Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

February 5, 2016

Diagnosing a sensitive tooth after a new filling

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Dr. Hall,
I wanted to get your opinion on a pain I am having after the filling on my molar was replaced two weeks ago (a silver filling was replaced with composite filling)

Here are my symptoms:
*moderate pain when chewing
*very mild sensitivity to cold
continuous moderate pain starting up in the evenings after dinner…
*I started taking 400mg Ibuprofen around midnight if I couldn’t sleep from the discomfort, and that really helps.
*In the mornings I have no pain.
(My wife, who is a doctor, suggested I take ibuprofen continuously to reduce possible inflammation. Started that today.)
*In the evenings, continuous mild pain and discomfort around my left jaw and tonsil.
*very slight tingling and numbness in my lower left jaw and chin, kind of like when anesthesia is almost completely worn off

So my question:

Do you think I should have the new filling replaced to address these symptoms? Or should I wait?
– Sergio from California

Sergio,
As thorough as you have been in describing your symptoms, I still haven’t got enough information to diagnose your pain. I don’t know how big your filling is. I don’t have an x-ray. I don’t know how deep the dentist had to go in doing your filling. Nevertheless, I think I can be helpful. Let’s examine your symptoms, point by point.
• Moderate pain when chewing. A sharp pain when chewing when there are no other symptoms indicates this peculiar sensitivity that seems to come because of a bonding failure. If that happens then yes, you want to have the filling replaced with some changes in the bonding procedure. But that’s not the case with your filling. The pain is moderate and there are other symptoms. I would attribute your sensitivity to one of two possible causes. Either this is a larger filling that has changed your bite somewhat, or the ligament attaching your tooth to the jawbone has been traumatized slightly. I would expect this to get better over time.
• Very mild sensitivity to cold. This would also happen if you had a large filling, or even one that was deep, where the pulp of the tooth was irritated because the dentist had to go close to the pulp to get the decay out. This type of sensitivity is routine for silver amalgam fillings but also happens with composite fillings when they are deep. As long as it gets gradually better, it is no cause for concern.
• Continuous moderate pain in the evenings. This is a little puzzling and is of more concern. Spontaneous pain in a tooth can indicate an irreversible pulpitis, especially if it is more intense when you lie down. Again, this could have been a deep filling. But if there is spontaneous pain, it would tend to indicate that some bacteria have gotten into the pulp. This doesn’t mean that the dentist did anything wrong. The dentin of your tooth is porous, and in the process of removing deep decay, some bacteria are going to be pushed into the dentinal tubules of your tooth. If the pulp is close to the floor of the cavity, those bacteria will end up in the pulp. If it’s not too many bacteria, your tooth can recover. But if your tooth isn’t getting better by now, it’s not recovering.
• Pain in the jaw and tonsil. This wouldn’t have anything to do with the tooth. It might be related to stress on your jaw or mouth from the procedure.
• Tingling and a sense of numbness in your lower left jaw. You had an injection to numb the lower left jaw. Residual tingling would indicate that the dentist hit the bullseye with the injection – a direct hit on the nerve he or she was targeting to numb. He or she may have even nicked it slightly with the needle. The target nerve here goes to the teeth on that side of your lower jaw and also to the lip and chin. This is of no concern and will completely go away in time.
Anyway, I hope this is helpful. You have an interesting mix of symptoms, and I’m hoping it makes an interesting and helpful blog post for others. Bottom line–most of this is not of any concern. But the spontaneous pain in the evenings worries me. Pain intense enough that you have to take ibuprofen to sleep is a concern. If it has been two to four weeks and there is no improvement, I would have the tooth x-rayed by a dentist who has a high level of expertise in radiographic diagnosis–possibly an endodontist (root canal specialist)–who should look for a widened periodontal ligament space around the root tip of this tooth. If that is present, the tooth may need a root canal treatment, and it would be better to have that done before the pain gets unbearable.

– Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

May 4, 2013

If the antibiotics don’t work, my dentist says he wants to pull the tooth.

Dr. Hall,
I have been trying to find information about calcification/mineralization of a tooth. (I was told by my dentist that, on x-ray, he does not see any remaining canal in one of my molars. It is one that already has a crown. After a round with antibiotics, if I still have discomfort in the tooth he says it may need to be pulled. Without a tooth canal present, he said he cannot do a root canal. I would rather keep all my teeth. Is there an on-line site with information about this subject so that I can read and be educated?) Thank you.
– Mikala from Wisconsin

Mikala,
I’m not comfortable with what you say your dentist is telling you.

