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Tips for root canal treatment on a porcelain veneer tooth

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Dr. Hall, For the past two months I have been experiencing slight pain, pressure, discomfort and even feeling as if my two front teeth are going to fall off. Hot or Cold do not bother my teeth. Approximately 9 years ago I chipped one and also had decay on my two front teeth. As a result, veneers were placed. Never had any problems until now. I went to a dentist that has been doing my cleanings and she did an x-ray and noticed inflammation on a nerve. Advised to take ibuprofen for 7 days for inflammation. I followed her instruction and it did work for 1-2 weeks until the same symptoms came back. I went back she took another x-ray, noticed the same inflammation. She stated if it continued then possible root canal would be the next step. However nerve had no damage, which it confused me as why she would do a root canal? I was advised from a friend that sometimes the nerve can be infected. I had some amoxicillin at home and took it for 5 days the pain once again was gone. Now 2 weeks later symptoms are back. My biggest fear is that veneers are going to fall off, is that possible? Even saliva feels weird around my front teeth only. Can you tell me if it may be possible for root canal?
– Sylvia from California

Sylvia,
I’m at a little bit of a disadvantage not being able to see this myself, but at least from what you’re telling me it seems pretty clear that your tooth needs a root canal treatment. And I will tell you why I think that.

I am interpreting the “inflammation on a nerve” that you are telling me about as signs on the x-ray of pulpal inflammation. When the pulp of a tooth is inflamed, often the first sign is either a widening of the periodontal ligament space around the end of the root, or a breakdown in the bony lining of the socket of the tooth, also occurring at the end of the root. When anything shows up on the x-ray like this that indicates inflammation of the pulp of the tooth, it is pretty certain that you are going to sooner or later need to have that root canal treatment.

Taking some amoxicillin you had at home for a tooth infection isn’t a good idea. But the response of your tooth – the pain went away and then came back two weeks later – is another pretty certain indication that the tooth is infected, which means you need a root canal treatment. The problem with having taken the amoxicillin is that now you are that much more likely to have an amoxicillin-resistant infection in your tooth. You can never wipe out a tooth infection with antibiotics alone because the antibiotics have no way to get inside the tooth. So the infection will always come back, and the next time it’s always more likely to be an antibiotic-resistant infection.

Your porcelain veneer won’t fall off this tooth if you get a root canal treatment. But let me give you some helpful advice on how to have this done so that you preserve the esthetics of your smile. And this is something that many dentists don’t know, unless they are really expert in appearance-related dentistry. There is a strong potential for a tooth with a root canal treatment to turn dark. That dark color will show through the porcelain veneer and will require it to be done over again unless the dentist takes this simple precaution. After the root canal treatment, the dentist needs to clean out all root canal filling materials and cement from the insides of the visible part of the tooth – the part that shows above the gumline. Then she should cement a translucent fiberglass post inside the tooth to reinforce it and fill up the rest of the inside of the tooth with a light-colored composite material that will preserve the original color of the tooth. It is the root canal filling material and cement inside that cause most of the discoloration of the tooth. But by cleaning all that out and filling it as I have described, it won’t permanently prevent any discoloration of the tooth, but it may put it off for a good five to ten years. At that point you can get new porcelain veneers or go to a crown on the tooth.

Show this e-mail to your dentist, and she can contact me if she has any further questions.

Having this delayed response to the traumatic injury and decay you experienced 9 years ago isn’t unusual at all. Most dentists have seen this sort of thing before.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Should I go to Clear Choice or Costa Rica for my dental implants?

