The Cosmetic Dentistry Blog

My dentist touched the pulp of tooth # 19 and now the tooth is infected. The tooth is cosmetically perfect and feels as strong and healthy as my other molars. He prescribed a week of amoxicillin and told me my only option is a root canal. What can be done to ensure that the crown does not leak or become infected? Is there a way to tell from an xray if a tooth will need a post? I have done my best to take good care of my teeth, and feel as if the only option the dentists I have seen offer is root canal followed by a crown, but I don’t understand why something less extreme like topical antibiotic and refilling the tooth isn’t possible? This filling last 12 years before this infection, and a crown would last about that long as well? Essentially, what is your opinion of pulp-capping? And is there a point of infection after which root canal is no longer an option?
- Roger from Alabama

Roger,
It used to be thought that anytime there was a pulp exposure on a tooth, the tooth needed a root canal treatment.

However, if there is a “clean” exposure of the pulp, it is very possible to preserve the vitality of the tooth and avoid root canal treatment. I did this vital pulp cap treatment many times, including to a fractured front tooth where the fracture had exposed the pulp.

The important issue is whether or not the pulp is healthy. If the bleeding is minimal and stops within a couple of minutes, that’s a good indication that the pulp is healthy. If the bleeding is hard to control, then the pulp isn’t healthy and the tooth will need a root canal treatment.

When I did these vital pulp caps, I would put a cavity cleanser containing chlorhexidine gluconate on the exposure, then some type of base such as calcium hydroxide, and a resin ionomer over that. Then you wait a few weeks to see if it heals. If the tooth becomes very sensitive, or if their is tooth pain, then the pulp cap didn’t work. But my experience was that usually the tooth would heal without incident.

You said your tooth #19 is infected. Just because the tooth has a pulp exposure doesn’t mean that it’s infected. If it doesn’t hurt, then it very well could be not infected. And the antibiotics won’t help. Penicillin won’t help an infection that is inside a tooth. I’ve never known penicillin to be any help in a situation like this.

I hope this is helpful. I don’t understand the other things you’re saying and asking about the filling and a post and everything else, but hopefully this information will be useful for you.
Dr. Hall

Hello Dr. Hall,
I am 26 weeks pregnant, and I recently had a digital xray, as tooth nr 15, up, was getting sensitive. This is a tooth that had a rootcanal treatment before, and it also has a pile in it. The dentist said that there was an infection under the roots, and he gave me 3 options: 1. retreat the root canal 2. apicoectomy 3. extract the tooth and do an implant I am still hesitating between 1 or 1-2 together, just to be on the safe side . He said that usually 60-70 % of the redone root canal treatments are successful, but in my case as I am pregnant what if not. As I will be soon getting in my third trimester it will be more difficult to operate. I am also worried because of the lidocaine injection, and what it might do to the baby. I know it is usually safe, category B drug, but still. My question is: 1. Does apicoectomy need more lidocain than retreating the root canal? Is the dosage bigger? 2. How fast would my dentist know if the just rootcanal would be succeesful? Would I feel pain in week or two if it was not successful, or not because there are no nerves in the tooth. He said he won’t know it in a year. That seems long to me, I am just talking to the redoing of the rootcanal treatment and not the apico. 3. Can apico be redone on the same tooth if it is needed? Basically if root canal would have solved the problem, having a done apico can shorten the life of a tooth if just simply cleaning up the canal would have done the trick? 4. I am also worried something may go wrong during the procedure and then I’d be in pain after and need to take drugs. Right now I am not in pain, although sometimes my tooth is sensitive. It hasn’t been lately, but I know there is no guarantee to when the infection advances and then I feel it. Thanks for your answer. Both my dentist and endodentist are basically new for me, and I wanted to have another professional opinion. I know it is not easy to answer not having the Xray there. I appreciate it.

Best regards,
Anna from British Columbia

Anna,
I would have the root canal treatment re-done and nothing more at this time. But I would have it done by a root canal specialist. Specialists would be likely to have the special tools that will make this treatment more predictable.

