Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

May 3, 2018

Whose fault is it that this tooth broke off?

Filed under: Fractured teeth — Tags: , , , , — mesasmiles @ 9:41 am

We thank our advertisers who help fund this site.

Dr. Hall,
I had a crown put on tooth #7 (right lateral incisor) about 40 years ago but no root canal. My dentist said I now need a root canal on that tooth due to decay under the crown. I’ve had no pain, abscess or any indication of infection. The dentist attempted a root canal through the back of the crown and after 2 hours he gave up and said the canal is calcified and he is unable to locate it. He put a temporary filling in the crown and said I will need an endodontic specialist to perform the root canal. Because I am not in pain, the endodontist booked me an appointment 4 weeks out. Well it’s been 2 weeks and now my crown (with some tooth inside) has broken off and I don’t know what to do. I’m elderly and can’t spend a fortune on this tooth issue when it probably should have been left alone in the first place. Should I just get an implant? Attempt a root canal? I doubt there is enough tooth left to put a new crown on even if the root canal is successful. I bought some DenTek at the drug store today and can reattach the crown myself. I would greatly appreciate your perspective on this.
Ruth

Ruth,
I’m going to start by trying to answer a question that you were too polite to ask: Whose fault is it that this tooth broke off?

Your dentist was drilling inside this tooth for two hours looking for the root canal and not finding it. It’s hard not to believe that doing so seriously weakened the tooth and is the reason it broke off. And having done that, he didn’t pass that information on to the endodontist or do anything in the meantime to strengthen the tooth. Hopefully he has learned a lesson from this, but meanwhile you are victimized here. It seems reasonable to me that he should accept some of the responsibility for the fix you are in.

With there being decay under the crown, the logical way to proceed here would seem to me to be to take the old crown off (it will have to be replaced anyway), get rid of the decay, and then finding the canal would be much easier. If the tooth really got infected, then the decay penetrated into the canal. But even if it didn’t, having the crown off greatly increases visibility and access.

Meanwhile, to answer the question you actually asked, if the tooth is down to a stump then yes, it may be difficult to put a crown on it and you could lose the tooth and need an implant. However, if your bite isn’t particularly stressful, the right kind of dental post in the tooth could enable it to hold a crown, even if there isn’t much of the tooth left. But after the fiasco you’ve been through, I’m doubtful that your current family dentist has enough expertise to pull that off. The placement of the post or posts would need to be done in such a way as to brace the restoration against rotational forces, and that can be tricky. Posts are round and lateral incisors are kind of round in cross section, and it doesn’t take much twisting force to loosen a crown and post in this situation.
– 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 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.

November 16, 2017

What to do when my dentist is getting really rude?

Filed under: Uncategorized — Tags: , , , — mesasmiles @ 6:16 pm

We thank our advertisers who help fund this site.

Hello Dr. Hall,
I went in for a normal root canal. As my numbing started to wear off it felt as if someone had taken a bat to my face. The next morning I woke up in terrible pain and a very swollen face for about 3 days. This was on tooth # 10 [upper left lateral incisor].

I called the dentist and he put me on Flagyl. One week later still in pain he did an x-ray said root looks fine continue with Flagyl.

After weeks of visits with doctors I was told the injection had caused irritation with a nerve. One doctor told me I have trigeminal neuralgia. They told me to let the dentist know. I did so he called me in and started to be very rude telling me no dental procedure could affect a nerve from simple numbing procedure. I didn’t argue I don’t know. Just doing what the other doctor told me. He then pulled up my pharmacy history and started asking about all my medication not pertaining to any of this.

I scheduled my appointment for my crown and when the nurse calls me back she says I need a clearance letter to be treated any further and the doctor stands at the door and again is telling me no injection can cause pain to a nerve. He won’t even enter the room. At no point have I accused him of wrong doing or been angry I have just seemed treatment for pain and to get my tooth fixed. I call the office to yet again make another appointment with a clearance letter and the lady tells me I have to send the letter and once the doctor reads they will call me back to let me know if he will continue treatment or not. At this point I feel like I am being treated very poorly at no fault to myself so I am seeking the completion of my treatment elsewhere but I would like my money back since he did not follow through with completion of my procedure and billed my insurance for an office visit when he failed to even see me.
– Tonya D.

