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We’d like your assistance in helping us with a patient who

has severe osteoporosis and needs...
We’d like your assistance in helping us with a patient who has severe osteoporosis and needs major dental work before he can start taking bisphosphonates. Any serious dental work done after he starts using the drug will increase the likelihood of developing osteonecrosis of the jaw thereby causing major health problems.
He recently had a thorough dental checkup with full mouth X-rays and panorama and of immediate concern is a bottom right molar that has a root canal, a defective crown, and multiple cavities under the crown. He cannot afford to lose this tooth because it's on the main side of the mouth he chews on.
While Cerec could work very well for some of the work he needs done, based on our research, our understanding is that it is not appropriate for this particular tooth he needs immediate work on because:
· He is a bruxer and seriously grinds his teeth at night (the crown on the root canal tooth has the enamel worn down on it, it's just metal).
· He needs something with very tight margins on the gum line, that’s extremely durable, that will last and not get worn down or break, etc.
Question 1: Because of the above conditions (especially with him being a bruxer), what is the best material for the crown? Gold, zirconium, ceramic, a combination? etc.?
Question 2: Our research indicates that it would be better to use the same 3D imaging that is used for Cerec (vs. a traditional mold), then work with a lab to make the crown. Do you agree with this approach?
Question 3: Because there are cavities on the root canal tooth under the crown, what would be the order of the procedures. Which comes first, second and third: for example, deal with cavities, new crown, then deal with root canal if it needs to be redone/fixed? Or is the root canal done first? etc.
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Answered in 50 minutes by:
11/7/2013
Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
Verified
Hello-- I'm Mark Bornfeld, DDS. Welcome, and thank you for putting your trust in me!

"Question 1: Because of the above conditions (especially with him being a bruxer), what is the best material for the crown? Gold, zirconium, ceramic, a combination? etc.?"
Assuming esthetics is not an issue, there is little doubt that a high noble cast metal crown (i.e., gold casting alloy) would be the best choice. Not only can gold casting alloy be fabricated to a very accurate gingival margin, but it will not fracture, nor will it abrade the opposing teeth as any of the ceramic crown iterations will. This is particularly true in a patient with bruxism.

"Question 2: Our research indicates that it would be better to use the same 3D imaging that is used for Cerec (vs. a traditional mold), then work with a lab to make the crown. Do you agree with this approach
I respectfully ***** ***** admit to being a bit of a throw-back, but I rankle at the wholesale rush of the dental profession to embrace new technology solely for the sake of its newness. 3D imaging is a fascinating technology, to be sure, but the CEREC methodology offers only one advantage over traditional laboratory-based crown fabrication-- that it can drastically eliminate the turn-around time required to send an impression to the dental laboratory and have a crown returned from the lab. This might be crucial if the patient needs to catch a flight out of town, but most patients are not under such tight time constraints. And in the case where optical scanning is used in conjunction with a laboratory rather than an on-site CEREC mill, that advantage evaporates. One cannot know what the future holds, but crowns made by using the current optical scanning methods do not approach the accuracy of conventionally fabricated crowns.

"Question 3: Because there are cavities on the root canal tooth under the crown, what would be the order of the procedures. Which comes first, second and third: for example, deal with cavities, new crown, then deal with root canal if it needs to be redone/fixed? Or is the root canal done first? etc."
The presence of decay under the crown implies that the extent of the decay has not yet been determined. I say this because a crown will tend to block the passage of x-rays, which will effectively obscure the visualization of decay below it. I must also admit to being a bit confused by this question, because the tooth was described as already having a root canal, and now there is some question of whether the root canal may need to be re-done.

So, the fundamental principal that applies is that diagnosis is key to making a reliable treatment plan, so that the patient can avoid being blindsided by an unanticipated complication. So, if the location of the decay and/or the status of the prior root canal treatment cannot be determined with the crown in place, it is necessary to remove that crown to see what is happening beneath it. Only then can a rational plan of treatment be formulated. If there is some question as to the serviceability of the previous root canal, this should be determined by an endodontist (root canal specialist) rather than a general dentist. It makes no sense to implement any treatment if, for example, the tooth is found to be too structurally undermined to support a new crown, or if a failed root canal cannot be rectified. In these cases, there would be no alternative but to remove the tooth and consider the options for prosthetic replacement. I concede that this is not a particularly happy outcome, but think of how much more unhappy things would be if the tooth failed after a long and expensive attempt to salvage it.

Since the issue of bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been raised, it deserves some mention here. (By the way, some experts use an alternative term: anti-resorptive osteonecrosis of the jaw, or ARONJ, to recognize that other medications used to strengthen bone in malignancy and osteoporosis may incur similar risk.)

According to a recent study, the risk of developing ARONJ in patients with a history of oral bisphosphonate use was estimated at about 0.1%, or one case in 1000 such patients. The risk for patients using intravenous bisphosphonates for malignancy was somewhat higher-- somewhere around 6.1%. The market release of once-yearly intravenous infusions of zoledronic acid (e.g., Reclast, Aclasta) is too recent to have useful statistics regarding their use.

The important take home message is that for oral bisphosphonate users, the risk of ARONJ is quite low, and would not necessarily rule out an extraction if one became necessary, even after the use of these medications. That does not mean that any backlog of dental disease should not be properly dispatched prior to bisphosphonate therapy, but that necessary dental interventions, including oral surgery, would not be precluded by drug administration. Keep in mind that dental infection is itself a risk for ARONJ in patients taking anti-resorptive therapy, so proper professional dental care would offset this risk.

Hope this helps...
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Customer reply replied 4 years ago

Thank you for your thorough reply. I had one more question, before I change the crown on the root canal tooth (that has decay under the crown), I’d like to know whether or not there is anything on the X-rays that indicate the root canal has been disrupted or needs to be fixed in any way. Are you able to tell what is the condition of the root canal from my X-rays?

To directly address your question: unless there are suspicious symptoms in the vicinity of the tooth, your x-rays do not indicate the need to re-treat the root canal. I've annotated the relevant x-ray here:


You will note a slightly darker area in the bone immediately adjacent to the root tips, as indicated by my arrows. This may represent scar tissue from a previous infection, but in the context of a tooth that is quiet and not manifesting sensitivity, I would be inclined to interpret these areas as innocent.

The relevant question about this tooth is really more related to its structural and periodontal health than the status of its old root canal. I have indicated the suspect areas in one of the bite wing x-rays:


There is significant tooth decay in both roots, and that decay is approaching perilously closely to the "furcation"-- i.e., the point where the two roots divide. This would severely compromise the ability of this tooth to stand up reliably to the rigors of chewing function. There is also horizontal bone loss, as well as bone loss in the furcation, which will diminish the support for this tooth. This is not to say that you should not consider attempting to salvage the tooth, but such a decision should be predicated on the knowledge that this tooth will never be truly out of the woods, and could fracture at any time. If the intent is to avoid extraction at all costs, that objective may not be met.

I also indicated a significant amount of decay on tooth #5-- the upper right first premolar. No doubt your dentist has already informed you of this tooth, which likewise has a very guarded prognosis. Even if this tooth has a root canal treatment and another crown placed, the amount of structural loss will make this a fragile tooth.