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Your website only discusses Clear Choice as a provider of the all-on-4 implant procedures. I went in for a 3d x-ray and initial eval at both Clear Choice (CC) and EON. My experience with CC was consistent with the experiences of others reflected on your website. EON seemed much better. In particular, the head of the EON clinic spoke with me. Apparently he used to be associated or partnered with CC. He stated that he left CC because he did not like the practice of abandoning the patients once they had the procedure done. Also according the the “evaluation done at CC and reported to me by the sales rep, I was a fine candidate for the procedure. The dentist from EON referred to the x-ray and mentioned several consideration that needed to be evaluated. Ultimately he stated that they could make the necessary modifications to allow insertion of the implants without bone grafting. If any of this seems odd or false, please let me know. I figured you might benefit from my description of the initial meetings with the 2 local competitors in Chicago area. Thank you. Mike Burke My next step, in addition to scouring the internet for justification and knowledge is to consider going out of the country to have the implants put in. Costa Rica?

Mike from Chicago

Mike,
I don’t understand. You are unhappy with the idea that you would go to Clear Choice and get dental implants and they wouldn’t have any follow-up. And for THAT you are going to Costa Rica? What kind of follow-up do you think they have in Costa Rica? Do you think THEY will call you for a checkup and a cleaning?

Having dental implants placed, even in the United States, is a risky procedure. We are seeing so much malpractice in this area. Dentists are getting into it without adequate training, and the standards of care are not well established because it isn’t a recognized specialty and is fairly unregulated.

But take the worst dentists you have in the United States, and remove ALL quality control standards that even they have, and that’s what you’ll have when you go to Costa Rica. If you are a brave soul, you could try getting crowns or bridgework done in Costa Rica, because you could always have those re-done if something goes wrong. But when something goes wrong with implant dentistry, you could end up a dental cripple, maybe with practically no jawbone. They could accidentally place implants in your nerve canal, in your nasal sinuses, they could perforate the bone. Infection could set in. The implants could be too short or too thin. They could be placed under load prematurely. They could come loose. If they place cheap fixtures, they could lack precise tolerances, which would leave openings for infection and coming loose. The fixtures could corrode. You could get peri-implantitis. There are so many things that could go wrong with dental implants. At least in the United States you might have some legal recourse if things go bad.

I am not a fan of Clear Choice. As you were told, they do not have any follow-up contact with you. We have numerous reports of high-pressure sales tactics. And the all-on-4 procedure has some risks – if anything goes wrong later with any one of the four implants they place, the entire case will have to be re-done. But you are far better off having this done by Clear Choice than going down to Costa Rica. If you want the best care, my recommendation would be to find a solo practitioner with expertise in dental implants. Look for credentials from either the International Congress of Oral Implantologists or from the American Academy of Implant Dentistry.

There are other dentists who do the all-on-4 procedure in the Chicago area. Dr. Anthony LaVacca in Naperville is one. He is a board-certified prosthodontist and is also implant surgery trained. Another option could be to get a second opinion from Dr. William Cohen in Glenview, who used to be my dentist when I lived in Iowa.

But please, please, don’t go down to Costa Rica for dental implants, not if your quality of life is important to you.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

A dentist is ethically obligated to give you all your options

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When I was a child I was hit in the mouth twice, once from falling out of a wooden school swing and the other time from throwing a croquet ball up in the air and catching it with my front tooth. Needless to say the older I’ve gotten the more yellow brown it has become. My dentist told me I would have to get an implant because there was no root but yet I still have the VERY UGLY BROWN TOOTH.

I also have several back teeth that need filings and at least 2 that need to be capped. I don’t have a lot of money to be putting into just one tooth when I have several others that need to be fixed, although the one that gives me an UGLY SMILE is the one everyone can see. PLEASE HELP ME.

Thank You so very much for your time.
Sincerely, THE GIRL WITH THE UGLY BROWN TOOTH
Danielle in Tennessee

Danielle,
I would switch dentists, and I will explain why.

One of these two traumatic incidents with your front tooth jarred it enough to sever the nerve and blood supply that go to the tooth. This would cause the tissue inside it to die, which would then cause it to become infected. It’s possible that if this tooth had received a root canal treatment at that time, it could have prevented the root of the tooth from being eaten away, but it’s also possible that would have happened anyway, as a side effect of the traumatic injury. The process is called root resorption, and it can happen because of an untreated infected tooth, or because of traumatic injury to the tooth.

