Toothache

If your tooth hurts, the pain usually comes from one of two sources.

	Pain can come from inside the tooth, and it indicates that there is an irritant affecting the tooth.
	Pain can come from the ligament that attaches your tooth to the jaw.

If your pain comes from inside, usually it is aggravated by cold, air, sweets, or heat. If any of these makes your tooth hurt worse, your tooth is irritated. Then it becomes important to know if you need to see your dentist.

There are two general cases where you absolutely need your toothache treated. If, when the tooth is provoked, the toothache lingers for more than one or two seconds, the tooth almost certainly needs to be treated. For example, let's say your tooth is sensitive to cold. You drink cold water, and you get a sharp jab in your tooth. In that case, it may not need any treatment. But if that jab persists more than two seconds, see your dentist. You probably need a root canal treatment.

Many people fear root canals. However, with recent technological advances, these appointments themselves are generally not painful, nor are they traumatic—there isn't a lot of grinding as there is with a filling or a dental crown. Most of the work is done with small hand instruments. And when the tooth is dead, which is often the case, it can even be done with no novocain. Root canal treatment often means the relief of toothache pain, and often that relief is immediate and dramatic. Extraction—taking a tooth out—is much more traumatic, from my experience as a dentist.

Also, if the pain progresses to where your tooth hurts without any outside stimulus, that is the second situation that definitely indicates you need to see a dentist, quickly. But if the pain is only provoked by a stimulus, and then it is only transitory, even if it hurts quite bad, there is still a chance that it could get better on its own.

The other source of toothache is the ligament that attaches the tooth to the bone. When the infection inside your tooth spreads through the tooth apex to the bone around the tooth, your toothache may become this type. In this case, cold or heat or air won't bother you at all, but your tooth will be sensitive to biting. However, most of the time when your tooth is sensitive to biting, it isn't infected. Check the link below for more information about sensitivity to biting.

The more promptly you seek attention for your toothache, the less likely you are to have pain after the treatment. When your tooth is infected, the longer you allow the infection to become entrenched, the more likely you are to have that infection try to spread when it's treated.

When you need a root canal procedure

Here are the instructions we gave to patients when they needed a root canal procedure—what to expect, and what to do after the appointment:

You shows signs of having a tooth infection, or a tooth abscess, which requires root canal treatment, otherwise known as endodontic therapy, in order to save it and to prevent or cure a toothache. While you may have a toothache before this procedure, these treatments have an excellent record of success and durability. Once this treatment is successful, it will never wear out or need any maintenance. It may well last you the rest of your life.

Although dentists may have a greater than a 90% success rate with this treatment, we cannot guarantee success. There is a less than 10% chance that your tooth could require root canal surgery (a procedure done to the tip of the root) after the treatment. There is a less than 5% chance that the tooth would need to be extracted after treatment, either because of a failure of the treatment or cracking of the root. Although an infected tooth can always be extracted, extraction of a back tooth can cause a major disruption of your bite and can weaken adjacent teeth unless the extracted tooth is replaced soon with a bridge or a removable partial. The extraction of a front tooth is unsightly. Extraction of a second molar, if it's the tooth furthest back in your mouth, causes the least disruption of your bite.

In times past, endodontic treatment was usually painful either during treatment or afterward. With what we now know, however, it can usually be done with only minor post-treatment discomfort. Sometimes, however, the ligament that attaches the tooth to your jaw becomes so irritated during and after treatment that the tooth flares up and becomes painful. If that happens, call your dentist as soon as possible. For any pain following root canal treatment, ibuprofen is an excellent medication, as it counteracts the inflammation that causes the pain. It's available from drug stores as generic ibuprofen, or as Nuprin or Advil. Take three of these 200 milligram tablets every six hours if needed.

A tooth that requires an endodontic procedure often has a large filling and/or extensive tooth decay, and is therefore weak. Additionally, after root canal treatment, a tooth will gradually become more brittle and more susceptible to fracture. We recommend restoring it with a core material to strengthen it somewhat soon after the completion of endodontic treatment. Sometimes this can be done during the same appointment. After that, within one to three months, it usually needs to have a dental crown placed. Sometimes, if it is strong enough, a filling may be used to restore it instead of a crown. The fee for the endodontic treatment does not usually include the placing of a core, crown, or filling.

There is a remote risk that root canal procedure could result in irritation or harm to the nerve tissue or other tissues, if they run near the apex of the tooth. This could result in numbness of the lip or a portion of the jaw. Other unforeseen problems or damage could occur.

