Tooth Check (X-ray)


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I just got several diagnoses that differ somewhat from one another, so I'm turning to you to find out what thoughts you have about the tooth depicted in the photo. Do you see anything wrong with the tooth? What do you see in the tooth, besides the filling? Do you detect any inflammation or anything out of the ordinary?

Thanks in advance.
 

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honestdoc

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I see root canals that are poorly filled with an abscess at the distal root (right side root tip with a dark spot). If the tooth is asymptomatic, you are lucky. If you want a more definitive result, have a endodontist (root canal specialist) retreat (redo) the root canal under microscope to check for fractures, extra roots, damage, etc and have your dentist place a crown. Otherwise you can leave it alone or extract it.
 
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Thank you very much for the answer! Could you please answer one more question? Do you see anything else, perhaps a cavity, in this picture?
tth2.JPG
 

honestdoc

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Tooth #3 (in US), #16, Upper Right first molar has a large cavity on Distal surface and moderate cavity on Mesial surface. Lower Right first molar #30 (in US) has recurrent cavity (cavity under filling) on Mesial surface or defective/fractured filling. X-rays don't show 3 dimensions (tongue or cheek sides).
 
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Thank you for the detailed answer! It helps a lot. :)

Regarding tooth #3 with the large cavity, do you think it has affected the nerve? What do you suggest doing to that tooth?
 

honestdoc

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If you have no pain and no swelling, try getting a filling. Have your dentist place a bioactive pulpal protectant liner like Lime-Lite. If you have intense pain that wakes you up that means your nerve (root canal) is damaged. If you have swelling, that means your nerve died and became infected. You would then need a root canal treatment and later a crown.

Beware, most dentists are production hungry and would skip all that in favor of root canal and crown. If you tell them you only want a filling, they would intentionally drill too deep. It is very hard to find a dentist (like an auto mechanic, contractor, etc) you can trust.
 
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Yes, I am quite weary of such types of dentists, which is why I've had to turn to this forum.

Could it be that the nerve is damaged but no pain is felt?

One doctor has suggested checking, but I'm concerned that this "check" will mean having to drill in order to determine whether the nerve is damaged. Is it in fact necessary to drill into the tooth to check if the nerve is damaged, or is there another way to determine this, for example by scanning?
 

honestdoc

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Cold test. We use liquid nitrogen spray to a cotton ball. If the tooth feels cold...great, the nerve is working. If no cold is felt, then the nerve may be necrotic (dead). If the dentist uses a Q-tip, false negative because it doesn't get cold enough. If the tooth feels intense lingering pain, nerve is damaged. On molars, it can get trickly because there are about 4 nerve canals and some canals maybe dead while others are good. If so, the tooth will need a root canal as well.

I feel the electric pulp tester is not as accurate especially if the tooth has a crown (cap). I like the cold test better.
 
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Yesterday, I felt a sensation in the back tooth with the large cavity that you had seen earlier (molar, I believe, which was pictured above in my post on April 26th). To be precise, the feeling was in the gums. I felt it after I drank something cold (and the same when I eat certain things), and I felt the sensation continue until I used an antiseptic, at which point the sensation subsided significantly but not entirely. Does this indicate that the nerve is damaged?

Also yesterday, I talked with my doctor about that back tooth and she suggested drilling into it to find out. Does this sound like an appropriate approach to you, given the trickiness of having 4 nerve canals in a molar? In other words, is it necessary to drill the tooth because of the difficulty of identifying damages to the nerves?

Lastly, would be okay to ask where your practice is located? If not, no worries. Thanks again for your thoughts.




 
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You should find a minimally invasive or conservative dentist for a second opinion. These professionals are committed to ethical dentistry and preserving the health of the natural tooth as much as is practically possible whilst solving any dental health problems. So if they do a filling they will remove only what is necessary.
 

honestdoc

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Did your dentist place a filling on the tooth with a large cavity? The tooth feeling cold is a good thing. It indicates the nerve is working. Damaged nerve feels intense pain that can wake you a night and you can't chew on that side. The dentist needs to drill on the tooth to fill the cavities. There should be no extra drilling to identify anything.
 
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No, the large cavity wasn't filled. Thank you for describing this test on whether the nerve is damaged!

The dentist I visited today said the following:
  1. The cavity has to be drilled into to see if the horns of the pulp (she calls "horns" the nerve's connective tissue/texture) are affected, because it could be affected, but I may not feel pain. The solution she proposed is to NOT remove the nerve but to try to cure it first, if the pulp is affected.
  2. The sensation I am feeling (which I described previously) comes from the unevenness of the gums between the teeth (indicated in the photo). She called it periodontitis. She thinks it is the result of the cavity in the tooth. She was able to stimulate the sensation by using an instrument that blew air into the area.