Tonya,
My goodness, what a reaction by your dentist!

There are several things that are odd about what he is doing, and you definitely need to sever the relationship and of course you should be entitled to a refund of any treatment that isn’t completed. Logically, it would seem that your dentist would welcome this and gladly hand you a check, but there seems to be a lot of emotion wrapped up in his actions, so I’m not sure what he will do.

The post-operative infection after the root canal treatment was unpleasant, to be sure, but not any certain indication of anything significantly wrong that your dentist did. There are sometimes these flare-ups and sometimes they happen in spite of the dentist doing everything right.

However, the use of Flagyl for your oral infection is a little odd. Flagyl is generally used for lower GI tract and vaginal infections—not for oral infections. It is an alternative antibiotic that is maybe a fifth or sixth choice for an oral infection when there is a reason not to use one of the others, and because of its limited spectrum it is usually combined with another antibiotic like amoxicillin in this type of setting.

But the oddest thing is your dentist’s extremely defensive reaction to the suggestion that you could have had irritation to a nerve from his local anesthetic injection. Now, just from what you’ve told me, it doesn’t add up to trigeminal neuralgia. Trigeminal neuralgia is characterized by extreme facial pain that is triggered by touching or stimulating an area of the face. It is something that recurs from this touching or stimulation, and so diagnosing that from a single instance and from an injection is a bit of a stretch. But my gosh, how about a simple “I disagree” and move on? Instead, he gets extremely defensive about it and feels this need to counter-attack the messenger. With that type of aggression being displayed by him, I can’t imagine you feeling safe under his hands.

So yes, go find another dentist to finish this, and insist on a refund, and, if you feel so inclined, report the “non-visit” to your dental insurance company. If I were you, though, I might ask for the refund and threaten to report the non-visit if this dentist gives you any flak over the refund. You could also report this to your state board of dentistry if he doesn’t cooperate.

Good luck,
Dr. Hall

Do you have a comment or a question 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 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 31, 2017

After my porcelain veneers, I need root canal treatments


We thank our advertisers who help fund this site.

Dear Dr. Hall,
I had full mouth smile makeover done (veneer crowns) in January 2017, 12 upper teeth and 10 lower teeth. After they put permanent crowns on, I felt sharp pain on teeth #5 and #13 (upper second premolars). The dentist did crown height adjustment 3-5 times, finally the pain went away, but tooth abscesses formed on top of both #5 and #13 teeth within 4-6 weeks. The dentist x-rayed and said the teeth nerves had died, and I need root canals. I was upset and didn’t realize that nerve damage could be a risk involved in veneer crowns. I remembered I asked if there is any risk doing smile makeover during consultation, I was told there is no risk. The X-ray showed that my teeth nerve are fine before the procedure. I am confused and don’t understand what is going on.

The dentist said he didn’t know why, it rarely happened, I am the unlucky one. He referred me to an endodontist to perform the root canal procedure, and the endodontist found more teeth showing no response to cold test, also my gum flared up, swollen and very painful. So far I have had root canals done on 4 teeth (#4, #5, #13, #14), and #12 needs a root canal too, just matter of time. The tooth #3 starts feel strange too. Dr. did agree to pay half of the cost of the 4 root canals, but I am worried it will be an ongoing nightmare. What if the crowned teeth one by one goes bad over the time? I am very frustrated and feel misled. It not only financially cost me, but also add lots of stress on me. Please tell me what i should do and I need some advice. Thanks!
Sincerely,
Jenny from Texas

Jenny,
To answer your question, I first need to lay down some terminology so we’re clear in what we’re talking about. I’m a big fan of clarity in communication, which requires precisely defining what words mean.

two front teeth, prepared for porcelain veneers

Porcelain Veneer Preparation

You’re saying you had “veneer crowns.” But a porcelain veneer is one thing and a porcelain crown is something very different. A porcelain veneer requires very light shaving of the front surfaces of the teeth—sometimes no shaving at all is required. I found this photograph that illustrates a typical porcelain veneer preparation. Maybe half a millimeter of tooth structure has been shaved off, and the porcelain will be bonded over this.

two front teeth, prepared for porcelain crowns

Porcelain Crown Preparation

This second photograph shows a typical porcelain crown preparation for the same two front teeth. Much more tooth structure has been removed.