But now that the tooth has no root left, you can’t save it.

There are three basic ways, however, to replace a missing tooth, and your dentist is negligent in only presenting one of them to you. He or she has an ethical obligation to give you all the options that would work. And while the implant option is probably the best choice for you, it is also the most expensive. Did you tell your dentist that this was too expensive for you? If you did, and you still didn’t get any options given to you, then it shows not only negligence but a lack of character on the part of your dentist.

A dental bridge is the traditional way to replace a single missing tooth. A bridge requires that the two adjacent teeth be covered with crowns (you may know them as caps), and then a false tooth is suspended between them. This is a little less expensive than an implant.

Another option is to use a removable partial denture that clips onto your other teeth and has a false tooth on it. While less comfortable than either a bridge or an implant, it is a fraction of the cost of a bridge. A flipper partial is the simplest way to do this, and it can cost as little as a couple of hundred dollars.

Find a dentist who is willing to give you all your options and who will work with you to keep the costs down. I don’t know everything that went on in your visit with your dentist, but just from the information that I have it doesn’t appear that you should trust this dentist.
– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

What treatment is needed for a calcified root canal?

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Hi Dr Hall,
First of all I appreciate the good work that you are doing.
Regarding my question: my daughter had yellow staining on her right front tooth. The doc did an x-ray and said the root canal is getting calcified and suggested a root canal. After the root canal we suggested to leave it as such but he said the tooth would fracture and a crown is a must. The crown he suggested was LAVA. We were not happy with the finish so we are trying an e.max or perhaps a metal-free ceramic. To push us to decide fast he frightened us that the gums are falling down. But I am happy I did not go with a badly made crown. I would like to know whether I have been taken for a ride and two which is the best crown to use? My gratitude for your enlightening blog I shall recommend to all my colleagues. My prayers and God Bless
– Bransdon from India

Bransdon,
I’m glad to be able to help.

First of all, I’m not sure why your daughter needs a root canal on this tooth. Just because the canal is getting calcified? As long as it’s not infected, she doesn’t need a root canal treatment. Calcification of a root canal is just the depositing of extra dentin inside the tooth. It  can happen after a traumatic injury – it’s the tooth’s attempt to protect itself against infection of the canal. Also, all teeth tend to have their canals get a little calcified as we get older.

Second, even if she has a root canal treatment, she doesn’t necessarily need a crown on this front tooth. While a back tooth that has had a root canal treatment will be prone to fracture if it doesn’t have a crown, a crown on a front tooth with a root canal treatment will weaken the neck of the tooth. A back tooth has a chewing surface. Chewing pressure on this surface will tend to push apart the cusps of the tooth, possibly causing it to split. But if a front tooth breaks, it tends to break around the neck of the tooth, and it just breaks off entirely at that point rather than splitting as back teeth do.

The Lava crown and the e.max crown are very similar to each other. They both have a very strong lithium disilicate base overlaid with a feldspathic porcelain, but they are made by different companies. They are a good crown for dentists who aren’t very good at cosmetic dentistry procedures, but they require aggressive tooth reduction, which will further weaken this tooth.

In India, you have to be very careful with getting crowns or any type of complicated dental care. I’m not all that familiar with their standards there, but I know they aren’t as high as they are here in the United States. But the best thing to do for a front tooth that does not have a large filling, which sounds like it is your daughter’s situation, is, after the root canal treatment (if it needs that), to then have a translucent fiberglass post placed to strengthen the tooth. Before placing the post, all of the root canal cement and root canal filling materials should be cleaned out from the inside of the visible part of the tooth – this will help insure against discoloration. If the color is off, I would have that fixed with a thin porcelain veneer. That will help the tooth retain its maximum strength. And I would try to seek out a dentist who is somewhat familiar with cosmetic dentistry procedures. There are dentists in India who are members of the American Academy of Cosmetic Dentistry, and I would seek out one of those. (You can go to the AACD website and pull up a membership list.)