Root Canal Treatment

Root canal treatment (endodontic treatment) is required when you have a tooth infection. When you have an infection, your body sends white blood cells and antibodies to the infected area to kill the bacteria. The tissue becomes red and swells. When you have an infection in your tooth, there is no room in the canal space for extra antibodies or white blood cells. When the tissue attempts to swell, it chokes itself and dies, and then it becomes a perpetual source of infection, called a tooth abscess, spilling into the bone tissue around the end of the tooth.

In endodontic treatment, the dentist removes this dead or diseased tissue, cleans the inside of the tooth thoroughly, and then places a sealer material inside the tooth. It's important that the tooth be filled to the very end of the apex of the tooth.

This treatment is generally not difficult for the patient, and pain after root canal is often not a large issue, in spite of its reputation. In my experience as a dentist, a tooth extraction appointment was the most traumatic for the patient, by far. Many of these appointments were very easy, and with some, we didn't even need novocain to keep the patient comfortable because the tooth was dead and had no feeling in it. Yet some people are so afraid of endodontic treatment that they choose to have a tooth extracted instead, which ends up being much more stressful for them than if they had the dentist save the tooth.

Other information related to root canal treatment:

	What to expect when you need a root canal procedure.
	Root canal cost estimated.
	Tooth infection antibiotics—When are they helpful?
	When this treatment is done on a front tooth, it can discolor after many years. Read your options for fixing this discolored tooth, including internal tooth bleaching.
	Donnie wonders, why put a crown on a dead tooth? But a dead tooth can last for many, many years if it is taken care of.
	Why a dental post may be placed in your tooth afterward.

An explanation of some root canal treatment terminology

The tissue inside your tooth is called the pulp. The pulp tissue is responsible for most of the formation of your tooth. It is present well before the tooth erupts in your mouth. The tooth actually grows from the outside in. As the tooth grows, your pulp tissue shrinks.

Once your tooth is fully formed and has erupted, the pulp tissue remains and performs a sensory function. If your tooth becomes irritated, it is the pulp tissue that senses this. Even a small cavity can sometimes cause inflammation in the pulp. The larger the cavity, the more the irritation. You may have sensitivity to cold or to air. It's a warning system that something is wrong.

If the pulp tissue becomes infected, the toothache can become severe and constant.

There are two parts to this pulp tissue. One part is in the crown or the visible part of your tooth. This pulp is in what is called the pulp chamber. This pulp tissue extends into narrow passageways in the roots of the tooth. These passageways are the root canals. At the end of the root is an opening to the bone. A blood vessel and a nerve come from the bone and into the tooth and supply the tooth with sensation and nourishment. The very tip of the tooth is called the apex.

These endodontic treatments do not need any maintenance and they are very durable. Once it is successful, it will never wear out or need any further attention. It could last you the rest of your life.

Problems with root canal treatments are caused by the dentist's inability to either completely clean out the inside of the tooth all the way to the apex, because of obstructions or curves, or an inability to completely seal the apex of the tooth, thus allowing leaking of living material into the tooth that can become a further source of infection. If this happens, it is called a failed root canal. A failure can be treated with root canal surgery, or the tooth can be extracted. An apicoectomy is the most common surgery. Fortunately, failures don't happen very often. Maybe 10% of these treatments are failures.

Endodontic treatment is more difficult with back teeth than with front teeth. A root canal on a front tooth is the simplest. A front tooth has only one root, where back teeth can have up to four. The root is generally straight, as opposed to curved roots on back teeth. And the access and visibility for a front tooth is much easier. Problems with endodontic treatment usually occur with back teeth

CEREC Material Partners

The Best in Dental Ceramics

The CEREC team at Sirona is fortunate to have partnered with three dental materials manufacturers. Vita manufactures CEREC Blocs by Sirona and VITABLOCS® Mark II for CEREC®. These blocks are made of feldspathic porcelain. Ivoclar-Vivadent produces Empress CAD® leucite-reinforced porcelain blocks. 3M™ ESPE™ makes the Paradigm™ MZ100 composite block for CEREC. Once again, Sirona has put to use our philosophy of the "Synergy of the Best" to bring to you CEREC by Sirona and materials by these fine manufacturers. Please click on the links below to learn more about our material partners and their dental material products: CEREC Blocs VitaBlocs for CEREC Empress CAD for CEREC Paradigm MZ100 for CEREC Merz Artegral ImCrown

CEREC Technology

Dental Technology of the Future...Today!

