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Medical Forum / General / Dentistry / November 2007Help me understand why I now need a root canal
Hi folks. I'll start a new thread for this because I didn't give enough information previously. I did get a second opinion from my father in law - the retired dentist and he is thinking that the dentist that did the work was not experienced enough in composite fillings. I am just trying to get to the bottom of this. I know that dentists take a lot of uncalled for BS about people whining about failures in their restorative work when they have green teeth and stumps to work with to begin with, but I feel this is not the case here. While the (non partner) dentist who did this work is no longer at the practice, I do have a very good relationship with the partners. We've talked very openly and honestly about what could be the cause of what went wrong. We're all human, and people make mistakes and learn from them. Again, I'm just trying to educate myself, so I don't make the same mistakes in the future. I do not plan any liability type actions. The money is too small to bother with it. HISTORY ======= I'm a 41 year old male. A very *very* small cavity was identified in a recent cleaning on back molar #18. It is my last molar on the bottom left side of my mouth. I had no prior restoration work done on this tooth (or at all in my entire mouth, except for one filling 20 years ago). The dentist pointed out the cavity, and I thought I would go ahead and have it filled . I asked for a white composite. (In hindsight, I now realize that white composite fillings do require a certain skill set). The filling was done, and I've basically been in pain ever since. A RCT is now needed, and I am being advised a crown too. My father in law the retired dentist has given his opinion on several things: 1) It would appear from the xray that no CaOH dressing was applied to the surface area. 2) The cavity was very small and didn't have an urgency to be filled. And my own observation on composite fillings is that I'm still trying to understand why so much surface area was filled, when the cavity was so small. Isn't that one of the advantages of composite fillings is that you don't need to prep such a large area ? Before Xray: http://users.rcn.com/mmcgourty/before.jpg After Xray: http://users.rcn.com/mmcgourty/after.jpg Thanks so much. You guys are the best. It's good to see this newsgroup thriving! ;-) 1) CaOH has not bearing on the final outcome of the tooth. It breaks down over time and leaves a tiny void. It, also has a different compressive strength than the filing material, so leads to cracks above it. Studies show that CaOH do not prevent RCT. It is a good bactericide as its acidity tends to kill bacteria. 2) The initial area of caries looks more "moderate-plus", than "small". 3) The size of the filling on the second image looks big for the size of the initial lesion, HOWEVER, there could have been caries or fractures in the tooth which do not show up in the first image. 4) The depth of the restoration does not appear to encroach on the pulp chamber (difficult to tell due to contrast of the image). I would not expect such a restoration to create the need for RCT. 5) Sometimes, a tooth will have a strange pulp extension from one of the pulp horns which extend almost to the enamel despite seeing recession of the pulp chamber on the image. If one of these long extensions contacted the caries, RCT follows regardless of how the tooth is treated. 6) Some pain will occur in this area on people who clench with great force during sleep. 7) Caries is always bigger in real life than it appears on x-ray images. 8) What did I miss??  Signature/ Amatus / > Hi folks. I'll start a new thread for this because I didn't give > enough information previously. I did get a second opinion from my [quoted text clipped - 45 lines] > Thanks so much. You guys are the best. It's good to see this newsgroup > thriving! ;-) Thanks Amatus. I may be getting some of the translation wrong, but the way it was explained to me is that since the tooth had no restorative work done it was very important to have the CaOH put down prior to the filling. It was explained to me that the composite is made of chemicals that could leech down through the pourous structure of the tooth to the nerve/pulp chamber and damage the tissue (irreversably). Are you saying that you disagree with this synopsis? Also - regarding the crown. I found out why it is not desirable to have a crown: 1) you get a part of your (in this case - healthy) tooth lopped off as part of preparation, so that the crown can seat properly on the tooth. 2) unless you have a really good crown work done - there are two spots where the crown typically leaves vulnerability to decay. (at the bottom of the crown). 