Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

July 8, 2019

My dentist wants to wait till the nerves settle down before replacing my crowns


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Dr. Hall,
My dentist convinced me to replace all my old amalgam fillings even though many were still stable. She was going to replace them with either composite or crowns depending on the size of the filling and how much tooth structure would be left. Anyway, we started on the project, and about six weeks ago she did three zirconia crowns for me. These crowns are so uncomfortable for me. They feel bulky to me, they press on my gums to the point that sometimes it hurts, and my bite feels off, making these teeth sore. It’s causing me a lot of stress, which especially concerns me because I have a new baby that I am nursing, and it’s like the stress is affecting her. She hasn’t been able to sleep lately and has been waking up crying all the time.
So I canceled the rest of her treatment plan. But of course she refuses to refund the money for the 3 crowns because she’s convinced they are fine and says if there is any problem, she will fix it. I don’t trust her to fix it though.
But now I have gone to a new dentist, and I want her to re-do these crowns. I realize that I will have to pay for this out-of-pocket, but I really want to get this done. But this new dentist says she does not want to touch my crowns until I give the nerves time to heal and lower the risk of needing root canals. But that can be months. I don’t know if I can wait that long.
 
– Gail from New Jersey
 
Gail
I’m confused by the reluctance of your new dentist to replace these crowns, saying that the nerves need to heal. The problem you have with the crowns—pressing on the gums, bite is off, they feel bulky—have nothing to do with the nerves of the teeth. If those nerves were irritated, there would be heightened sensitivity to cold in those teeth. While it doesn’t sound like your first dentist has a strong level of expertise when it comes to crowns, it doesn’t sound like your new dentist has a firm understanding of dentistry either.
Yes, a crown preparation, where the dentist is cutting deeply into the tooth, can be irritating to the nerve of the tooth—in some cases highly irritating. But removing an existing crown is only mildly irritating, if any at all. If, indeed, the nerves had been highly irritated by the first crown preparations, which it doesn’t seem like has happened, six weeks would be enough time for them to settle down.
I wish you well and hope you get this problem solved. I see no reason for a delay in replacing these crowns, and I am very wary of the level of expertise of this new dentist of yours. She is displaying timidity in tackling this problem—not a good sign at all. I warn patients in several of my blog posts about how easy it is to push some dentists outside of their comfort zone, and she is giving you a red flag here that she isn’t comfortable re-doing these crowns. Maybe what is making her timid is the difficulty in grinding off zirconia crowns. They are very tough and very hard to grind off, especially if they are bonded on. The worst thing you could do would be to urge her to go against her instincts here.
If you’d like help finding a dentist who could do a good job on this for you, let me know and let me know exactly where in New Jersey you are. I know a number of excellent cosmetic dentists there.
Good luck,
Dr. Hall

 

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About David A. Hall

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

April 21, 2018

Water relieves the pain in my tooth


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Dr. Hall,
It’s been ten years since I got my two fillings. One fell out but doesn’t hurt. The other one is still in but is causing severe pain. It doesn’t bother any to bite on it, but it hurts most of the time. The only thing that relieves the pain is water and only for a few seconds. Any advice?
– Brandon from Oregon

Brandon,
I wish I had better news for you, Brandon, but your tooth, the one with the filling, is showing classic signs of a dying pulp and you’re going to need a root canal treatment on it. I’d get the other filling replaced before it’s too late.

Here’s what’s going on. There has been some decay get into the tooth, probably getting under the filling. That decay has grown until it has infected the pulp. As the infected pulp tissue dies, it can go into a state where it is called a gangrenous pulp. In that state, it gives off gasses that increase the pressure inside the tooth and cause a toothache. When you cool the tooth with water, it causes the gas to shrink somewhat and eases the pain.

This is a classic situation. When a patient reports that cold water or ice water is the only thing that relieves their toothache, you can be 100% guaranteed that they’re suffering from a gangrenous pulp in a tooth that has almost died. Relief can be obtained by simply creating an opening into the tooth to relieve the pressure, but then it needs to be followed up with a root canal treatment to fully remove all of the infected tissue inside the tooth and seal it against further problems.