I do not recommend, in the United States, relying on membership in the AACD for any type of assurance that a dentist will do good cosmetic dental work. But in India, it does show a strong level of commitment to cosmetic dentistry to be willing to fly to the United States to learn these procedures.

– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

I love my Nesbit partial

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Dr. Hall,
Not a question, but just a statement. I have had a Nesbit partial (left small incisor) since 2004 . I swear by it. Never came close to swallowing it or to losing it. One has to be aware of sink drains, however. I can see that the old ones, having metal parts, would be dangerous to swallow.
– Ed in Delaware

Ed,
Thanks for sharing that.

For those who aren’t familiar with the Nesbit partial, it is a small, clip-in replacement tooth replacing one tooth, or possibly two adjacent teeth. It clips onto the adjacent teeth. The clasps used to be made with metal, but now is almost always made with plastic clasps.
Dr. Hall

Link: Click here to read more about removable partial dentures in general.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

The lifespan of a Maryland Bridge

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Dr. Hall,
I am having a Maryland Bridge put in tomorrow. I keep forgetting to ask my dentist a question about it. He said it would have a lifespan of about 10 years. What happens after that 10 years? It is fixed. Does it loosen after that period of time? If it reaches it’s life span, then what happens? Thank you so much for any information that you can provide to me. I’m hoping that I’ve made the right choice, but have already been fitted and the bridge made, so there’s no turning back now.
– Theresa from New York

Theresa,

It’s confusing to people when dentists put a lifespan on dental work. The lifespan will vary so much from patient to patient, it’s hard to really say how long it will last. And it’s not entirely a question of something “wearing out,” it’s more a question of how long it will be until something goes wrong with it.

A tire has a pretty definable lifespan – the rubber wears away on the road at a certain rate, and with average driving conditions you can predict pretty closely how long it will be before the tread wears away and you need a new tire. Dental work is different. I like to compare it to a bookcase. If you have no children in the house and you just put books on it, it doesn’t get any water stains, and you use a wood polish on it periodically, a nice wooden bookcase may last 40 or 50 years and still look pretty good. But if you’re a young family with children and they are putting their drinks on it and their toys and maybe some really heavy things, it’s going to get scratched and stained and maybe in five years it will look pretty bad and be ready for replacement. That’s more like the way dental work is rather than like a tire.

A Maryland bridge is susceptible to loosening, but it depends on the stresses present in your mouth. If you have a stressful bite that tends to flex your teeth, a 10-year lifespan may be optimistic. If you don’t, it could last much longer than that. You could also get decay around the attachments, but that is going to depend a lot on your eating habits, particularly how often you snack. And then the other factor in the lifespan is the rate of staining of your natural teeth. The false tooth in a Maryland bridge is made out of porcelain, which doesn’t absorb stain like your natural teeth do. If you consume a lot of highly pigmented foods like certain berries, coffee, tea, etc., and you don’t do any bleaching of your teeth, the color mismatch could become bothersome, if this is a tooth that shows in your smile, after ten years or so.

I hope this is helpful.
Dr. Hall

(Note: What I say here about the lifespan of the Maryland bridge would apply also somewhat to the lifespan of an Encore bridge, though I would expect less lifespan out of an Encore bridge. The technique is similar – the Encore bridge is just made out of tooth-colored materials which are more flexible and thus more susceptible to de-bonding.)

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

I’m 16 and still have my baby canine teeth. Can I get dental implants?

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Dr. Hall,
I’m 16 and I currently still have two baby teeth – my two top canines. Last year I found out that my two bottom canine were baby teeth as well, and had them removed. It was very embarrassing but luckily my right permanent canine was behind my baby tooth and over a year is somewhat in the regular spot but, my other canine tooth on the bottom(left) was removed and my permanent tooth is growing far behind and close to my lateral incisor.