3) crowns can and do go bad after some time and need to be replaced. So while the dentist and the endodontist are saying "get a crown" - which as previously discussed is standard procedure in the U.S. . My father in law will consult me on that decision after the RCT is complete. The outer circumfrence of the tooth is completely intact, plus no other restoration work has been done. He is saying as long as the endodontist doesn't penetrate too deeply the outer circumfrence of the tooth, a crown really isn't necessary. > I may be getting some of the translation wrong, but the way it was > explained to me is that since the tooth had no restorative work done [quoted text clipped - 3 lines] > nerve/pulp chamber and damage the tissue (irreversably). Are you > saying that you disagree with this synopsis? Usefullness of CaOH was something taught in the 1980's. So, is the concept that you must separate resin from dentin. Pulp health does best when the resin is bonded directly to bare dentin, (if a restoration must be placed). Today, we bond without any CaOH. > 2) unless you have a really good crown work done - there are two spots > where the crown typically leaves vulnerability to decay. (at the > bottom of the crown). The crown cannot decay, but the tooth that remains exposed can. So, the entire periphery of the crown is susceptable to decay. This is a bigger problem in patients who clench and grind isometrically. That activity tends to chip out the adhesive and open spaced for bacteria to get into. > 3) crowns can and do go bad after some time and need to be replaced. We always say that NO dentistry will last forever. However, a lot of well done dentistry will outlast the patient. I suspect this is limited to the "ideal patients". When a crown fails (assuming it will eventually fail), it either gets a LOT of decay inside it, or it snaps off at the gum-line. Either scenario is very bad for the tooth. Sometimes the dentist is lucky and discovers a problem with an existing crown before it is very advanced, but often not. Having said that, crowns will last a VERY LONG time in the right patient. > So while the dentist and the endodontist are saying "get a crown" - > which as previously discussed is standard procedure in the U.S. . My [quoted text clipped - 3 lines] > the endodontist doesn't penetrate too deeply the outer circumfrence of > the tooth, a crown really isn't necessary. I am a big fan of bonded machine milled ceramic onlays rather than full crowns. So,,,, I am not the best person to comment, since I am biased. In my office, if the tooth is only missing one third (or less) the width of the tooth, and the outer walls are clean and free of fractures, I do NOT cut down the sides of the tooth. This type of talk is heresy to the average dentist. Dentists are taught repeatedly that teeth with RCT MUST have full crowns. It takes a lot of thinking outside the box to realize that this is not *always* the case. Ever try to talk evolution to evangelical (born again) christian? >Thanks Amatus. > [quoted text clipped - 5 lines] >nerve/pulp chamber and damage the tissue (irreversably). Are you >saying that you disagree with this synopsis? Newb piping in here: Absolutely. CaOH was routinely placed under amalgam fillings, mostly as a thermal protective layer and there is some anti-cariogenic activity. The current generation of bonding agents seal both dentin and enamel. There is IMO no need for CaOH liners under composite restorations nowdays. Am using a flowable composite in deep preparations, separately cured before placing a filled composite. >Also - regarding the crown. I found out why it is not desirable to >have a crown: > >1) you get a part of your (in this case - healthy) tooth lopped off as >part of preparation, so that the crown can seat properly on the >tooth. Then get an onlay. >2) unless you have a really good crown work done - there are two spots >where the crown typically leaves vulnerability to decay. (at the >bottom of the crown). No more so than any other What's the other spot ? >3) crowns can and do go bad after some time and need to be replaced. So ? Cars go bad and sometimes need to be replaced. >So while the dentist and the endodontist are saying "get a crown" - >which as previously discussed is standard procedure in the U.S. . My [quoted text clipped - 3 lines] >the endodontist doesn't penetrate too deeply the outer circumfrence of >the tooth, a crown really isn't necessary. OK, so what do you prefer ? A crowned tooth that is structurally sound, functional, and protected ? --or-- A tooth so hoplessly fractured that extraction is required ? You pays yer money, and you takes yer chances. >1) CaOH has not bearing on the final outcome of the tooth. It breaks down >over time and leaves a tiny void. It, also has a different compressive [quoted text clipped - 23 lines] > >8) What did I miss?? CaOH not an acid, it is a base. <pun intended> >Before Xray: http://users.rcn.com/mmcgourty/before.jpg Both films are rather dark. Can you try for a better pic ? Even after some phun with photoshop, still think a better image is in order. > Thanks so much. You guys are the best. It's good