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Bleeding between my two front crowns

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Dr. Hall,
In 2016 I had 6 anterior crowns placed. I have had problems with bleeding between 8&9 (the front two teeth) and sloughing of skin. I asked for a certificate of the alloys used but received no real information as to the composition of alloys used. I did note, however, that e.max was not referenced in this “certificate” but instead GC LiSi Impress. I have tried researching the materials in this product but quite honestly the only thing I can find, besides the marketing from the company, is a thread started by lab technicians. Can you tell me anything about this product?
Thank you.
Carol from Huntsville, AL

(See Dr. Hall’s answer below.)


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Carol,
I’m assuming that all the crowns were made from the same material. So, if you were allergic to the crowns you would be having inflammation and discomfort around all of them, not just between the front two. Also, I have not heard of an allergy to dental work causing bleeding. This sounds more like there is some problem with catching food particles or some other functional problem between those front two teeth—a margin that has an overhang or something in the shape of the crowns that causes food particles to get trapped there. My recommendation would be to be sure you floss there. And then, if you floss, notice if there is a ledge under the gum that catches your floss—this would indicate an overhang that your dentist needs to correct.

As far as the material in the crowns, it sounds like it’s GC LiSi Press. The reason your dentist couldn’t give you an identalloy certificate is that certificate shows the metals in the crown, and these crowns are metal-free. GC LiSi Press is a high-density lithium disilicate. I haven’t heard any reports of allergy to lithium disilicate, and researching it right now I can’t find any credible reports of documented allergy.
– Dr. Hall

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.

Using a cheap alloy and calling it a gold crown

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Dear Dr. Hall:
I had asked my dentist to use a gold alloy crown on my root-canaled tooth #15. When I asked about the alloy that was used, my dentist hadn’t even obtained the alloy certificate from the dental lab. So he got it from the lab, and I found out that the crown was made with 35% Palladium, 30% Indium, 30% Silver, 3% Zinc and ONLY 2% Gold. While the root canal itself was done properly, I am very much worried about Palladium and especially Indium in my crown for systemic impact on my health and allergic issues (though the dentists say there is no apparent allergic reaction around the
tooth) which from certain on and off vague external and on face skin reactions. Are these materials questionable? Especially Indium which I believe does not have long history of use in the crown. I would greatly appreciate your response. Thanks.
I found you by searching for dental crown metals.
Ranjit from New Jersey

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Ranjit,
I don’t have any good information about the incidence of indium allergy or indium sensitivity. I haven’t heard of any. When I search online, there are some questions about it but no hard data. Indium is frequently used in alloys for dental crowns, but it’s usually present at a much smaller percentage, maybe 5% or less. Its use in such a large amount here appears to me to be a way to make the alloy a little softer without using as much gold, thus making it a cheaper alloy. There are two reasons gold is such a good metal for dental crowns. One is that it will not corrode. Another is that it is soft and thus the margins of the crown can be burnished to the tooth to make an excellent fit of the crown, eliminating the gap between the crown and the tooth that can harbor bacteria that will cause recurrent decay. Palladium is a very hard metal, so the inclusion of indium and silver will make the alloy softer, helping it fit better.

Palladium has also come under question. Are there documented palladium allergies? I can’t find any. You can read my earlier blog post where I answer the question, Is palladium a toxic metal? Palladium is present in almost all dental crown alloys without any apparent adverse reactions.

Do you need to be concerned about possible reactions to this alloy? I don’t know. If you are sensitive, yes, you would expect to see some inflammation where your gum tissue touches the crown. You’re not having that, so that’s a good sign.

But I will tell you that I am very suspicious of what your dentist did here. You asked for a gold crown, and it’s looking to me like he found an alloy as cheap as possible that could be called a gold alloy. And I do not believe that your dentist didn’t get the identalloy certificate until you asked—I think he threw it away. By law, the laboratory is supposed to send that certificate with every case and the dentist is supposed to put it in the patient’s chart. Is this an effort to conceal or just sloppiness? I don’t know, but I’m suspicious.

There are three broad categories of dental alloys that are used in crowns:
– high noble (called gold)
– noble (called semi-precious)
– low noble (called non-precious)

There are two requirements for an alloy to be called high noble or, in common terminology, gold. First it must have at least 60% of a combination of gold, platinum, palladium, and silver. Your alloy comes in at 67% there, so it meets that requirement. But the second requirement is that it needs to have at least 40% gold, so your alloy comes in way short on that.