It’s a similar situation when a tooth is sensitive to heat—it’s a nearly dead tooth.

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.

October 9, 2017

Saving your tooth looks like a no-brainer to me


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Dr. Hall
I have to have either a root canal or implant in the first molar on the left side, bottom. There is no molar behind it, and I am wondering if there is a “snap on” smile version that would be less expensive, invasive and will allow me to cover the empty space, should I decide to have the tooth pulled?
– Beth from Washington

Beth,
Having the tooth pulled and replaced with a Snap-On Smile would be the worst of several options for treating your infected tooth.

Let me go through your options and their pros and cons.

You’re telling me that there is no molar behind your first molar. So you’ve already lost your second molar. Losing your first molar would leave you with no molars on your left side. I guess if you’re planning on going on a soft or liquid diet you won’t need to chew, but you really need something there. A Snap-On Smile is a temporary tooth replacement solution designed to help you, say, get through a job interview or a social function and look like you have teeth. It isn’t a functional replacement for molars. It isn’t very durable and isn’t all that cheap, either. The least expensive functional tooth replacement would be a removable partial denture.

But any type of appliance you put in your mouth that is removable and designed to be a functional tooth replacement is going to be much more stable if you have teeth in the back to anchor it. Imagine having a table that has legs only in the middle and on one of the ends, as I have pictured below. This is called a cantilever and isn’t very stable.
An unstable table with legs in the middle and on one end
This is like the situation you are creating in your mouth when you lose these back teeth. When you try to attach a tooth appliance onto the front teeth and expect it to replace back teeth, it’s not very stable. In addition, it creates a twisting force on the teeth that are supporting it, which can lead to the early loss of those teeth. There are partial dentures that are designed to absorb the stress with the soft tissue on your ridge, but they would require clasping other teeth, too, probably going on to the other side of your mouth.

The root canal treatment makes the most sense because that saves your own natural tooth. Being a molar, the tooth would likely need a crown also. But there are people who argue that a dental implant is a very predictable solution also. The root canal and the crown would be less expensive, though. To me, it’s a no-brainer to save your tooth.

– 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.

January 20, 2017

Tooth with a crown is sensitive to heat


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Dr. Hall,
I have several crowns, some on natural teeth some on implants. I have two crowns next to each other on top and front. The crowns are maybe 20 or 25 years old. 1 week ago I saw my dentist for a cleaning and today I woke with constant strong pain but much worse when sipping coffee warmer than room temperature. My dentist isn’t in for a few days and the pain seems to be growing to include the crown on the tooth next to it. Any ideas?
– Randy from Illinois

Randy,
I’m sorry to have to be the one to give you the bad news, but the pulp of your tooth is dying and it is going to need a root canal.

You have two of the classic symptoms of a dying tooth. Teeth can be sensitive to a number of things, and that sensitivity can sometimes come and go and may not indicate a dying tooth. But if you have strong pain that isn’t provoked, that’s an indication of a dying tooth. Adding to it, your pain is aggravated by heat–a doubly bad sign.

What happens is that an infected pulp will draw in body defenses including white blood cells. The tissue wants to swell, but being in a confined space, it chokes itself and then dies. As it dies, it can sometimes give off gasses. Any warming up of the tooth increases the pressure of those gasses and increases the pain. Cold will cause the gasses to contract and will generally provide relief in this situation.

So what do you do when you have a crown on the tooth that needs a root canal? It isn’t difficult to make an opening in the crown and do the treatment through the crown. However, if I were your dentist, I would want to remove that crown and find out what is going on under it. I would also want to replace the 20-year-old crown on the adjacent tooth, because something similar may be happening to that tooth.

Why is this happening? There are several possibilities. One is that decay has gotten in under the crown. This can happen through a leaky margin that your dentist didn’t catch or maybe did see but didn’t attach enough significance to it. Another could be that the tooth has become irritated through exposed root surface.

– 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.