to see this newsgroup > thriving! ;-) Couldn't get the pics up, but I trust AC's descriptions. I also agree about CaOH. It is an obsolete dental material (as a liner under restorations). I would remove all of the existing restoration and have it replaced with Clearfil SE Bond, flowable composite, and a good posterior composite resin with very careful attention to occlusion (and maybe even an NTI for a while...if not forever <G>). Using a rubber dam would also be a great idea. If it still hurts after that, endo is likely the only workable option. JMO, Steve SNIP > My father in law the retired dentist has given his opinion on several > things: > > 1) It would appear from the xray that no CaOH dressing was applied to > the surface area. > 2) The cavity was very small and didn't have an urgency to be filled. You sound like a really nice guy, willydog, but the above opinions you received from your father-in-law are just not correct in today's dentistry. I say this with all due respect. Family ties run deep, I can understand, but if he's also telling you not to get a crown (or at least a restoration that provides cuspal coverage) if you have the root canal, I would question that too, given his track record. The greatest force generated in the mouth is between the second molars (ie. closest to the TMJ).....So if you don't have any cracks now in the tooth, there will be a few years from now after the endo is done. We just can't tell you right now if that will translate into a cracked, nonrestorable tooth, if cuspal coverage is not provided. John John, I personally think cracks in endo teeth are related to isometric bruxism during clenching, not RCT. I could look to see if I still have the articles describing the amount of forces generated between occlusal surfaces during chewing. Very light. Signature/ Amatus / > > SNIP [quoted text clipped - 19 lines] > > John > John, I personally think cracks in endo teeth are related to isometric > bruxism during clenching, not RCT. > > I could look to see if I still have the articles describing the amount of > forces generated between occlusal surfaces during chewing. Very light. And of course, not just endo teeth either. ;-) Steve >> John, I personally think cracks in endo teeth are related to isometric >> bruxism during clenching, not RCT. [quoted text clipped - 6 lines] > ;-) > Steve Good point. I was not saying that endo itself causes the cracks, just thinner tooth structure can propagate a crack much more easily. John Thanks everyone for all the wonderful information! You folks are the best! I'm actually able to "hang" with your dentist conversations..lol. Well the latest news on this is that the condition may be RE-VER-SING! emphasis sing! lalalala !! Now before you all go off and tell me that ir-reversable means irreversable, just hang with me. I've been living with this for 3 months now, and I'm more than prepared to go another 3 if the condition continues to improve. I still have the temporary filling in, and I still get toothaches, but it's not nearly as bad. I'm at about 90% with chewing and can't "feel" anything except for one particular chewing stroke that is still sensitive. . The sensation to cold is greatly diminished, but still there. I don't take the NSAID's as much anymore. I do know that long term taking of the NSAID's is no good. I'm all the way from 2 400mg dosages a day to current - a minimal 200mg dosage of advil (one pill) very rarely. I'm averaging maybe 3 advils a week at this point. I'll go 50/50 this point on avoiding a RCT, and I have no plans to even think about it until my traveling for college football is over sometime in November. I just continue to chew on the right side of my mouth and every once and a while "experiment" on the #18. Any comments? What happens when you wake up on a Sunday with a swollen face and can't get anyone to treat you for a few days? Signature/ Amatus / > Thanks everyone for all the wonderful information! You folks are the > best! I'm actually able to "hang" with your dentist [quoted text clipped - 21 lines] > > Any comments? > What happens when you wake up on a Sunday with a swollen face and can't get > anyone to treat you for a few days? Point taken. Perhaps I was a little too kiddy about reversing. I took a good swish of cold water, and it's still bad enough. I just want to avoid a RCT so bad, it's making me crazy, especially reading that other persons post about the failed RCT/crown with the infection. I was told by my father in law that I can get the first part of the RCT done now, and the medication can stay in the tooth until I complete my traveling. I don't want to get caught up with RCT complications while I'm traveling. But if I'm not abusing the NSAID's, and it's been like this for 3 months, I figure another 3 weeks will be fine and I can be home for an extended period of time just in case there are some complications.... plus that outside shot at a reversal... I don't think it's necrotic, I can definitely feel