About Mark Bornfeld DDS Expertise I can respond to all questions dealing with the practice of dentistry, from both the dentist`s and patient`s perspective. I am knowledgeable about all dental disciplines, from cosmetic dentistry to surgery, from restorative dentistry to root canal treatment. I have strong opinions about controversial issues in dental practice, including those topics which directly impact on the reputation of the profession in the eyes of both the lay public and our health profession colleagues.
Experience
Past/Present Clients Editor, Queens County Academy of General Dentistry newsletter; contributor to Dentistry.com 29 years practicing general dentistry partnered with brother Steve as one-half of the DentalTwins®
Question I had a composite filling done on my Right lower molar ( the one in front of my wisdom tooth) a couple years ago. For the last week I have developed a toothache on the inner half of the tooth when I clench and bite down on my teeth. I can only eat on the left side of my mouth. I have also developed an small oval ulcer, painless, no pus around the base on the gum on the inside, possibly due to irritation from toothbrush (i'm not sure). The dentist I went to said she wants to remove the current filling because she doesn't like the way it looks and because it chipped so you can actually see the small hole and replace it with a new filling. Is this current standard of care to remove a filling and replace it. Would I need a root canal? She said the ulcer looks like HSV-1 but doesn't HSV-1 occur on keratinzed surfaces after the primary infection? She told me to wait until it heals and then have the filling done. I'm just afraid that walking around for weeks until this ulcer heals will worsen my tooth and possibly lead to infection. My tooth is not sensitive to hot or cold. Please let me know what you think.
Answer Dear Carol,
The legal standard of care is a legal rather than a health care concept, and this is a matter that attorneys establish in a court of law, based on expert testimony. In the clinical setting, what is right and wrong has more to do with what is going on in the patient's mouth, and that is based on diagnostic criteria that cannot be assessed here.
Given the symptoms you have presented, you may have any of several different things going on-- each calling for different potential treatments. Some possible examples:
1. Your filling indeed has a gap, and that is the basis for your symptoms; the ulcer on your gum is unrelated.
2. The ulcer on your gum is due to a fistula from periodontitis (gum disease), and is the cause of your symptoms; the gap in your filling is unrelated.
3. You have a fractured tooth cusp; the gap in the filling is due to displacement of the cusp; the ulcer is unrelated to the symptoms.
4. You have a vertical fracture through the tooth that runs through the pulp chamber, causing an endodontic abscess; the gum ulcer is a fistula from this infection.
5. Your tooth is suffering from "trauma of occlusion", or injury from a large magnitude chewing force that could have been either a single acute event, or chronic.
6. The gap in your filling is unrelated to the pain, which is entirely caused by a severe apthous ulcer (canker sore).
It is true that intraoral recurrent herpetic infections are located almost exclusively on keratinized tissue (there are exceptions to this rule-- for example, in HIV or other immunosuppressed patients), but there is keratinized gum tissue on the lingual side of the lower molars. Nonetheless, this would be an unusual presentation for a herpetic ulcer; they are much more common on the outward-facing gum and the hard palate, and they are almost never solitary ulcers, but come in clusters. It is more likely that the ulcer is either a traumatic injury, an aphthous ulcer, or a fistula as explained above.
In any event, I don't think your ulcer should take more than a few days to heal; if it doesn't, this would be stronger evidence that it is a fistula and the need for re-filling the tooth should take a back seat to finding the cause of the infection and treating it. So, I don't think your dentist should need to wait too long to decide whether to intervene.
Hope this helps...
Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY
