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Root canal re-treatment isn’t working

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Dr. Hall,
I had a root canal re-treatment on my front tooth 3 weeks ago, by an endodontist specialist. I had the tooth checked just over a week ago and although I was still having pain around the tooth, he said that there was no swelling and it would all settle down. However, it is still very sore and sometimes the gum throbs, particularly if I am active, which surely tells me there is inflammation still. I am unable to take ibuprofen or aspirin and take paracetamol when needed.

I had gum swelling around the tooth before the root canal re-treatment, which was treated by erythromycin and this was finished about a week before the treatment was completed.

My question is what should I do next? It does not seem to be settling and I am worried if the bone around the tooth is infected and if it could spread. Should I wait more time to see if settles or see if the dentist will prescribe more antibiotics?
– Diane from Ashfield, UK

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Diane,

It doesn’t look good for your front tooth. Your instincts are correct – after three weeks it should be feeling better. Am I correct in assuming there is no improvement in the tooth? Residual tenderness in a tooth after any root canal work isn’t that unusual, but there should at least be some gradual improvement which you should be able to notice after three weeks.

I would not do any more antibiotics. Antibiotics won’t get at the source of the infection in a tooth – they only assist your body in fighting off the infection. Yes, the tooth would feel better for a while but then when you quit taking the antibiotics, since you haven’t eliminated the source, the pain will come back and now you will have an antibiotic-resistant infection.

There is no significant risk of the infection spreading at this point. You aren’t having an increase in pain, from what you are saying, and there isn’t any serious swelling.

Something is still wrong with the tooth that wasn’t fixed with the root canal re-treatment. Re-treatments don’t always work and it appears that yours isn’t. After initial root canal failure, which you experienced, the chances for success for re-treatment are somewhere in the range of 50-80%, depending on the nature of the problem that led to the failure.

The way antibiotics were used in your case seems strange to me. You said you had erythromycin before the treatment, and this was finished a week before doing the re-treatment. That would just give the infection a chance to come back before starting the re-treatment. If antibiotics were needed, I would have started them, done the re-treatment after they had taken effect, and then continued the antibiotics for a couple of days afterward. I just mention that because it’s strange – that’s not why your tooth isn’t getting any better.

Your options at this point are limited. You could have root canal surgery, but I’m skeptical about the chances for success of that treatment in your case, since, based on what you’re telling me, your endodontist isn’t inspiring me with a lot of confidence. You could maybe try that if you get outside your UK National Health Service. Your other option would be to have the tooth extracted and then replaced with whatever options they give you in the UK.

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.

Finding a cosmetic dentist in the Cayman Islands

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Hi there Dr Hall,
Many thanks for such helpful information on your website. Your support is greatly appreciated! I currently reside in the Cayman Islands, my front right tooth slightly overlaps my front left tooth. Is there anyone you could recommend in Grand Cayman, so many cosmetic dentists I don’t know where to start. I have visited one, whom suggested getting all my teeth whitened, then 2 zirconia crowns on both front teeth as sister teeth. Are there any other options to compare, or does that sound wise. I am 34 with 2 young kids and finally want not to be too embarrassed to smile.

Many thanks
– Denise

Denise,
What you’re telling me about what this dentist wants to do makes me nervous. The idea that he or she wants to do zirconia crowns on these front teeth rather than bonded porcelain makes me think that he or she is not comfortable with bonded porcelain. Bonded porcelain would be preferable to zirconia. Zirconia is great for back teeth or bridgework, but I wouldn’t recommend it for an esthetically critical situation on your two front teeth. And I would think the ideal treatment would be porcelain veneers anyway, not crowns at all. Doing two or more crowns on front teeth can put you at risk of breaking them off from lateral stresses.

I don’t understand all these cosmetic dentists you are talking about. I just googled cosmetic dentists in the Cayman Islands and looked at several websites and couldn’t find anyone I would trust with even the simplest cosmetic procedures, much less something as involved as what you are telling me. Even in the United States, fewer than one dentist out of fifty could do a beautiful job on your case. I would be surprised if you could find a dentist in the entire Caribbean area who could do a nice job on this. Quite frankly, I would fly in to Miami and have someone there do this. Dr. Sam Sadati near West Palm Beach is one I know personally who would do beautiful work for you. You could have your teeth whitened there locally and then get the two veneers or whatever your case requires done in Florida.

Why spend money to give you a mediocre cosmetic result and then possibly end up with damaged front teeth besides? Spend a little extra for a couple of trips to Florida and get it done right.
Dr. Hall

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About David A. Hall

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

A case of implant dentistry incompetence from the U.K.

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Dr. Hall,
I had implants fitted and the crown came loose. I went back to the dentist and he x-rayed my mouth and reassured me that the implants looked fine and that it was just a case of cementing the crown back in place. When he tried to remove the loose crown it would not come away and he had to use a special tool, when it came away the implant came with it ! is it possible that he pulled it out accidentally or would an implant not succumb to force?
– Ann Marie from the U.K.