It appears from your description that what you had done were porcelain crowns, not porcelain veneers. It is very rare that a porcelain veneer preparation on a tooth will end up making it need a root canal treatment. But a crown preparation will go much deeper into the tooth, increasing the risk of a pulp exposure, resulting in an infection of the pulp and the need for a root canal treatment.

A smile makeover, by itself, does not require any aggressive grinding down of the teeth, which is what must have been done in your case. If your teeth had large fillings or decay before getting your makeover, then grinding them down was necessary. If that is the case, it wouldn’t be surprising if some of those teeth ended up needing root canal treatments. Anytime there is a lot of decay or large old fillings, there is a risk of teeth getting infected. But I would call that procedure a full-mouth reconstruction, not a smile makeover.

But if this that you’re calling a smile makeover was just for aesthetic reasons, then your dentist was much more aggressive than he needed to be, and I believe he should be responsible for the cost of the damages he caused. If you weren’t told of any of these risks up front, he is especially vulnerable.

A smile makeover should be done with porcelain veneers whenever possible, to avoid problems like you are having. There is even a trend in recent years for excellent cosmetic dentists to place what are called ultra-thin porcelain veneers, which require even less preparation than is shown in the photograph above. Some even try to do the makeover without preparing the teeth at all. But many dentists who aren’t expert in cosmetic dentistry simply don’t know how to do porcelain veneers very well, and so they resort to full coverage crowns. Porcelain veneers aren’t taught in dental schools—they’re a cosmetic procedure for which a dentist should get post-graduate education.

As far as what you should do now, I don’t know what to tell you. You don’t really have any option, if you want to save these teeth, besides having the root canal treatments done. And it’s curious that your dentist is offering to pay half the cost of the root canal treatments. This seems to indicate that he is feeling some guilt over this. If that’s the case, I would press him to pay the whole thing.

About what to expect long term, it’s hard for me to tell for sure from here. My guess would be that any teeth that end up having problems, you will find out within the first few months and then things will stabilize.

Dr. Hall

Do you have a comment or a question 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 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.

April 5, 2016

Fixing a single discolored front tooth

We thank our advertisers who help fund this site.
.

Dear Dr. Hall,

I had a left central incisor that underwent root canal treatment in 2004. It subsequently turned grey and I underwent internal bleaching last year.

The tooth still looks grey under certain lighting conditions and does not match my right central incisor. I am hesitant to get a porcelain veneer or crown as I would like to be as conservative with tooth structure as possible.

Also, I am aware of people who have problems with their porcelain veneers/crowns – poor colour matching, cracks, dislodgement, that result in repeated adjustments and more damage to the enamel each time.

Hence, I am considering composite veneers on either one or both central incisors to match them – if I need to change the composite veneers due to staining 5-7 years later, will I end up grinding off more enamel each time the composite veneer is changed? Is it possible to only drill off part of the old composite and bond a new composite veneer on the old composite itself(i.e. composite-composite bond)? If a composite-composite bond is feasible, then I could replace the veneers as required without harming any more natural tooth structure each time.

As composite veneers only last 5-7 years, I am worried that repeated replacements will eventually damage all my remaining enamel if more enamel has to be drilled each time (I am in my late 20s).

Please kindly advise if composite veneers would be a feasible long-term solution. I do not mind repeated costs, or having to visit the dentist every few months for touch up. My main concern is being conservative to the enamel, and finding a sustainable solution in the long run.

Also, will well-maintained and well done composite veneers look natural and blend well with the rest of my teeth?

Thank you Dr. Hall
– James, from an undisclosed location

James,
You’re not going to have to worry about possible damage from having this work re-done repeatedly if you get it done right. But if you don’t have it done right, yes, I have seen a minor correction to make two front teeth match escalate into two full crowns for the front teeth, where each tooth gets whittled down to a stub.