QUESTIONS:

1. Do you agree with her conclusion and proposed approach about the horns of the pulp?

2. Do you agree that the sensation is because of periodontitis? And how is the periodontitis related to the cavity?
 

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honestdoc

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Where are you located? You discussion with the dentist is odd. I agree not to remove the nerve. I recommend a pulpal protectant (bioactive dentinal liner) such as Lime-Lite near the pulp before a filling is placed. This product helps the nerve heal. Periodontitis is diagnosed after probing your gums for attachment loss. If the probe reads 5 mm or deeper then you may have active disease. GET THE TOOTH FILLED as soon as possible. Afterwards, have your gums probed and determine if you have active disease. If so, you may need deep cleaning.
 
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I am from Russia, and unfortunately, here the dentists tend to contradict each other. So the diagnoses and approaches are different.

Do you have a general recommendation that I can follow? In particular, dentists want to remove the nerve, but I don't want to, so what should be the least invasive solution for my situation? I'm concerned that some of them don't know what Lime Lite is, so they choose instead to just remove the nerve. Is removing the nerve the only approach available if Lime Lite is not an option?

Is it possible that an internal cavity (like I have) will be so complex to reach that it will be necessary to reach it through the neighboring tooth? Obviously, I wouldn't want anyone drilling two teeth to get to one cavity.

Thank you for all your help. It's really difficult getting consistent consultation where I live.
 

honestdoc

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Do you live close to a big city? I may be naive to Russia, but I assume the big city dentists may have more modern equipment/supplies. The most conservative/least traumatic procedure is to do the filling. I'm not sure Lime-Lite is readily available in Russia but an older alternative is Dycal (Calcium Hydroxide liner) to protect the nerve. Have the filling done as soon as possible so it doesn't get bigger. Even better is going to a teaching facility like a Dental School and have instructors overlooking or doing the procedure. They may not be as aggressive to want to remove the nerve.
 
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Yes, I do live in a big city, but when you get different opinions, it makes you question the motives of the dentists.

Do I understand correctly that Lime-lite is used only to protect the remaining uninfected pulp and nerves? In other words, the dentist will remove the infected parts of the pulp together with the infected nerves and apply Lime-lite to the remaining uninfected pulp and nerves. And afterward, the dentist will put a filling to seal up the tooth. This avoids a fill root canal as there remains good pulp and nerves in the tooth.

This means Lime-lite doesn't cure the infected pulp and nerves, it only protects further spread of the infection and inflammation to the rest of the pulp and nerves.

Is above understanding correct?

I don't want to lose the nerves if it is not necessary, but I can't understand whether the problem is so serious that l should simply agree to lose all the nerves or continue looking for a dentist that performs such a procedure. What would you say in this case? Is it so serious that I should forget about saving the nerves with even if only some of them?

I've spoken to at least 5 dentists since this problem began.
 
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Are you in any position to perhaps hop on a plane to Hungary? They have some of the best dentists in the World.
 

honestdoc

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When the cavity gets close to the nerve (pulp) of the tooth, I like to use Lime-Lite (by Pulpdent) which protects the nerve from injury and inflammation. The nerve is very fragile and when you have a cavity close to the nerve, the nerve can get injured or die from the trauma of removing the cavity or contamination from the cavity. The nerve must not get drilled into and keep intact. If the nerve is exposed, you will need a root canal treatment removing the entire nerve down to the root tips.
 
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Thank you for your reply. Of course, my first choice is to go to Europe to attempt treatment, and to the list of Germany and France, I'll be considering Hungary also.

Unfortunately, it's not so easy to get a visa to the EU. So, I am considering Israel. I've heard Israel has a lot of good dentists there, and I wouldn't need a visa.

What do you think about treatment in Israel?
 
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When the cavity gets close to the nerve (pulp) of the tooth, I like to use Lime-Lite (by Pulpdent) which protects the nerve from injury and inflammation. The nerve is very fragile and when you have a cavity close to the nerve, the nerve can get injured or die from the trauma of removing the cavity or contamination from the cavity. The nerve must not get drilled into and keep intact. If the nerve is exposed, you will need a root canal treatment removing the entire nerve down to the root tips.
Thank you for the explanation.



I am attaching a scan of the upper area. Do you see anything here to be concerned about? These dentist visits of mine seem to create more problems than solve them.
 

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