Here is a sample of an identalloy certificate that should be sent by the laboratory every time a dental restoration is shipped to a dentist. This one is color coded yellow, meaning that it is a high noble or gold alloy. You may note that it has 2.6% palladium and 1.6% indium.
An example of an identalloy certificate. Its contents are explained in the text.
Please note the instructions at the bottom of the form: “DENTIST CERTIFICATE (attach to patient record).” I’m wondering why these instructions weren’t followed.

My advice here? If you have any reason to believe that you are having a reaction to this alloy, I would demand that your dentist replace the crown with a more suitable alloy or you will file a complaint with the dental board. In accepted terminology, your dentist did not give you a “gold” crown, which would mean using a high noble alloy. You got a semi-precious crown, which is a step below and cheaper.

– Dr. Hall

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.

Burning gums from new crowns

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Hi Dr. Hall,
I’m having issues with 6 crowns placed on my front teeth.
Initial temporaries were horrible, felt there was a leakage – I expressed to my dentist that I was worried it was it infected. They took the temps off and he wanted a fluoride treatment done to the nubs, also prescribed an antibiotic, but never said I needed more done like a root canal. Finally got my crowns fitted and the bite was off, he had to do a lot of filing down to make it seem normal. They were ok at first but then too much fluid was going through the new teeth, so they sent the crowns back. Had to go back to temporaries that actually fit better this time. Anyways, new crowns come and I’m in week two of these crowns that are supposed to be permanent. Well I’m still having issues. Burning gums, teeth sensitivity, and now a hole in the back of one my front teeth. I’m supposed to go on Tuesday for these to be permanent but I just don’t think they’re still right. What do you think is causing this? Thank you for your help!!
– Becca from Alabama

(See Dr. Hall’s answer below.)


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Becca,
While I can’t tell you for certain what is wrong with your crowns without an exam, I can definitely be helpful.

The first thing I want to emphasize is to tell you not to let them permanently cement these crowns until you feel perfectly comfortable. Make that clear to them. This is Friday. I would call them on Monday and tell them that.

The second thing I want to key in on is this that you mentioned “burning gums.” You need to get to the bottom of that. Are these porcelain fused to metal crowns? If so, this could mean that you are allergic to the metal in the crowns. If that is the case, I would insist that they tell you the exact composition of the metal, and if there is any nickel in it (Ni), to tell them they need to use a different material. They would have received an identalloy certificate from the laboratory telling them the exact composition of the metal alloy. If these are pure ceramic crowns, you still need to get to the bottom of why you have this burning feeling in your gums.

There are several things you told me about what your dentist has done that make me wonder if he is in over his head. Doing a nearly complete smile of crowns on the six front teeth is very different from doing one or two crowns—much more complicated, and I would recommend a dentist with some credentials in cosmetic dentistry for that. Your bite being way off is a hint of a red flag. Yes, the bite can be adjusted, but with quality dental care, most of the time there will be little adjustment required. Doing a fluoride treatment to your prepared teeth doesn’t make sense. If your temporaries were leaking, then you got bacteria up in under them. Fluoride isn’t an antibacterial—it helps remineralize early decay lesions. A peroxide rinse or daubing the teeth with chlorhexidine would be a more appropriate treatment, since these are two great oral antibacterials.

About this hole in the back of one of your teeth—I would need to see that. I’m also not sure what this “fluid was going through the new teeth” is. Not sure what you’re referring to there.

If I were you, I would have them temporarily cement the new crowns and then find another dentist for a second opinion. Tell them you want to be sure they are comfortable before you make them permanent. You can tell them I told you that, if you want. I have said this before—a new crown should feel so comfortable you forget it is there.

– Dr. Hall

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.

Am I Allergic to These Crowns?

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Dr. Hall,
 

I had 3 crowns cemented two weeks ago. They were recommended by my dentist in order to strengthen 3 teeth that had large 20 year old amalgam fillings that needed to be replaced but were too big to fill and crowns were recommended.
 

Since they started working on my teeth, the crown prep, impressions, temporary crowns, permanent crown cementation, the total work lasted 6 weeks. For the entire 6 weeks, since the beginning of the process, I have had severe dry mouth, a sore/burning tongue, and tingling/numbing feeling on the side of my mouth with the crowns. I was worried I might be allergic to some dental material being used but the dentist insists it can’t be an allergic reaction since there are no other allergy symptoms occurring. I even went for bloodwork with my primary care doctor to see if anything else could be causing the dry mouth but all bloodwork came back fine.
 

Is it possible that my body is rejecting the crowns, can I be allergic to some material, or is it completely unrelated? I just can’t figure out what’s causing the dry mouth that started as soon as they started working on my mouth. The dry mouth is also making it hard for me to adjust to the feeling of the new crowns because my cheeks and tongue keep sticking to them and adding to the foreign feeling in my mouth. I am so miserable.
 

