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Search Results for: gum disease

Can my tooth survive a furcation involvement?

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Hello Dr. Hall,
I was told that my tooth #19 (lower left first molar) has a furcation involvement. I also have puffy gums and some pus and bleeding around that tooth and besides, it has a root canal. Can the tooth be saved?
– Vern

(See Dr. Hall’s answer below.)


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Vern,
I’m more concerned about the pus around the tooth than the furcation involvement. Let me explain a little about each of the problems you are mentioning.

The root canal treatment isn’t a concern for the longevity of the tooth. When there is an infection in the pulp of your tooth, the pulp has to be removed and the space it occupied needs to be sealed with a root canal filling material. Yes, there can be times when the root canal treatment doesn’t work and infection will re-appear at the tip of the root. But root canal failure will be evident within the first couple of months. Once healing has occurred, the tooth will not relapse.

A furcation involvement is a situation in which gum recession or bone loss around a molar has exposed the separation between the roots of the tooth. When this occurs, it is a problem, but isn’t critical. It indicates that there has been some loss of bony support of the tooth, but the tooth may still have 80-90% of its bony support, which is enough to keep the tooth solidly retained. It also complicates your home care. The furcation, since it is protected, can accumulate plaque, so it needs extra attention for your home care. It needs to be cleaned out daily. You can get special brushes to access this. The photograph below shows furcation involvement in a lower molar and a small brush in the furcation. This small brush is attached to a handle and your dentist should be able to provide you with the brush and handle.photo of a lower first molar with furcation involvement between the roots and a small brush in that furaction

Gums will be puffy or bleed when they are inflamed, and the inflammation comes from toxins produced by plaque bacteria. It is a sign of gum disease. But it isn’t necessarily serious. We see puffiness and bleeding in the early stages of gum disease. If left untreated it will progress to the loss of your teeth. But with deep professional cleaning and conscientious follow-up with good home care, it will usually resolve.

When there is pus around the tooth, however, that indicates a more serious infection that is in urgent need of getting under control. There will be a deep pocket around the tooth where bacteria are multiplying, undisturbed. This will be impossible for you to clean with home care, and will be difficult even for a hygienist to clean. Whether or not the tooth can be saved will depend on how much bone support is left for the tooth. Sometimes surgery is needed to remove some of the gum tissue and open up the area so that you can clean it daily. But it is possible that the tooth is hopeless.

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The deep cleaning is so painful, I don’t know what to do

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Hi Doc.
I did a deep cleaning 2 years ago but my problem is that I have deep gaps pockets that it never heals no matter how much I go and have my teeth cleaned. Now my teeth are so sensitive that is so painful. I try to go back to the doc and have my teeth cleaned but I can’t do it because of the pain. Please I what can I do. I am 53 years old. I never have problems with my teeth but sense I did the deep cleaning now I have this problem. I feel like it was a mistake to have the deep cleaning done. I am desperate and in too much pain. 😢 Please help—tell me what to do.
– Lisandra

(See Dr. Hall’s answer below.)


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Lisandra,
You clearly have serious gum disease and need to get that taken care of or you will lose all your teeth.

As to why you have this pain when you have your deep cleaning, I’m not clear about that. Deep cleaning, when it is done correctly, can be painful, so it should be done under local anesthetic. The gums are usually infected and inflamed, and the teeth have to be cleaned clear down to the attachment of the tooth to the gums. That’s why it is called “deep cleaning.” But I’m guessing that’s not the type of pain you are experiencing.

Because of the infection of the gums, there is a potential for post-operative pain. That doesn’t always happen, but if the infection is particularly active, the deep cleaning can provoke it. It’s sounding to me like this is what you are experiencing. The way to handle that would be with antibacterial agents. One possible way would be to have you on a course of antibiotics for the duration of the deep cleaning appointments. So, for example, your deep cleaning could take four appointments. They could be done over a two-week period with you taking the antibiotics for the duration.

