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Is there another option besides implants for my mother?

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Hello Dr. Hall,
I am asking on behalf of my mother. She is 79 and has always had very poor teeth. He dentist told her 15 years ago that she would need all her teeth out at some point. She has a dental bridge in her upper jaw but has been advised that she will need to have all the lower teeth removed and a full clippable set of false teeth implanted. She has a lot of other health issues like high blood pressure, pre-diabetic weight and is hypersensitive to soaps. She has had polymyalgia and uses cortisone cream for an undiagnosable body wide skin itchiness. She has recently had a cancerous growth removed from her nose and another rough grey blotch frozen ofc her cheek. She takes multiple meds including serdep. I’m concerned that the extensive and traumatic nature of this surgery may have a very poor outcome or even cause further infection and put her overall quality of life ar risk, or even kill her.

Are there any other options?

Kind regards,
Kate from Cape Town, South Africa

(See Dr. Hall’s answer below.)


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Kate,
I do want to be clear that, not having examined your mother, I don’t want my answer interpreted as a definitive answer for her. But one thing I am fairly confident saying is that yes, I’m sure there have to be other options. Especially when talking about replacing missing teeth, there is always more than one way to tackle the problem.

And while I don’t know the condition of your mother’s teeth, I do get the feeling from you that there isn’t a lot of compassion from the dentist recommending this treatment. You’re listing a number of ways in which your mother is medically compromised and they’re wanting to do a fairly aggressive treatment plan. And the fact that they didn’t give you an option of a removable denture (which would clearly be an option here) makes me question even the recommendation that she have all her lower teeth removed. Is the dentist thinking more about the fee that will be collected rather than the welfare of your mother?

In my opinion, there are two essential ingredients to quality dental care. Competence of the dentist is clearly required. The dentist and the other staff need to know what they are doing. But equally important is compassion. The dentist needs to care. And maybe, in this case, I would relate compassion as being more integral to quality care than competence.

Why do the lower teeth need to be removed? Why ALL of them? Knowing similar situations, it seems unlikely to me that all of a sudden they all are hopeless. If there are some strong teeth, there are options for retaining those and building a removable denture around them. Maybe none of them need to be removed. My question is, how is she getting along with those teeth? Is she eating okay?

You can maybe judge the “vibes” you are getting from the dentist. Do you sense true compassion? Or is the approach more coldly clinical. And my advice would be to get a second opinion. Without giving the second dentist any clues about what answer you are expecting, I would just listen to what is recommended. If you aren’t given an option of a removable appliance, they’re not telling you the whole story and I would question all of the recommendations.

I hope this is helpful,
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.

I can’t stop gagging wearing my upper denture

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Dr. Hall
I got an upper denture but can’t stop gagging. What can I do?
– Teri from Peoria, IL

(See Dr. Hall’s answer below.)


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Teri,
That can be a tough problem, but let me suggest a couple of possible solutions.

drawing of an upper jaw with four implants embedded in the jawbone, and replacement teeth positioned ready to be fastened to themThe best and easiest solution would be to have an implant-supported denture. A removable denture, to get appropriate suction (because that is what holds it in), has to cover your entire hard palate. An implant-supported denture only needs to cover the gum tissue. So there would be no triggering of the gag reflex.

But, if that is beyond your budget, it may be possible to solve the gagging problem without going to implant support.

A photo of two dentures on plaster casts, one extended to the vibrating line and one cut to be short of that line

Screenshot

Ideally, the base of your denture should extend to the limits of your hard palate, to what we call the “vibrating line,” which is where your soft palate begins. If that makes you gag, it may be possible to get adequate suction without going back that far. A prosthodontist in Lancashire, England, Dr. Finlay Sutton, has published his technique for providing upper dentures to patients with an extreme gagging problem. On the left is his photo of two dentures on plaster casts. The upper shows the denture extended all the way to the vibrating line. The lower photo shows a denture trimmed to be short of that to accommodate patients with a severe gagging problem. It has to be trimmed expertly, because if it is trimmed too much or in the wrong places, it will weaken the suction too much to the point where the denture won’t stay in.

