Sedative Restorations

Sedative restorations are placed for several different reasons. The most common reason is tooth pain. The pain may be constant, intermittent, or a reaction to sweets or a cold or hot stimulus. If the sensitivity is due to decay and it is very deep and close to the nerve, there is the possibility of exposure of the pulp (nerve) once all the decay is removed. If the cavity is especially deep, as much of the decay as possible will be removed, and a medicated, sedative filling will be placed in the tooth. This will serve to calm the nerve and give it a chance to heal. The sedative restoration, if done for this reason, should stay in your mouth for a number of weeks. Then the sedative restoration will be removed and the tooth will be examined to determine the need for further treatment. It may be able to be restored with a filling or cast restoration. However, if the decay was quite deep and the nerve does not heal, endodontic treatment (root canal therapy) will be required to alleviate pain and save the tooth.

If you have multiple large cavities and/or other serious dental problems, we may choose to first restore all the teeth with sedative restorations. This will quickly stabilize all the teeth so that they do not continue to deteriorate from the decay. Then the other, perhaps more serious dental problems, can be addressed and treated. Once you are out of an emergency situation, we will have the time to thoroughly plan the best methods to restore the teeth.

A third use of sedative restoration is an aid in diagnosing sensitive teeth. You may have a problem with a single tooth, or perhaps you are unable to specifically pinpoint the exact tooth. If the tooth (or teeth) already has a restoration in it, we may need to remove the restoration and directly look at the prepared portions of the tooth. If we do not feel that it is appropriate to place a final restoration at that time, we will place a sedative restoration to be in place for a few weeks. Occasionally, the tooth feels better as soon as the sedative restoration is placed. However, it will still be necessary to observe the tooth for a few weeks before placing a final restoration.

Infrequently, the placement of the sedative restoration offers no apparent relief. In this case other possibilities must be explored. Most often the tooth will require endodontic treatment. Other times, it just takes several days to get a positive result. If possible, give the sedative restoration time to work. But under no circumstances must you live in constant pain. Do not be afraid to call and ask to be seen if the sedative restoration does not appear to be effective.

If you have any questions about sedative restorations, please feel free to contact us at any of our three office locations:

Hymeadow: (512) 250-5012

Jollyville: (512) 346-8424

West William Cannon: (512) 445-5721

Prevention of Decay

Dental Decay

Dental caries (decay) is a bacterial infection, first of the enamel, then of the dentin of the tooth. The tradition in dentistry has been to surgically remove the diseased portion of the tooth by “drilling” out the decay and then filling the resulting hole in the tooth with some inert material. As most adults know, this procedure will be performed over and over again when new decay begins or when the filling (often silver) breaks or the tooth fractures.

Would it not be better to eliminate the cause of the infection and thus not be forced to have big holes drilled in the teeth? We believe the bacterial cause of the infection should be addressed.

Preventing the Risk of Dental Decay

There are several positive steps that you can take to reduce your risk of dental decay. First, all of the active decay in your mouth should be treated immediately. Next, all the teeth that would benefit from sealants should be treated. This will prevent bacteria from reaching into the pits, fissures, and grooves that normally exist on the occlusal (biting) surface of teeth. Any stray bacteria that may still be in the sealed area are effectively cut off from their food source and become inactive. Although sealants are most effective on teeth that have not been previously restored, they can be successfully placed on teeth filled with bonded fillings.

The infection can be treated with antimicrobials. We believe that the use of a fluoridated mouthrise twice daily or use of a prescription fluoridated dentifrice as directed provides great advantage. Not only is fluoride effective against bacteria but it also creates an environment that promotes remineralization of slightly damaged enamel. The decay process is reversed and the tooth may not have to be drilled. We may also prescribe a chlorhexidine mouthrinse, an antimicrobial oral rinse that has a great effect on Streptococcus mutans.

Your diet and oral self-care are important in dental decay prevention. When you eat junk food and drink sugary liquids, your teeth are more prone to decay. The more frequently you snack, the more prone your teeth will be to decay. If your brushing and flossing are not effective, your teeth will be more prone to decay. When you can’t brush after a meal, at least rinse your mouth with water within 15 minutes to dilute the acids forming from the ingested food or drink. If you have a diminished salivary flow, take frequent sips of water during the day to help dilute the acids produced by the bacteria.

If you have a continuing problem with active decay, we recommend more frequent preventative recare appointments. It has been repeatedly shown that patients who have good oral self-care and maintain a recare interval of 3 to 4 months have many fewer dentally related (cavities or gum disease) problems.

The routine 6-month recare interval is no longer our recommended schedule. That interval was based on a 50-year-old philosophy that never had any scientific basis! Times have changed. Present dental practice is based on proven scientific information. You might need to have your teeth cleaned by the hygienist twice each year or you may need to be seen more frequently.

For certain individuals, we also suggest testing the oral bacterial levels to determine the magnitude and presence of a Streptococcus mutans infection and to determine your risk level for future dental disease.