My recommendation to you would be to find another dentist. Given the difficulties you’ve had, I would go to a periodontist (gum specialist) and when you make the appointment, I would explain your experiences so far and ask them what they would plan to do to make this tolerable for you. A periodontist should have a lot of experience with your type of case.

The bottom line—your gum infection is clearly serious and needs to be solved or your teeth will end up falling out.
– Dr. Hall

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My CEREC Crown Is Too Bulky

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Dr. Hall,
I recently had a crown replaced on an upper molar (second molar from the back) due to the first crown breaking after several years. I needed it done quickly, so I went to a new dentist who used CEREC to make a same-day crown.

The crown feels like a wad of bubble gum stuck to my tooth. There was a large “bubble” that stuck out into my mouth and was rubbing my tongue. When I went back, she could see that it was misshapen, and she filed it down some. It STILL feels too big. It rubs my tongue when I talk, and I think I’m biting my tongue in my sleep. Should I go back and have more filed away? I have had upwards of 10 crowns, so I’m not just unused to the feeling of a crown in my mouth. I also thought that with CEREC, the computer would make the crown fit really well. I’m not sure how to proceed. Thank you.
– Renee from Utah


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Renee,
How is it you keep ending up with these dentists who don’t seem they know what they’re doing? My first question would be about the crown that broke. Crowns aren’t supposed to break, even after several years. They are supposed to be super-strong and are put on the tooth to keep IT from breaking.

But anyway, about this replacement crown. I would insist that this crown feel right to you. Besides feeling bulky or misshapen, it needs to be shaped so that you don’t bite your tongue in your sleep. Persistent tongue biting, lip biting, or cheek biting is a serious problem that in some cases can lead to the growth of a tumor. Proper overlap between the upper and lower teeth should prevent this. A properly shaped crown should not feel noticeable in the slightest.

With CEREC crowns, the dentist can scan the tooth before it is prepared for a crown and use the shape of the existing tooth as a guide in directing the CEREC machine in how to shape the tooth. Since the old crown had broken, she didn’t have that to go by. But then the CEREC software is fairly easy to direct so that the tooth is shaped properly. I’m just guessing based on what you’re telling me, and my guess is that your dentist didn’t know how to work the software to shape the crown without the original tooth or old crown to guide her.

If I were you, I would ask the dentist to take this crown off and start over again. Shaping a crown freehand after it is cemented is an arduous job and is next to impossible to do. That’s the reason crowns are made outside of the mouth, either in a laboratory or in a CEREC machine and then placed on the tooth after its shaping is finished. For example, one serious limitation is that she isn’t going to be able to shape it between the teeth at all. Another is that it is going to be quite difficult to shape it right at the gumline. Trying to shape it there, unless you have a dentist with uncommon skill, would result in either overcontouring or gouging the tooth. Overcountouring in these two locations will lead to food trapping and gum disease.

Based on your experience so far, I would have a hard time trusting your dentist with shaping the crown with the CEREC software, so I would ask your dentist to have the crown made by a dental laboratory. I hate sounding so tough on her, but you’re going to end up with problems with this tooth unless this crown can be made right.

To illustrate the problem with having an overcontoured crown, here is a photograph courtesy of the dentalcaseoftheday.com website submitted by Dr. Arthur Volker, a dentist in Queens, NY. This patient had this overcontoured crown for 7 years and presented to Dr. Volker complaining of constant bleeding of the gums around this crown. You can see from the purple color of the gums around the crown that there is gum disease here. Renee, I’m visualizing the crown you’re describing to me is worse than this one.
a photo of the front upper and lower teeth, showing a large crown on the right central incisor with inflamed gums around the crown

Good luck.
Dr. Hall
 
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Is a peroxide mouthwash for porcelain veneers a good idea?

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DR. HALL,
IS THIS OK? I MADE MY OWN MOUTH WASH: 8 OZ FILTERED AND BOILED WATER, 8 OZ OF 3% HYDROGEN PEROXIDE, 2 TBS SEA SALT.
I HAVE PORCELAIN VEENERS ON MY TEETH.
THANK YOU IN ADVANCE…….
-Lorece from Illinois


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Lorece,
Well, at least you aren’t using a mouthwash with alcohol. That would soften the bonding agent used to bond the porcelain veneers which will cause ditching and staining around the edges.