Finally, one more incidental finding, which may or may not be significant:

This shows a remnant of a root tip lying in your right sinus-- evidently left over from a tooth extraction from long ago. Although this may be just sitting there quietly, it should be investigated if any symptoms of sinus disease emerge.

Hope this helps...

Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
Verified
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Customer reply replied 4 years ago

It's interesting what you said about sinus disease because I have this ongoing sort of bad tasting, bad smelling discharge draining from my sinuses into the back of my throat or into the lungs that I cough up in the morning. What kind of symptoms should I look for to know if I have sinus disease?

Customer reply replied 4 years ago

DENTIST'S WRITTEN EVALUATION:


































































Tooth #



Combined clinical and radiographical impressions



2



Worn PFM crown (fractured porcelain) – Ideal treatment is new crown or can leave as is (no caries apparent)



3



Worn PFM crown (fractured porcelain) with possible recurrent caries on distal—recommended new crown



5



PFM crown with deep recurrent caries which would need, if it can be saved, root canal therapy, post and core and crown.



6



Mesial facial lingual composites with distal caries – needs distal lingual facial composite.



7



Distal facial lingual and mesial lingualfacial composites with distal caries – needs distal lingual facial composite.



8



Distal facial lingual composite is fractured – recommend new distal facial lingual composite.



10



Panoramic x-ray shows horizontal line across root which could be a fracture, or it may be nose line superimposed. Can be determined with a periapical x-ray.



18



Worn PFM crown (fractured porcelain) caries on lingual – recommend a new crown, or at least repair lingual caries.



19



Worn PFM crown (fractured porcelain) with hole on occlusal – recommend new crown.



20



Occlusal and mesial caries – needs new mesial occlusal composite

Summary of verbal: Has cavities, will need some filling.



28



Facial composite is worn – needs new facial composite.

Summary of verbal: The tooth could use a new composite on there, but no decay.



29



Natural crown is fractured – recommend a crown.



30



Worn PFM crown (porcelain fractured ) – ideal treatment is new crown, or can leave as is (no caries apparent)



31



PFM crown with failing composite on the occlusal and has lingual and facial caries. Slight radiolucency on the mesial root tip, so root canal may be failing. Recommend new crown and endodontic evaluation.



Other Notes:

I recommend an evaluation by a periodontist as bone loss is present. Periodontal status is moderate periodontal disease with localized severe areas.

I recommend seeing a root canal specialist to assess and manage root canals with cavities.

A night guard appliance is also recommended due to severe wear from bruxing.

Notes from verbal consultation

Tooth #2

Porcelain crown is worn off the top, but tooth is covered. Ideally a new crown would be good, but you can leave it. Doesn’t appear to have any caries on it.

Tooth #3

X-ray shows a hint of something suspicious on the distal, like it could be leaking, right at the edge of the crown where the roots come out. I couldn’t catch under there, but it looks a little dark to me. Sometimes panoramas look that way too, but I think I see enough on the bitewing to make me think that there might be something there.

Tooth #5

There’s a big dark area under there on the X-ray, but it looks like if it can be saved. He would need a root canal, a post and a new crown. He definitely would need to see the root canal specialist for that tooth.

Tooth #6

Has several existing composites, making it hard to tell from the X-ray. The newer composite is lighter in color, potentially there’s decay around the older one. I’d almost have to reevaluate the tooth.

Tooth #7 – May need to be reevaluated, staining present

Also looks a little dark. Could be reevaluated. He has staining so cleaning would be good.

Tooth #8

In the anterior on the top, some old restorations are breaking down, but nothing major.

Tooth #10

At first it looked like there’s a horizontal crack in the root tip end of the tooth, but I think it’s the shadow of his nose. Could take an x-ray from a different angle to verify, but I think it’s just the shadow.

Tooth #18

Fractured porcelain crown where metal is exposed. Cavity on the lingual side. Best thing would be a new crown, but might be able to get by putting a little filling there.

Tooth #19

Porcelain is fractured or worn off on the top, so metal is exposed. Have a little hole in the metal on that one. Definitely recommend a new crown because there is a break in there where bacteria can get down under the crown for sure.

Tooth #20 – Has cavities, will need some filling.

Has cavities in between the teeth. Recommend a filling.

Tooth #28

Facial composite is worn. Could use a new composite on there, but no decay.

Tooth #29

Doesn’t appear to have a cavity, but the crown of the tooth is kind of fractured and worn. It is opposing porcelain, so it’s probably going to continue to wear. It has a better chance of not wearing down more if a crown is put on.

Tooth #30

Porcelain crown has kind of worn or fractured on the top. Ideally put on a new crown, but you can leave it. It doesn’t appear to have a cavity. Pano looks a little dark in the bone, not as radio-opaque between the roots. Reevaluation may not be a bad idea.

Tooth #31

Had a root canal after the crown was placed, so crown has a composite filling on top. That filling is kind of failing, it’s kind of ditched out.

Cavities on both the lingual and the facial at the gum line.

It’s slightly dark at the very root tip, the one that’s more mesial. It may be the trabeculation of the bone, but it would be good to have the root canal specialist evaluate that because he might have some bacteria that’s gotten down in there and re-infected that.

QUESTIONS:

Prioritizing serious cavities vs. cavities that can wait until summer

Because of my severe osteoporosis, I need to do any dental work before flu seasons starts in Hawai‘i (which could be in a month or less from now). Last winter I got pneumonia and I fractured my spine from coughing. I can’t afford that to happen again. Based on my dental x-rays and the attached dental examination provided by my general dentist, could you please advise me on cavities you believe I need to prioritize before flu season and how many appointments will it take, vs. the other dental procedures that can wait until summer?

Please note that I would be seeing specialists for each of the different jobs:

Endondist for root canals

Cosmetic dentist for the crowns and possible bridge

Fillings could either be done by my general dentist or the cosmetic dentist.

I’m still trying to determine who would be best to do possible extractions.

How many of my affected teeth need fillings?

How many visits would it take to take care of these?

Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?

Please indicate which fillings would be considered “difficult” to do (in terms of hard to get to because they’re between the teeth, etc.)? I’m asking because perhaps I could get the more difficult ones done by my regular dentist and easy ones done by a dentist who does house calls (her drill is not as advanced).

How many of my affected teeth need root canal work?

And how many visits would it take to take care of these?

Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?

How many of my affected teeth need crown work?

And how many visits would it take to take care of these?

Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?

Generally I would like to know how many appointments does it take to do fillings vs. crowns? And how many appointments does it take to do 2 root canals vs. extractions?

Possible options to manage my affected teeth

I have some ideas on possible options to manage my affected teeth and would value your opinion. I would also like your help in comparing the different options from the angle of how many appointments it would take for each one.

Specifically, I am hoping that you could put together some specific treatment options (based on the following ideas), indicating what work needs to be done on each tooth; total number of fillings, crowns, root canals, extractions, bridges needed; along with how many appointments required for each part of the work.

Option 1: Only do priority composites, root canals, and crowns

Get fillings done on priority cavities only – leaving the rest of the cavities for summer (How many appointments would this take?)

Get a root canal on teeth #31 – the bottom molar with existing root canal; and #5 – the pre-molar you noted that has serious decay (How many appointments would this take?)