I don’t know what to do, it is very embarrassing to have an empty spot in my teeth. My top baby canine teeth are still here though, I had to go to the dentist to remove them but I don’t want to have gaps in my smile, especially since I will be taking my senior pictures soon. I also don’t want to remove them because I’m scared that like my bottom canine they will grow far behind. What should I do? Are dental implants a possible solution to this?
– Cathryn from California

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Cathryn,
Are you having regular dental checkups? And if you are, why hasn’t your regular dentist addressed this? This is not an uncommon problem, and dentists are taught in dental school about how to address it. Knowing what to do requires good x-rays of your entire jaw.

If you still have your baby canine teeth at age 16, the most likely reason is that your permanent canine teeth are impacted. In order to do the right thing with your baby canine teeth, you need to know about the permanent teeth. Where are they? Are they impacted? Are they in fact behind your other permanent teeth? Or are they in front of them? And if they are impacted, then an orthodontist should be able to help get them erupted into the correct positions.

There can be permanent teeth that never form, but it is very rare for those to be the canine teeth. Lateral incisors are one of the most common teeth to not form, as well as lower premolars and sometimes wisdom teeth. When you still don’t see the permanent canine teeth at age 16, it’s usually because their eruption is blocked. The treatment for that is to help them erupt, usually by making a surgical opening in the tissue to expose the tooth and then possibly to attach a bracket to the tooth and help it erupt using braces. Though sometimes surgically exposing the canine is all that is needed to help it erupt.

If there isn’t room enough for the canine tooth to erupt into its normal position, then that is a question for the orthodontist to address. Since the canine tooth is an anchor tooth and an important part of your smile, it is usually best to remove the first premolar to make space for the canine and then straighten the remaining teeth.

Replacing the canines with dental implants won’t work if your permanent canine teeth are impacted, because the implants will run into those teeth. You can only place dental implants if there are no teeth under the surface where you’re putting them.

Having said all that, there is no rush to take out the baby teeth. Wait until after your senior pictures, for goodness sake. I hope your dentist wouldn’t be that insensitive.

I hope this is helpful.

Dr. Hall

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

I would be asking some serious questions of this dentist, about this root canal and crown

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Back in Dec I had a root canal done by an endodontist on tooth 14 that already had a crown. After this procedure I felt fine, no pain or hot/cold sensitivity and went to my dentist and he stated I had to have a new crown. He removed the old crown and gave me a temp for two weeks. I immediately started having sensitivity to hot/cold. After the permanent crown was put on this continued and has for the last month. Any ideas on whats going on here? Thank you.
Jerry from Ohio

Jerry,
I don’t want my comments to be taken as a substitute for an examination by an in-person dentist who can test your tooth and look at x-rays, but I can be helpful and tell you what your problem sounds like.

What you are experiencing is consistent with a missed canal in the tooth. If this is what is happening, the endodontist, in doing the root canal treatment on your molar, thought he or she had treated the entire root canal system but missed a part. If the root canal had been done completely, there would be no sensation whatsoever in this tooth to heat or cold.

Tooth #14 is a maxillary first molar. This tooth has a frequent anomaly in the root canal structure. Usually, there is only one canal per root of a tooth. But in the maxillary first molar, there can be a second canal in the mesiobuccal root. This canal can be hard to find, and studies show that it is the most frequently missed of any canal in root canal treatment. So I would have the endodontist re-check this tooth, test it, and see if this is what is happening.

With a crown already on the tooth, it is only a little more challenging to go back into the tooth and work on the root canal treatment. An opening will need to be made in the crown, and then that opening will need to be sealed over later with a durable filling material. For most crowns, this won’t have an effect on the structural integrity of the crown.

This is a frequent error and I’m confident it has happened to most endodontists, and isn’t necessarily an indication of incompetence or sloppiness. However, I would expect there to be no extra charge to fix this.