Apicoectomy

Why Would I Need It?
Most dental problems involving an infected tooth root are solved by a root canal. Although endodontic treatment has an extremely high rate of success, it is not 100% effective. Some teeth may not respond as expected to the root canal therapy. Sometimes, it is clear from the beginning that the root canal is not working as planned. Other times, it may be years later that the need for other treatment arises.

Typical reasons for an apicoectomy may include re-infection of the root canal site with signs like pain in the tooth, tenderness or swollen gums that occurs after a root canal.

The first and most desirable method of solving the problem is to re-treat the root canal at one or more roots. In other words, the root canal treatment is redone in a method similar to the original therapy. If it is possible to re-treat the root canal with this nonsurgical approach, this is best.

What Is It?
If not, a different form of treatment, an apicoectomy (root end surgery), must be considered. An apicoectomy is an oral surgery procedure that removes the tip of a tooth root to save the tooth from being pulled out. Keeping your teeth intact is the dentist's mission.

Teeth are held in place by tooth roots. The tips of each root, called the apex, serve as an entrance for nerves and blood vessels into the tooth. During an apicoectomy, the apex is removed, almost with the infected tissue, and then sealed with a tooth filling. 

What Can Be Corrected With An Apico

• teeth that have narrow, curved roots
• "blockages" of the canal
• root resorption
• persistent infection
• fractures
• a wide open apex
• associated cysts

Reasons Not To Perform The Apico

• surgical inaccessibility
• poor or lack of bone support
• short roots
• vertical fracture of the root.

The Procedure 
1. The root or roots that are to receive the apicoectomy are measured with radiographs, and the approximate location of the root tip is estimated.
2. The area to be treated is anesthetized with a local anesthetic.
3. An incision of the gum is made over the root tip area and the gum is moved to the side. Access is made through the bone, and the tip or apex of the root can then usually be seen through this "window" in the bone. 4. The infection is visualized and cleaned out.
5. The tip of the root is usually removed, and a sealing filling is placed in the remaining tip opening.
6. The tissue is then sutured back into place.

Done with a surgical microscope, this procedure is also known as endodontic microsurgery and usually takes between 30 to 90 minutes, depending on the tooth's location and complexity of the root structure.

Who Performs The Procedure
Though general dentists can do an apicoectomy, most are performed by endodontists, or root canal experts.

What To Expect After The Procedure
The tooth does not lose significant stability from this procedure. There is no pain during the surgery. Postoperative discomfort will be eliminated with anti-inflammatory and analgesic medication. There is usually some slight swelling of the surgical site. The swelling is temporary and will disappear after a few days. When the "apico" is begun and the tooth can actually be seen, another type of problem may be noted. A fractured root may be the problem, and an apico would not work and the tooth would have to be removed. This procedure can be completed by a general dentist, but it is most often referred to an endodontist (root canal specialist) for evaluation and treatment.

Recovery Tips

• Apply a cold compress to the area for 10 to 12 hours after the surgery
• Avoid any strenuous activities and make sure to get enough rest
• Take over-the-counter pain medication to manage any discomfort
• Allow your tooth and the gums around it to rest while it heals. Avoid eating crunch or hard foods, as well as brushing the affected area and rinsing too vigorously 

If you have any questions about apicoectomy, please feel free to ask us.

Cracked Tooth Syndrome (CTS)

What is CTS?
Minuscule cracks can form on your teeth, threatening your dental health. Why? 

• Age plays a factor - as we get older, our teeth tend to weaken, making them susceptible to tiny hairline fractures that are not visible to the naked eye. 
• We increase our chances of developing cracked teeth by exposing them to trauma, such as bruxism and chewing on hard objects.
• When teeth have been heavily filled, it is not unusual that they develop cracked (or split) tooth syndrome (CTS). 

Symptoms include a sharp pain when you bite down into something hard. When you open your mouth and the teeth are no longer touching, the pain goes away. The pain does not usually linger after the biting action is finished. The fact that you feel pain when pressure is applied to the tooth means that the nerve is being affected. If the problem is not solved quickly, the nerve may die and the tooth will then require endodontic treatment (root canal).

Why does it hurt when I eat?
Pressing an object against the tooth opens the crack, causing the underlying dentin to move and irritating the pulp chamber (which contains the tooth's nerves). When the pressure is released, the crack immediately closes, causing a sharp pain. If left untreated, the pulp will eventually become damaged, and you will start to feel sensitivity to hot and cold or prolonged pain.

Common sites of cracked teeth

• Premolars and molars, the back teeth that grind and crush food 
• A tooth that has recently been drilled and a great amount of tooth structure has been lost
• A tooth that has an extensive filling (usually silver amalgam) that has been in place for a long time 
• Or a tooth that only has a small silver filling  
• The filling has weakened the tooth just enough so that when you chew or bite, the tooth and filling separate slightly (flex), causing immediate and sometimes severe pain.

