Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

March 18, 2013

Can I switch from having crowns on my front teeth to having porcelain veneers?

Dr. Hall,
If my top two front teeth were initially ground down for crowns and there is no crown on the teeth will veneers work on the teeth now?
– Tina from Kentucky

Tina,
Once a tooth has been prepared for a crown, a crown is the only restoration that will work for that tooth – it will always need a crown.

The difference between a crown and a porcelain veneer is that the veneer covers just the front of the tooth and not the back, whereas a crown covers the entire tooth. But the distinction is not cut and dried. Some veneers can also involve the sides of the tooth. And some dentists will talk about placing porcelain veneers and then prepare the teeth for crowns. I disagree with this practice, and most expert cosmetic dentists would feel the same way, but it happens. To make it more confusing, many dentists will charge the same fee for a veneer as for a crown. So if the dentist covers the entire front of the tooth, both sides, and half of the back of the tooth, is that a crown or a veneer? I would call it a crown, but some dentists would call it a veneer.

Removing a lot of tooth structure is aggressive dentistry. However, I like the philosophy of minimally invasive dentistry, meaning that the dentist removes the least possible tooth structure to accomplish the desired outcome. This is the practice of the great majority of excellent cosmetic dentists – the type of dentists we recommend on this website. So if you need a new smile, we would shave about half a millimeter of enamel from the front of the tooth, which is about the thickness of a fingernail. There would still be enamel covering the tooth – it would just be a little thinner. That allows for half a millimeter of porcelain, which is adequate for changing the look of the tooth – the shape and the color. If a tooth is out of alignment – say it protrudes out in front of the others – then more would need to be removed to leave it in line with the others. Likewise, if it is turned inward, there may need to be little or no enamel removed at all to give an attractive result.

A crown will strengthen a back tooth against tooth fracture in almost every situation in which it is used. However, on front teeth, since they are subject more to horizontal stresses, a crown can weaken an otherwise healthy tooth, making it more susceptible to lateral shearing forces. That is why I like to be as conservative as possible in treatments to front teeth. A well-placed, conservative porcelain veneer will not weaken a tooth.
– 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.

March 2, 2013

Do you need a crown on a front tooth with a root canal treatment?

Just had a root canal on the tooth right next to the front tooth. Is it necessary for a crown to be put on ? Can a post only be put in and if so, repair the discoloration with a porcelain veneer ?
– Ann from New York

Ann,
There’s a simple answer to your question and a more thoughtful answer, and I’ll give you both.

The simple answer is that dentists were taught in dental school that if a tooth has a root canal treatment, it is weakened, and thus it needs a crown to strengthen it and prevent tooth fracture. Plus, after a root canal treatment, a tooth will turn dark, so a front tooth should have a crown to preserve its appearance.

The more thoughtful answer differs from this approach in two ways. First, on the “likelihood to break” issue:
– Yes, a tooth is weaker after it has had a root canal treatment. But there is a difference between back teeth and front teeth. Back teeth, because they have a flat chewing surface and cusps are prone to splitting – the chewing force comes down between the cusps and this pressure tends to force the cusps apart. A crown will prevent splitting of the tooth. A front tooth, however, doesn’t have these forces. The risk with a front tooth is that chewing creates a horizontal force that may break off the tooth. A crown, since it requires removing 1-2 millimeters all around the circumference of the tooth, will actually weaken it against these horizontal shear forces and make it MORE likely to fracture.

On the discoloration issue, yes, teeth with root canal treatments will discolor. However, if the root canal cement and the root canal filling material are carefully cleaned out of the inside of the crown of the treated tooth, that discoloration will take years to occur and will be mild.

My preference for a front tooth would depend on the amount of healthy tooth structure remaining in the tooth. If, say, 70-80% of the tooth is healthy tooth structure, I would recommend restoring the tooth simply with a translucent or white fiberglass post and composite. Then, when the tooth begins to discolor, that could be corrected with a porcelain veneer or a crown at that point. If substantial amounts of tooth structure are missing, I would use the same white or translucent post with an all-ceramic crown.

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.

July 17, 2012

Why you have to be able to trust your dentist

Dr. Hall,
I have a split tooth but the x-ray reveals a healthy root…my doc want to extract and I want him to save it! How do I convince a dentist to try something new like that described in your paper? Dentists seem to want to extract to solve all problems, use scare tactics and it’s hard to believe they are not doing it for the money since much more expense is involved in an extraction and insertion of a new tooth….I want to keep as much of me together as long as I can!!!

thanks
Mike from West Virginia

Mike,
This is one thing I worry about when I give patients these answers to their dental questions, that they will take this information and go back to their dentist and try to “convince” the dentist of one thing or another, or tell the dentist how to make their cosmetic dentistry more beautiful, or tell the dentist what type of filling or crown they want, different from what the dentist recommends. That will not work. The purpose of this website isn’t to help patients educate or change their dentist. What you need instead is to find a dentist with a philosophy that you are more comfortable with.

You aren’t going to convince your dentist to save this split tooth if he has told you that he wants to extract it. It would be misguided of us to even have me personally call your dentist and convince him to save it. I couldn’t do that because I haven’t examined you and for all I know maybe that is the only option here. But there are dentists who are strongly inclined toward saving teeth, and other dentists simply don’t want to do that. And this philosophy permeates their practice at many levels. If a dentist wants to save teeth at all costs, for example, he or she will need to spend focused study on the techniques for saving teeth, dealing with cracks in teeth, what to do for failed root canal treatments, advanced periodontal techniques, and a whole host of things. At the other end of the spectrum, if a dentist just wants to take out problem teeth then they won’t go through all that extra trouble. What point is there, then, trying to convince a dentist to save this tooth when he probably doesn’t even know how?