Any advice would be appreciated.

Thank you,
Sandra from California
 


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Sandra,
I don’t know where your dentist gets this idea, “it can’t be an allergic reaction because there are no other allergy symptoms.” There are varying intensities of allergic reactions with a variety of symptoms. With what you’re experiencing, it certainly sounds to me like an allergic reaction is indeed a possibility. But I can understand why your dentist would want to be in denial over that possibility because the solution, if you are allergic to anything in the crowns, would be to replace the crowns, maybe at your dentist’s expense. Now I’m not saying that what you’re experiencing is for sure an allergic reaction. I’m saying that is a possibility that should be checked out.
Here’s what I would do first—find out what these crowns are made of. You didn’t say anything about what type of crowns they are. If there is any metal in them, that’s where I would start. If there is, ask your dentist for a copy of what is called the identalloy certificate. This is a certificate that dental laboratories are required to provide dentists that lists the exact composition of any metallic alloys used in any dental restoration they make for the dentist. If there is any nickel in the metal, that is a prime candidate for an allergic reaction. Other possible metals that could be causing a sensitivity reaction could be beryllium or chromium. If the crown is metal-free all ceramic, a sensitivity reaction would be very rare, but I wouldn’t totally cross it off.
If you run into any roadblocks with this, I would get a referral to an allergist.
I would also add that it’s possible that the condition in your mouth is stress related (i.e. burning mouth syndrome). Since you had this reaction from the beginning of the work before the crowns were put into your mouth, that could be an explanation. If nothing else seems to provide an adequate explanation, maybe an allergist would be able to help you figure out if burning mouth syndrome is a contributing factor.
 
Dr. Hall

(Please see the comments below where I learned from Sandra’s initial response that the crowns were metal-free zirconia, and then 5 months later, where Sandra discovered that this was not an allergy at all but burning mouth syndrome, very possibly triggered by the stress of the dental work.)

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.

Is she allergic to the metal in her crowns?

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Dr. Hall,
I am 64 years old…had metal fused porcelain crowns (5 upper front teeth) placed 4 years ago. After countless dentist visits, a nightguard, a guard for my bottom teeth, tensing of the jaw, etc., I cannot stop grinding my teeth. I am constantly aware of these crowns with the sensations I feel in the roof of my mouth. Do you think that maybe I cannot tolerate the metal? Previous to these crowns, I had gold backed crowns for 42 years which I never had a grinding problem. I have no peace and I am ruining my bottom teeth. Could I be allergic to the metal? (only because it actually feels “itchy” at the roof of my mouth.)

– Mae in Pennsylvania

Mae,

I need a disclaimer because of not being able to examine you myself, but just going from what you are telling me, it sounds to me like you have two separate problems.

The itchy feeling around the metal backings to your new teeth could well be from a metal allergy. Here’s what I would do: Ask your dental office for information on the composition of the alloy used in the metal of your porcelain fused to metal crowns. The laboratory would have sent them what is called a “Identalloy” certificate, which lists all the metals in the alloy. If you see “Ni” among the metals listed – this stands for nickel, and nickel allergies are fairly common.

Are you sensitive to any metals in earrings, for example? Women who have nickel allergies need to wear hypoallergenic earrings, and they have to be careful with what metals are put in their mouth.

Let me explain these dental metal allergies. In the medical history that the dentist took before starting any treatment, he or she should have asked if you have any history of metal sensitivities, and if you have anything like that in your history, the dentist should have prescribed metals for use in your mouth that have no nickel in them. The problem is, those metals are more expensive than ones that do have nickel. There are three expense classifications of metals used in crown and bridge work. The highest is called “high noble.” The gold backing you used to have would be in this category. Other alloys have high platinum. This type of metal makes a finer margin and is more malleable, meaning that it can be made to fit the tooth the best. The second highest is called “noble.” These will have a higher silver content, but will have no nickel or beryllium, which are metals that can cause sensitivities in some patients. They are somewhat malleable and make a very nice fit to the tooth, but not as high quality as the high noble.

The lowest category is called “base metal.” These are very stiff alloys and tend to be cast with small gaps between the metal and the tooth, so they don’t fit quite as well and they aren’t malleable at all. They will have some nickel in them and sometimes some beryllium.

Your new crowns may have also disrupted your bite. The metal sensitivity shouldn’t be causing you to grind your teeth, But if you had crowns on five front teeth, that has a strong impact on your bite and your bite could be thrown off to where it is making you want to grind your teeth. If this is happening to you, I would wear a nightguard every night until the bite is adjusted to where you don’t grind any more.

A particular problem if you have porcelain crowns on your front teeth that don’t have a full metal backing is that the porcelain on the upper teeth is highly abrasive to your lower teeth, and you will gradually wear down your lower front teeth. So I would get this fixed.