The key is going to be getting the right dentist. It is a small minority of dentists who will be able to get your tooth matched. And it is a slightly smaller minority who will do that in an ultra-conservative way, which sounds like what you want. But even if the dentist isn’t ultra-conservative, as long as it is done right you shouldn’t have to worry about repeated assaults on your tooth.

So your situation is one slightly discolored front tooth, and you’re apparently happy with the rest of your smile. The way I liked to treat cases like this was with direct dental bonding. I would shave off some of the front surface of the tooth to make room for the bonding material and so that the result would be no thicker than the companion front tooth. And then, with a combination of opaquers, tints, and composites of varying shades and translucencies, I would build up the discolored tooth to match its companion. I preferred using composite to doing a porcelain veneer because I could monkey with the color right there and get a perfect match without trips back and forth to the lab and having to communicate what I was seeing to the lab technician.

The same result could be accomplished with a single porcelain veneer. Some dentists will be very aggressive in their tooth preparation for a porcelain veneer and will grind away a lot of the tooth. But most expert cosmetic dentists will be pretty conservative, removing only a fraction of a millimeter of tooth structure. I would think that would meet your requirements of conservatism. And with a porcelain veneer, if the cosmetic dentist has done a lot of these, he or she will want to charge a premium fee, as I did, because there are going to be many trips this veneer will make back and forth to the lab with multiple try-ins to get the color perfect.

Lifespan of dental bonding

As far as the lifespan of the work, I will explain why I don’t think that should be a problem. With the bonding, it is the surface that deteriorates after maybe 3-5 years (longer if you use a gentle toothpaste like Supersmile), and the maintenance would simply be re-surfacing the composite. It wouldn’t have to be totally ground off and start over. With the porcelain veneer, if it is done right it could last many years. There isn’t a fixed lifespan there. If you take good care of it so that you don’t get decay on the edges or fracture it, it could possibly last twenty years. It’s not like a tire that wears out, but more like a piece of fine furniture that could fall prey to abuse, but if it is well cared-for could last indefinitely. And then a good cosmetic dentist would have tools to be able to remove the porcelain and bonding composite without significantly affecting the tooth.

If you get a dentist who wants to treat both your front teeth so as to guarantee a perfect match, take that as a red flag. The dentist doesn’t have confidence in his or her color skills to be able to match the adjacent tooth.

If you do want to share your location, I could help you further by possibly steering you to a cosmetic dentist who would be up to this task.
– Dr. Hall

Do you have a comment? 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 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 31, 2016

A smile makeover over a fractured tooth spells trouble for Aaron

We thank our advertisers who help fund this site.
.

Dr. Hall,

I had a traumatic fall 12 years ago fracturing 2 front teeth and my smile was restored with root canals and Procera crowns by my family dentist. With age and time, I didn’t like the way my adjacent natural teeth looked with the Procera. Also, I had one left upper molar that had a pretty deep filling and was giving me trouble. I am 38 years old and that filling was almost 30 years old. I decided that it was time for a smile makeover. So I went to a cosmetic dentist here in Lexington who gave me a combination of porcelain crowns and porcelain veneers.

I love my new smile. After the restoration however, my #9 front fractured tooth began giving me trouble. It was tap and pressure sensitive, so I went back to my cosmetic dentist and she told me I need to get an implant and another restoration. I had a gum pimple at the time and was referred to a periodontist.

root fracture on tooth in a smile makeover

The x-ray of Aaron’s front tooth.

I went on a course of antibiotics immediately (Amoxicillin 500 mg). I saw a periodontist last week and he confirmed that extraction of my newly restored tooth was needed. I requested my x-ray, showed it to my family dentist, and he doesn’t necessarily agree that extraction is warranted. He is contacting the West Virginia University, University of Kentucky, and University of Louisville dental schools to see if this tooth can be saved by periodontics or endodontics. I really do not want to lose #9, especially after a $1500 crown was placed, and not to mention IT IS MY FRONT TOOTH. Wish me luck. Please feel free to comment. I have attached the x-ray.

– Aaron from Kentucky

.