But it is not true that “dentists” in general just want to extract teeth. There is a wide variety of inclinations here. And I firmly believe, from my experience with the dental profession, that the vast majority of dentists are highly ethical people who honestly try to do the best for their patients. They have varying levels of skills and different philosophies. And if you have cause to believe that your dentist is just in this for the money, then you need to find a different dentist. There is no way to work around this trust issue. There is no way, as a patient, that you can check up on your dentist to make sure he is making the right decisions for your teeth. In this situation of yours, even I, as another dental professional, don’t know enough about your case to be able to say if your dentist is doing the right thing or not. You HAVE to be able to trust him. If you don’t, then find another dentist.

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.

March 9, 2012

Several ways for a dentist to screw up a root canal treatment

My husband fell on 11/29/11, while coaching my son’s basketball team. He suffered concussion, chin laceration with sutures and his front two teeth fractured. He was treated same day in dentist and ER. Dentist did not want to do any treatment for 2 weeks. In 2 weeks, tooth #8 (right front tooth) started to discolor without pain-she felt only dried blood and no treatment at that time.He was fitted for temp crowns and placed within 3 weeks.

Two months later, he had severe pain and an emergency root canal began with amoxicillin for 5 days. There was slight relief of pain for 24 hrs and then severe pain up to his nose with a cold sensation. Root canal finished one week later without pain relief.

Two weeks after that, the dentist root canaled tooth #9 (left front tooth) because she didn’t understand why there was still pain. Novocaine in place, still no relief and pain never by tooth #9?  Probable unneeded root canal.

I decided to get oral surgeon second opinion, who suggested Augmentin TID for 7 days with medrol dosepak. 5 days into meds, cold sensation resolved and tooth #9 RC completed by general dentist who then removed filling from tooth#8 and my husband felt pain free for 1st time in 3 months! However, it returned at 50% within 24 hours, but cold sensation gone. I am a NP and I spoke with a pharmacist friend who said you will often see rebound pain with medrol dosepak quick tapers? He recommended a 2 week taper of prednisone with abt in place now that canal is open and can drain possibly? What would be recommended next step? My neighbor thought maybe tooth fractured at gum line? The dentist says she sees black spot on x-ray, but thinks it is nothing? My husband has been tortured for months without any pain control offered and is a teacher and is suffering. Do you think this tooth should have been root canalled immediately when it turned dark or 2 months later? Would that have saved the tooth and torture he is living? Do you think tooth could be saved? Should he need extraction, would you recommend implant next to permanent crown or bridge?
– Kathleen in New Jersey

Kathleen,

When tooth #8 (your husband’s right central incisor) started to discolor two weeks after the traumatic injury to the tooth, it clearly needed a root canal treatment. The nice thing about doing the root canal treatment at that time is that there is less chance of post-operative complications since infection would not have settled in yet – it would be just a matter of cleaning out the dead tissue, maybe leaving the tooth open for a couple of days as a precaution against flare-up, and then sealing it. I cannot for the life of me understand what your dentist thought was going on inside this tooth. Dried blood?? If there is dried blood in the tooth, isn’t it pretty clear that the tissue inside the tooth is dead?

And I don’t understand why there was a prescription for amoxicillin and for only 5 days. So if I am understanding this treatment sequence correctly, the tooth was opened and the amoxicillin started. I can’t tell from what you are saying whether the tooth was left open during this time or not. But then the amoxicillin ran out, and AFTER that, the root canal was completed – in other words sealed. Doing it this way, there would be a fairly substantial risk of flare-up. Once a root canal tooth is sealed, there is no longer any pathway for drainage for any infection that may be there. And a five-day course of amoxicillin would not be enough to completely wipe out the infection. In fact, amoxicillin would not be a first-choice antibiotic anyway for this type of tooth infection.

My recommended next step? See an endodontist (root canal specialist). An oral surgeon would not be a good choice of specialist to see here. And a pharmacist doesn’t have the correct training either. There is something to be said about getting a professional involved who has the specific training for this type of problem. I can’t tell by just e-mails what is happening here. But I can tell you I disagree with some of the treatment choices made by your general dentist, and the flare-up is not surprising to me at all. Doing a root canal on the other front tooth appears to me to have been a stab in the dark, and it also doesn’t surprise me that it didn’t help. And the prednisone would also be the wrong treatment if the infection isn’t resolved. And what is this about your dentist seeing a “black spot” on the x-ray but thinks it is nothing? That sounds almost grade school. Is there a continuous, intact lamina dura around the tooth? Is there a widened periodontal ligament space? You need an endodontist to look at this x-ray and read it, not someone who will try to take wild guesses at what is going on.

There should be no need to extract this tooth. None of what has happened is any indication that the root canal was not sealed properly. And even if there was that type of error here, there are several options for correcting that, short of extraction. You need the correct choice of antibiotic therapy – probably clindamycin at this point – which in most circumstances should get this to settle down in a couple of days. However, if there is a root fracture, that is a different story.

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.

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