something there. On a separate note, I really feel for cancer patients, and other people with more serious illnesses. I got enough of a taste of that "hope" for a cure with the RCT. I've had enough close one pass away from disease. God bless them, and let's hope we someday find a cure for that , and all , the terrible diseases on this earth. Gee Whiz! Just get it done already. RCT is usually just one appointment. Signature/ Amatus / >> What happens when you wake up on a Sunday with a swollen face and can't >> get [quoted text clipped - 20 lines] > from disease. God bless them, and let's hope we someday find a cure > for that , and all , the terrible diseases on this earth. Hi folks just to follow up on this..especially for the poor dope two years from now researching RCT. lol. I did finally get the RCT done... today as a matter of fact. As per the endodontist, the nerve was "pretty bad", and I was about 2 weeks away from swelling. Of course, the endo isn't going to speculate what caused the problem, she just told me what the problem was. The diagnosis was that the nerve was fried (for lack of the medical term that escapes me at the moment) and it was "in pretty bad shape". That said, we all know that the original DDS (no longer with the practice) botched the filling and fried the nerve when doing the prep. Nobody is going to tell me that outright, but it's pretty obvious. The original filling was no where near the nerve, the tooth was perfectly healthy and then the nerve is fried since stepping out of the chair?? hmm. I'm not a lawsuit happy person. I don't believe in that, and I do feel that dentists in general and doctors in the larger picture get way too many lawsuit happy people. I will not be doing that. We're all human However, I do not feel I should pay any out of pocket costs associated with this incident. How do I approach my DDS and have a good open discussion about this without sounding threatening about liability and the such? We have a good relationship so far, and I like him a lot. We're all human, we do make mistakes. It is what it is. Thanks, you guys are the best. ;-) > Hi folks just to follow up on this..especially for the poor dope two > years from now researching RCT. lol. [quoted text clipped - 23 lines] > > Thanks, you guys are the best. ;-) You're not going to like my answer, but we do NOT "all know" that the original DDS "botched" the filling--we really have only your side of the story. Honestly, there is no way to tell after the fact whether the dentist drilled further than he had to. Even a pre-op radiograph can only hint at whether a problem might have been avoided. Even if the pulp was not physically entered, the accumulated insults of being filled repeatedly can send it over the edge. It is tempting to try and blame someone when something unexpected like this happens, but trust me--he may have done something wrong, but a similar outcome may easily result even when things are done 100% by the book. It happens to every dentist--myself included. It's really just one of those things. If your relationship with your dentist was previously good, you may wish to discuss this with him for explanation, but often there is none, and you might consider whether the loss of your dentist is worth it. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 > You're not going to like my answer, but we do NOT "all know" that the > original DDS "botched" the filling--we really have only your side of the [quoted text clipped - 13 lines] > > Steve Thank you for your thoughts Steve. I will talk to the partner that took over from the associate who did the original work. The associate is no longer at the practice. He was a real nice guy too. No ill will on my part towards him, just maybe a little inexperienced that's all. Steve and others - I'm looking at things from a 20000 foot perspective. I had a very small cavity (those xrays I posted don't do it justice) which had been on my xrays since 2003, no pain, no prior restoration work done, basically a judgement call to even bother getting it filled. It was a very happy and healthy tooth. I have none/ zero/nada history of dental decay other than one composite filling done over 20 years ago on the other side of my mouth. .I try to take good care of my teeth to avoid these headaches. The pain/sensitivity was immediate after the filling. It didn't "devleop" over time. One piece of information I never relayed is that even with 2 full shots of novacaine the associate used (the partner used only 1 on the subsequent medicated temporary filling) I *felt* pain in the nerve . Just a little discomfort as you can probably imagine with 2 shots on numbing agent, but definitely there nonetheless. Since it appears that the filling did not actually hit the nerve itself, I can only speculate that it was the prep (not enough water maybe?) or something else related to the procedure that sent the nerve over the edge. Again, thanks for all the wonderful dental professionals who provide