Get crowns on teeth #31 and #5 and any other priority crown work that needs to be done before flu season (How many appointments would this take?)

Option 2: Pulling teeth instead of root canals

Note: I am considering getting teeth #31 and #5 pulled because it is a gamble as to whether or not they can be saved, and my priority is managing my osteoporosis (part of which is taking bisphosphonates). I’d be reluctant to start bisphosphonates knowing that the teeth could need to be extracted or major work done if the treatments fail. One issue with this option is that I have gotten teeth pulled in the past and it is quite traumatic and exhausting. I don’t believe I would be ready to have more work done for a month, which would be mid- December when flu season has already started, which, as I explained, is not really an option for me.

Get priority fillings done.

Pull teeth #31 and #5. (Could I get 2 teeth pulled on the same day? Is a consultation appointment necessary before the work is done?)

Get a bridge on tooth #5. (How many appointments would this take? Is it possible to wait until summer to get the bridge done? Is there something temporary that can be done in the meantime, and how many appointments does that take?)

Alternative: Pull tooth #31 and get a root canal on #5. That saves me from getting a bridge on #5. How many appointments less would this be?

Option 3: Temporary treatment

What do you think about the option of not getting the crowns done now, but just fill the cavities with composites as a temporary treatment and do the crowns in the summer? Which teeth do you think I could get by with “temporary” fixes like this? What work would I need to get done for this option and how many appointments would it take?

Possible reasons for current state of sensitive tooth

Tooth #31 is more sore/sensitive since before I visited the dentist. I’m wondering how is it possible if the tooth is dead?

Does this mean there’s a bone infection?

Could it mean it’s an infection on the tooth next to it?

Could it simply be trauma caused by the TMJ and the bruxing and possibly eating hard food like chips, cookies, or a couple almonds?

Before I move on to your subsequent questions, allow me to deal with the first:

"It's interesting what you said about sinus disease because I have this ongoing sort of bad tasting, bad smelling discharge draining from my sinuses into the back of my throat or into the lungs that I cough up in the morning. What kind of symptoms should I look for to know if I have sinus disease?"
As a dentist, it is not my prerogative to provide guidance as regards ***** ***** and treatment of sinus disease, because it is not a dental issue-- regardless of whether it may have its origins in a dental procedure. This would be best managed by an otolaryngologist with a subspecialty certification in rhinology. Although consideration of symptoms may comprise part of the formal diagnostic assessment, they are of limited use in diagnosing sinus disease, as significant issues may exist in the absence of symptoms. My intent is simply to inform you of the presence of a tooth root in your right sinus, which certainly merits an examination by an ENT specialist.

As for your questions about diagnosis and treatment specifics: because this forum does not establish a formal doctor-patient relationship, and because your panoramic x-ray and few bite wing x-rays convey far less information on their own than is required to do justice to the diagnostic process, I am not sufficiently informed in the diagnostic sense to provide specific treatment guidance, nor do I have the legal standing to provide such guidance. However, I can provide a general framework that may be of assistance in having an informed discussion with your dentist regarding these matters. These are completely legitimate questions, and based on your transcript of your dentist's diagnostic report, his diagnostic interpretation of the x-rays is consistent with my findings, and there is no reason to believe that his answers would be any less credible or rational than mine.

"Because of my severe osteoporosis, I need to do any dental work before flu seasons starts in Hawaii‘i (which could be in a month or less from now). Last winter I got pneumonia and I fractured my spine from coughing. I can’t afford that to happen again. Based on my dental x-rays and the attached dental examination provided by my general dentist, could you please advise me on cavities you believe I need to prioritize before flu season and how many appointments will it take, vs. the other dental procedures that can wait until summer?"
I honestly don't see any particular issue that is objectively time-critical. The only exception would be the presence of any infections for which an acute flareup may be imminent, and any decay that is sufficiently deep that a timely management might make the difference between needing a root canal treatment or not needing a root canal treatment. As I see it, the only tooth that may fall into this category is #5, and perhaps #31 if symptoms are already present.There may be other decay that is more pressing, but it is not evident in your supplied x-rays. The number of visits required would depend on the treatment that is selected. As I have already mentioned previously, neither of these teeth are in particularly good condition, and you should have a candid discussion with your dentist whether their dubious prognoses justify the effort and expense of salvage, or whether it would be more rational to remove these teeth and consider some form of prosthetic replacement, which would be postponed for the future.

"How many of my affected teeth need fillings?
How many visits would it take to take care of these?
Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?
Please indicate which fillings would be considered “difficult” to do (in terms of hard to get to because they’re between the teeth, etc.)? I’m asking because perhaps I could get the more difficult ones done by my regular dentist and easy ones done by a dentist who does house calls (her drill is not as advanced).
How many of my affected teeth need root canal work?
And how many visits would it take to take care of these?
Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?
How many of my affected teeth need crown work?
And how many visits would it take to take care of these?
Of these, which are priority (i.e., need to be done before flu season because can’t wait until summer)?
"
Again-- these treatment decisions require access to more diagnostic information than can be extracted from your x-rays, and I commend you to your dentist, who has the advantage here.

"Generally I would like to know how many appointments does it take to do fillings vs. crowns? And how many appointments does it take to do 2 root canals vs. extractions?"
Generally? There is considerable variation in methodologies and styles between dentists, so there are no clear cut answers. Filling, when performed as "direct" restorations rather than as laboratory-fabricated inlays, generally take one treatment visit to complete. Dentists tend to place fillings one quadrant at a time-- that is, all needed fillings in one quadrant of the mouth (e.g., upper right, lower right, upper left, lower left) at once, but this too can vary according to a dentist's customary way of doing things. Crowns may take anywhere from one visit to three visits, depending on whether your dentist uses a CAD-CAM milling approach (CEREC), or whether he verifies his crowns in a separate "try-in" appointment. Again-- crowns may be fabricated on a quadrant-by-quadrant basis, so more than one crown may be implemented simultaneously.

Root canals also vary considerably in time required. There are one canal teeth, two canal teeth, three canal teeth, four, and even five canal teeth. The canals my be straight, or curved, or obstructed, or branched. Root canals vary widely in their complexity and the challenges they pose to the endodontist, so they may require anywhere from one treatment session to many. And extractions-- each should be completed within one treatment session, and again may be performed by quadrant.

As for your alternative treatment scenarios:

"Option 1: Only do priority composites, root canals, and crowns"
Perfectly rational, especially if your time is limited. Whether and how much work would need to be deferred would depend on how quickly the work can be completed, and this is often determined by factors beyond the control of the patient or the doctor. Your respective schedules will influence the amount of work that can be completed. I do believe that prioritization is the way to go, regardless of which treatment option you ultimately select. This assures that at least the most important aspects of treatment are resolved as quickly as possible, which in itself will eliminate the uncertainty of being blindsided by an unanticipated acute infection or pain event.