It is also possible that your dentist has made your denture to extend onto your soft palate, which is wrong for any patient. If you suspect that is the case (because you normally don’t have a gagging problem), I would get a second opinion.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

All-on-4 Implants from ClearChoice leave her bite off

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I received All-on-4 implants in June 2023. They teeth are too big and don’t align. My bite is off. It’s hard to chew and swallow. ClearChoice said they are fine the front teeth set on top of each other. I feel like the back teeth are taller on the right then the left. I don’t know what to do.

– Kimberly from Visalia, CA


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Kimberly,
I’d start with a second opinion from another dentist with some expertise in dental implants. If ClearChoice did something wrong here, another dentist would be able to let you know that and put some pressure on ClearChoice to make this right for you.
– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

Do I really need to have this bridge replaced?

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Dr. Hall,
I have a bridge on my upper right side and my dentist said I need to replace the bridge because one of the teeth holding the bridge is cracked below. I have no pain or symptoms, and replacing the bridge and crowns will be very costly.
Is there another way?
– Meredith from Newport Beach, CA

(See Dr. Hall’s answer below.)


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Meredith,
Thanks for your question.The first thing that occurs to me about your situation is that your case is a great illustration of one of the chief advantages to replacing a missing tooth with an implant rather than a bridge. While a bridge may be less expensive up front, if anything goes wrong with any tooth that is part of the bridge, you will probably need to replace the entire bridge. With a dental implant, if anything goes wrong later with an adjacent tooth, it won’t affect the implant. (See my page on dental implant vs bridge for a discussion of these advantages.)

So, assuming that one of the abutment teeth in your bridge is cracked, that tooth would need to be extracted and you would need a new, longer bridge that is now replacing two teeth.

a drawing of a dental bridge replacing a missing lower first molar.

A dental bridge

Having said that, I am skeptical of this diagnosis for a couple of reasons.

First, you aren’t having any symptoms. If this tooth is cracked, it would be the root that is cracked, and there would ordinarily be some sharp pain when you bite anything hard.

Second, it would be very unusual for a tooth that has a crown on it to crack. When a tooth is weak or cracked and in danger of splitting, the proper treatment is to place a crown, which will prevent the crack from growing and destroying the tooth. I have had patients with a strong bite that is sometimes called a gorilla bite who have broken off teeth at the gumline, but I have never seen a tooth with a crown on it develop a crack in the root.

To emphasize the preservative nature of a crown on a cracked tooth, I published research a number of years ago showing that even if a tooth is completely fractured through the root, under proper conditions the pieces can be forced back together, the tooth crowned, and the tooth can be saved.

Anyway, I’d recommend getting a second opinion before you do anything. But be careful of how you do this. Don’t go to Dr. Jones and say, “Dr. Smith said one of the teeth in my bridge is cracked and I need a new bridge. What do you think?” No, don’t identify your dentist because he or she may be friends with the other dentist. Also, give as little information as possible about what you were told, so that the opinion given will be completely independent. Don’t put the idea in their head that another dentist said the tooth is cracked. If the second dentist asks, just tell them you don’t want to say until they give their opinion. Go and say, “Dr. Jones, I want a second opinion. Do you see anything wrong on my upper right?”

If your dentist’s diagnosis comes from an x-ray, you could even send me a copy of the x-ray and I’ll tell you what I think.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

My dentist extracted my tooth but the root broke off

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Dr. Hall,
I had an upper first molar extracted. My dentist had some trouble with the extraction. Part of one of the roots broke off. So he referred me to an oral surgeon, and I am now scheduled in three months for the oral surgeon to remove the rest of the root. Should I have it done?
– Marco from Buffalo

(See Dr. Hall’s answer below.)


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Marco,
There are a couple of things I don’t like about this situation. Let me explain.

It’s not unusual for part of a root to break off during an extraction. Some roots are of such a shape that they don’t come out easily and will break off. So this happened, and your dentist realized that he didn’t have the expertise to go after the root fragment—that’s an indication of being responsible. Hopefully, with more experience, he will know ahead of time when an extraction will be beyond his ability and will refer out the entire procedure.