Ann Marie,
Clearly your crown was not loose – it was the implant that was loose all the time. A loose crown is so easy to remove that it usually falls off of its own accord – it would never require any kind of special tool. And I’m sitting here trying to imagine the gross incompetence of the dentist not being able to figure out that the crown was not loose, when he was not able to remove it. Now I realize that standards of health care in the UK are not very high, but even with that, I’m having trouble reconciling this that happened to you with incompetence. It kind of seems like the dentist wanted to go through the motions of recementing the crown to cover up that the implant was loose. A loose dental implant is serious. A loose crown is easy to fix.

A loose dental implant can happen for several reasons. You didn’t tell me the time frame of when this came loose, but if it is right after the crown is placed on it could be an indication that the crown was placed prematurely – before osseointegration was complete. Or it could be that the stress on the crown was too much for the situation, that the implant was not substantial enough to take the stress, or that the quality or amount of bone support of the implant was inadequate.

It’s also possible that the implant became infected. However, that would probably have been associated with pain, so I’m going to put that further down on the list of possibilities.

Fixing this is not a simple matter. It’s more complicated than just replacing the implant. The bone will have to be filled in again – the bone that was removed before the implant was placed. It’s possible that more bone will have to be grafted in because what was there may not have been adequate in the first place, and with what has happened in the loss of the implant, there is likely to be some shrinkage. And then, of course, you need to find someone that will do this right. I wouldn’t go back to the original dentist – no way.

If you were in the United States, I would advise you to demand that this dentist pay whatever it costs you to fix this right. You would have excellent legal leverage. In the UK, however, you have different standards of care and a different system, so I don’t know what to advise you about that.

– 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.

How long after cosmetic dental work should I feel pain?

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One month ago, I went to Mexico for cosmetic dentistry. The dentist completed 12 lower crowns and 6 veneers on the front upper teeth. Since getting the work completed (2 1/2 weeks ago now), my lower jaw has been extremely painful. It’s not in the gums, but my jaw itself. One tooth hurts to chew anything (even something soft, like bread). I asked the dentist about it and she said to take ibuprofen for a few weeks because so much work was done in such a short amount of time; and that the crown on the tooth that’s sensitive to chewing may have high contact, or need a root canal. That tooth does not touch any of the top teeth when I clench. I’m concerned that I’m having to take so much ibuprofen, and that it’s not really helping the real issue. Should I still be experiencing pain at this point? I take 800mg of Ibuprofen every 4-6 hrs – that can’t be good!!
– Julie from Iowa

Julie,
This doesn’t sound good.

The dentist told you to take ibuprofen for a FEW WEEKS??? Are you serious? So much ibuprofen over that long a period of time can damage your liver or your kidneys. You are taking 3200 to 4000 milligrams a day. I think the maximum recommended dose is about 2400 mg per day over short periods.

No, this kind of pain after getting crowns or porcelain veneers is not normal. Something is wrong. Some tenderness or soreness for a couple of days maybe could be expected. And your teeth should all be touching evenly.

You need a second opinion from a reputable American dentist. You have two excellent cosmetic dentists near you. [Names not included in this post]. Have one of them look you over and see what is wrong before this gets out of control and so you can get off this ibuprofen immediately. It does sound like you may need a root canal treatment. Don’t have that done in Mexico, please.

Only about one out of every fifty dentists in the United States is capable of doing a beautiful smile makeover. However, most of our dentists are fairly competent in general dentistry. If you go to Mexico, your chances of getting in trouble with even basic general dentistry are high, and there are probably only a handful of good cosmetic dentists in the entire country. I know of a couple, so it is possible to get quality work there. But clearly you didn’t end up with one of the good ones.

Dr. Hall

Links: Read more about cosmetic dentistry costs.
Read more about the quality of dental care outside the US.

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About David A. Hall

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

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

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

Mike from Chicago

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

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

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

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

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

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

Dr. Hall

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About David A. Hall

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

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.

Looking for a cosmetic dentist in Indonesia

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dear, i desperately looking for a dentist nearest my city/my country,iam women,36,a business woman. i need to makeover my smile,i have tetracycline tooth but not so bad,years ago dentist told me to do full veneer or crown that i refused to do,today i heard about lumineers but a doc says i had to braces my tooth before..about 1 year ahead.it seem long time .i just need to cover neck of my teeth with composite bonding but need a good trained dentist around jakarta or other country around south east asia cos my work make me travel often.can you suggest few names of dentist nearest my country ,hope you kindly give me their contact number/addresses.i’ll really appreciate and thank full.i am waiting so long to take decision since i also afraid of being dissapointed about the resultof my apperance if i got untrained cosmetic dentist who are many in around us but just announced by him/her self. from Indonesia.

Megan,
Maybe two out of every hundred dentists in the United States are good at appearance-related dentistry. When you go into some of these foreign contries, it’s much much tougher to find good cosmetic dentists.

We have a handful of world-renowned cosmetic dentists in Denmark, in Dubai, in Melbourne, in a couple of places in India, and in southern Brazil. With these other countries, I think you’re just going to have to lower your expectations somewhat. But at the same time, I urge you to be very careful, because covering tetracycline stain is very difficult. Ask the dentist to show you pictures of a tetracycline case he or she has treated before to see if they have experience at this.