"Option 2: Pulling teeth instead of root canals
Note: I am considering getting teeth #31 and #5 pulled because it is a gamble as to whether or not they can be saved, and my priority is managing my osteoporosis (part of which is taking bisphosphonates). I’d be reluctant to start bisphosphonates knowing that the teeth could need to be extracted or major work done if the treatments fail. One issue with this option is that I have gotten teeth pulled in the past and it is quite traumatic and exhausting.
"
I'm with you on this one, although there is no absolute right or wrong. Both these teeth represent a toss of the dice, and if you are uncomfortable with uncertainty, extraction is a reasonable and rational alternative to root canal treatment. I won't dispute whether extraction is traumatic an exhausting, but that often depends on who is doing the extraction-- which should be extra incentive to letting an oral surgeon do them. In the aggregate, I suspect the root canal and re-crowning of the teeth will be no less exhausting. As I said before, I don't think the issue of your bisphosphonates is particularly significant here, but doing the extractions now rather than later does leave you with one less thing to ponder.

"Pull teeth #31 and #5. (Could I get 2 teeth pulled on the same day? Is a consultation appointment necessary before the work is done?)"
There is no practical reason why both teeth could not be removed during the same treatment session, but that would depend on the oral surgeon's style. Some manner of consultation would likewise be required prior to the extractions, if only to satisfy the legal requirement of informed consent. This could potentially be dispatched during the same treatment session as your extractions.

"Get a bridge on tooth #5. (How many appointments would this take? Is it possible to wait until summer to get the bridge done? Is there something temporary that can be done in the meantime, and how many appointments does that take?)"
A conventional fixed bridge generally takes 3 or 4 consecutive weekly visits, once the extraction socket has completely healed (about 5-6 weeks after the extraction. Either a temporary fixed bridge or a removable "flipper" appliance could be placed, if deemed necessary to maintain cosmetic appearance. This would require either 1 or 2 treatment visits, depending on whether your dentist has an on-site dental laboratory.

"Option 3: Temporary treatment
What do you think about the option of not getting the crowns done now, but just fill the cavities with composites as a temporary treatment and do the crowns in the summer?
"
Your first priority would be to deal with the imminent infections and deep fillings. As stated above, the x-rays are not sufficient to determine which of these teeth are priorities, except for #5 and #31. Anything that is not infected or with deep decay can be put on the back burner for now.

"Tooth #31 is more sore/sensitive since before I visited the dentist. I’m wondering how is it possible if the tooth is dead?"
Because the infected periodontal tissues around its roots are very much alive, and richly supplied with nerve endings.

"Does this mean there’s a bone infection?"
Technically, this would be designated a "chronic dentoalveolar abscess" rather than a true bone infection ("osteomyelitis"), but the salient point is that it does represent infection.

"Could it mean it’s an infection on the tooth next to it?"
There may indeed be an infection on the adjacent tooth, but that cannot be determined by the x-ray you have provided. Each tooth is independent, and an infection on tooth #31 does not mean that there is an infection on tooth #30.

"Could it simply be trauma caused by the TMJ and the bruxing and possibly eating hard food like chips, cookies, or a couple almonds?"
Based on the x-ray, this represents more than just occlusal trauma. Mind you, bruxism may be a contributory factor, but it is not the fundamental problem; infection is.

Hope this helps...

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Customer reply replied 4 years ago

Thank you for your helpful reply.

Regarding "chronic dentoalveolar abscess" rather than a "true bone infection:"

So where is the infection then? Is it in the periodontal tissue?

This is really a matter of semantics, because the infection is actually within the bone. (We generally include alveolar bone and periodontal ligament as both being part of the "periodontal tissues").

However, a dentoalveolar abscess generally remains contained within the immediate vicinity of the tooth root tip. In some cases, a dentoalveolar infection can progress to either a fascial space infection, a cellulitis, or an osteomyelitis, which is a true bone infection.

Osteomyelitis is characterized by penetration of infection to wider areas of bone, and causing significant "osteonecrosis"--i.e., devitalization of bone, with expulsion of dead bone sequestra. The clinical manifestations of osteomyelitis are therefore much more serious than simple dentoalveolar infection, although both could be said to be infections within bone.

Hope this helps...
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Customer reply replied 4 years ago

After careful consideration, I plan to have tooth #31 and #5 pulled.


There is an oral surgeon that will fit me in this morning.

As far as any future bridgework, I would get that done after flu season. I would get a bridge for #5 to prevent shifting. What could be done for tooth #31? Is it possible to do nothing there or would it be better to get a partial plate to have a chewing surface for the back teeth?

I'm wondering if it is necessary to take molds of the teeth first, so plans can be made for bridges or other appliances in the future? This wouldn't be possible if I have them pulled today because I do not want to get traditional molds taken, I would want to get 3D digital images done.

Doing nothing to replace tooth #31 is a possible option, but there are consequences. Not only would you lose the chewing area, but the opposing tooth (#2) would be rendered non-functional, and would begin to erupt downward, eventually necessitating the removal of that tooth as well. That is not to say that you would be significantly impaired by the loss of this tooth contact, but the retention of the upper and lower second molars will maintain better function and bite stability.

Just how you would replace #31 would need to be decided. As the most rearward tooth in that quadrant, a conventional fixed bridge would be a "cantilever"-- i.e., supported only from the teeth further forward, and many dentists prefer not to design bridges as cantilevers because they generate destructive forces on the abutment teeth that support them. The most obvious and advantageous way to replace #31 prosthetically would be a single-tooth implant, but you and your dentist(s) will need to decide whether your anticipated bisphosphonate therapy would contraindicate that method. (There is no formal, generally agreed-upon guidance in this matter.) Certainly, a removable partial denture could be constructed, but that's a lot of hardware to replace only one tooth. You should discuss all your prosthetic options with your dentist.

Taking impressions for the purpose of making plaster study models is sometimes helpful in the diagnostic sense, but is certainly not mandatory.

I respect your decision to select 3-D imaging as a source for laboratory fabrication, although you should know (and I think I conveyed this opinion before) that the CAD-CAM methodology confers no practical advantage in service of the prosthetic goal, and is actually somewhat less accurate than the more time-tested traditional impression approach. I appreciate the "coolness" factor, though.

Hope this helps...
Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
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Customer reply replied 4 years ago

I couldn't figure out how to make a new question, so just added another tip:

I had tooth #31 and #5 extracted yesterday, operation ending at 9:40am. Used novocaine.

After eating a smoothie with 8oz of yogurt for a late lunch around 3pm and felt nauseous around 40 minutes afterward.

Do you know why I would be experiencing nausea?

I didn't eat dairy for dinner (I usually have another 12oz of yogurt for dessert). I am wondering if dairy has anything to do with my nausea and if I should continue to avoid it.

If you're taking pain medication-- especially one with a narcotic-- that would account for nausea. Otherwise, there would be no reason to expect you to experience nausea from the extraction per se, although there might be a slight taste of blood that some might find distasteful. Dentists customarily tell their patients to bite down on a piece of gauze until bleeding has stopped, and that can make some people gag, but I suspect you have already removed the gauze from your mouth.

If you have previously tolerated yogurt well, there is little reason to implicate it now. In the absence of some other unknown factor, it might just be due to the stress of the experience.

Hope this helps...
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Customer reply replied 4 years ago

Some additional post-care questions:

1. Today I'm supposed to apply moist heat to the affected side of the face several times a day. I'm wondering if taking cold showers will cause any problems after tooth extraction?

2. Can I go into ocean after tooth extraction? When can I go into the ocean? Does it make any difference that I keep my head above water (but of course a little seawater might get in my mouth)?