And did you mention the sensitivity to the dentist that put the crown on? I’m surprised that he didn’t catch this. When the new crown was seated, it should have been obvious that there was some vitality in this tooth, if it was sensitive to hot and cold. There should not have been any novocain administered for seating a crown on a tooth that had a root canal treatment. So I have two questions for this dentist. The first is why, because of the root canal treatment, you needed a new crown. Was the root canal treatment being used as an excuse for doing an extra procedure? Just having a hole drilled in the crown for the root canal treatment isn’t reason for re-doing the crown – there needs to be something else wrong. And the second question is why he didn’t pick up on the problem with your tooth sensitivity. I would be asking some real questions here.

And realize that in saying what I’m saying, I’m assuming that I have accurate information, and that the source of the sensitivity is this root canal tooth and not really some other tooth and it feels like the root canal tooth. Clinical testing would answer that question.

Dr. Hall

Links: read more about root canal failure.
Read more about pain after a root canal.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Several ways for a dentist to screw up a root canal treatment

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My husband fell on 11/29/11, while coaching my son’s basketball team. He suffered concussion, chin laceration with sutures and his front two teeth fractured. He was treated same day in dentist and ER. Dentist did not want to do any treatment for 2 weeks. In 2 weeks, tooth #8 (right front tooth) started to discolor without pain-she felt only dried blood and no treatment at that time.He was fitted for temp crowns and placed within 3 weeks.

Two months later, he had severe pain and an emergency root canal began with amoxicillin for 5 days. There was slight relief of pain for 24 hrs and then severe pain up to his nose with a cold sensation. Root canal finished one week later without pain relief.

Two weeks after that, the dentist root canaled tooth #9 (left front tooth) because she didn’t understand why there was still pain. Novocaine in place, still no relief and pain never by tooth #9?  Probable unneeded root canal.

I decided to get oral surgeon second opinion, who suggested Augmentin TID for 7 days with medrol dosepak. 5 days into meds, cold sensation resolved and tooth #9 RC completed by general dentist who then removed filling from tooth#8 and my husband felt pain free for 1st time in 3 months! However, it returned at 50% within 24 hours, but cold sensation gone. I am a NP and I spoke with a pharmacist friend who said you will often see rebound pain with medrol dosepak quick tapers? He recommended a 2 week taper of prednisone with abt in place now that canal is open and can drain possibly? What would be recommended next step? My neighbor thought maybe tooth fractured at gum line? The dentist says she sees black spot on x-ray, but thinks it is nothing? My husband has been tortured for months without any pain control offered and is a teacher and is suffering. Do you think this tooth should have been root canalled immediately when it turned dark or 2 months later? Would that have saved the tooth and torture he is living? Do you think tooth could be saved? Should he need extraction, would you recommend implant next to permanent crown or bridge?
– Kathleen in New Jersey

Kathleen,

When tooth #8 (your husband’s right central incisor) started to discolor two weeks after the traumatic injury to the tooth, it clearly needed a root canal treatment. The nice thing about doing the root canal treatment at that time is that there is less chance of post-operative complications since infection would not have settled in yet – it would be just a matter of cleaning out the dead tissue, maybe leaving the tooth open for a couple of days as a precaution against flare-up, and then sealing it. I cannot for the life of me understand what your dentist thought was going on inside this tooth. Dried blood?? If there is dried blood in the tooth, isn’t it pretty clear that the tissue inside the tooth is dead?

And I don’t understand why there was a prescription for amoxicillin and for only 5 days. So if I am understanding this treatment sequence correctly, the tooth was opened and the amoxicillin started. I can’t tell from what you are saying whether the tooth was left open during this time or not. But then the amoxicillin ran out, and AFTER that, the root canal was completed – in other words sealed. Doing it this way, there would be a fairly substantial risk of flare-up. Once a root canal tooth is sealed, there is no longer any pathway for drainage for any infection that may be there. And a five-day course of amoxicillin would not be enough to completely wipe out the infection. In fact, amoxicillin would not be a first-choice antibiotic anyway for this type of tooth infection.