What is CEREC? CEREC is an acronym... Chairside: The technology is in the dental operatory and used while you are in the chair Economical: The procedure is economical for both dentist and patient Restorations: The procedure restores your tooth to its natural beauty, function, and strength of Esthetic: The restorations are metal-free and tooth-colored Ceramic: High-strength ceramics are used that are close in composition to your natural tooth structure. for an advanced dental restorative system that allows your dentist to restore decayed teeth, place crowns, remove defective amalgam fillings, or place cosmetic veneers in just one appointment. This allows you to have the highest quality, most lifelike dental restorations in just one visit to the dentist...in, out, and on with your busy life. The state of the art CEREC system was developed in 1985 at the University of Zurich in Switzerland by a dentist, Dr. Werner H. Moermann, and an electrical engineer, Dr. Markus Brandistini. Today, CEREC 3 with CEREC 3D software is still the world's only chair side dental CAD/CAM restorative system. At the heart of the system is the innovative technology. CEREC Acquisition Unit The CEREC Acquisition Unit is mobile and houses a medical grade computer and the CEREC camera. Your dentist uses the camera to take a digital picture of your prepared tooth. This picture is used instead of a traditional impression. This means no impression tray and material for you to gag on. The computer and CEREC 3D software converts the digital picture to a three dimensional virtual model of your prepped tooth. Your dentist then designs your restoration right on screen using the software while you wait (and watch!). This software can assist your dentist with designing any single tooth restoration: crowns, inlays (fillings), onlays (partial crowns), and veneers. Once your dentist has designed your restoration (usually about 5 minutes), he or she clicks a button, and the design data is communicated via a wireless radio signal to the CEREC Milling Unit. CEREC Milling Unit Your dentist or dental assistant selects a ceramic block that matches the shade of the tooth being repaired. He or she then inserts the block into the Milling Unit. The data from the Acquisition Unit is used to direct two diamond coated burs to carve the block into the indicated shape of the restoration. This process usually takes 8 to 18 minutes depending on the size and type of restoration. After the milling is finished, your dentist polishes the finished filling or crown and bonds it into place. With CEREC technology, your dentist can restore damaged teeth or enhance your smile with bio-compatible, tooth-colored materials in a single appointment. This technology has a track record of almost 20 years, and more than 100 studies confirm the clinical excellence of the method. Ask your dentist about CEREC today

The CEREC Procedure

Because Your Dentist Values YOUR Time

Let's face it, very few of us have perfect teeth, free of decay and fillings. You can probably see a filling or two in your own mouth, which do just that -- "fill" a cavity, or hole, in your tooth left from the excavation of decayed tooth structure. In many cases, those fillings are made of metal material and can go bad, weaken the tooth, or get additional decay under or around it. In fact, 1.2 billion of these metal fillings will need to be replaced in the next 10 years.* CEREC is a method used by thousands of dentists worldwide since 1987 not only to replace these fillings, but also to restore any tooth that is decayed, weakened, broken, etc. to its natural strength and beauty. Better yet, it's done with all-ceramic materials that are tooth colored in a single appointment! So, how does the CEREC procedure work? Exam and Preparation First, your Dentist examines the tooth and determines the appropriate treatment. It could be a simple filling, or a full crown, depending on how much healthy tooth structure is remaining and the clinical judgement of your Dentist. Next, he or she administers an anesthetic and prepares your tooth for the restoration, removing decayed and weakened tooth tissue. This preparation is just like he or she would do for many other restorative techniques. Optical Impression Then, your Dentist takes an Optical Impression of the prepared tooth. Instead of filling a tray with impression "goop" that you must bite into and hold in your mouth until it hardens, your Dentist coats the tooth with a non-toxic, tasteless powder. A camera is then used to take a digital picture of your tooth. This whole Optical Impression process only takes a minute or two. No Temporaries Next, the CEREC machine helps the Dentist create the restoration for your tooth. The CEREC 3D software takes the digital picture and converts it into a 3-dimensional virtual model on the computer screen. Your Dentist then uses his or her dental expertise to design the restoration using the CEREC 3D computer program. Within a few minutes, your Dentist clicks a button, and the restoration design data is sent to a separate milling machine in the office. A ceramic block that matches your tooth shade is placed in the milling machine. About 10 - 20 minutes later, your all-ceramic, tooth-colored restoration is finished and ready to bond in place. Finally, your Dentist tries the restoration in your mouth to ensure proper fit and bite. The restoration is then polished and bonded to the prepared tooth. Your tooth is restored with no "temporary" or return trip necessary. All of this is done in a single appointment! Ask your Dentist about CEREC today. *Harvard Health Letter, March 2000; NIDR of NIH, Dental Amalgam Study, 1993.

