“My Tooth is Still Hurting”

Dr. Al Danenberg Nutritional Periodontist

April 20, 2020 [printfriendly]



George contacted me by email a few weeks ago. He wrote, “My tooth is still hurting, and my dentist can’t find out why.” He lives outside of the US, found me on the Internet, and wanted another opinion.


I responded to him and explained, “I cannot make a diagnose over the Internet. But I will look at your x-rays and review your medical and dental history. Then, I should have some ideas and actions you could take that I will discuss with you.”


George emailed back, “That makes sense to me.”


He then filled out an online questionnaire and other information. George submitted them to me online. Also, he had his dentist email the dental x-rays. I took a look, gathered my thoughts, and we talked via Skype.



George’s Dental Problems

George’s acute problems centered around two recent dental procedures: a dental implant to replace his missing lower molar and a completed root canal on a tooth that was abscessed.


After we met via Skype, George explained the details of his dental fiasco.


He had an implant placed in his lower left molar area, which did not cause any pain while it was healing for several months. Then a crown was cemented onto the implant. Within a couple of weeks, he noticed some tenderness in the gum tissue surrounding the new crown. He went back to his dentist who took a new x-ray and told him, “That’s normal. You need to clean the area better.” George left thinking that it would get better. It didn’t!


In addition, the same dentist completed a root canal on his lower right bicuspid, which was abscessed and hurting. The root canal was done while the implant was healing on the left side of his lower jaw.


Shortly after the gum surrounding the implant crown became sore, the root canal tooth became extremely tender. George returned to his dentist to check it out.


The doctor checked that tooth, took a new x-ray, and made sure that the tooth had normal biting pressures when George brought his teeth together. The doctor tried to encourage him, “Your tooth will be fine. It just takes some time to heal after the root canal.” It didn’t get better.


George lost confidence in his dentist and didn’t know where to turn. That’s when he found my website and contacted me. Once he decided to schedule a consultation, George requested his new x-rays and sent them along with other documents for our Skype meeting.



Causes of the Pain

The sore gum around the implant crown


The x-ray of the crown on the implant showed a small amount of cement pushed under the gum tissue after the crown was cemented. Excess cement left under the gum tissue is unfortunately a frequent problem after the cementation of a crown.  This may be difficult to see on an x-ray. However, it is evident on an x-ray when someone looks for it.


I explained to George that the dentist or hygienist would need to take the time to delicately clean out the area. I suggested that, “the cement fragment is just like a splinter in your finger. It is an irritant. Your finger will not heal until the splinter is removed completely. And so, the gum around the implant crown will not heal until the cement is removed thoroughly. If the cement remnant is not removed, infection eventually will destroy the jawbone around the implant. That could cause the implant to be lost.”


George agreed with me and promised that he would schedule another appointment with his dentist.



The root canal tooth


The cause of George’s other problem was more difficult to determine. After his dentist completed the root canal on his bicuspid, the pain not only continued but actually got worse. I suggested that George see a root canal specialist to evaluate that tooth and take a three-dimensional (3-D) x-ray of the area. I suspected a crack in the tooth root. This specialized x-ray could show a crack better than a standard dental x-ray.


I pointed out to George my thoughts about a crack. It could occur if too much pressure was applied to the tooth by his dentist when he performed the root canal. Or, heavy chewing pressure could cause the fracture. If the root is fractured, it might have been present even before the root canal was started.



Tooth Pain Resolved

George was able to have the cement removed that was lodged under his implant crown. Also, George had an endodontist evaluate his root canal tooth and took the necessary 3-D x-ray.


The x-ray clearly showed a hairline fracture in the root of the tooth. Unfortunately, the only option George had now was to extract that tooth. And so, George had the bicuspid extracted. I told him that later on the space could be replaced with an implant or a bridge cemented on the teeth on either side of the missing tooth.


At last, George was able to get his pain to stop. But only after the cement was removed from under the gum and after his cracked root canal tooth was removed.