But the mouthwash you are mixing up at home will cause other problems. The active ingredient in the formula you gave me is the hydrogen peroxide. Hydrogen peroxide will kill a number of micro-organisms. Many of the bacteria that contribute to gum disease are what we call anaerobic—they thrive without the presence of oxygen and, in fact, oxygen will kill them. Hydrogen peroxide, when you rinse with it, bubbles and releases oxygen, killing these harmful bacteria. However, the peroxide will also kill many beneficial microbes that live in your mouth, which causes other oral micro-organisms to thrive because of the absence of competition. One of these micro-organisms is the yeast, candida albicans.

The result of all this is that occasional or short-term use of hydrogen peroxide as a mouthwash can be very helpful. But if you use it steadily for a period of, say, two weeks, you will end up with an oral yeast infection because the candida albicans will grow without restraint. In an oral yeast infection, the mucosal surfaces in your mouth turn white and peel, leaving raw, red, and painful patches.

There are a number of alcohol-free mouthwashes that you could use to help you care for your porcelain veneers, if you want to use a mouthwash. Check the link for more information about that. But my advice is that if you brush and floss faithfully and correctly, any need for a mouthwash would be minimal at best.

– Dr. David Hall

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My teeth look splotchy after my bonding was removed

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Dr. Hall
I had extensive bonding on teeth to improve some wear and chips. I hated it as it felt bulky and I couldn’t speak properly. I had it removed but my teeth have been left patchy and discoloured. My dentist and the one she referred me to for another opinion both tell me it’s my natural teeth and I just hadn’t seen it before. I’m devastated as feel my teeth have been damaged.
– Marie from the UK

Marie,
I can’t fully tell what has happened to you without seeing your case personally, but I can make a good guess based on what you are telling me.

It sounds like you are in the hands of a basic general dentist who doesn’t know enough about cosmetic dentistry to give you a beautiful smile, and there are two things that were done wrong.

The first is that your bonding made your teeth bulky, so much so that it interfered with your speech. Dental bonding should never add significantly to the bulk of the teeth. That doesn’t produce an attractive appearance, plus it can interfere with speech, and it could create food traps that can lead to either tooth decay or gum disease. I don’t understand, if you’re just dealing with wear and chips, why you would need any bulk at all added to your teeth—the dentist should be able to just fill in the chips and replace tooth structure that has worn away. Look at the photographs of dental bonding work on this website. None of them look bulky at all.

The second mistake was in removing the bonding. While some dentists who lack confidence in their cosmetic dentistry skills will tell patients that dental bonding is a reversible procedure because it can simply be ground off if you decide you don’t like it, that may not be as easy as it sounds, especially in the hands of a basic general dentist. So the dentist starts grinding off the composite bonding and stops when he or she hits the enamel. But the composite looks just like the enamel, so how do they know when it stops? In this process, it is very easy to believe that your dentist may have removed a small amount of the enamel of your teeth. I don’t know—I’m just guessing. But you clearly know that they don’t look the same as they did. Of course she’s going to want to tell you that this is how your teeth were. And as far as the dentist she referred you to, there is no way for that dentist to tell you how your teeth used to look or whether any enamel was removed. Your complaint is very credible to me. If your teeth were always splotchy, that would have been your chief complaint and the reason you got the bonding, and you would certainly know it.

A good cosmetic dentist would have taken “before” photographs, and there would be no argument then about how your teeth looked before the work was started.

So what do you do now? I would go to an expert cosmetic dentist and either have this bonding done correctly or go with porcelain veneers, which will be the much more durable and cost-effective alternative. You should be able to get a beautiful smile out of this. We have an excellent cosmetic dentist listed in London, and I see by the city you mentioned that you are just outside of London. He should be able to take care of this for you.