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.

Allergic to the Metal in her Crowns

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This is a follow-up e-mail from Carolyn in New Jersey. She asked about the types of metals that are used in porcelain-fused-to-metal crowns.

Dr. Hall,
Thank you very much for your informative answer.

At this point, my last concern is aesthetics. I seem to be reacting to a metal in my porcelain-fused-to-metal crowns. (Tongue inflammation where the tongue touches the metal parts of my crowns, inflammation in the skin on the lips and around the mouth, and general facial inflammation).

I saw the metal shell underneath each of these porcelain crowns just before they were placed in my mouth. I hadn’t been informed, first, that such a metal shell could or would exist under the porcelain, so there was no time to halt the procedure in order to seriously question the makeup of that shell. It was rough, grainy, and very dull silver-colored. I suppose this is the “black” that is now appearing near the gums. I’m guessing this would have to be a “base” metal. It certainly wasn’t “shiny.” More like the lowest grade of industrial steel.

In addition, I’d asked for a gold surface on top of some of the the porcelain crowns. I had no metal in my mouth prior to this and my goal was to have only gold, if any metal at all. I have a TMJ problem so a forgiving metal was needed on some surfaces.

Understanding completely that there is no “pure gold” for the mouth and that all gold comes as an alloy, I still cannot believe that these surfaces on top of the porcelain crowns are actually gold. They are quite dark silver now, “hot” to my tongue, they burn my tongue, and now the tongue is swollen in those places. I do have an all-gold crown, in the back of my mouth, to compare these dark silver metal surfaces to. The all-gold crown looks, feels, and acts like gold. It’s beautiful and feels good. These “gold” surfaces on top of the porcelain-fused-to-metal crowns, however, look and feel so dark and so hot. I’m suspecting an electrogalvanic reaction between the upper metallic surfaces and the baser metals at the gumline.

I’d questioned the gold content of these upper surfaces (because they looked silver) and received the answer that the colors can be different due to the fact that the gold comes as an alloy. But “this degree of different” is really strange. If my white gold ring began to look this way, I’d take it back to the jeweler for a refund.

So I’m trying to gather intelligent background information, independently, on what I might have received in my mouth that is causing my mouth and tongue to burn, and my facial/lip skin to become so inflamed with scaly red patches around the mouth. I realize that no one but my dentist can give me the chemical composition for sure. I just wanted to have a ballpark idea of what might be happening to me before I approached him on this.

In general terms in the profession: Is it possible for a patient who has paid in full for such crowns to go back, a mere two or three years later, and receive from the lab the exact metallic composition of each crown that they produced for me?

Any further information on any of these points would be greatly appreciated. I understand completely that only my dentist can give me the “bottom line” on my own case. I’m just looking for accurate ballpark info so that I do not permit myself to be led astray.

Does the black at the gumline, therefore, give evidence of a “base metal” having been used for the metal shell under the porcelain crown?

Thank you.
Carolyn

Carolyn,
No, the black line at the gumline doesn’t give any clue as to what metal you have in the crowns, nor does the rough appearance of the metal on the inside of the crown (it is left rough to be more retentive – a shiny surface would slip off the tooth more easily). But your sensitivity gives a strong clue. I would give at least 95% odds, based on your reactions, that nickel was used in your crown, as that is the metal that usually provokes this kind of reaction. That is one of the base metals.

And to answer your previous question, yes, the dentist should retain documentation of what alloy was used and its composition. The dental laboratory is required to send to the dentist what is called an identalloy certificate that lists the composition of the alloy that was used, and the dentist is required to retain this. The dentist bears responsibility for insuring that you don’t have this kind of reaction. Do you have any history of metal allergies, such as a reaction to any metals in earrings? We always asked whether people had any reaction to metals, and flagged the charts of those patients who had metal sensitivities, so I would know when to avoid base metals. Although we got to where we simply didn’t use them on anybody because of the risks involved, except for Medicaid patients, where the government specified that they wanted us to use base metals, because they were cheaper. If your dentist didn’t ask you this, then he or she is responsible for this and should make it right with you.
Dr. Hall

Dr. Hall,
Again, thanks so much. I very much appreciate your insight and your time.

The one overwhelming thing known about me by the dentist and his staff is my multiple chemical sensitivity. That reality looms larger than my name, at this point. I have been my dentist’s “chemical education,” with all the difficulties and humorous moments that implies.

Although mercury made me miserable (all those teeth fell apart and the mercury was incidentally removed before these metal-shelled crowns were installed) I never had a nickel allergy to report! I supposed now I will.

Carolyn

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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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