My Recommendation

Pain is a terrible thing. Especially when professionals you trust can’t make it go away. It is not wrong to get another opinion from another professional. I always encourage patients to seek other ideas from other medical and dental experts if there is a concern or an unresolved question. Sometimes the cause of a dental problem is very difficult to determine; sometimes the problem is the result of poor dentistry.


At times, the dental problem is related to other problems occurring in different parts of the body. The mouth is intimately and intricately connected to the rest of the body. Whatever affects one cell will ultimately affect all other cells. The mouth is not an island unto itself.


Whenever there is pain, it could be the result of uncontrolled inflammation and infection. If infection and inflammation become systemic, many other parts of the body will be affected. The source of the problem must be discovered and treated appropriately.



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Important Facts If You…
Are Considering or Have Dental Implants

Alvin H. Danenberg, DDS Nutritional Periodontist
January 30, 2017 [printfriendly]


Dental ImplantsAre you considering dental implants to replace your missing teeth? Do you already have dental implants in your mouth? If either answer is “Yes”, then you may want to read some important facts I discuss in this article.

Last week I posted an article about implants and inflammation. I discussed some published medical science that showed titanium particles are released from the surfaces of dental titanium implants under specific circumstances. These particles could cause chronic inflammation. In turn, this could result in the loss of the implant and possibly could aggravate other chronic diseases in the body.

So, what should you do if you are planning to have implants placed into your jaw or if you already have implants in your mouth? The following are my thoughts based on facts:


If you want a dental implant…

Dental implants replacing missing teeth have had a high success rate for many years. Titanium-based implants have been used more than any other implant material. They are manufactured internationally and are used throughout the world. In addition to titanium-based implants, there are zirconia-based implants, which are not made of titanium.

If you are considering an implant, your dentist may suggest a titanium-based implant or a zirconia-based implant. There are mechanical and esthetic advantages and disadvantages with both. Here is an article that compares the two.

However, this recent article suggests that there may be an inflammatory response from the zirconia surface like that from the surface of titanium implants. What can you do to provide a healthy environment for a dental implant?

Before having an implant placed in your mouth, you and your dentist must be proactive. Here are four things you should know:

1. If you use tobacco, your risk of implant failure is greatly increased. You should consider quitting smoking as soon as possible to reduce your risk.


2. If you have gum disease, you must have your dentist diagnose your problem and treat it correctly. It is necessary to have treatment to remove this disease before placing an implant. Here’s why:

Patients with existing periodontal disease have a significantly higher risk of developing peri-implantitis. Peri-implantitis is an infection that can develop around an implant in the jawbone and cause the implant to fail. The bacteria from periodontal disease can cause two harmful effects:

  • Corrosion of the implant surface releasing titanium ions (This article explains the immune response that is created in the body from titanium particles.)
  • Inflammation and infection in the bone and tissues surrounding the implant (peri-implantitis)


3. You should eat nutrient-dense foods and remove foods from your diet that are inflammatory. Nutrient-dense foods help maintain a healthy balance of good bacteria in your body as well as your mouth.


4. You must take the time to clean your mouth efficiently. If you allowed bacteria to overgrow around your implants and your teeth, they could increase the risk of gum disease and the loss of the implant.


If you have a dental implant…

As I already discussed, you need to be proactive to keep your implant healthy. You should brush and floss efficiently first thing in the morning and last thing at night. Also, you should eat nutrient-dense, anti-inflammatory foods, which will help prevent chronic inflammation throughout the body.

Let me reemphasize: Periodontal disease can cause peri-implantitis. Periodontal disease is a result of a nutrient-deprived, toxic-loaded body with an abundance of unhealthy bacteria in the mouth.

In addition, I do not recommend antibacterial mouthwashes. These kill microbes indiscriminately in the mouth and can disturb the balance of healthy bacteria. Furthermore, they actually can increase the severity of gum infection by damaging an important digestive process that has been shown to heal gum disease. I wrote an article about the harm of antibacterial mouthwashes.