3. I'm trying to find a way to prevent infection in my gums and remaining teeth since I'm not able to rinse or clean as well.

a. Is antibacterial mouthwash recommended after tooth extraction (I wouldn't swish with it)? If not, why not? If yes, what kind would you recommend? Is chlorhexidine good?

b. Is Xylitol okay to put in mouth after tooth extraction (I wouldn't swish with it)?

4. The gum line has a white appearance on the edge of the teeth that are adjacent to the teeth that have been extracted, like they've been traumatized in some way. What is the cause? Is there something that can be done for the gums?

Thank you.

My apologies for the delay in responding...

"1. Today I'm supposed to apply moist heat to the affected side of the face several times a day. I'm wondering if taking cold showers will cause any problems after tooth extraction?"
Unless you are experiencing spasm of your jaw muscles (this would be signified by "trismus", or limitation of jaw range of motion), moist heat is not customarily prescribed after tooth extractions. It is more common to recommend application of cold, with the intent of limiting the amount of postoperative swelling. Since it's already a full day after the procedure, there is no need to apply either heat or cold, and either stimulus is unlikely to confer any benefit or risk.

"2. Can I go into ocean after tooth extraction? When can I go into the ocean? Does it make any difference that I keep my head above water (but of course a little seawater might get in my mouth)?"
Immersion in water, whether in the ocean or otherwise, is unlikely to pose any risk to the healing of your extraction wounds at this point.

"3. I'm trying to find a way to prevent infection in my gums and remaining teeth since I'm not able to rinse or clean as well."
It is unlikely that infection or inflammation of the gums will result from the short interruption in your normal oral hygiene regimen caused by this surgery. If you're concerned, you may rinse with a commercial oxygenating mouth rinse, such as Amosan, available at your local pharmacy for purchase over the counter. This can help maintain cleanliness until you can resume your normal brushing and flossing.

"a. Is antibacterial mouthwash recommended after tooth extraction (I wouldn't swish with it)? If not, why not? If yes, what kind would you recommend? Is chlorhexidine good?"
Some dentists will recommend chlorhexidine gluconate rinses for post-surgical use. However, this is more common in cases of periodontal surgery rather than tooth extraction. With the exception of the chlorhexidine gluconate rinse manufactured by the Butler-GUM brand, most generic chlorhexidine rinses contain alcohol, which may irritate the tissues. Again-- it is unlikely that using such a product will confer significant benefit for the brief time that normal self-care will be interrupted.

"b. Is Xylitol okay to put in mouth after tooth extraction (I wouldn't swish with it)?"

Xylitol gums or lozenges would not pose any harm, as long as excessive chewing was not done in the vicinity of the extractions.

"4. The gum line has a white appearance on the edge of the teeth that are adjacent to the teeth that have been extracted, like they've been traumatized in some way. What is the cause? Is there something that can be done for the gums?"

This is likely a fibrin residue from the postoperative bleeding. After the clot has been exposed to saliva for more than a day, it loses its red color and takes on the appearance of a white membranous film. This is normal, and does not signify injury. It can be safely ignored.

Hope this helps...

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Customer reply replied 4 years ago

I'm going to attach several pictures of the two teeth that were extracted #5 and #31). I have two main questions:

1. Can you tell from the photographs whether the root canal of tooth #31 was still intact? I'm trying to see whether the endodontist who did the root canal is a good endodontist to go to.

2. Please note the giant cavity underneath the crown of tooth #31. I'm trying to understand what was the cause of this decay because my mouth is full of crowns that look just like that. Some of them were put in at exactly the same time, for example the tooth in front and behind it. The crown looked tight and felt tight. There was no inflammation around the gum. There was no evidence of a cavity until I did the X-ray. There was no sensation of pain or sensitivity, no redness, etc. The only thing I can think of is that the crown wasn't tight, and from what I saw, flossing would not have solved that.

I will post pictures of tooth #31 in this post and tooth #5 in a separate post.

Tooth #31 broke into 3 pieces.

Customer reply replied 4 years ago

Tooth #5

Although I appreciate the time and effort it took to provide these photographs, they convey almost no information that would aid in answering these two questions. Extracted teeth are removed from their context, and the extraction process itself can break or otherwise alter the teeth. I will offer you what I can in this regard:

"1. Can you tell from the photographs whether the root canal of tooth #31 was still intact? I'm trying to see whether the endodontist who did the root canal is a good endodontist to go to."
The quality of a root canal can only partially be assessed after the fact, and not by a photograph, but by x-ray. Perhaps more information can be derived from an x-ray previously provided by you:

An x-ray can indicate how well the canals within a tooth have been sealed, and this x-ray shows well-sealed canals. If one were to judge an endodontist's skill from an x-ray, I would judge this endodontist to be skillful. Having said that, the sealing of the canals is but one part of the endodontic process, and there is no way to exclude the possibility that there may have been some deficiency somewhere other than at the canal sealing step. As I said previously, there is no obvious sign that the root canal was anything short of successful, and that also reflects positively on the endodontist's skill.

"2. Please note the giant cavity underneath the crown of tooth #31. I'm trying to understand what was the cause of this decay because my mouth is full of crowns that look just like that."
The causes for decay are well known-- in general. For decay to exist, three things need to be present: a tooth, oral bacteria, and nutritional substrate (sugar). What cannot be known is precisely why this tooth became decayed. Granted, there are some ways that a crown might contribute to decay risk, but those deficiencies are not evident, based on the appearance of the crown on the x-ray I've reproduced above. Crowns may contribute to the development of decay when, for example, their margins do not fit the tooth well, but the margins did fit well, as indicated on the x-ray. (The fit of the crown cannot be assessed on the photos of the extracted tooth because it was broken off the tooth during the extraction process.) Suffice it to say that some teeth will become decayed and some will not, depending on their environment, and depending on some unknown intrinsic tooth quality. Decay is always a potential risk as long as there are teeth present. Your dentist can assist you in providing strategies for reducing that risk, but it can never be completely eliminated.

Hope this helps...
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Customer reply replied 4 years ago

The white edge I’m talking about is not from the clot, because my understanding is that the clot is the center of the tooth #31 that was pulled. The white I’m talking about is along the gum-line of tooth #30 (the tooth next to the tooth that was extracted). It's white flesh, like busted-up tissue or something. I inserted a picture below with an arrow pointed to the area to show you what I'm talking about. It’s a lot worse today. I’m not sure why it would be white like the clot, because he didn’t pull that tooth. But if it has to do with clotting, then maybe the gum of tooth #30 was also bleeding due to trauma and had to clot on the edges of the gum line. I don’t want it to get infected, but I don’t want to brush it if it is caused by trauma because that could make it worse. Does the picture help you understand more what it is and what I should do with the area?

That is indeed the fibrin clot-- probably mixed together with other oral debris (the proteinacious components of the blood do tend to spread over a larger area than just the immediate wound itself). This is a common postoperative finding, because patients instinctively avoid chewing and even cleaning the immediate area surrounding the surgical site, which allows for accumulation of any organic debris that forms in the area, including exfoliated epithelial tissue. Your photograph displays a surgical site that is within normal limits, at least in terms of appearance.

What should you do in the area? Simply allow nature and time to take their course. You can resume your normal oral hygiene regimen as soon as comfort allows.