Aaron,

I actually have a couple of problems with your smile makeover. Not with its appearance. You also sent a photograph of your smile and it looks great! But it leaves me wondering if your dentist took x-rays before doing this smile makeover or, if she did, if she fully comprehended what she saw or gave it proper weight.

Root fracture on tooth #9

Your tooth #9 doesn’t look good at all. I have a fair amount of expertise in x-ray diagnosis and taught x-ray technique at the University of Minnesota, and I’ll tell you what I see. Right in the middle of the root there is a horizontal radiolucent line that looks like an old fracture. This must date from back to your original accident. The root canal filling crosses this fracture line, so the dentist who did the root canal either didn’t see the fracture or figured he or she could navigate through it, remove all the necrotic soft tissue, and hopefully get healing. And it looks like this happened to some extent, at least. The end of the root looks healthy. But just above the fracture line, the tooth looks moth-eaten. It appears that some of the root canal filling material is gone. If the pimple on your gum traces to that area, that spells trouble. And my guess is that it does. The moth-eaten appearance suggests that there is infection eating away at the root of your tooth. If this is the case, the tooth is unrestorable.

Does tooth#8 need root canal re-treatment?

If this weren’t enough, the other front tooth is suspicious. If I had done this case, I would have addressed the problem with #9 before starting, but I would have also recommended re-doing the root canal treatment on #8, because the root canal filling stops several millimeters short of the end of the tooth. Now that the crown is on that tooth, I wouldn’t do anything more than wait to see if it flares up. There aren’t any signs on the x-ray of any infection here, just evidence of a situation in which infection could develop.

So yes, I think you’re going to lose tooth #9. From everything I can tell, your dentist is an excellent cosmetic dentist, so I would have her stay with this case and finish it. But I think she missed the diagnosis here and should make concessions on the fee to get this fixed right. If I had made this mistake, I would ask you to pay for the extraction and the implant but then not charge you anything for the implant crown. That would make it so the total fee you pay would be equal to what you would have paid had the tooth been extracted in the first place and an implant placed, which is what should have been done.

– Dr. Hall

Do you have a comment? 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 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 5, 2016

Dentistry in Costa Rica

We thank our advertisers who help fund this site.
.

I’ve written before warning about getting dental work done in Costa Rica. But I just became aware of an incident that truly highlights the risks. Because I am only able to partially confirm this patient’s claims, I am not publishing the name of the dentist, which she had provided, only her story because it illustrates the risks in dental tourism.

dental tourism in Costa Rica

Dr. Hall,
I went to Doctor [name withheld] at [name withheld] Dental Clinic just outside of San Jose Costa Rica for some dental work and to have porcelain veneers placed. The dentist broke one tooth and caused me to need three root canals. He left me with ten open margins, I had crowns pop off, and he screwed up my bite so badly that I now suffer from severe TMJ, constant pain, can’t eat or speak properly etc… I have an estimate of $35,000 to fix my bite (which I don’t have) which doesn’t include the root canals. He refuses to refund the small fortune that I paid him and refuses to pay to have my teeth fixed.

But the story gets worse.

After my follow-up with an American dentist who said that I was the victim of criminal negligence, I hired a Costa Rican attorney. We were able to get three Costa Rican dentists to concur with the American dentist. We met at the Dental Colegio. But all that mattered at the Colegio board meeting was the fact that I complained publicly about Doctor [name withheld]. It was explained to me that it is a felony to speak against the reputation of a Costa Rican citizen unless or until that person has first been found guilty of a crime in a Costa Rican court of law. It did not matter that I filed those complaints online about the dentist from my own home in America. I had to flee Costa Rica immediately to avoid being arrested.

As far as filing criminal charges or a lawsuit, my attorney told me that the dentist would just bribe an official and make the case go away. My only hope was with the Costa Rican dental Colegio and they cared nothing about justice. Their legal system in Costa Rica is very corrupt. There is no justice there for Americans.

I also learned that this dentist didn’t graduate from a dental school in Miami as it claims on his website. He only took a class there.

