Too much decay even for crown

Zzzdentist

Zzzdentist

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I was hoping zz would be able to elaborate more on how long it takes for any bone loss to be apparent if only one tooth is removed (if this happens at all with only one tooth).

Zz can you confirm how long between tooth removal and bone loss - months, years, or never for one tooth?

Bone loss does vary from person to person, but an extraction of a upper second molar probably results in an erosion of that area over several years as in like anywhere between 5 and 10 (?). Some people have incredibly robust bone which doesn't seem to care whether the teeth are present or not, but typically when the teeth are taken out, the bone does tend to follow. I don't do dental implants so one would have to consult a dentist that does them to determine whether waiting would be an issue.

In regards to whether a tooth is worthwhile restoring, the patient should definitely be in on the decision, but honestly the dentist is often the one who makes that determination as most patients aren't able to in some cases. It's not a matter of money for the dentist, but rather advising the patient on how best their money can be spent and what the expected outcomes are. A lot of the time, dentists give patients all of the options as well as the pro's and con's, but patients just aren't able to decide. There are dentally sound decisions that have to be taken, and those are what dentists usually recommend.

For example, if a dying tooth is on it's last legs, restoring it with a root canal, core buildup, post, pins, and crown would be highly questionable. It's not a matter of money but whether the treatment makes sense.

If someone insists on fixing a hopeless tooth that probably will fall out the next day, I would send them along to the next dentist regardless of the money. There's no personal reward in receiving payment for something that isn't sound dentally for me. There can be exceptions like that wedding the next day or whatever, but what I'm saying is that the choice isn't always up to the patient. In some cases the only option available is an extraction, like it or not. Money can't change that.
 
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Miker

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Bone loss does vary from person to person, but an extraction of a upper second molar probably results in an erosion of that area over several years as in like anywhere between 5 and 10 (?). Some people have incredibly robust bone which doesn't seem to care whether the teeth are present or not, but typically when the teeth are taken out, the bone does tend to follow. I don't do dental implants so one would have to consult a dentist that does them to determine whether waiting would be an issue.

In regards to whether a tooth is worthwhile restoring, the patient should definitely be in on the decision, but honestly the dentist is often the one who makes that determination as most patients aren't able to in some cases. It's not a matter of money for the dentist, but rather advising the patient on how best their money can be spent and what the expected outcomes are. A lot of the time, dentists give patients all of the options as well as the pro's and con's, but patients just aren't able to decide. There are dentally sound decisions that have to be taken, and those are what dentists usually recommend.

For example, if a dying tooth is on it's last legs, restoring it with a root canal, core buildup, post, pins, and crown would be highly questionable. It's not a matter of money but whether the treatment makes sense.

If someone insists on fixing a hopeless tooth that probably will fall out the next day, I would send them along to the next dentist regardless of the money. There's no personal reward in receiving payment for something that isn't sound dentally for me. There can be exceptions like that wedding the next day or whatever, but what I'm saying is that the choice isn't always up to the patient. In some cases the only option available is an extraction, like it or not. Money can't change that.

Thanks again Zzzdentist. I am encouraged by your estimate of 5 - 10 years. Realizing that implants are not your specialty, even your low end estimate of 5 years...I should be able to save up the money for an implant well within that time frame (even if some bone grafting or other such services are required). With any luck, maybe I am one of those people with "incredibly robust bone".
 
Zzzdentist

Zzzdentist

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Just to clarify, I'm not saying in your case Mike that you only have the one option of extraction, but your dentist should be able to give you their professional opinion on the likelihood of success for the other options so you can decide. If he can restore it, but isn't sure how long it may last, you certainly can go that route. If he's saying it's just not worth even trying, that should give you a good indication of what shape it's in.

