to keep these clean.
Problems With Dentures
It isn’t unusual to have problems with your dentures, especially right after having them made and also after you’ve had them for a long time. Many of these problems are minimized if you use an implant retained denture.
Sores and Irritations
When you first have your dentures made, you’ll likely need several adjustment visits. New dentures sometimes create pressure spots that turn into sores or irritated areas in your mouth. Your dentist will mark these pressure spots and then remove a small amount of material on the denture to relieve the pressure. Make sure and wear your dentures at least 24 hours prior to your adjustment appointment so that your dentist can see exactly where the irritated spots are. If they can’t see them, it is very difficult to adjust the denture accurately.
Denture Stability
Complete dentures without implants are never very stable. Top dentures usually do OK because they create a seal that keeps them in place. Lower dentures are never very stable because they don’t have suction. They basically sit on your gum tissue and have a tendency to lift up when you move your tongue. I highly recommend to all my patients to get a couple of implants in the lower jaw to stabilize their denture if it is any way in their budget. If your dentures are brand new, give them a little time to settle into place. The muscles and tissue will adjust slightly to having them there within a couple of days to weeks. If your dentures are old and are less stable than they used to be, it might be time for you to get a reline.
Eating With Dentures
Eating with dentures can be challenging, especially at first. Everyone adjusts a little differently to them and has a different tolerance to what they can eat. The most important things to remember when eating with dentures are to not use the front teeth for eating (only the back teeth), cut up food first, start with a soft diet, and chew food on both sides at the same time to keep them stable. Over time you’ll get better at eating with a denture and will start to eat more challenging foods.
Talking With Dentures In
When you first get dentures you may speak funny and this is perfectly normal. When speaking your tongue likes to touch the roof of your mouth and behind the front teeth. Both of these positions change slightly with dentures and so your tongue has to get used to this new position. Practice speaking with no one around and you’ll improve quickly. Most people are talking normally again within 1-2 weeks.
Gagging
Some people have a very strong gag reflex and struggle putting their dentures in. Most people are able to adjust to this with some time. Practice putting them in while breathing in and out through your nose and staying calm. Much of your gag reflex is mental and takes some time to retrain.
Allergies
A very small percentage of people in the population are allergic to one or more ingredients used to make dentures (acrylic). There are different materials that can be used in these rare cases.
Other Denture Tips
Always take your dentures out a night. Wearing dentures all night would be like wearing your shoes all day and then going to bed with them on. Your mouth needs time to breathe!
Clean your denture everyday. Using a denture brush with soap and water is best for most people. Don’t use toothpaste as this will scratch the surface. Dentures that aren’t cleaned can cause you to develop infections in your mouth under your denture. Another option is to use an ultrasonic cleaner. This is what we use in the dental office to clean your denture. It vibrates at an extremely high rate of speed which removes any debris.
Try using a denture adhesive for better retention. I’ve found that Fixodent powder works best for most people but everyone is a little different in what they prefer. Fixodent gel also works well.
Orthodontics
Orthodontics is the field in dentistry that deals with straightening teeth. Orthodontics has come a long way in the last several decades and there are more options than ever to do this.
Early Orthodontics
For children with certain types of dental features, they should be seen by an orthodontist early on (around age 7 or 8). The most common type of feature is when they have what is called a posterior crossbite. The top teeth end up being very narrow and sit on the inside of the lower teeth instead of the outside. A palatal expander is used to slowly increase the width of their top arch of teeth. If you wait too long, the bones of the palate fuse and can no longer be expanded easily.
Comprehensive Orthodontics with Braces
Comprehensive orthodontics with braces is what is most people think of when they first think of orthodontics. The goal in comprehensive orthodontics is to align all the teeth, front and back, into the best alignment for function and esthetics. Brackets are bonded to all your teeth and attached with various types of wires to accomplish the proper movements. These types of cases usually end up taking anywhere from 1-3 years on average.
Lingual Braces:
Instead of those metal brackets bonded to the front of your teeth, they are bonded to the back of your teeth. This gives your orthodontist a bit more flexibility in how to move your teeth while still maintaining a nice (non-braces) smile. The biggest challenge with these is learning how to speak regularly again which can take several weeks. They also have the tendency to irritate your tongue quite a bit more than traditional braces.
Invisalign
Invisalign is an orthodontic system that uses multiple sets of clear plastic aligners to slowly move your teeth to the correct position. Invisalign can be used to do comprehensive orthodontics or to accomplish limited tooth movement goals. It has been getting much better over the years and can now be used to correct most orthodontic issues.
Cosmetic Orthodontics
Cosmetic orthodontics usually have more limited goals than comprehensive orthodontics. The goal is to align and front teeth to create a nice smile without altering the back teeth in any way. This allows the treatment time to be much shorter, usually on the order of 6-9 months. Several companies train dentists in this under the names Six Month Smiles and Powerprox Six Month Braces.
Removable Appliances
There are a lot of different options out there for appliances that are used to correct minor issues with tooth spacing. Spring retainers and Inman Aligners are some of the more common ones that are generally used to correct minor rotations and crowding in your front teeth.
Surgical Orthodontics
In some rare cases the teeth can’t be aligned by simply moving them. The entire upper or lower jaw have to be repositioned surgically and then braces completed. Recovery from these types of surgery takes a significant amount of time. After surgery your jaw is wired shut for approximately 6 weeks.
At Home Orthodontics
One of the newest developments in orthodontics is an Invisalign style system that you can order from home. You take your own impressions and pictures and they send you back the aligners. The company is known as Smile Direct Club. We have a specific page with more information on this product.