valuable insight. I am going to run the idea of a bonded onlay by the partner and see what he thinks. So far the endo and the partner are sticking with the (safe) crown recommendation. They do not consider alternative approaches from what I gather for the rear molars, regardless of how much tooth structure remains - as it's "playing with fire" (endo's exact words). I still wonder what would have happened with a new filling with a good 'bond-o-dontist' doing the work (and maybe an NTI). Even cutting without a water spray on a high speed, I would not expect to 'fry a nerve' with any reasonable care. I respect endodontists for their abilities, but a 'hot' tooth is often not given any other option by the time it shows up at the specialist. JMO, Steve Since it appears that > the filling did not actually hit the nerve itself, I can only > speculate that it was the prep (not enough water maybe?) or something > else related to the procedure that sent the nerve over the edge. Hi Steve. Thank you for taking the time to reply to my posting. I believe the nerve was in fact shot and there was no hope for reversal. Not sure if that is what you were talking about with NTI? I already had one composite filling that more resembled an amalgam filling in area drilled (not publically criticizing, just rehashing other opinions I received), along with a temporary filling done as a last resort to RCT, along with 2 bite adjustments from the first filling. somewhere between all that the nerve went over the edge... As correctly pointed out, I will reserve judgement and "blame" and together with the partner objectively try to identify what may have happened based on the emperical evidence and prior experience. Blame doesn't really matter at this point. The associate was a very nice dentist, with great bedside manner that genuinely cared for my health. Even in the remote chance there was an error, it was an honest mistake, not something caused by a hurried or careless procedure. The best value I have learned from this experience is to take care of my teeth! I had stopped flossing... I have started again. ;-) I have a temporary filling in now, and the RCT seems to have been successfull. So far so good... I need to get a second opinion on the need for a crown. Certainly the retired dentist father in law can provide one, but I want an opinion of an active professional too. I'm willing to shell out the money for a bonded onlay if it can hold the tooth together as well as/better than a crown. Better yet, if I can get by with a composite and no crown, no onlay - that would be even better. The circumfrence of the tooth structure is in tact, and given my history of minimal decay, I am hoping nothing is needed other than a composite filling. Question: Is it better/worse or indifferent to leave the temporary filling in after the RCT? Should I look to do this right away, or wait a while. >Question: Is it better/worse or indifferent to leave the temporary >filling in after the RCT? Should I look to do this right away, or wait >a while. I never put temporary fills in teeth with completed RCT. Am currently placing fuji 9 as a core build up with the rubber dam still in place. Crowns should be fabricated for RCT teeth within 4 - 6 wks. The endodontic seal must be from root tip to cusp tip. Monobloc. Newbie - are you saying that you are in the traditionalist "always crown" camp for rear molars, or are there sometimes conditions where you feel crowns are not necessary? I do not clench (that I know of anyway). Recall Amatus's previous comments, which agrees with that of my father in law: ========= John, I personally think cracks in endo teeth are related to isometric bruxism during clenching, not RCT. I could look to see if I still have the articles describing the amount of forces generated between occlusal surfaces during chewing. Very light. ========= A crown wouldn't be the worst thing, but it's another contraption in my mouth that I don't want. You all know the pro's and con's of this better than I. >Newbie - are you saying that you are in the traditionalist "always >crown" camp for rear molars, or are there sometimes conditions where >you feel crowns are not necessary? >I do not clench (that I know of anyway). How could you possibly know if you clenched in your sleep ? >Recall Amatus's previous comments, which agrees with that of >my father in law: For all molars and *most* bicuspids there must be cuspal coverage or replacement Standard C&B or Cerec. The masticatory system functions like a class 3 lever, there is much more force exerted in the posterior than the anterior. >========= >John, I personally think cracks in endo teeth are related to >isometric >bruxism during clenching, not RCT. Strongly disagree. It's about the loss of dentin that must be removed just to gain access to the canal system. The roof of the pulp chamber is gone, that leaves the cusps without a significant portion of their support. Add a little parafunction and you are asking