But not being able to get you in for three months to get the root out—that’s too long. That’s enough time for bone to start to fill in, making the procedure that much more complicated. That follow-up care should be in a few days, maximum.

Finally, this is an upper first molar. Often, the roots of maxillary first molars are very close to the sinus wall, and going after them can poke them into the sinus. This causes a sinus perforation, which is an additional complication, plus now you need to have that root tip retrieved, which is tricky surgery. Letting three months of healing go by before going after the root will increase this risk.

Bottom line, I would get a second opinion on this, and I would do it right away. If the piece of root is small enough and close to the sinus wall, it may be best to leave it alone. If that’s not the case, the surgeon should go after it within the next few days.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

Can there be a cavity in a tooth without any outward signs?

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Dr. Hall,
My right lateral incisor (#7) has been diagnosed with a cavity inside it, and dentist claims it needs a root canal. Interestingly, she has referred me to a root canal specialist who has the same very uncommon last name as hers. My previous dentist of last year’s x-rays didn’t indicate any issues with this tooth. And the outside of the tooth has never had work done on it and no surface cavity is showing. This tooth does stick ‘out’ at an angle in the front of my mouth a bit, thus is not receiving pressure from the lower teeth when chewing. I can’t find on the net any answer to is it possible to have a cavity inside of a tooth that has no outward signs of holes or wear?
– Theresa
(See Dr. Hall’s answer below.)


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Theresa,
You don’t have to go to the root canal specialist that your dentist recommends. Given the possible conflict of interest with your dentist and with this diagnosis you are questioning, I’d get another opinion from another specialist or general dentist.

About having a cavity in a tooth without having any external point of entry, no, that can’t happen. Decay has to start on the surface and eat its way into your tooth. When it goes deep enough, the bacteria causing the decay will infect the tooth, which will require a root canal treatment.

an x-ray of two lower premolars and a molar, showing a dark spot in the middle of the first premolar

Internal resorption in a lower premolar. X-ray courtesy of East Hill Endodontics, Kent, WA.

However, it’s possible that your dentist is using different language to describe a problem called internal resorption. Internal resorption is a rare condition where the pulp of the tooth begins to eat away at the tooth from the inside. The cause isn’t known, but this is an inflammatory reaction, so it seems that there needs to be something that begins irritating the pulp. Since there is no history of decay in the tooth, the only way I can imagine this happening is if there was some trauma to the tooth from its sticking out further than your other teeth. But again, this is unlikely, since this is very rare, so my advice would be to find an endodontist for a blind second opinion to confirm the diagnosis. Check my post on how to seek a second opinion:

  • Ask for a copy of the x-ray to take to the other dentist.
  • Don’t let the second dentist know the name of any other dentist involved.
  • Don’t even share the first diagnosis.

You could also send me a copy of the x-ray and I would be happy to render an opinion.

– Dr. David Hall

(There is also a pathology called external root resorption, which happens on the outside of the tooth. This could have the same x-ray appearance as internal resorption. Taking two x-rays at significantly different angles would help pin down whether the resorption is occurring inside the root or outside.)

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

I have throbbing pain in my gum in one spot

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Dear Doctor Hall,

I am intrigued but also worried by a persistent sore point between by last molar top right and the next molar. The gum, not the tooth, is incredibly sensitive and always hurts after eating with a throbbing pain. The pain goes away completely after about 30 minutes-1 hour (better after tooth brushing) after eating and doesn’t return until I eat something again. This has been going on for over a year with a very slight improvement (pain not as bad as 12 months ago) No problem with hot and cold. My dentist has examined it twice and x rayed and can find nothing. There was a root canal treatment on one of the teeth which may well have triggered something but seems to be nothing visibly wrong and the pain is not under or in the tooth but next to it. It is exactly the gum between the teeth which hurts, not the teeth themselves. The dentist advises removing the tooth if the pain doesn’t heal. Seems a pity as I don’t think it is the tooth itself causing the pain, but I might be wrong. Any idea what could be going on? All my other gums are fine. No sign of an abscess no bad breath just very painful on the gum specifically in the space between the two teeth. Comments much appreciated.