Temporary Crown

When you have a dental crown made, it is generally made in a laboratory. The tooth is shaved down all around, and then an impression is taken. The impression is sent to a dental lab where your permanent crown will be made according to the dentist's prescription. Meanwhile, your tooth needs to be covered with something or it will be very sensitive.

Here is a picture of a temporary crown made out of acrylic. They can also be made with an aluminum shell. Then it is cemented with a weak cement. It is important that the temporary not be too durable or too strong, because it needs to be removed easily when it is time for the permanent crown.

Functions of a temporary crown:

	It needs to cover the tooth to prevent sensitivity. If any of the dentin of a live tooth is exposed, air, cold, and sweets can be painful. Continued exposure over a week or more could permanently damage a tooth to where is may even need a root canal treatment, so covering it is important. Click here to read more about root canal treatment.
	It needs to touch the teeth on either side of the tooth receiving the crown, and it needs to occlude with the opposing tooth. Without this contact, the tooth will move between appointments and the crown won't fit.
	It helps keep the gums healthy between appointments. If the temporary crown has normal tooth contours, it keeps the gums in their natural position, which keeps them from being overly irritated.

If you are having a Cerec crown, it is placed the same day the tooth is prepared, and there is no need for a temporary.

Read Dr. Hall's blog postings about dental crowns.

All-Porcelain Crowns

The most beautiful crown for a tooth is, without question, all-porcelain or all-ceramic. With porcelain fused to metal crowns, there has to be an opaque layer put over the metal to block out its color. This makes it impossible to have a translucent restoration that mimics the translucency of natural teeth. Only with pure porcelain or pure ceramic can you have such translucency.

To define some terminology, porcelain is a particular type of ceramic that is built by stacking and firing. When we say ceramic, we include porcelain—porcelain is a type of ceramic.

The reason all dentists don't use all-porcelain crowns for front teeth is that the technique for placing them is very demanding and isn't generally taught in dental schools. They are translucent, and their color is influenced by the color of the underlying teeth. General dentists aren't usually very skilled at color manipulation in these situations. Also, placing them requires the use of sophisticated bonding techniques that aren't fully taught in dental schools. At mynewsmile.com we recommend that if you want one of these beautiful crowns for your front tooth, have it done by an expert cosmetic dentist such as we have listed on our site. See our referral page for referral to an expert cosmetic dentist.

Here is a photograph of a patient's front teeth. One of these teeth is an all-porcelain crown, done by an expert cosmetic dentist in our referral network. Can you tell which one it is? The crown is on the patient's left lateral incisor, the smaller tooth just to the right of the two larger front teeth in our photograph.

after (click here for larger photo)

The work was done by Dr. Duane Delaune, of Metairie, Louisiana. Notice how closely it mimics the appearance of the natural teeth. For contact information, see our page of Louisiana cosmetic dentists.

CHOICES IN ALL-PORCELAIN AND ALL-CERAMIC CROWNS

There are various types of all-porcelain or all-ceramic crowns. Let's explain the differences between some of them:

	Feldspathic porcelain is the standard, traditional porcelain that is used for crowns. Many cosmetic dentists feel that this is the most beautiful porcelain.
	The Empress crown - Empress is strictly speaking not a porcelain, but is more like a glass. It can be called a ceramic material. The Empress material is cast rather than baked as a feldspathic porcelain crown is. The fit of Empress is more precise than the baked feldspathic porcelain. However, the color in Empress is mostly baked on the outside. Empress can be very beautiful. For appearance's sake, some expert cosmetic dentists prefer the feldspathic porcelain, and some prefer the Empress.
	The Procera crown - Procera is a milled ceramic on the inside with a more traditional porcelain baked onto the outside. The advantage of Procera is its exceptional strength. However, the milled ceramic core is opaque white, so many cosmetic dentists feel that it isn't as natural-looking as the more translucent materials. An advantage of Procera is that it doesn't have to be bonded to the tooth but can be cemented with ordinary crown and bridge cement, a technique familiar to all dentists.
	The Lava crown - Lava is similar to Procera, but the milled ceramic on the inside is a more translucent Zirconia, rather than an opaque white material. The Zirconia is shaded, and then the final esthetics of the crown are achieved in the baked-on outer layer. The Lava crown can also be cemented with traditional techniques. However, any crown cemented with a traditional crown and bridge cement is going to be susceptible to a compromise in the appearance if that cement line ever shows.
	Zirconia crowns, if they are done right, can be translucent enough to look natural. And if they are bonded to the teeth, instead of being cemented with conventional dental cement, they won't show a black line at the gumline.
	The Cerec crown - Cerec is are also milled from a block of very hard ceramic material. What's unique about Cerec is that the crown is milled by a computer in the dentist's office rather than in a separate dental laboratory. Thus, the dentist doesn't have to send out for it to be made—it can be made on the spot. So, no second appointment is required, and no wearing of a temporary crown between appointments. Cerec is milled from a block of ceramic that is a single color, so it is generally not considered esthetic enough for demanding cosmetic dentists. A few exceptional dentists who are artists, however, are able to custom stain Cerec for front teeth so that they are truly beautiful. Some even make Cerec veneers that can be placed the same day. To be precise, Cerec is actually a technique and not a material. There are several companies that make ceramic materials for use in Cerec machines.
	The InCeram crown - InCeram is made of a very dense and very tough aluminous porcelain. It also has excellent esthetics, but is more opaque than feldspathic porcelain. InCeram is also strong enough to be cemented with traditional dental cement.
	There are other types of all-ceramic crowns. We're not going to list all of them here.