Types of cracked teeth:

• Fractured Cusp: When the cusp (the raised section of the biting surface of your tooth) becomes fractured. If a fractured cusp does not break off on its own, it will need to be removed by a dentist and replaced by a dental crown.
• Cracked Tooth: Run vertically, originating from the top part of the crown and working their way down. Treatment typically entails a root canal followed by a dental crown. If the crack has extended below the gum line, the tooth may require a tooth extraction. 
• Split Tooth: When a cracked tooth is not treated, the crack can extend beyond the root, causing the tooth to split. Although these teeth are difficult to save, they can sometimes be treated with a root canal. 
• Vertical Root Fracture: Sometimes the crack starts at the bottom of the root and works its way up. If caught early, endodontic dental surgery may correct the situation. 

Treatment

Vertical Fracture

• Treatment will involve at least one x-ray to assist in the diagnosis and to rule out other causes. We will try to find the section of the tooth that is causing the problem by pushing on the various sections of the tooth or having you bite on a hard object.  
• When the section of the tooth that is cracked is found, it makes treatment easier. First, the tooth is anesthetized and the old filling is removed. 
• Then we carefully inspect the area to determine whether the cracked section can be seen. Very often it is visible at this point. 
• The next step is to see whether the split area can be fixed with a direct filling (bonded). This is the ideal situation if the crack is small.  If the crack is small enough, it may be removed by replacing the filling. Bonded white fillings and bonded amalgam filling will hold the tooth together making it less likely to crack



Crown

• Your dentist may first place an orthodontic band around the tooth to keep it together. If the pain settles, the band is replaced with a filling that covers the fractured portion of tooth (or the whole biting surface).
• Unfortunately, this rarely occurs. If the crack goes too far vertically, there is a possibility the tooth may need to be removed and replaced with an artificial one (bridge, denture, or implant). More often (over 95% of the time), the biting surfaces of the tooth must be entirely covered and protected first with a provisional (temporary) onlay or crown. 
• If this is successful in eliminating the pain (we usually wait for a few weeks to be sure the problem is resolved), an impression for a laboratory-fabricated casting - either a porcelain or resin onlay or a crown - is made. If adequate tooth structure remains, a partial coverage restoration - an onlay - is preferred. If the tooth has been badly cracked or if not much tooth remains, then a crown will be necessary. The purpose of either type of cast restoration is to unite all sections of the tooth so it cannot move or separate under normal biting forces. If the provisional restoration is successful in eliminating the pain, we expect that the final cast crown or onlay will correct the problem. 
• The nerve may sometimes be affected so badly that it dies. Root canal treatment will be required if the tooth is to be saved.

The earlier a split tooth is diagnosed and treated, the better success there is in treating it. If the split is severe, a root canal may be necessary to save the tooth. Depending on the symptoms you describe, we may choose to treat it as a bite adjustment, small filling, or larger preparation for an onlay or  crown. If these do not work, the treatment plan will be modified. If left untreated, the tooth may eventually be lost. It is also possible that the initial split of the tooth may be such that it cannot be saved, despite our best efforts.

Delaying Treatment
What happens if CTS is not treated quickly? The best you can hope for is that the tooth continues to hurt only when you chew or bite. This does not often happen. Usually, the broken section of tooth gets weaker and weaker until it fractures off. Additionally, if the crack gets deeper into the tooth, the nerve will die and the tooth will need endodontic treatment before the crown or onlay is placed. Sometimes the nerve is immediately affected by the initial split and dies. This may occur quickly or may take years before it is evident. Every case of CTS is unique. If it is any consolation, the cracked tooth is not your fault. It is a result of your teeth being drilled and filled with big silver fillings when you were younger. We see this particular dental problem mostly in patients who are between 25 and 45 years old.

Unfortunately, cracked teeth do not go away. Many times, they only hurt when you bite on them from one particular angle. If the fractured segment is not stressed, the tooth feels normal. You might also be able to "train" yourself to chew on different teeth and avoid the cracked tooth. At best, you only postpone necessary treatment while the nerve may be slowly dying.

After Treatment
If treated by adjusting your occlusion (bite) on the tooth
This will lessen the symptoms. If the discomfort you feel when you bite is not eliminated within one week of treatment, please call our office and let us know. If the split is still present, a different approach will have to be tried. Give the tooth a few days to "calm down" before you try to bite down on hard foods.

If treated by removing the old restoration and placing a bonded filling in its place 
If the split is small, this may eliminate the problem. Do not bite down hard on the tooth for a few days, then gradually place more pressure on the tooth. Call our office in one week and let us know how it feels. If the split is still causing a problem, a different approach must be tried. If left untreated, the tooth may split further and you may need endodontic treatment and a crown. If the tooth splits severely, it may have to be extracted.

If treated by cementing a temporary crown onto the cracked tooth with temporary cement 
Because the crack was so severe, this procedure was used to determine whether or not the tooth can be treated without performing a root canal. Please give the tooth several days of rest before you try biting down on hard foods. Expect the tooth to be sensitive for a few days after the temporary is placed. This is normal. Gradually apply more force when you bite into foods, and gradually try to eat harder foods. Expect the temporary crown to remain in place for several weeks, until it can be determined whether or not the problem is solved.

If you have any questions about cracked tooth syndrome, please feel free to ask us.