AboutBenjamin Schwartz, D.D.S. Expertise I can answer a range of questions in dentistry, ranging from cosmetic dentistry, fillings, root canals, and comprehensive treatment. Specifically, my fields of interest are in CEREC technology, Invisalign (Invisable braces), and Endodontics (root canals).
Experience
Licensed and full time general dentist. Treated over 200 Invisalign patients and have placed numerous CEREC restorations.
Website and Office Information: ProDent NY
Organizations
American Dental Association
Member of the Academy of General Dentistry
New York State Dental Association
CEREC Doctors
League of Dentists
Publications Schwartz Benjamin, Boczko Fae, McKeon S. Oral Care For The Elderly. Perspectives in Gerontology December 2006
Education/Credentials New York University College of Dentistry - D.D.S.
Woodhull Medical Center, 1 year post-graduate residency program - GPR
I recently went to a dentist because an old crown had become pressure sensitive and I was periodically experiencing low-level aching for hours at a time on and off. I assumed I would need a root canal.
The dentist says he prefers not to do root canals unless absolutely necessary, so after removing the existing gold crown and prepping the tooth he placed the temporary with medication and told me that if the pain did not get worse over the next week a root canal would not be necessary. Over that week the pain I experienced was exactly the same as before, no worse.
He then put an indirect pulp cap on the tooth and cemented the crown. This was three days ago. He told me the tooth should no longer be pressure sensitive now that the crown has been cemented, but it is. My symptoms continue to be exactly the same as before, but I am experiencing the low level aching more of the time.
Here are my questions:
1. According to the research I’ve done on the Internet, an indirect pulp cap is supposed to be followed up no less than two months later with a removal of the remaining caries. I asked the dentist about that and he said "Regarding the method for indirect pulp capping the article does not mention the use of UV rays, chlorhexidine, which are used in the newer methods of indirect or direct pulp capping." Is this a valid response?
2. The preparation of the tooth involved filling of two cavities that had developed under the crown, and medication for both the temporary crown and the permanent crown (indirect pulp cap). For this he charged me an amount almost equal to the cost of the crown itself. The cost of the crown itself was directly in line with what other dentists in his area charge, so the total was almost double. This does not seem right to me. Does it seem right to you?
3. The dentist guarantees his crowns and tells me that if a root canal becomes necessary within the next five years I will not have to pay for a replacement crown. However, what is less obvious to me is whether there may be other "hidden" charges based on my question #2. So while I believe he is a good dentist (notwithstanding my doubts re question #1), I am not sure at this point whether I can trust him not to overcharge me.
Thank you for any perspective you can offer!
ANSWER: Hi Gail,
When a tooth with a crown becomes pressure sensitive, there are two main reasons associated with it;
1. Because the tooth has a peri-apical infection, and will require root canal therapy (RCT).
OR
2. Because there is a fracture in the tooth, and may require RCT, or even extraction depending on the depth of the fracture.
Indirect pulp capping refers to placing a 'liner' into the deepest portion of the tooth, very close to the nerve. Sometimes, when removing decay, the dentist can see the nerve, but it is not exposed yet. Since the nerve is not exposed, it is referred to as an 'indirect' cap, (as opposed to a 'direct' cap).
So, to answer your questions...
1. Most indirect pulp caps are left to stay in place. Sometimes, they will need to be removed, based on the need for further treatment (like a root canal). With the newer materials, like glass ionomers, and the use of chlorhexidine as a anti-bacterial wash, many indirect pulp caps are able to seal off the bacteria entirely. Once sealed off, they no longer get oxygen, and will die, leaving the tooth with no more infection.
The literature does vary greatly on this point. Some proponents adamantly oppose leaving bacteria behind, while others say to leave it. So either camp is right on this point, and it just depends on what your doctor holds.
As long as your doctor doesn't see any infection present on the xray, and he didn't see any fractures when preparing the tooth, then he may be right about this point.
2. Often, when preparing a tooth for a crown, there is an additional fee known as a 'build-up'. Sometimes, there is very little tooth structure remaining, and material must be placed to build-up the tooth to support the crown. Otherwise, the crown would not have proper retention and resistance, and would fall out.
Your doctor should have made you aware of the fees before-hand, but so far nothing seems too out of whack.
3. As for hidden charges, only he would know that. I would make sure to ask him this specifically. I know most dentists will happily redo any work that needs to be repaired for free, if it breaks within a certain time frame. However, others will only replace it if you show up for all your hygiene appointments, and take meticulous care of your mouth. It is best to have this discussion with your dentist.
QUESTION: Thank you for your quick reply, Dr. Schwartz! It was very helpful to learn about the indirect pulp capping remaining in place. I have one more question based on what you said about infection.
The problem with the original crown was that it was improperly seated when it was first cemented. I remember that day well, even though it was at least 30 years ago. The dentist forgot to tell me to bite down when he cemented the crown, so when I finally did close my mouth it was extremely high instead of a perfect fit as it had been before being cemented.
I remember the dentist telling me I had ruined his day by telling him that. Unfortunately, at the time, I did not realize that I should have had him do it over again. He merely filed it down so that the bite was OK and that was that.
So 30 years down the line I'm paying the price. Bacteria was able to enter and create decay.
My current dentist observed a dark area in the Xray just under the main part of the tooth, but no abcess in the roots. He didn't Xray the tooth again after the week with the temporary. So when you say "As long as your doctor doesn't see any infection present on the xray" I'm not sure what the answer is to that. I was assuming that the dark area was infection. What would a dark area around where the roots and the tooth meet mean?
Answer Thanks for the great feedback Gail.
I too believe that your mind plays a big part in how things turn out. If you have the right outlook and optimism, I think you can go a lot further that way.
You can either contact me through this website or the prodentny address. Either way, please let me know how this turns out!