July 30, 2016

My tooth was fine until my dentist worked on it


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Dr. Hall,
I went to my dentist recently and he filled a front tooth. While in the chair he stated that he saw a small crack on the rear molar on the left side, and he said it needed to be repaired. He drilled the tooth out, banded it, and filled it with composite. I called him the next day because the tooth was extremely painful. Two days after he did the procedure I was back in his office, and after a cold test he said that I needed a crown and a root canal. I had him pull the tooth. Should I pay him for the extraction when there was no issue with the tooth, before he removed half of it, other than a small crack?
– Mark from Georgia

Mark,

Nothing you told me indicates to me that your dentist did anything wrong. Yes, it’s possible, because I don’t know the whole story. But I’ve seen this sort of thing many times, and it sounds to me like your dentist did the right thing.

When you say that there was nothing wrong with this molar but a small crack, that’s not the complete story. A crack is almost always a symptom of a major underlying problem with the tooth. A tooth that is otherwise healthy will not have a small crack in it. From subsequent events, it seems clear to me that this tooth was already infected. Yes, working on it irritated it a little more and placing a well-sealed filling over the infected pulp of the tooth caused an immediate painful reaction. Had your tooth been healthy before your dentist worked on it and had merely had some accident during the procedure, your tooth would have started to get diseased and it would have taken some time for it to flare up. The fact that it was immediately painful indicates that this disease process was probably already pretty advanced.

The reason your dentist was concerned when he saw this “small crack” was that the tooth probably had a large filling in it. You didn’t say what type of filling, but almost all teeth with cracks have large fillings in them, usually amalgam fillings. The crack would probably indicate that there is some leakage around the filling, meaning that decay will be able to leak through and get under the filling.

Not being able to see the x-ray, and not having looked over the shoulder of your dentist while he was working on your tooth, I can’t say with certainty what happened, but let me tell you what probably happened, based on my experience with many of these situations. Your dentist removed the old, leaky filling, likely with some decay underneath it. The dentin that was left between the bottom of your cavity and the pulp of the tooth was thin but intact. However, dentin is porous, and because of how the tooth reacted it appears to be clear that bacteria from the decay had been able to penetrate that porous dentin to infect the pulp of the tooth, causing it to be slightly inflamed. Working on the tooth irritated it somewhat, as it always does. Your dentist then replaced the old leaky filling with a new composite resin filling, bonded to the tooth and tightly sealed. The well-sealed filling now caused the internal pressure of the inflamed pulp to increase, which is what caused your immediate painful reaction.

I’m sorry for your sake that you had the tooth pulled when it could have been saved, but that is water under the bridge now. If it was the tooth furthest back in your arch, that shouldn’t have a serious impact on your bite, but you might eventually end up also losing the opposing tooth because it now may have no tooth to chew against and will hyper-erupt.

My recommendation to you would be to have your dentist look at your entire mouth and all your old dental work with a new set of eyes, and replace any old, suspicious fillings with new, well-sealed composite fillings, to help prevent this from happening again.

– 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.

December 20, 2013

Taking antibiotics for an infected tooth

Filed under: Infected teeth — Tags: , , , — mesasmiles @ 12:53 pm

Dr. Hall,
My tooth became infected about 11 days ago. I saw the dentist Friday. I have been taking Keflex 500 mg three times a day, and since Friday, also Flagyl 250 mg three times a day. The swelling was almost gone, but 2 days ago, it swelled up again. My gums are red and swollen, and painful sometimes. Initially, the swelling was all of the way up to my eye and down to my chin. There has also been a yellow spot there, and I can taste the bacteria in my mouth. Now what?
– Susan from Indiana

Susan,
I”m hoping that you are either not understanding what your dentist is doing or you aren’t communicating it to me clearly enough, because if I’m getting an accurate picture of what is going on here, your dentist doesn’t understand tooth infections.

Antibiotics are not a proper treatment for a tooth infection – they are only an aid to treatment. The reason is that when a tooth becomes infected, the living tissue inside it dies. Therefore, there can be no circulation inside your tooth and there is no way for any antibiotics or other defenses to get into the tooth to eradicate the infection. The dead tissue has to be removed by one of two methods. The tooth can be opened up, the tooth cleaned out, and then sealed so bacteria can’t get back in. This is called a root canal treatment. The other option is to remove the entire tooth which, of course, also removes the dead, infected tissue.