– Kimberly from Florida

I thought I would just pass on Kimberly’s experience here, as there isn’t much I can do to help other than to help publicize her plight. I did look up the dentist she mentioned, and the website looks very inviting and gives you the feeling that you’re going to get wonderful care. The credentials presented look legitimate. However, as a dentist, I noticed some red flags that I think would escape the normal patient. For example, this dentist claims to have had a minor in implant dentistry from Miami University, as Kimberly mentioned. But there is no such thing as a minor or major or any organized course of study in implant dentistry at any American school—it isn’t a recognized specialty. He also claims to have a minor in Orthodontics and Prosthodontics from the DaVinci Institute. Besides the fact that this makes no sense—there are no “minors” in any dental field in the United States, only majors. And the combination of those two specialty areas in dentistry is made up. If minors did exist, he would have two separate minors—one in Orthodontics and one in Prosthodontics. Besides this, the DaVinci Institute is a think tank in Colorado. It may sound dental because of the famous DaVinci Dental Studio in California (a renowned dental laboratory that makes porcelain veneers), but there is nothing dental about the DaVinci Institute. Then, googling the dentist’s name and the name of his clinic, I discovered that the name of the clinic had been recently changed, a tactic used to escape a bad reputation. Also, there are no Google reviews for this dentist or his clinic, under either of its names, which is very strange. These are all red flags. But they would escape the typical dental patient.

I also found another serious complaint filed against this dentist on the website ripoffreport.com.

Bottom line: Beware! Just don’t do it. Both implant dentistry and beautiful cosmetic dentistry are risky enough in the United States. Don’t compound it by going to a place where you have poor standards of care and absolutely no legal recourse in case something goes wrong.
– Dr. Hall

Do you have a comment? 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 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 4, 2016

Fixing a broken front tooth on a 7-year-old

We thank our advertisers who help fund this site.
.

Dr. Hall,
When I was about 7, I slipped on a monkey bar and it cracked and chipped my right upper front tooth. I didn’t get it fixed right away, but a couple of years later the dentist did a root canal and I also had it filled to kind of match my other front tooth. But now it looks horrible because it’s smaller than my other tooth and it’s discoloring. Would there be a way for my smaller discolored tooth to match my bigger front tooth? And to get rid of the discoloration?
– Vance in Arizona

Vance,
This could be a real problem, if you ask your family dentist to do this. But if you go to an expert cosmetic dentist, such as the ones I recommend on this website, it’s a fairly straightforward case that should require a single all-porcelain crown.

Many cosmetic dentists, me included, won’t recommend doing a porcelain crown on a patient in their teens or younger because often the tooth hasn’t fully erupted. If the tooth continues to erupt after the crown has been placed, the margin ends up very visible, which is not good. So they will repair the tooth with composite, if that is an option, and then do the crown in the patient’s late teens or maybe a little later. And since a composite filling isn’t as strong as a crown, making it a little smaller can keep the composite from breaking.

One problem, though, with composite on the front tooth is that it can be susceptible to staining. An expert cosmetic dentist will have a selection of highly stain-resistant composites to use, but most dentists will just stock all-purpose composites. And then, the tooth itself is subject to discoloration once it has had a root canal treatment.

Here is a photo. discolored front toothThis isn’t Vance, but is a photo of another patient who has had a root canal treatment on a front tooth and a composite repair, similar to what Vance would have had. The composite covers about 1/3 of the tooth, consisting of the lower left corner as we are looking at it. You can see that the composite, while it is lighter than the rest of the tooth, is darker than the adjacent tooth. So the composite has discolored some, and the tooth has discolored more.

When a front tooth has a root canal treatment, it also tends to become more brittle over time and more prone to breaking. Doing a crown on such a tooth will actually weaken it more against lateral stresses, which are the types of stresses to which front teeth are most susceptible. So it is wise to put a post in the tooth to strengthen it. A metal post can show through slightly. An expert cosmetic dentist would use a white or translucent fiberglass post. A general family dentist also would probably jump right in and do the crown, but an expert cosmetic dentist would probably want to bleach the tooth first because the darker tooth structure would have to be blocked out making it more opaque than the adjacent tooth, when you want these two front teeth to look exactly the same.