Hope this helps...
Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
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Customer reply replied 4 years ago

Regarding jaw pain and swelling after extraction:

The surgeon said the swelling will reach its peak around 48 hours after surgery.

Is it also normal that the pain will increase and peak at 48 hours?

Following is the level of pain and swelling I have experienced since the extraction:

Pain (on scale of 1-10)

(Note: Took aleve at 8pm the evening of surgery and 8pm the evening of second day)

First 42 hours: level 1.5 to 2

From 3am to 8am (42-47 hours after surgery): level 4 to 4.5 (pain worse, mainly lower jaw)

10:30am (49 hours after surgery): level 3 to 3.5

Swelling (on scale of 1-10)

First 42 hours: level 3

From 3am to 8am (42-47 hours after surgery): level 4.5 to 5

10:30am (49 hours after surgery): level 3.5 to 4

"The surgeon said the swelling will reach its peak around 48 hours after surgery.

Is it also normal that the pain will increase and peak at 48 hours?"

That would be a reasonable approximation. This is because the surgical procedure induces what is essentially a wound, which in turn elicits an inflammatory response. All the classical manifestations of inflammation (from the Latin "rubor, tumor, dolor, and functio laesa", which translates to "redness, swelling , pain, and loss of function"), follow essentially a simultaneous course of onset and resolution, so the swelling ("tumor") and the pain ("dolor") generally rise and fall in lock-step.

The exception would be in those cases where "dry socket" develops. This is a trivial but quite uncomfortable condition that sometimes sets in 4-5 days after an extraction. It is characterized by the onset of new, intensifying pain at a time when the pain should be diminishing. This is easily treated, and you should contact your oral surgeon if you don't experience a definite improvement in the symptoms over the next few days.

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Customer reply replied 4 years ago

Could you please describe in detail how the dry socket is easily treated?

From what the oral surgeon has written in the post-op instructions and what I've read online, it sounds very difficult to treat, so I was surprised to hear you say that it is easily treated.

From the post-op instructions, pain medication usually doesn't help and treatment involves placing medicated dressing in the empty tooth socket and the dressing needs to be changed every day or two for 5-7 days (2-3 days after you have been pain-free). Apparently the dressings don't help it heal, it just controls the pain if over-the-counter pain medication isn't working.

Can the dressing be applied and changed at home, or can it only bed one at the dentist office? What if the dry socket problem starts over the weekend?

Is there anything else that can be done?

The reason I'm concerned is because when I irrigated the bottom socket with salt water using the irrigating syringe (as I was instructed to do on the third day), the white blood clot was quite loose. It's very soft and moves around when the water goes on it. It also seemed reddish, like it had been disturbed by the food. I ate some soft vegetables today.

Allow me to preface my response by saying that it is offered as a matter of academic curiosity rather than being pertinent to you, because you have not developed dry socket-- at least, not yet.

"From what the oral surgeon has written in the post-op instructions and what I've read online, it sounds very difficult to treat, so I was surprised to hear you say that it is easily treated."
Dry socket is a self-limited condition that heals on its own without intervention; treatment is solely intended to improve comfort while it resolves. The protocols of pain management are well established. I find it curious that an oral surgeon would have anything to gain by suggesting that the condition is more serious or difficult to manage than it is, because doing so is psychologically counterproductive. Either you misinterpreted the intent of his description, or he misrepresented matters based on an ulterior motive, which brings me to your second question:

"From the post-op instructions, pain medication usually doesn't help"
That statement is patently false. Narcotic analgesics are used to manage the pain of cancer and other severe conditions that manifest with a degree of pain that is far worse than dry socket. The only conclusion that can be drawn here is that your oral surgeon prefers not to prescribe controlled substances, or is not registered with the DEA so he is not legally empowered to prescribe controlled substances. This would be quite unusual for an oral surgeon, but might be intended to discourage patient's attempts to procure narcotics. It is true, though, that dressings placed directly in the socket are a mainstay of dry socket control, because it avoids systemic side effects.

"treatment involves placing medicated dressing in the empty tooth socket and the dressing needs to be changed every day or two for 5-7 days (2-3 days after you have been pain-free). Apparently the dressings don't help it heal, it just controls the pain if over-the-counter pain medication isn't working."
This is true, although (as I said previously), your oral surgeon should not cut you adrift with OTC medications as your only recourse. It is true that drug abuse is a pervasive sociological problem, but appropriate pain medications should be used when they are indicated. There is nothing that helps dry socket heal except the passage of time. Dressings placed within the socket may be helpful as part of a pain management strategy, but they actually delay healing and make matters much smellier and less hygienic. That is why oral analgesic medications have the advantage, except for their side effects (sedation, nausea, and constipation, which are shared to some degree by all opiate medications).

"Can the dressing be applied and changed at home, or can it only bed one at the dentist office? What if the dry socket problem starts over the weekend?"
Placement and removal of a dry socket dressing is not rocket science, but it is best performed by a dentist rather than the patient. If the dry socket problem starts over the weekend, you should contact your oral surgeon over the weekend by calling his answering service. An oral surgeon is required to provide continuous access to emergency care, even during non-office hours.

"Is there anything else that can be done?"
For dry socket, nothing else need be done.

"when I irrigated the bottom socket with salt water using the irrigating syringe (as I was instructed to do on the third day), the white blood clot was quite loose."
This does not raise any suspicion of dry socket. You'll know it if it happens. At this point, your best next step is to do nothing, and allow time for nature and healing to run its course, as invariably will.

Hope this helps...
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Customer reply replied 4 years ago
Thanks. I would like to ask my doctor if he will prescribe an oral anger sic medication should I develop dry socket. What type is most effective? I would also like to look up the side effects in advance
I will leave that to your prescribing doctor, because it will depend on the specific drug categories for which he has registered with the DEA.

I've already told you the side effects of narcotics, which are fairly uniform across the entire opiate class; the severity of those side effects (sedation, nausea, and constipation) vary according to dosage and individual patient physiology.

Hope this helps...
Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
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Customer reply replied 4 years ago

I appreciate your answering all my questions. One thing I should have mentioned is I can't tolerate narcotics because of constipation. I was taking codeine cough syrup last year and ended up going to the hospital for an early partial small bowel obstruction de to ileum secondary to codeine intake.

Yesterday my pain decreased around 4pm to a 2.5 or 3 out of 10, but then last night I woke up at 4am and it was a lot more sore again, back to a 4 or 4.5. It has stayed at that level of pain through the morning, and is still at this level at 1pm. Although the throbbing I only felt throbbing once around 12:30pm that went away after 2 minutes (but the overall pain level remained the same).

The swelling, however, has been gradually going down.

1. Does the fact that the pain has increased but the swelling is the same or a little less point to dry socket or partial dry socket?

2. Or is it possible that the increased pain may have something to do with my bruxing, since both nights pain increased around 3am to 4am. Yesterday evening was also the first time I ate semi-solid foods (soft vegetables, cottage cheese), so maybe some of the things I ate were too rough. It feels a little irritated.

3. Why does the pain of dry socket tend to come on overnight? The night before last my pain increased overnight, but then got better around 10am. Last night the pain increased overnight, but hasn't gotten better yet.