Here are two dentists in Indonesia who are members of the American Academy of Cosmetic Dentistry, meaning they travel to the United States for training at these AACD annual meetings. This is at least an indication that they have been exposed to advanced cosmetic techniques and are interested in becoming skillsful cosmetic dentists. I would ask lots of questions and ask to see photographs of their work and ask to talk to previous patients, because of the uncertainty involved. But here are their names.

I have no knowledge of these dentists or their work, but these are two dentists who have been general members of the American Academy of Cosmetic Dentistry:
Adrie Limen, DDS
Jl Tebet Raya #30 AB
Jakarta, 12810 INDONESIA
62-21-7278-0585
FAX: 62-8294236
General Member Print Profile
Doctor • Member Since 2006
Send an Email

——————————————————————————–

Charlius Tjiptarahardja, DDS
Kapuas 10
Surabaya, 602 65 INDONESIA
011-6231-5677-209
FAX: 011-6231-5666-610
General Member Print Profile
Doctor • Member Since 2008
Send an Email

That is where I would start. I make no promises about what kind of work they do. I only state that your chances are better going to one of these two than going to just anybody.
Dr. Hall

Click here to find an excellent cosmetic dentist in the United States.

 

 

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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.

Roots of wisdom teeth were left in the jaw.

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Dr. Hall,
Hello. I had a wisdom tooth partially removed with the roots still intact. The dentist could not pull out my tooth. It was pretty excruciating. I sat for four and a half hours before he called it quits. He partially removed some bone to try to extract it the tooth but it didn’t work. He broke the tooth and took out what he could and cleaned up the bone as much as possible before sewing me up. He stated that he cut down the tooth enough for the bone to grow back over the roots that was left and that tissue will heal and start to grow back over the wound. My question to you sir is it OK for the roots to still be there? Am I still prone to serious infection if the bone grows over the roots, and will tissue grow back over some of my exposed jaw bone? I appreciate the help.

Thank you
–  Darian from Belgium

Darian,
I was surprised to read what had happened to you. I have heard of general dentists attempting wisdom teeth extractions and other difficult extractions, and finally giving up because they became too difficult. But in the situations I have heard of, the dentist then referred the patient to an oral surgeon to complete the work.

I don’t know how much of the tooth was left in your jaw, but the larger the piece, the greater the risk of subsequent infection, or cyst formation, or other complication. In some cases, it is wise to leave a root tip in the jaw when it is in a risky position such as near a nerve or near the sinus. But that doesn’t seem to be the case here – it just seems like it is a matter of the tooth being beyond the difficulty of your dentist. Yes, if enough of the tooth was removed, bone will probably grow over the roots, and it is possible that you won’t have any further trouble with this. But it is also possible that you will.

And four and a half hours – what an awful experience for you! Most wisdom teeth should come out in about 15 minutes – half an hour for the difficult ones.

I would suggest going to an oral surgeon in the next couple of days and having him or her x-ray this tooth and examine you, and see what they think should be done.

Dr. Hall

PS – The following was not part of my e-mail to Darian:

I get frustrated when I hear Americans complain about health care in the United States. There are a number of stories I have heard from people in Europe and Asia that are like this and reveal a much lower standard of dental care than would be considered acceptable in the United States. This corroborates what I saw in my practice when I had to re-do foreign dental work. I guess it is just a human tendency to not fully appreciate the good things we have.

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About David A. Hall

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

A putrid smell in my mouth, after getting 28 crowns.

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Sir i got all my 28 teeth replaced with crowns for the purpose of teeth lengthening. Upper & lower molars(8) of Porcelain fused to Metal. Premolars of Zirconia(8). Incisors & canine (12)of Empress. And now after 2 months from the procedure done am having very much bad breath that its very much difficult to live with and even to breathe, and it tastes like vomit. Still after using mouthwash and brushing twice a day its not helpful and the smell is as it is. even i got done scaling but still the smell and taste of the teeth remains. Please tell me some solution that can be done now to get rid of this as its too much difficult to live like this. i am really helpless. And also tell me is it was right for the teeth lengthening??
– Ogas in India

Dear Ogas,
There is something very wrong with your dental work. It my days of practice, I had several occasions to replace dental work done in other countries, and I frequently found poor dentistry with overhangs that would catch food or other basic defects.

The materials your dentist used sound first class. But if there are overhangs on all the crowns, that could produce the putrid smell that you’re experiencing. I can’t tell if that’s the case. There are other possibilities.

If this problem is allowed to remain, it will likely lead to gum disease and early loss of your teeth.

There are excellent dentists throughout the world. But I believe the consensus among the world’s dentists is that there is no place that has as high standards for dental care as the United States. So what I would look for would be a dentist in India with some credentials from an international organization based in the United States. A couple examples of that would be accreditation or some other credential from the American Academy of Cosmetic Dentistry (There are two accredited members of the AACD in Mumbai, India, and several accreditation candidates in the country), or fellowship or diplomate status with the International Congress of Oral Implantologists. There may be other credentials. I would track down a dentist with a credential like that and go there for an opinion on your case. Go to the website of the specific organization and they usually have a search tool for finding a credentialed member.
– 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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