I think your leverage for a claim against your current dentist is rather weak, because of the lack of documentation of what you are saying. Maybe you can get some kind of refund from her, but it seems to me that this would be entirely voluntary on her part.

– Dr. Hall

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I have dry mouth ever since getting my new crowns

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Dr. Hall,
I had porcelain crowns for all upper and lower teeth. Ever since these were put in I have had dry mouth. This was a cosmetic procedure and I obviously regret doing it. I am wondering if there is anything I can do next. The dentist widened my bite so you can see more of my teeth when I smile and I try to remember to keep my mouth closed and breathe through my nose. I know the dentist can grind down the new crowns and try to match my original bite but not sure if that is really a good answer. Any ideas you have would be greatly appreciated.
– Randy from Pennsylvania


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Randy,
So you had crowns on all your teeth–we would call that a full-mouth reconstruction. You wanted more teeth to show, so the dentist “opened your bite.” In lay terms, he or she made the crowns “taller” than your natural teeth were.

Unfortunately, this hasn’t worked out so well for you and now you are suffering from dry mouth—called xerostomia in clinical terms. This isn’t just an annoyance but is a real threat to the health of your teeth, which I will explain below. In your case it appears to be caused by a condition that is called “lip incompetence,” which is defined as a lack of closure of the lips when the mouth is at rest. In other words, as you have explained it, you have to consciously try to keep your mouth closed.

This was a serious mistake by your dentist, and in my opinion he or she should accept responsibility for getting this corrected. If he or she doesn’t, you have a valid case for malpractice damages. Was your dentist so attracted by the high fees from doing 28 crowns on you that they jumped into this case and got in over their head? That is possible. Dentists don’t get enough training in dental school on full-mouth reconstructions. This is a highly complex procedure, and there are several post-graduate training institutes that offer this advanced training.

The proper way to do a full-mouth reconstruction, especially if the bite is going to be opened, is to first open the bite temporarily by some mechanism. What I did was build up the back teeth with composite to test how far I could open the bite. It can also be done with temporary crowns, though that commits you to having crowns. As a patient, you should wear the temporary crowns or the buildups long enough that you can be sure you’re comfortable with the new opening. And the dentist should never open the bite beyond the point of lip competence. This is one of the key things that needs to be checked–with your mouth at rest, do your lips come together naturally or is it a strain to close them? This is the test that is used to discover how much you can open it. You never go past that point.

Saliva a Defense Against Decay

Many people don’t realize that your saliva has important defense mechanisms against decay. Besides its washing and buffering action, it contains antibodies that fight decay bacteria and minerals that help remineralize early decay lesions. A serious complication of dry mouth is a greatly increased decay rate. And don’t think that your crowns make you immune to decay. It isn’t hard for decay to get in at the margins where the crown meets the tooth. Also, dry mouth exacerbates gum disease.

What to Do Now

With what appears to be a lack of prudence and care by your dentist in doing this case, I wouldn’t ask him or her to fix it but would seek a second opinion. I will email you privately a dentist near you that I would recommend for this second opinion–I don’t want to publicly give any more clues about your location. Yes, the bite needs to be closed down, but grinding the teeth down may not work. It may be that your case needs to be completely re-done at the expense of your dentist. Proper shapes of the teeth need to be preserved in order for you to have a healthy bite. And if the crowns have a metal foundation under the porcelain, you don’t want to grind through to the metal.

So go to the dentist I recommend. If he feels that this is your dentist’s fault, ask him to help you get satisfaction from your current dentist. Based on what you’ve told me, it sounds like you could take this dentist to court for malpractice, but it’s always better to give them a chance to rectify the problem.

Dr. Hall

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Putting my teeth back in with crazy glue

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“Bout 3 months ago my teeth just starting falling out root and all the whole tooth. I been using crazy glue but it is starting to mess up the inside of my mouth and it hurts all the time the crazy glue is killing me cause when I’m inhaling it but I have to leave the house and I want let people see me with out teeth but I only go out when I have to I have no life I stay home out the times I don’t date I want go out with friends please help me.”
– (we’re not posting a name with this question)


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Unfortunately, I don’t think I have a good answer for this poor woman. There is an answer, but it’s not a good one that she’s going to like. I’m writing this blog post because I think it’s interesting what she has tried to do.