4. The other thing is, my lymph nodes are swollen. Why would that be if it's not an infection?

5. I read that some people have had good success with Red Cross toothache kit for dry socket. http://www.walgreens.com/store/c/red-cross-toothache-complete-medication-kit/ID=prod1769-product But I also read that Eugenol (clove oil) causes burning on tissue and to avoid applying it to gum tissue. Would it damage the clot tissue if it's applied to the "dry socket?"

6. Why can the dressings the surgeon applies delay healing? If it's because the dressing disturbs the site, perhaps the Eugenol could be applied with a cue-tip?

7. What would the visual evidence of dry socket be? If I can still see some white tissue in there, like the fibrin you described, not bone or anything, does that mean it's not dry socket? I'm wondering how valuable visual inspection is to tell if I have dry socket.

I am trying to understand the expected path after tooth extraction vs. developing complication.

Thanks for your patience to answer all my questions.

quot;1. Does the fact that the pain has increased but the swelling is the same or a little less point to dry socket or partial dry socket?"
Not necessarily. Dry socket is heralded by the onset of significantly more severe pain, rather than the incremental fluctuations implied by your numerical pain scores.

"2. Or is it possible that the increased pain may have something to do with my bruxing, since both nights pain increased around 3am to 4am."
Not unless you experienced pain around 3-4 am prior to the extraction. Bruxism does not typically affect postoperative extraction pain, since the occlusal forces cannot be exerted to tissues in which there is no tooth.

"3. Why does the pain of dry socket tend to come on overnight? The night before last my pain increased overnight, but then got better around 10am. Last night the pain increased overnight, but hasn't gotten better yet."
Most head pain, regardless of its source, gets worse when the body is in a recumbent position. It is a result of increased blood pressure in the head due to the altered hemodynamics; it is a posturally-related effect.

"4. The other thing is, my lymph nodes are swollen. Why would that be if it's not an infection?"
The lymph nodes that are regional to inflamed tissues will become inflamed ("lymphadenitis"), regardless of whether the inflammation is caused by infection or tissue trauma. Lymphadenitis need not be a result of infection.

"5. I read that some people have had good success with Red Cross toothache kit for dry socket. http://www.walgreens.com/store/c/red-cross-toothache-complete-medication-kit/ID=prod1769-product But I also read that Eugenol (clove oil) causes burning on tissue and to avoid applying it to gum tissue. Would it damage the clot tissue if it's applied to the "dry socket?"
It has not yet been established that you have dry socket, and it would be premature to treat your extraction site as such. Eugenol does have the potential to cause some mild burning of the tissues, but it is common constituent in dry socket preparations, along with other somewhat caustic materials, such as phenol or salicylic acid. Although these dressings can burn, they paradoxically make the tissues feel better. However, they also delay healing, and the mechanical disruption caused by placing the dressings in the socket can add to the delay. I would discourage you from this kind of self-treatment, as it can be counterproductive.

"6. Why can the dressings the surgeon applies delay healing? If it's because the dressing disturbs the site, perhaps the Eugenol could be applied with a cue-tip?"
See #5 above. Also, the dry socket dressing is typically carried on a wad of iodoform gauze, which forms a perfect substrate, along with the tissue exudate which seeps into it, for bacterial growth. If you think your mouth tastes bad now, just imagine what it will taste and smell like when you have a mass of gauze, clot, and bacteria fermenting in an open wound.

"7. What would the visual evidence of dry socket be? If I can still see some white tissue in there, like the fibrin you described, not bone or anything, does that mean it's not dry socket? I'm wondering how valuable visual inspection is to tell if I have dry socket."
Although the classical appearance of a dry socket is, as its name implies, a "dry socket" with nothing but bone visible in the hole, a sizable number of cases of dry socket look nothing like that. Therefore, visual identification of dry socket is not a useful endeavor. The most prominent feature of dry socket is its pain, and that is the single most accurate diagnostic criterion. It is also the only manifestation of dry socket that merits attention, as pain control is the only intent of dry socket management. Dry socket treatment consists solely of symptom management; the healing of dry socket is the work of nature alone.

Hope this helps...
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Customer reply replied 4 years ago

Your responses are very helpful.

First, a couple clarifications/replies to your responses:

"Not unless you experienced pain around 3-4 am prior to the extraction."

Actually, I do regularly have a sore jaw in the middle of the night.

"It has not yet been established that you have dry socket, and it would be premature to treat your extraction site as such."

I wasn't planning on using it, I was just going to have it on standby and wanted to understand how it works. What you said is very helpful and I appreciate it.

Then just wondering if the following is a concern:

In comparing the white clot in the bottom socket before and after dinner, after dinner it definitely lost some of the white clot, even though I was really careful eating. And there's also less clot after dinner tonight than there was after dinner the evening before. In other words, it seems like each time I eat I lose some of the clot.

And how important is it to use the syringe they gave me to rinse the socket with salt water? I'm very careful with it and just do a few drops very lightly.

Thanks very much.

"Not unless you experienced pain around 3-4 am prior to the extraction."

Actually, I do regularly have a sore jaw in the middle of the night."
That logically would imply that your current nocturnal jaw soreness could be a manifestation of any pain-causing condition that preceded your extraction, and would also imply that your pain will not necessarily resolve despite healing of your extraction wound, because it is at least partially due to a separate issue. Whether that issue is bruxism or something else could only be determined in the course of a proper diagnosis. As I said previously, all inflammation-based or vascular-based pain in the head region does tend to worsen when the body is in a recumbent position.

"In comparing the white clot in the bottom socket before and after dinner, after dinner it definitely lost some of the white clot, even though I was really careful eating. And there's also less clot after dinner tonight than there was after dinner the evening before. In other words, it seems like each time I eat I lose some of the clot."
This is perfectly normal. Once the bleeding has stopped and healing begins, the clot has served its purpose.

"And how important is it to use the syringe they gave me to rinse the socket with salt water? I'm very careful with it and just do a few drops very lightly."
This is intended to keep the socket relatively clean while the area is too sore to brush. Its main intent is to keep bad tastes and odors to a minimum, but it really does not confer much of a therapeutic effect-- it's really a cosmetic exercise By the way, if you're just gently putting in a few drops at a time with the syringe, you're really not accomplishing anything. It's intended to mechanically flush our debris, and the syringe can't do that unless you give the bulb a good squeeze-- as hard as necessary to wash out organic particles from the socket, but not too hard to cause pain. There is nothing magical about salt water per se-- the salt is just intended to make the solution isotonic and less irritating to the tissues, but plain water will do the same thing, as long as you're using just the right amount of fluid flow. The irrigation process can be discontinued as soon as the socket is mostly closed, or when you can resume normal brushing and rinsing-- whichever comes first.

Hope this helps...

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Customer reply replied 4 years ago

Regarding this Q&A:

"In comparing the white clot in the bottom socket before and after dinner, after dinner it definitely lost some of the white clot, even though I was really careful eating. And there's also less clot after dinner tonight than there was after dinner the evening before. In other words, it seems like each time I eat I lose some of the clot."
This is perfectly normal. Once the bleeding has stopped and healing begins, the clot has served its purpose.