ADVANTAGES AND DISADVANTAGES OF ALL-PORCELAIN AND ALL-CERAMIC CROWNS

Let's compare all-porcelain with porcelain fused to metal.

	All-porcelain is generally not as strong as porcelain fused to metal. It has to be bonded to the tooth in order to have adequate strength for oral function. The bonding technique is very demanding and is not fully taught in dental schools. We recommend that you only have an expert cosmetic dentist place this type of crown.
	With porcelain fused to metal, the porcelain has to be opaque in order to block out the appearance of the metal underneath. They all also eventually develop an unsightly dark line at the margin where the edge of the crown meets the tooth.
	Some of the all-ceramic systems that have an inner ceramic core with an outer layer of porcelain baked on require more tooth reduction. Grinding away more of the tooth is often not desirable.
	Some of the ceramic materials that are very tough and fracture resistant are also quite abrasive against the opposing teeth. Of the crowns listed above, the Empress is the kindest to the teeth it chews against.

GENERAL RECOMMENDATIONS FOR ALL-CERAMIC CROWNS

	There are several factors that need to go into the selection of a crown material: strength requirements, esthetic requirements, the abrasivity of the material against the opposing teeth, and the skills of the dentist. There is not a single crown that is clearly superior for all situations. Many cosmetic dentists will have several types that they will use, each for a different situation.
	It is generally a poor idea for a patient to go to a dentist and request a specific type of all-porcelain or all-ceramic. We have received many e-mails from patients who have done this and have been very disappointed with the results, because they were pushing their dentist to use a material the dentist was not comfortable with, and many dentists will try very hard to conceal from patients any discomfort they feel with a procedure. There is also the factor of the dental ceramist, whom you will most likely never meet. The material that is used for the crown should be intimately familiar to the dentist and to the ceramist for the best results.
	You cannot learn, as a patient doing online research, which crown is best. First of all, there simply isn't one all-ceramic material that is always best. Second, in a web page such as this, we can't list all the properties of all them. Third, in evaluating these crowns, there is a great deal of background information needed in order to evaluate which research claims are fully established and which claims should be questioned.
	Our recommendation, at mynewsmile.com, is that you find a cosmetic dentist you can trust and that understands your needs and is passionate about creating beautiful dentistry. Then ask that expert cosmetic dentist to use the technique that he or she is most comfortable with in creating the all-ceramic crown that will be best for you. The choice of the material is secondary to the skills of the dentist and of the ceramist in working with that particular material. There are subtleties in working with all of these all-porcelain and all-ceramic materials that need to be mastered by the dentist and the ceramist to produce the most beautiful result.

Other information about related subjects:

	Information from a survey on the costs of porcelain crowns.
	A discussion of porcelain crowns comparing them with porcelain fused to metal crowns, gold crowns, and resin crowns.
	Porcelain crowns for front teeth. Discusses which types are best for front teeth.
	An e-mail from a patient: Chris in Oregon is having eleven crowns done on her top teeth. After the first appointment, the lab technician said they were going to do porcelain to metal crowns, but she wants Empress. Dr. Hall tells her what to do from here.
	Dr. Hall answers a patient's e-mail asking what type of porcelain crown she should have for her front tooth.
	A patient said her husband's dentist wanted to do a porcelain fused to metal crown for a front tooth. Dr. Hall advises her on why he said that and what they should do now.
	Dinah asks how realistic it is to expect her dentist to get a perfect color match porcelain crown for her front tooth. Read Dr. Hall's answer.