First I want to comment on the severity of her gum disease and the hopelessness of trying to get these teeth to stay in, even with crazy glue or superglue. I have seen gum disease so bad that the teeth fall out spontaneously, and to be that bad the teeth already have to be dangling somewhat from the root. Here is a photograph of the teeth of a patient with advanced periodontal disease. As bad as this is, it’s not nearly the stage of periodontitis that this woman is experiencing.

Photograph of severe gum disease with most of the root showing on the lower front four teeth

Photograph courtesy of Dr. David Mastro, Roswell, GA

This patient’s lower four incisors are getting close to being loose enough to fall out, but they’re not that bad yet. Imagine a little more of the root showing—this is what this woman had.

Putting them back in with crazy glue or superglue? These glues have cyanoacryate, which is is an excellent soft tissue adhesive, but it would only hold for a day or two, maximum. I’m guessing that from my experience with this glue. And the teeth would still flop around, but they will flop around as a group rather than individually.

My guess is that it’s been a number of years since this woman visited a dentist. Otherwise, she would have been warned about teeth close to falling out. And even now, she is trying to solve the problem herself without the benefit of professional care.

She needs a dentist badly now, and my guess is that none of the teeth are savable at this point. She needs removable dentures or dental implants.

– Dr. Hall

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Ugly e.max crowns are too thick

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Good morning, Dr. Hall.
My question: Can adhesive-bonded e.max crowns be safely removed without breaking the natural tooth which is already fragile?
History: I recently had the front six teeth re-crowned with e.max. The four front teeth have now been crowned for the 5th time (all by different dentists). I was happy with the first crowns I had, but after 15 years they needed to be replaced. I have yet to find a dentist who can replicate the smile I had before. I’m now stuck with e.max crowns that are thick and bulky with dark showing around the gum over my central incisor. My dentist said he would replace them but I know with each manipulation, I am risking the possibility of losing a tooth (or teeth).
My dentist said he made the e.max crowns thicker because my gums were thick (the gums have buttressed from years of clenching). He has now asked I have crown-lengthening and have some if the bone removed before replacing crowns.
I am so afraid of losing my teeth and having to have dental implants but I so want my old smile back.
Any advice would be greatly appreciated.
– Carol from Alabama


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Carol,
If I’m getting this straight, your dentist gave you thick crowns because your gums are thick. If that is his true reasoning, I wouldn’t let him re-do your case. There is a gross misunderstanding of esthetic and functional principles here. Thick crowns will cause the gums to become inflamed and puffy, so this has the potential to be a functional disaster. Plus there is no aesthetic reason for your crowns to be made thick in this situation. The dentist should make sure there are natural contours to the teeth as they come out of the gum.

Let me explain.

I found this photograph showing thick crowns with puffy gums what happens when crowns are too thick. It creates a protected space where the crown meets the tooth and in that protected space, gum-disease-causing bacteria multiply freely. Microscopic food particles will get trapped there, it is impossible to clean effectively, with resulting gum disease and puffy gums.

After almost 40 years of experience in dentistry, I must say I have never heard this aesthetic principle taught or even mentioned, that thick gums mean you need to do thick crowns. Rather, what I have heard is that you always need to have a natural emergence angle where the crown meets the tooth. You should not be able to feel any bulges as you run an explorer up from the root of the tooth onto the crown – the contour should be straight and smooth.

Now, as to your actual question about removing e.max crowns. These crowns are made of a very tough material – lithium disilicate – which makes them difficult to remove. And you say they were bonded on. The only way to get these off is to grind them off. Your dentist will need a supply of diamond burs to methodically grind these off your teeth. If the dentist is good and knows what he or she is doing, there should be no damage to your existing teeth. That isn’t a problem.