Done correctly, the dentist should get a perfect match with the adjacent natural tooth. It will likely take several try-in appointments to get the color match perfect, and it will require teamwork between the dentist and the ceramist to do this. The tendency of family dentists is to get the color “close enough” and be satisfied with that. But here is a photograph of a case done by one of our mynewsmile network dentists. One of these front four teeth is a porcelain crown, but it is impossible to tell, from the front, which one.

porcelain crown on a front tooth

My recommendation—go to one of our recommended cosmetic dentists and get this done right.

– Dr. Hall

Do you have a comment? 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 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.

February 5, 2016

Diagnosing a sensitive tooth after a new filling

We thank our advertisers who help fund this site.
.

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

Do you have a comment? 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 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 28, 2012

Why couldn’t my dentist get me numb?

Dear Dr Hall,
I have a peculiar problem which my dentist could not solve even after 11 sittings. My front lower teeth (two of them, I think they are called central incisors) are partially dead (injury from football during college) now half of it is infected and half of the nerves are still alive. I have got 5 injections and a paste on the tooth to numb it, it simply does not numb enough for a root canal. My dentist returned my fee, I am virtually living on ultraset since last 2 weeks now. your view and guidance would be a blessing.
Best regards,
Ankur from India.

Dear Ankur,
I’m confident I know precisely the answer to your problem, because the same thing has happened to me, when I had a root canal treatment done.

There is always a certain amount of anxiety when you’re having dental work done. And especially after trying and failing to get a tooth numb for dental work (you said 11 times), the amount of anxiety is going to increase dramatically. A lot of dentists don’t understand the connection between this anxiety and the novocain that they depend on to get you numb, but the anxiety counteracts the novocain and can even make it impossible to get you completely numb.

This happens with me, and once I understood this, I saw this in many of my patients who were difficult to get numb. What you need is some type of anti-anxiety medication. Taking 10 or 20 milligrams of Valium could do the job. Or, if you can find a dentist who uses nitrous oxide gas, that could do it also. If it’s Valium, take that at least 30 or 40 minutes prior to your appointment. But be sure you have someone who can take you to the appointment and take you home, as you will not be fit to drive probably the rest of the day. There are other good anti-anxiety medications that are useful for dentistry also, such as Halcion.

Dr. Hall

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.

February 20, 2012

Does this tooth really have to be extracted?

Filed under: Extractions — Tags: , , , , — mesasmiles @ 4:49 pm

I had a crown when I was younger that fell off and left half of my tooth there, my dentist tells me I now have a tooth infection under it. There is a little white bubble under my tooth – he didn’t say what the name of the infection is but I’m kinda worried about it. My dentist says he just has to take out my tooth but from what it says on your website he’d have to do a root canal right?
– Maggie from Rhode Island

Maggy,
I think it would be worth it to seek a second opinion about this extraction and see if the tooth can’t be saved. Some dentists, unfortunately, are all too eager to extract teeth when it isn’t necessary.

It could be that your dentist is right, that the tooth has to be extracted. But your dentist should have explained why the tooth can’t be saved and why a root canal treatment and a crown wouldn’t work. If he didn’t, ask another dentist.

It could be that the tooth has decayed so much and there is so little left that there is no way to restore it. It could also be that with the crown of the tooth being missing for so long, the teeth on either side have drifted together so that there isn’t space enough to restore the tooth. But if your dentist didn’t explain this to you, I would get a second opinion to ask another dentist if he or she thinks the tooth can be restored.

Your question reminds me of a man who was president of the American Dental Association in the 1980s who was kind of a crusader for saving teeth, Dr. Burt Press. He often said that too many dentists are too eager to take teeth out. He had a funny way of putting it. When we were in dental school, we were given statistics about how many teeth are lost because of gum disease versus how many are lost because of tooth decay. He said he questioned those numbers. “You know why so many teeth are lost?” he asked. “Because dentists take them out.” But rescuing teeth is hard work, and sometimes you fail. Some dentists like to try to save them, because it’s a noble feeling to save a tooth. But some dentists don’t have that attitude and just take them out.

So my advice is to get a second opinion.

Dr. Hall

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.

Older Posts »

Powered by WordPress

Follow this blog

Get every new post delivered right to your inbox.


Categories