I am confused. I thought the clot served to cover the bone so you don't have air hitting the nerves or whatever while it's healing, since it takes time for the gums to heal and grow over the bone. In other words, I thought the whole point of avoiding dry socket is to make sure the clot is not dislodged.

That is in essence a good example of why the term "dry socket" is a misnomer. Dry socket is technically known as a "localized osteitis", or more simply, bone inflammation. It is uncertain whether the blood clot (or lack thereof) plays any role in the etiology of dry socket.

The blood clot serves primarily as a mechanism that stops bleeding, and secondarily as a scaffold to allow new connective ("granulation") tissue and epithelium to form in the socket. There will always be something within the socket on which the healing tissues will grow; sometimes it's a remnant of the clot, sometimes it's a remnant of the periodontal ligament-- i.e., the connective tissue that held the tooth in place. As I said, the clot has served its purpose in the first day or two after the extraction, and the socket will ultimately heal, barring infection or metabolic bone disease, regardless of whether parts of the clot remain after that.

Hope this helps...
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Customer reply replied 4 years ago

So when you say, "once the bleeding has stopped and healing begins, the clot has served its purpose," are you talking about the main bleeding that stops within 24 or 48 hours, or are you talking about tiny amounts of blood that might come out when brushing your teeth or rinsing?

I'm referring to the initial bleeding that accompanies and immediately follows the extraction procedure and the initial clot that forms. Keep in mind that the clotting mechanism is in effect whenever bleeding occurs. Delayed bleeding, such as what may occur when brushing the teeth, is new bleeding rather than a resumption of the initial bleeding. The tissue that is in the healing socket is "granulation tissue", and it is relatively fragile, very densely supplied with tiny capillary vessels, and may be provoked into bleeding by minor trauma. This bleeding is of a much more trivial nature than the initial bleeding that occurs at the time of extraction, but it is no less dependent on clot formation than the previous bleeding. But this is new bleeding, and it stops due to formation of a new, tiny clot whereever there is rupture of a blood vessel. Clotting occurs whenever bleeding occurs, no matter how small the area of bleeding is. That is why even the most trivial bleeding is dangerous in a patient with a clotting disorder. The clotting mechanism occurs spontaneously, every time one experiences bleeding of any kind.

Hope this helps...
Mark Bornfeld, DDS
Category: Dental
Satisfied Customers: 6,023
Experience: Clinical instructor, NYU College of Dentistry; 37 years private practice experience in general dentistry, member Academy of General Dentistry, ADA, American Academy of Oral Medicine
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Customer reply replied 4 years ago

Hi Dr. Bornfeld, my extractions seem to have healed well, so now I am looking into fixing my next priority teeth.

I have a few questions:



I need to replace some crowns that have fractured. What kind of dental work are we looking at if I decide to replace the crown (in terms of level of difficulty)?

Is the affected tooth put into much trauma when the crown is removed, or is the crown relatively easy to remove?

How do you take the crown off without causing trauma to the tooth and chancing an abscess?

When choosing a dental professional to work on my crown, is it sufficient to go to the general dentist I usually go to for routine dental health who does many does one crown a week? Or is it better to go to a specialist who has more experience replacing crowns?



How easy is it to take off a one-day crown, if i decide to replace it with say a gold crown a year from now?
Customer reply replied 4 years ago

Can you tell from my X-rays if i need any work done on tooth #4?

quot;I need to replace some crowns that have fractured. What kind of dental work are we looking at if I decide to replace the crown (in terms of level of difficulty)?"
The level of difficulty would be determined by the specifics of your case. In general, though, the replacement of a crown is no more difficult than the initial placement of a crown.

"Is the affected tooth put into much trauma when the crown is removed, or is the crown relatively easy to remove?

How do you take the crown off without causing trauma to the tooth and chancing an abscess?"

The amount of trauma sustained by a tooth during crown removal depends on how the task is accomplished. There are brute force techniques that can injure and even fracture the tooth, but it is possible to avoid injury, although it is a bit more time consuming and tedious to do so. The technique I use is to cut the crown into two sections with a drill, and pry the sections apart. This avoids delivery of harmful force to the tooth underneath.

"When choosing a dental professional to work on my crown, is it sufficient to go to the general dentist I usually go to for routine dental health who does many does one crown a week? Or is it better to go to a specialist who has more experience replacing crowns?"

It depends on the level of skill of the respective doctors. Normally, the replacement of crowns is well within the capabilities of a general dentist. A prosthodontist would on average have a higher level of skill, but in this case that extra skill might be overkill, and you'd pay handsomely for specialty care.

"How easy is it to take off a one-day crown, if i decide to replace it with say a gold crown a year from now"

I regret that I am unfamiliar with the term "one-day crown", but I don't imagine it would be any more difficult to remove than any other type of crown.

"Can you tell from my X-rays if i need any work done on tooth #4? "

There are no conspicuous issues on tooth #4 displayed on the x-rays you have supplied. Keep in mind, though, that a complete diagnostic assessment requires an in-person inspection, because not all problems display on x-ray. Therefore, I cannot rule out the possibility of the need for service on #4, despite its apparently normal appearance on x-ray.

Hope this helps...

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Customer reply replied 4 years ago

A one-day crown is a CEREC ceramic crown.

Thanks for the clarification. A CEREC crown would be no more or less easy to remove than any other crown attached with temporary cement.

Hope this helps...
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Customer reply replied 4 years ago

Thanks. I'm going to get a gold crown on tooth #3 because I want it to be strong but not too hard because I don't want it to break down the opposing tooth. (It opposes my last molar left on the right side, which is my main chewing side.) I want the top of the line gold crown, regardless of price. Are there different types of gold crowns, i.e., different alloys? I was told that it is called "gold," but actually it is an alloy of Gold, Silver, Copper with some Platinum and Palladium (like wedding rings). If I tell my dentist I want a gold crown will I get this alloy or do I have to specify what alloy I want to get the very best?

A gold crown is a good choice, as long as you tolerate the appearance. For those patients who customarily smile broadly, a metallic crown on the upper first molar will be partially visible.

There are fine permutations of dental casting alloys, but for a full cast gold crown, the American Dental Association specifications for type 2 high noble alloy are relatively standard; a specific proprietary brand need not be specified.

Keep in mind that the predominant determining factor of the quality of a crown is not its material of composition, but rather the care and skill in which the crown service is executed-- by both the dentist and his dental laboratory technician. Therefore, rather than specifying a specific casting alloy, you will more strongly influence the quality of the crown by selecting a highly skilled dentist. A prosthodontist would be an appropriate choice.

Good luck!
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Customer reply replied 3 years ago

I had the gold crown on tooth 5 placed today. I noticed that this evening when I had some hot vegetables, the new gold crowned tooth is really sensitive to the heat. When I had the temporary on, it wasn’t in any way sensitive. Would this have to do with the gold metal? I’m not sure what I’d do about it.

It is not unusual for a tooth to become temporarily more sensitive after permanent cementation. This is because the permanent cement itself provokes some pulp inflammation due to its acidity, and also because a metal crown conducts heat and cold more effectively than an acrylic crown. Depending on the condition of the tooth, this reduced temperature tolerance can persist for a week or two, so you're still well within a time frame where heat sensitivity would be considered normal. I would recommend that you give the tooth some time to settle down, as it likely will.

Hope this helps...
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