When it comes time to have a dental cleaning with a hygienist, the dental hygienist should not use an ultrasonic cleaning instrument on the surface of the implant. Also, you should avoid fluoride treatments in the dental office as well as avoid fluoride in toothpastes and in drinking water as much as possible. The reasons: Both the cleaning of an implant with an ultrasonic instrument and the use of fluoride in the mouth have been shown to release titanium ions from the dental implant surface that can get into the tissues attaching to the implant.


Concluding thoughts

Dental implants are a means to replace missing teeth. If you have decided to have your dentist place implants in your mouth, you have choices between titanium-based implants and zirconia-based implants. But, your mouth should be disease free before they are placed. Once implants are in your mouth, you must be proactive to keep them healthy, as I have described in this article.


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Will Dental Implants Cause Infection In My Jawbone?

      Alvin H. Danenberg, DDS     January 19, 2016   [printfriendly]

Dental ImplantI get this question frequently from patients. The short answer is, “No, not really.” My more detailed answer follows:


First, I describe the materials used for dental implants and some of the preexisting conditions in patients that could cause implant failure. Then I discuss specific situations where the actual placement of implants could cause damage in the jawbone and failure of the implants.


Materials Used for Implants


The majority of implants today are made from titanium alloy (titanium plus other elements). The new kid on the block is made from zirconia (zirconium dioxide combined with other elements). Both include metals. Both are combined with other elements to give them enhanced properties. Both allow bone to grow onto their surfaces. However, there could be rare cases of sensitivity to these metals. (There is a blood test provided by MELISA.org that can test for various metal allergies, but this test is not conclusive.)


Titanium alloy has been used in dental implants for decades and has had a long and positive track record. Zirconia dental implants have been used only for several years and have not stood the test of time.


Preexisting Conditions in Patients


While these implant materials do not cause infection by themselves, certain underlying conditions in patients could cause poor reactions in the bone and gum tissues. Some important patient risk factors include:

  • Existing gum disease that was not treated before placement of the implants
  • A compromised immune system that would not allow the bone to grow onto the implant surface
  • A smoker whose habit contributed to poor healing potential


Situations Causing Damage Around Implants


Dental implants must be placed properly, or else they could lead to inflammation and infection in the jawbone. Three situations where improper technique could cause damage are:

  • Bone could be traumatized during the placement of the implant
    In order to place an implant in the jawbone, the dentist will drill a small hole in the bone in which to screw the implant. This surgical procedure is performed with sterile saline solution at very low pressure on the bone in order not to heat up the bone. If the bone becomes overheated and traumatized, bone may not grow onto the implant surface. This could result in inflammation, infection, and loss of the implant.
  • Heavy biting forces could be wiggling the implant and damaging the surrounding bone
    If other teeth in your mouth are touching the implant with wiggling forces or heavier forces than are normal, the implant could be wiggled in the jawbone. This wiggling motion of the implant could damage the bone surrounding the implant and create inflammation, infection, and the loss of the implant.
  • Cement residue could be left under the crown, which is attached to the implant
    The tooth crown may be either cemented onto the implant or screwed into the implant. If cement is used, the dentist must remove any excess cement immediately and completely. If there is any residue of cement left under the gum tissues around the implant, this could cause inflammation, infection, and the loss of the implant.




Patients must be shown the proper methods of cleaning their implants. Implants do not cause infection by themselves. Patients who have preexisting risks may not be candidates for implants. Most jawbone problems from implants are the results of dentist error.


The placement of dental implants needs to be performed by a dentist experienced with the proper procedures. Infection and eventual loss of implants could be eliminated if the dentist placing the implants (1) is aware of preexisting patient risks and selects patients accordingly, (2) is careful with the surgical technique, (3) controls the chewing pressures on the implants, and (4) makes certain that no cement is left under the crown that is attached to the implant.


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