for a failure. >I could look to see if I still have the articles describing the amount >of >forces generated between occlusal surfaces during chewing. Very >light. >========= But not in parafunction or when conciously clenching with maximum force. >A crown wouldn't be the worst thing, but it's another contraption in >my mouth that I don't want. You all know the pro's and con's of this >better than I. Let's cut to the chase shall we ? I rarely have to extract endodontically treated teeth that have been restored with crowns. Those that have not however, are an entirely different kettle of fish. Agreed. Steve >>Newbie - are you saying that you are in the traditionalist "always >>crown" camp for rear molars, or are there sometimes conditions where [quoted text clipped - 40 lines] > been restored with crowns. > Those that have not however, are an entirely different kettle of fish. It's always nice to have agreement from a highly esteemed colleague. Thanks dude, you made my day. >Agreed. > >Steve I think I am the one who should be flattered. :-) Steve > It's always nice to have agreement from a highly esteemed colleague. > > Thanks dude, you made my day. >>Agreed. >> >>Steve > How could you possibly know if you clenched in your sleep ? Sleep? What's that? I'm a software developer. We *NEVER* sleep. Just slide some pizza under the door and we're all set. LOL. Seriously, I am relatively sure I do not clench. > Let's cut to the chase shall we ? > I rarely have to extract endodontically treated teeth that have > been restored with crowns. > Those that have not however, are an entirely different kettle of fish. I'll speak to my dentist and we'll go over the options. He does CEREC and bonding too, but he's already echoed your sentiments. I'm leaving the ranks of single guy shortly, I don't care about aesthetics that much... better get a 24K crown though so I can look good in case I get divorced . ... LOL Anyway, I will talk to the father in law, my dentist, and maybe get a second opinion to make my decision an educated one. Hopefully this will be my one and only RCT I ever have to deal with. I do want to get this temporary out of there after reading your post, whatever the restoration ends up being. Cheers to all, Bill >> How could you possibly know if you clenched in your sleep ? >> >Sleep? What's that? I'm a software developer. We *NEVER* sleep. Just >slide some pizza under the door and we're all set. LOL. Seriously, I >am relatively sure I do not clench. Hmmm. Let's examine your above statements, doesn't sleep because of your profession. Er, well, software developers are renown for major caffiene and sugar consumption. When you do sleep, do you dream of code ? Prolly gnashing the crap outta yer teeth. You *cannot* assume that you don't clench during sleep just because you are aware enough to not clench while awake. As for pizza, do you like anchovies ? <hehe> If you want to be SURE that you do not clench during sleep, an NTI is recommended. >> Let's cut to the chase shall we ? >> I rarely have to extract endodontically treated teeth that have [quoted text clipped - 6 lines] >much... better get a 24K crown though so I can look good in case I get >divorced . ... LOL 24K gold is too soft to function as a cast crown. Your best bet is to choose either full cast high noble, or Cerec, or if you want a Porcelain Fused to Metal <PFM> . >Anyway, I will talk to the father in law, my dentist, and maybe get a >second opinion to make my decision an educated one. Hopefully this >will be my one and only RCT I ever have to deal with. I do want to >get this temporary out of there after reading your post, whatever the >restoration ends up being. Be sure to know what material was used as a 'temporary' . Cavit or IRM are not suitable for teeth with completed RCT. Have an endo buddy that places Fuji 9 as a temp. At the very least while you are contemplating the definitive restoration, at least get a solid "Build-Up" in your tooth ASAP. Discuss the materials with your dentist. Composite can be an acceptable interim restoration but there needs to be a definitive cuspal coverage restoration. >Cheers to all, >Bill Same to ya ! > I had a very small cavity (those xrays I posted don't do >it justice) which had been on my xrays since 2003, no pain, no prior >restoration work done, basically a judgement call to even bother >getting it filled. >It was a very happy and healthy tooth. Assumes facts not in evidence. You stated in the sentence above this one that there was decay. > I have none/ >zero/nada history of dental decay other than one composite filling >done over 20 years ago on the other side of my mouth Have seen teeth without decay or any restoration whatsoever inexplicably and suddenly progress to pulpal necrosis without any apparent problems. Your best bet is just go ahead and get the endo and crown, and be done with it. Further discussion will not help your tooth or alleviate your pain. |
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