Expert: Steven C. Scherr, D.D.S. - 10/5/2006

Question
Hello Dr. Scherr,

I just want to throw my arms up in complete disgust.  First, a little background...

Over the past 18 months I have had extensive dental work done.  3 root canals, 2 apicoectomies, and two teeth pulled as a result of failed root canals--and lots of infection and agony in between.  So here I am, a year and a half later and I only have 3 small cavities left to fill.  The problem is that I'm very nervous in the dental chair, and my current dentist was not very sympathetic to my fears.  So I switched.  Today I saw my new dentist for the first time--and he dropped a bomb shell on me.  He said that my upper left canine (sorry, can't remember the tooth number) has to have a root canal done on it.  You see, the tooth has been discolored for years.  It is darker than any of my other teeth, but had never shown any sign of infection.  No abcess, no pain, no sensitivity when tapped, no cavity, no nothing.  It feels perfectly fine.  My new dentist says that it's a ticking time bomb waiting to go off.  If this is the case than why was it never detected at all my previous appointments/x-rays/cleanings?  I'm so confused.  With my history of failed root canals, I feel that this tooth (once it has RCT) will be desitined to fail and I'll be making an appt. with an oral surgeon within weeks.  The whole thought makes me want to cry.  I've been down this path lots of times before.  It is possible for a tooth to have a dead nerve and not show any signs of a problem?  I have had this discoloration for years with no issues.  Am I better off leaving well enough alone or is this tooth going to get infected at any moment?  Should I seek a second opinion?  This is so frustrating...just when I was seeing the light at the end of the tunnel--WHAM--here we go again!  I HATE MY TEETH!!!!

Thanks for the help!

Answer
Tanya,

Congratulations for making the commitment to get your mouth healthy again.  I have no way of knowing what is best sight unseen.  The best I can do is try to provide some direction.

I understand your frustration related to your prior treatment detours.  It sounds like your mouth was a real mess 18 months ago.  It seems that all that is left now is to make a decision about 1 final tooth.  So lets look at the alternatives.

A tooth can be discolored for several reasons.  Lets assume it isn't stained on the outside since that would typically affect multiple teeth.  Some medicines taken during childhood, like Tetracycline, can also discolor teeth, but the discoloration is usually banded and impacts multiple teeth.  I think this can probably be ruled out also.

Discoloration that comes from inside the tooth can be due to one of the following:  1. bleeding within the tooth,  2. dark calcification in the nerve space, or  3. nerve death (necrosis) inside the tooth.

Bleeding within the tooth is most likely to result from injury to a young tooth.  The tooth may initially look pink, and later become dark.  If the nerve survives, no treatment is needed.  However, most of the time the nerve will not survive and root canal therapy will be needed to remove the damaged nerve.  If the injury was severe, such as a tooth that is knocked loose, early root canal therapy may reduce the risk of resorption that could later jeopardize the tooth.

Every tooth is subject to daily irritants - hot, cold, biting, fillings, clenching, grinding, etc.  Sometimes, the body lays down new calcified material in the nerve space.  When extreme, this can completely obliterate the nerve space all together.  It is common for this new calcified material to be dark in color.  If the darkness shines through, the whole tooth will appear dark.  If there is no sign of infection or other pathology, no treatment is need.  If infection, bone sores, or other pathology develops, then root canal therapy is needed.  If the calcification blocks access for needed root canal therapy, an apicoectomy is needed.  Today, with the success of dental implants, some dentists recommend the removal of such teeth when complex apicoectomies are required, and replacement of these teeth with implants.

If a nerve dies within a tooth, the nerve remnants will need to be removed.  The presence of pain is always important.  Unfortunately, the converse isn't always true.  This is because a dead nerve may be pain-free, yet can lead to a sudden abscess and swelling without warning.  A bone sore (that can be either painful or pain-free) will ultimately appear in the bone next to the involved tooth on an xray once the nerve has died.  If a bone sore is present, even if there is no pain, a root canal is needed.

Tanya, I recommend you sit down with your dentist and ask for an explanation of why treatment is being recommended.  Be sure to express your reservations.  Go in with an open mind.  If you still feel unsure after the meeting, you are always free to seek a second opinion.

I wish you well.

Steve