Michael W from Germany

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Michael,
You need a second opinion. Is there a periodontist (gum specialist) you can go to?

It really bothers me that your dentist wants to take out the tooth simply because he or she can’t figure out what is wrong. I suspect this wouldn’t be all that complicated for a dentist that knew a little more.

This is a gum problem. I’m pretty confident that the root canal in the one tooth has nothing to do with this. An x-ray of the tooth probably isn’t going to tell you much about the gums. I don’t know much about the status of dental practice in Germany, but even here in the U.S. where we have fairly high educational standards for dentists, some dentists pay very little attention to gum health.

Of course I can’t tell you for sure what is wrong without a personal examination. But the first thing I would check would be for pockets between these two teeth. This could be a periodontal abscess which would mean that there is a particularly deep pocket between these teeth. Food particles could end up here after you eat and when they disintegrate the pain goes away. It’s possible that a quality deep cleaning could solve your problem.

Do you floss? If you don’t, that could be a contributing factor here, because you would be much more likely to develop gum disease if you don’t floss. If you do floss, I’d be curious to know if flossing between these teeth, with a technique that gets the floss down into this pocket, has any effect on the pain.

Anyway, please don’t let this dentist take out your tooth, and see if you can find a dentist who knows what is wrong.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

The dentist keeps adjusting, but his bite is still off

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Hello Doctor Hall:

I have ten zirconia crowns and they have all been burred down trying to fix my occlusion – after the first adjustments I developed hives on the inside of my lips and gums, and no dentist seems to be able to figure out where these hives came from or how to deal with them. Is it possible that shaving the crowns may have released something that now is irritating my mouth? This has been going on for eight months, the entire case has been a mess, my bite is off, etc. But the thing that no one can tackle is why I have hives now? Is it possible that burring through the finished surface of the zirconia has made my mouth react like this? – Richard

(See Dr. Hall’s answer below.)


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Richard,
Zirconia is a very tough material, and this would be a difficult appointment, having them ground down to fix your occlusion.

Let me deal with your question directly, first, and then offer some other comments about your case.

Yes, theoretically you could have had an allergic reaction to all the zirconia dust, but that would go away once the dust had cleared out of your system. I wrote in an earlier post that we have no confirmed cases of zirconia allergy reported. If you were truly allergic to zirconia, you would have had a reaction before any of the grinding. Yours seems to be another case of burning mouth syndrome, which appears to be triggered by stressful dental experiences.

About your ten crowns that have apparently disrupted your bite. And you say that your bite is still off. It’s a nice feeling when your teeth all mesh together harmoniously and you can chew normally. When your bite is off, that can throw your jaw muscles into spasm and can lead to headaches and various other problems, associated with TMJ disorder. I would recommend that you get a second opinion, because I’m worried that your dentist is in over his or her head.

Training in the complexities of how the teeth meet together and mesh to provide a harmonious bite—this isn’t part of the regular dental curriculum. To study this in depth, dentists attend one of several post-graduate institutes. Four of those are:

  • The L.D. Pankey Institute in Florida
  • The Dawson Academy in Florida
  • Spear Education in Arizona
  • The Las Vegas Institute for Advanced Dental Studies in Nevada

I would find a dentist who has graduated from one of these institutes and get a second opinion on your case. I’m just guessing that the lack of harmony in your bite is an ongoing source of stress, and I wouldn’t be surprised to learn that is the cause of your hives.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

My crown has fallen off three times!

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Dr. Hall,
My crown has fallen off 3 times. I have returned to him again and he says I need a gingivectomy to keep the crown secure by giving the crown more tooth area to bond the crown. This sounds extreme to me. Also the base of my tooth is blackened where I recall it was not when he placed the crown the last round. I’m holding the loose crown now and need to decide soon!

Please advise!

– Nancy from San Francisco

(See Dr. Hall’s answer below.)