First of all, this idea that if you’re not comfortable after the round of antibiotics you need to have this tooth pulled. Antibiotics alone in treating a toothache doesn’t solve anything. Sometimes antibiotics are used as a diagnostic tool – if the antibiotics solves the tooth pain, then we know your pain is caused by a tooth infection. That would be an indication that the tooth needs a root canal treatment or an extraction. But once you stop taking the antibiotics, if the pain has indeed gone away, it will return sooner or later, because you haven’t addressed the source of the infection.

But if the antibiotics don’t solve your tooth pain, then that would be an indication that the pain is NOT caused by a tooth infection, and the dentist should be looking for some other explanation for the pain. It could be from nerve irritation or who knows what. In that situation, he doesn’t have a diagnosis, so proceeding with treatment would NOT be the next step. It’s like he has this backwards.

And I have a problem with the notion that because the dentist can’t see a canal in the tooth, it doesn’t have one. Especially in an upper molar tooth where there is a lot of bone around it, it can make the root canal hard to see.

If you want to try to save this, I would get a second opinion. Look up endodontists in your area. Those are root canal specialists. Or just tell your dentist that you want a referral to an endodontist. If it were me, I would look up an endodontist on my own for fear that the dentist would send me to a buddy who would simply parrot what the dentist has said.

And to explain calcification, here’s what happens. As we get older, the canals in our teeth tend to shrink. This is a natural process that can be aggravated if there is irritation in the tooth, the tooth builds up more dentin on the inside of the pulp chamber and the canals of the tooth, making them narrower and possibly harder to find. It can make root canal treatment more difficult and sometimes, in extreme cases, can block the canal. But root canal specialists should have special tools to navigate through these calcified canals.

Good luck. If you want to save this tooth, go for it.

– Dr. hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

March 9, 2012

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

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 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 complete Internet marketing for dentists.

March 9, 2011

Root canal tooth still hurts after three weeks. Should we put off doing the crown?

Filed under: Root canals — Tags: , , — mesasmiles @ 2:55 pm

Dear Dr. Hall:
Exactly three weeks ago I got my 2nd endodotic treatment (root canal). The first session seemed to go well, but the endodontist had me come back for a second appointment because he suspected a fourth canal. After much digging and discomfort he did find a fourth canal on molar #14. The endo also found a crack while doing the treatment. I had pain and swelling for several days following the procedure. Now, I don’t feel the swelling, but I do feel intermittent dull pain more like in the jaw area of the tooth. Sometimes I feel a dull ache radiating to my ear. Sometimes it’s just a dull headache similar to when you have sinus pressure. I am due to go get the tooth crowned but have postponed one week to see if this goes away.

I am taking ibuprofen every 6-8 hours. Is this normal and should I give it more time to heal? Or, is this the signs of something worse happening? I know he did dig for a long time to find the fourth canal. I am only eating soft foods like mashed potatoes for fear that the tooth gets further damaged. I am so frustrated because I have been suffering with problems with this tooth for 5 months now, and no one can give me a straight answer. Last Friday, I also got an x-ray taken of the tooth, but the general dentist saw nothing out of the oridinary. That’s when he recommended I take ibuprofen and postpone the crown for a week.

Thank you for any recommendation you may have.
Cyndi from Florida

Cyndi,

That was good advice from your dentist to wait before doing the crown, but not good to wait just a week. It can take a month or more to be able to tell if this tooth is going to “make it.”

Root canal treatment can be somewhat chancy in some cases. With this tricky fourth canal and the crack the endodontist saw, the treatment may indeed not be successful.

In dental school, they made us wait 6 months before putting a crown on a tooth that had a root canal treatment. In practice I didn’t wait that long, as long as I felt confident of the result, but the point is that it can take a while for the problems to show up. If the tooth is infected, it won’t show on the x-ray until the infection has settled in, and even then, the signs on the x-ray may be subtle and beyond the diagnositic abilities of your dentist.

Before going ahead with the crown, I would ask for a green light from the endodontist. I would ask the endodontist to follow-up, either by you personally visiting his office or having your dentist send him a copy of the x-ray to evaluate.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

October 16, 2010

Can you tell a cracked tooth from an x-ray?

