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Can there be a cavity in a tooth without any outward signs?

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Dr. Hall,
My right lateral incisor (#7) has been diagnosed with a cavity inside it, and dentist claims it needs a root canal. Interestingly, she has referred me to a root canal specialist who has the same very uncommon last name as hers. My previous dentist of last year’s x-rays didn’t indicate any issues with this tooth. And the outside of the tooth has never had work done on it and no surface cavity is showing. This tooth does stick ‘out’ at an angle in the front of my mouth a bit, thus is not receiving pressure from the lower teeth when chewing. I can’t find on the net any answer to is it possible to have a cavity inside of a tooth that has no outward signs of holes or wear?
– Theresa
(See Dr. Hall’s answer below.)


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Theresa,
You don’t have to go to the root canal specialist that your dentist recommends. Given the possible conflict of interest with your dentist and with this diagnosis you are questioning, I’d get another opinion from another specialist or general dentist.

About having a cavity in a tooth without having any external point of entry, no, that can’t happen. Decay has to start on the surface and eat its way into your tooth. When it goes deep enough, the bacteria causing the decay will infect the tooth, which will require a root canal treatment.

an x-ray of two lower premolars and a molar, showing a dark spot in the middle of the first premolar

Internal resorption in a lower premolar. X-ray courtesy of East Hill Endodontics, Kent, WA.

However, it’s possible that your dentist is using different language to describe a problem called internal resorption. Internal resorption is a rare condition where the pulp of the tooth begins to eat away at the tooth from the inside. The cause isn’t known, but this is an inflammatory reaction, so it seems that there needs to be something that begins irritating the pulp. Since there is no history of decay in the tooth, the only way I can imagine this happening is if there was some trauma to the tooth from its sticking out further than your other teeth. But again, this is unlikely, since this is very rare, so my advice would be to find an endodontist for a blind second opinion to confirm the diagnosis. Check my post on how to seek a second opinion:

  • Ask for a copy of the x-ray to take to the other dentist.
  • Don’t let the second dentist know the name of any other dentist involved.
  • Don’t even share the first diagnosis.

You could also send me a copy of the x-ray and I would be happy to render an opinion.

– Dr. David Hall

(There is also a pathology called external root resorption, which happens on the outside of the tooth. This could have the same x-ray appearance as internal resorption. Taking two x-rays at significantly different angles would help pin down whether the resorption is occurring inside the root or outside.)

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

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 front tooth is slowly turning dark

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Dr. Hall,
I’m 35 years old, and my tooth number 7 (right lateral incisor) is turning dark and has been for at least 5 years. My endodontist said the tooth is still viable (I was able to feel ice and an electric current, although my response was delayed). There was a possible, very faint horizontal fracture observed on the x-ray, and a root canal was deemed optional at this time.
I’m debating between getting the root canal done or pursuing a cosmetic procedure.
I’m under the impression that a root canal can weaken the tooth, but I was also advised by the endo that bonding would have to be applied to several teeth in order to achieve a cohesive look.
What are the cosmetic options for this kind of issue? Should I go ahead and get the root canal done now since I’ll likely need it in the future, or is it better to hold off and keep the tooth strong for as long as possible.
Which option is the least invasive and best for my oral health?
– Amanda


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Dear Amanda,

To me, “optional root canal” is the same as saying “not necessary to do a root canal.” So why would you want to do a root canal if it isn’t necessary? Either your tooth is infected or it isn’t. If it is infected, a root canal treatment is necessary. Since it’s not, I would leave it alone.

And I am skeptical that you have an actual horizontal fracture in the root of the tooth. A crack would be possible. A fracture seems highly unlikely. If you had a fracture, the tooth would be dead. Furthermore, if there were really a fracture, a root canal treatment would be problematic because it would traverse the fracture and thus be susceptible to leaking and failure.

Your tooth gradually turning dark could be because of some trauma you had some time ago, at least the five years during which it has been turning dark. Trauma can cause a tooth to build up defenses in the form of what is called secondary dentin. This will cause the tooth to darken somewhat and will also cause the living pulp tissue to shrink which would make your tooth less sensitive to cold or other stimuli.

The bottom line is that, from what you’re telling me, the only problem that has been diagnosed for your tooth is that it is turning dark. The solution to that would be a porcelain veneer or direct composite bonding, either one at the hands of a true dental artist. In the unlikely event that you later need a root canal treatment on this tooth, it would be a simple matter to do that after the veneer or bonding, since root canal access is gained from the back of a front tooth. You need to be very careful who you ask to do this cosmetic work because the color manipulation would be quite tricky and you do need to have this tooth match the surrounding teeth. I believe that only 1-2% of dentists have the passion for appearance-related dentistry plus the training to make this tooth look perfectly natural. I would not bond several teeth because it isn’t necessary, provided you have a properly skilled cosmetic dentist. The reason your endodontist is suggesting bonding several teeth is because your basic family dentist would not be able to get this tooth to match any other way. Furthermore, the problem with getting a dentist to bond several teeth is that if he or she doesn’t know how to color match teeth in this situation, they probably aren’t very good at bonding either and would want to crown several front teeth instead. But if you gave me your city, I could find you a dentist who could get the tooth to match – perfectly – with a very conservative restoration.

Good luck with moving forward.

Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

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.

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