My recommended next step? See an endodontist (root canal specialist). An oral surgeon would not be a good choice of specialist to see here. And a pharmacist doesn’t have the correct training either. There is something to be said about getting a professional involved who has the specific training for this type of problem. I can’t tell by just e-mails what is happening here. But I can tell you I disagree with some of the treatment choices made by your general dentist, and the flare-up is not surprising to me at all. Doing a root canal on the other front tooth appears to me to have been a stab in the dark, and it also doesn’t surprise me that it didn’t help. And the prednisone would also be the wrong treatment if the infection isn’t resolved. And what is this about your dentist seeing a “black spot” on the x-ray but thinks it is nothing? That sounds almost grade school. Is there a continuous, intact lamina dura around the tooth? Is there a widened periodontal ligament space? You need an endodontist to look at this x-ray and read it, not someone who will try to take wild guesses at what is going on.

There should be no need to extract this tooth. None of what has happened is any indication that the root canal was not sealed properly. And even if there was that type of error here, there are several options for correcting that, short of extraction. You need the correct choice of antibiotic therapy – probably clindamycin at this point – which in most circumstances should get this to settle down in a couple of days. However, if there is a root fracture, that is a different story.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

My new dental implant bridge doesn’t line up with my bite.

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This is an exchange with Lilly from California. Here is her original question and my reply. Then she replied, and I answered again, and that is below:

Dr. Hall,
I have a new implant bridge, with two implants, replacing four teeth on my bottom right. I notice now that when I bite down on the right side, the bottom teeth and the top teeth line up, but my teeth on the left don’t line up. Is this normal? What can be done?
Lilly from California


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Lilly,
This is not right. All your teeth should come together at the same time. Something isn’t right here. And if this isn’t fixed, it could lead to TMJ disorder.

This gets me to a recurring issue, and that is the quality and standards of implant dentistry in the country. This is one of the top areas for dental malpractice. One of the reasons is that the dental profession has not made it a recognized specialty, so anyone can claim to be an implant dentist with no extra training whatsoever.

My recommendation would be to have another dentist look at this. Look for a dentist with credentials from one of the two major dental implant organizations – the International Congress of Oral Implantologists, and the American Academy of Implant Dentistry. Fellowship or diplomate status in either of these organizations would indicate a dentist who understands and practices quality implant dentistry.

There are two possibilities for what went wrong. It’s possible the implants were restored incorrectly. I think more likely is that the surgery placed the implants in the wrong position.

Sometimes, if the surgery is done by one dentist and the implants are placed by another, there is a communication problem and they are placed in a position that makes it difficult or impossible to restore them correctly. What should be done is that the restorative dentist should make some type of surgical guide that fits in your mouth and that fixes the exact position and angle where the implant should be placed. But a lot of dentists don’t do that.

I wish you the best,
– Dr. Hall

This is a reply that Lilly sent

Dr. Hall,
Thank you for the comprehensive answer. I am suspecting the problem lies with the surgeon. He insisted he was in charge. I never saw the restorative dentist he referred me to until after he was done with the implants.

I have an appointment with both the surgeon (periodontist) and the restorative dentist in two weeks. I am hoping that these implants don’t have to be redone. In that case, is it fair for me to request a refund? I don’t want to return to this periodontist and dentist. You would think the restorative dentist would have known better than to just go ahead and make the bridge and charge me when he knew it was wrong.
-Lilly from California

Lilly,
Very interesting, to get that additional information from you. In my humble opinion, you are within your rights to ask for a refund, assuming that we have this sized up correctly. It is an established principle of implant dentistry that the implants need to be placed according to a restorative treatment plan, and that a surgeon should not place them until the restorative dentist has examined the case and made the determination of where they need to be. Sounds like the surgeon skipped that step.

Get your independent opinion from an implant dentist with a credential from the ICOI or AAID, as I mentioned in my earlier e-mail, and if it is determined that the problem was in the location of the implants and that they need to be replaced, then yes, I would complain. And actually, rather than a refund, ask that the surgeon pay whatever the cost would be to fix the problem, because it will likely cost more to get this fixed right than it cost to do it in the first place, plus you have to re-do the restorative part. I think there is some legal liability here to get this fixed right.
– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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