But I wouldn’t trust your current dentist to do that very carefully. His idea about thick crowns doesn’t show much care for precision in knowledge, which would make me worry about his being clinically careful. I would go to one of the dentists on our recommended list–I’m confident any one of them would do a great job for you here in carefully removing the existing crowns and replacing them with a beautiful smile.

Besides the functional mistake in your new smile, there was a serious aesthetic mistake, and I want to say something about that, too. No good cosmetic dentist would have ever bonded these crowns onto your teeth without a test-drive first, either duplicating the new smile in plastic so you could wear that as a temporary smile makeover, or temporarily cementing the new crowns, so he and you could make sure that you love this new smile before it was bonded permanently.

I hope this is helpful.

Dr. Hall

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Looking for a lab that makes gingival masks

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Dr. Hall,
Hi. We have a couple of patients who are in need of a gingival mask; but no labs in our area fabricate them. Can you please give me the name of a lab that we could work with that makes them?

Thanks!
– Diana from a dental office in Mt. Shasta, California


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Diana,
For background for our visitors who may not know about the gingival mask, it’s a prosthesis for replacing gum tissue that is lost from severe gum disease, or after periodontal surgery. It is flexible and pink, and it snaps between the teeth to cover the black triangles left by severely receded gums. It’s usually made out of silicone, but I’ve heard some labs talk about making it out of soft denture liner material such as Molloplast.

A lot of dental labs make these, so I thought you’d have several choices, but then I looked up Mount Shasta and I see that you’re in a relatively remote area of northern California. So I can see where you would have problems maybe finding a lab that would make this.

In other parts of the country, you may want to consider Glidewell Dental Lab in Newport Beach, California, where they are used to shipping cases all over the country. They are fairly familiar with gingival masks. While just about any dental lab that makes dentures would be able to make one of these, if you have to explain to the technician what a gingival mask is, that wouldn’t inspire you with confidence. That won’t happen with Glidewell.

Thanks,
– Dr. Hall

Question and answer go here.

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A couple of teeth just fell out!

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Dr. Hall,
My mother is 85 years old. Just last week she had two teeth filled. She recently lost a tooth and has a partial for that area. Then a few days ago, another tooth fell out. Both missing teeth are from the lower jaw. Fortunately they are in different areas of the mouth. She is very self-consious. At her age, her remaining teeth and gums are probably not in the best of health. We are considering a bridge(s) but are not sure as we don’t know how healthy the rest of her teeth are. Do you have any affordable recommendations on what we can do for the area that is missing teeth?
– Diane from Colorado

Diane,
If I am understanding you correctly, these two teeth just fell out. If that is the case, your mother has advanced periodontal disease (gum disease). It doesn’t get more advanced than that, for teeth to be so loose that they just fall out.

Continuing on with that assumption, it is likely that she has no really solid teeth left, so bridges would be out of the question. A bridge anchors replacement teeth to the remaining teeth, but in doing so it puts additional stress on those remaining teeth. In your mother’s case, that would hasten their demise.

The ideal replacement for missing teeth is dental implants. However, you asked for something affordable. Your mother would likely need full-mouth restoration, and the price for doing that with dental implants could easily get to be $20,000 to $40,000.

Given the condition of advanced periodontitis, all of her teeth are likely loose and would be candidates for extraction. I would seriously look at complete removable dentures. The main disadvantage of removable dentures is that it begins a long-term process of bone resorption. But at the age of 85, that would not be likely to be a significant problem for her.

Cu-Sil partial denture

A Cu-Sil partial
(image courtesy of Dental Arts Laboratory, Peoria, IL)

Another solution would be a type of partial denture called a Cu-Sil partial that is built like a complete denture, but has holes in it to allow the existing teeth to poke through, and there is a silicone ring in each hole that snugly holds each tooth. This is a little more stable than a complete denture, and as additional teeth are lost, it is a simple matter to then close each hole and put in a new artificial tooth.

A conventional removable partial denture also puts extra stress on the remaining teeth. It’s not as much stress as a bridge, but it’s still enough to weaken the teeth, so I wouldn’t recommend that either.

Dr. Hall

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