Filed under: Fractured teeth — Tags: , , , — mesasmiles @ 9:58 pm

Is it easy for an x-ray to miss detecting a cracked tooth? I had full mouth x-rays-taken at two different dental offices within a month of each other. Neither set of x-rays detected a cracked tooth. But when I changed to another dental office and that dentist referred me to an Endodontist, from the x-rays the Endo took, he told me I had a cracked tooth that needed a root canal right away. I’m wondering why the other two dental offices missed seeing that cracked tooth in the x-rays, and am wondering if it is common for an x-ray and/or dentist to miss detecting a cracked tooth?
– Grace from California

Grace,
I would put the answer to your question this way – it is very difficult to detect a cracked tooth on an x-ray. Unless the x-ray is taken at the exact angle of the crack, it won’t show up.

I suspect that the endodontist didn’t actually see the crack, but saw some subtle evidence that suggested a crack.

I have four molars of my own that all ended up needing root canal treatments because of cracks developing in them. But none of the cracks have ever shown up on an x-ray.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

August 16, 2010

Tooth still hurting after root canal treatment

Filed under: Root canals — Tags: , — mesasmiles @ 6:22 pm

Dr. Hall,
I recently (5 weeks ago) had a root canal in my right crowned front tooth by a very highly skilled Endodontist (he used a microscope). I still experience discomfort in this tooth, (no hot or cold). If my tongue touches the tooth, when I chew food or if I slightly push on the tooth it is sensitive. Should I give this a little longer, or should I contact my dentist and advise I am still experiencing discomfort? I have already had my permanent filling put in.
– Susan from Maryland

Susan,
I can’t tell from what you’re telling me if something is wrong with this tooth or not. It’s typical for a tooth to be at least a little sensitive to pressure after a root canal treatment. Five weeks is a little long for this to be going on. But if it’s still getting better, it should be okay. If the root canal treatment caused a little swelling, which would cause this tooth to swell up a little in its socket so that you hit it first, it could take a while for that to heal itself.

If it is getting better from week to week, I wouldn’t do anything now. But when you go to your dentist for your next regular checkup, I’d ask them to x-ray this tooth and check it out, just to make sure it’s okay.
Dr. Hall

You may want to read more about pain after a root canal treatment.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

December 12, 2007

A broken file in a root canal tooth

Filed under: Root canals — Tags: , , — mesasmiles @ 3:17 pm

Dr. Hall,
My dentist performed a root canal today and informed me that a tip of one of the metal instruments broke off in the canal. (I actually heard it and thought my tooth had broke!) He informed me that he was not going to try to fish it out. Since it was ‘sterile’ he was just going to leave it in the canal and put the post and cap on.

Is this what he should be doing? Or will it hurt me in the long run? This doctor has become notorious for not taking a lot of time with patients and overcharging, so I am nervous.

Thanks in advance for your help.
– Connie in New Jersey

Connie,
These metal files can break off easily, and that happens to a lot of dentists. And while it is best to retrieve the broken piece, that can be difficult to accomplish and can be beyond the ability of many general dentists. If your dentist can negotiate around the broken piece and seal the apex of the tooth, the root canal treatment will probably be successful. If the broken piece blocks access to the apex of the tooth, the root canal treatment could still be successful but the chances for success are greatly diminished.

If the tooth has problems later, it could end up needing re-treatment for the root canal. Cementing a post in the tooth could possibly make re-treatment impossible, depending on how many roots this tooth has. If the dental post is to be in the same canal as the broken instrument, I’d advise you not to let him put the post in the tooth.

The safest thing would be to ask to be referred to an endodontist (root canal specialist), who should have special equipment to be able to retrieve the broken instrument and fill the root canal. Depending on your relationship with the dentist and your personality, you may or may not want to do this. However, if the post is needed to help hold the crown on and if it is in the same canal as the broken root canal file and that broken file blocks the canal, I would insist on seeing an endodontist. If your dentist doesn’t refer you to one, you can seek one on your own. Otherwise the risk of losing this tooth would be too great, in my opinion. Meanwhile you could wear a temporary crown on this tooth or a temporary filling.
– Dr. Hall

Related information:
Failed root canal treatment
Root canal surgery
Dead tooth

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

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