There are cases where, if a tooth is infected and you are swollen, that you would start by taking antibiotics and then commence treatment after the infection is under control somewhat. If the tooth is an upper tooth and the plan is to extract it, the infection will interfere with the ability to get the tooth numb, so it would have to be controlled first, and then the tooth extracted. But in most cases, the best emergency treatment is to begin getting rid of the source of the infection. If the tooth is opened up, often that will provide drainage for the infection through the tooth. In some cases, the act of opening the tooth will provide immediate relief from pain, also. Your infection sounds pretty serious, and why nothing was done clinically is troubling, so I’m hoping I don’t have the full story. The yellow spot is probably a point of drainage of the infection, which would give you that taste in your mouth.

If the dentist prescribes antibiotics, he or she should explain clearly what the action plan is, and the treatment should be scheduled promptly. If you simply take the antibiotics without getting rid of the source of the infection, you will be cultivating antibiotic-resistant bacteria and complicating later treatment. So I’m hoping your dentist made this clear to you and scheduled your follow-up. If not, I would find a new dentist who is more competent and caring.

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About David A. Hall

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

September 29, 2012

Can Ali trust this dentist?

Hi and thank you for taking my question!

For about 2 weeks I have been having jaw and tooth pain that comes and goes and seemed to move. I went to the dentist who I have not seen before. He did X-ray and found a large cavity in a tooth that already had a filling. He said he feels there is only a 10% chance he can save the tooth because there won’t be enough actual tooth to work with and it is probably going to be extracted the same day after he cleans it out and finds how deep it is. Then he suggests an implant or bridge but leans toward a implant and bone grafting.

I strongly dislike any dental work and am petrified of all this. The tooth is 4 from the back on my right side which still has wisdom teeth. Does this sound correct to you or should I seek a second opinion? He said there was no infection he saw at this time but put me on amoxicillin for precaution since I had some pain. I have the worst fear of having some type of allergic reaction to the local anesthesia or something going totally wrong and I am having constant anxiety over this. Thanks for any advice!
– Ali from Maryland

Ali,
I can’t say for certain without seeing your tooth, but I am skeptical of what you are saying your dentist is telling you, for a couple of reasons.

First, if this is the first time you have had a toothache in this tooth, then the tooth has just recently become infected. I am having a hard time believing that this tooth is as far gone as your dentist is saying, if that is the situation. A hopeless tooth would have most likely begun hurting months ago.

Second, a tooth that has been so extensively destroyed that it isn’t savable, this would not require an x-ray to see it. It would have an obvious, big, gaping hole in it, and the filling would have fallen out long ago. Usually.

So yes, a second opinion would be smart.

A word of advice about getting a second opinion – make sure it is a BLIND second opinion. Don’t let the second dentist know what the first dentist said. You are entitled too be able to get a copy of the x-ray to take to the second dentist, but you need to conceal the diagnosis because that knowledge can possibly prejudice the second opinion.

And another point. You say you are having a lot of anxiety about facing this work and are worried you may be allergic to the anesthetic. In all my years of practice and the thousands of people I treated, I never had a genuine case of allergic reaction to any local anesthetic. I had people claim they were allergic, but upon administering the anesthetic, there was no allergic reaction. But I saw a lot of anxiety like yours. In fact, I myself am an anxious patient. You need to find a dentist who practices sedation dentistry who can give you something to take care of your anxiety. For me, if I just have nitrous oxide, that works and I’m fine. For others, they may need conscious sedation. When you have a certain level of anxiety, your body actually fights off the local anesthetic and it may be impossible to get you completely numb. And that just perpetuates this vicious cycle.

So, yes, get your second opinion, and I would recommend finding a dentist who could offer you sedation.

Dr. Hall

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About David A. Hall

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

October 16, 2010

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

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

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

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

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

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

Dr. Hall

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.

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