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Dear Nancy,

The procedure is called crown lengthening—trimming the gum and maybe some of the bone to expose more of the tooth so that it can retain a crown. Sometimes that is necessary, and I had occasion to do that in my practice.

My problem with your situation is that your dentist should have known up front that crown lengthening would have been required to retain the crown. Coming to you after the crown has fallen off three times makes me not trust him. Did he not realize when he first prepared your tooth that crown lengthening would be required? Or is it that crown lengthening isn’t actually required in your situation and this is just an excuse he is giving you?

It is possible to do a crown on a short tooth and have it stay on without doing crown lengthening and without having any problem. But the tooth has to be carefully prepared with only a very slight taper and possibly cutting some grooves into the sides of the tooth. I have a blog post about crown retention form that you can read here. It cuts into the excuses that many dentists use to explain why their crown fell off. In over twenty years of practice, I never had one of my crowns fall off, because I always prepared them with a tight draw. Many dentists don’t like to prepare a crown with a tight draw because it is more demanding and even a slight error can mean that the crown won’t fit at all.

It is when a tooth is “bombed out” with most of the crown either broken off or eaten away by decay that crown lengthening is required.

Bottom line—I wouldn’t trust this dentist to try again and would get a second opinion. He’s clearly planning to do a new crown for you, so I’d have another more expert dentist do it. I don’t know what the blackening of your tooth is, but something doesn’t sound right about that either.

Oh, and I think your dentist should refund you AND the insurance company, if insurance was involved. If he doesn’t, I’d complain to the dental board and to the insurance company. A crown isn’t serviceable if it won’t stay on, so there should be no fee for it.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

Are the same-day crowns as good as the old-fashioned ones?

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Dr. Hall
I was reading on your site about removing a metal post in a tooth, which made me think of my experience. In May of this year I saw my dentist in The Netherlands for a checkup. I had a crown that was made by computer in 2017 and she said that this crown wasn’t fitting well and needed to be re-done. Also, the previous dentist had removed metal posts from my tooth before placing the crown. The new dentist said that the posts should have been vibrated out with ultrasonics and not by drilling.

My questions are:
1) Is the computerized-3D crown process as good as a ceramic old-fashioned crown?
2) Did drilling the posts out of the tooth damage my bone?

Thank you very much
Tessa from the Netherlands

(See Dr. Hall’s answer below.)


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Tessa,
Yes, it’s nice if you can vibrate out the post with an ultrasonic device. Most dental offices have ultrasonic scalers. But I can tell you from experience that this may not work. So, if you want the metal posts out, there may be no option but to drill them out. No, this won’t damage the bone. How can drilling on a tooth damage the bone? Dentists are always drilling on teeth. The risk in drilling out the post is that the drill could slip and perforate the side of the root, which would damage the tooth to the point where it would have to be extracted. For any people who have experience drilling into metal, you know that it is very easy for the drill to skate along the surface of the metal, so this is a real risk. But it sounds like your dentist got through that without any unfortunate accidents.

And then telling you that this crown “isn’t fitting well” makes me wonder. I’m not sure what that means. Are there gaps at the margins of the crown? If so, why doesn’t she say that clearly? That’s what we look for when we’re checking a crown—we use an explorer and run it around the margin to see if there are gaps. If there aren’t any, then the crown is fine. Also, her statement that drilling out the posts would damage the bone, that makes me suspicious. Some dentists try to accuse a previous dentist of doing something wrong as a way to get you to believe that they are better and to justify their plans to re-do the dental work of the previous dentist. I don’t know if that is happening in your case, but I have enough suspicion to make it prudent, in my opinion, to seek a second opinion about this crown that supposedly “isn’t fitting well.”

About crowns made with a computer. This process was developed about 35 years ago by Dentsply Sirona, which is when CEREC crowns were introduced. In the early days there were issues with the accuracy of fit, but that is no longer an issue. When I needed a crown 15 years ago, I decided I wanted to experience this technology and so went to a colleague who had a CEREC machine. I have had no trouble with that crown. It fits just fine. The whole process, which includes optically scanned impressions of your teeth instead of impression paste is a highly precise process that creates a high quality crown.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

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

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