As far as the local anesthetic is concerned, I wouldn’t worry about it. To re-treat the root canal would require very little anesthetic, because the tissue inside the tooth is dead. Root canal surgery would require considerably more anesthetic. Ask the dentist to use only the minimum anesthetic required. Yes, Lidocaine is one of the few drugs that has been proven safe during pregnancy, but still, there is no need to overdo it. And another point about your pregnancy, I imagine that the infection is a minor one, but it would still be better to be rid of it.

The dentist should be able to tell right away if the treatment went well. While it is true that re-treatment is unsuccessful somewhere between 25% and 50% of the time, when it isn’t successful, it is usually because there was a difficult problem during the treatment – such as a blocked canal, a ledged canal, curves that were difficult to negotiate, or some other cause. And the dentist will know if there were any of these difficulties. If no problems like this arose, and the dentist feels that he or she was able to instrument the root to the very tip and got a good apical seal, the results should be fairly predictable. On the other hand, if the treatment didn’t go well, you could then make the decision to go ahead with the apical surgery (apicoectomy).

Congratulations, by the way, on your pregnancy, and good luck with your tooth.
- Dr. Hall

Read more about root canal failure.

Dr. Hall,
I had an abscessed molar and my dentist took the crown off from a previous root canal and performed another root canal. Once this was completed I had an on-going infection for about a month. I then had to go to an oral s! urgeon who was able to get rid of the infection but told me to not have a crown put on for several months to make sure the tooth didn’t need to be extracted. It’s now been several months and I still have some issues with the tooth. I’ve decided that if it gets bad again I will have it extracted. My dentist had already submitted and had a crown made for the moler from my initial visit and I had paid for that service. I’ve asked for a refund since I will not get that crown put on and they are refusing. Is there no way to get any of my money back for this? I understand there should be some money not returned for me for the actual lab work performed but no partial refund?
- Kristin in Kentucky

Kristin,
It sounds to me like you are being very reasonable and polite with your request. I don’t think I’d be so polite, and let me explain why.

It is wise not to put a dental crown on a tooth after a root canal treatment until the dentist knows that the root canal treatment is successful. A certain percentage of root canal treatments will fail. In dental school, we had to wait six months before putting a crown on a tooth that just had a root canal. I doubt that most dentists in private practice wait that long, but the principle is the same – there is an element of doubt as to whether the tooth will make it or not.

Now, I think it is fair to give your dentist the benefit of the doubt when his root canal treatment failed. Sometimes they fail in spite of everything a dentist can do. Maybe he screwed up on that, maybe he didn’t. Give him the benefit of the doubt there. But I think it’s fair to hold him responsible for using poor judgment in having a crown made for a tooth that didn’t have a chance to heal yet from a root canal treatment. He should have known he was taking a risk, and I think you should get a complete refund, including the laboratory fee. I think you’re in a strong position on this matter. Tell him that if they don’t, you’ll take it up with a court of law, and then make good on that threat if they don’t comply. You won’t necessarily need a malpractice attorney – you may be able to get satisfaction in small claims court. And you could take this e-mail as evidence, or use the blog posting once it is up. Though I think you’d be better off with an attorney.

And save the extracted tooth as evidence until you get your money back.
- Dr. Hall

Dr. Hall,
I have had two dentists try to do a root canal on a front tooth of mine. Both were unable to get through the root to the end because of calcium build up. I am now looking at having an implant done on this tooth. Is this the best choice or is there a dentist out there who would be able to do something the other two dentist could not and get all the way to the end of this root canal?
- Teri in Utah

Teri,
Sometimes teeth have blockages in the roots and it isn’t possible to do a root canal treatment.

But before you give up on your front tooth, be sure that a root canal specialist (endodontist) has tried. They have special, fine, ultrasonic tips that can sometimes break through these calcium buildups. Usually general dentists will do root canal treatments on front teeth, because the roots are straight, there is easy access, and they are uncomplicated. But it sounds like you need a specialist.

It’s also possible to seal the root end of a tooth surgically, without going through the tooth. That isn’t difficult to do on a front tooth. It’s called an apicoectomy and retrofill. That might be an option to consider in your case, though there are extra possible complications when you can’t clean out all of the dead tissue inside the tooth. I’d look to the opinion of a specialist on that issue, too.

In my opinion, it’s always best to save a tooth if it is reasonably possible. There’s no substitute that is quite like your own natural tooth.
- Dr. Hall