I also want to point out that the patient always has the option of doing nothing (ie. leaving it as is) and seeking another opinion as long as they accept the consequences (eg. worsening infection, toothaches, etc). I'm all for empowering the patient to have an active role in deciding about their treatment options, but some choices just fall outside the point of worthwhile restorability (eg. a severely decayed root fragment deep under the gum line isn't going to be helped by trying to do a root canal and put a crown on it).
 
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brit

brit

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I also want to point out that the patient always has the option of doing nothing (ie. leaving it as is) and seeking another opinion as long as they accept the consequences (eg. worsening infection, toothaches, etc). I'm all for empowering the patient to have an active role in deciding about their treatment options, but some choices just fall outside the point of worthwhile restorability (eg. a severely decayed root fragment deep under the gum line isn't going to be helped by trying to do a root canal and put a crown on it).

But surely few patients would argue with that ....your position is entirely ethical :respect:....and also makes sense, because it does your reputation no favours, to do sth you know will fail because a patient insists....because of course when it does fail...the story will be told along the lines of what a poor dentist you are...not along the lines of I was warned this probably wouldn't work but insisted anyway. :cheers:
 
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annie778

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Well given the above discussion I am in an interesting situation. Today I've been told via a second opinion that rather than have a root treatment for my problem tooth (cracked on one side and pain on heat), I should have the filling replaced with a bonded white filling (partial onlay) which he thinks will stabilise the tooth. The dentist I saw today thinks that as the nerve is not dead and there is no sign of infection yet (no pain on biting, no gum tenderness, a reaction to cold sensation, etc)that it is not a good move to rush into a root canal. He is going to try something much less invasive which will hopefully work. If it does not work then I am only marginally worse off financially but have the chance of saving the nerve.

So on the one hand I get told by an endo that I need a root treatment and that he thinks he may save the tooth but if not then I might need it taken out and an implant. On the other hand I am told that I should go with a completely opposite conservative approach and see if that works. Both dentists and endo cannot see much on the x ray to indicate any problems with the tooth. Endo indicated a line next to the tooth which he said was my body reacting with the situation and recognising a problem, second dentist said this line is normal and does not think it is a problem area. He said he cannot see any abnormality in the root or bone.

I am going with second dentist as a) cost is phenomenally cheaper and b) I get to keep the nerve for now and c) the appointment will take less than one hour and will be done in one day.

All three of these people are professionally qualified but they are on different parts of the conservative vs radical spectrum. I'm interested to see what transpires. So to some the tooth is on it's last legs and to others it is not.
 
Zzzdentist

Zzzdentist

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Definitively to complicate matters are varying opinions from different dentists. There are options, opinions, and endless what if's and maybe's. It like on House MD when someone asks an oncologist for an opinion they see cancer, an immunologist they see an autoimmune disease, etc, etc. In the case where the tooth is restorable, there can be several options to consider which is what you are looking at.

If your tooth is in the condition that I think it is in, there is a crack line visible, but it does not appear to be causing any symptoms. The tooth's pulp chamber has been cleaned out and the remaining nerve portions in the root canals have been capped with some sedative material and then the whole works filled over. The tooth is cracking due to the stress on it and the fact the pulp chamber roof structure has been removed. I wonder if that tooth might not have developed the crack if it had been crowned in the first place, but that's neither here nor there.

If that's the case, it can appear to be one of those hmmm what should we do situations. Endodontists see a non-completed root canal system, but with the absence of pathology or symptoms, they can only go by what they feel is best for the tooth which according to what they have learned is to complete the root canal if possible providing that the crack isn't too bad. They can't really say, let's leave it, and then what happens if it does flare up because the root canal was not done to modern standards?

The dentist sees something that was done in an unconventional way perhaps (partial pulpectomy), but it's still working so why try to fix it? He just wants to prevent the crack from getting worse and has chosen a conservative treatment (ie. the filling) instead of a crown because if the tooth flares up, the cost and consequence of drilling through a new crown in the eyes of the patient are not good things.

I would say that as long as you're willing, and as it has been several years for the tooth to be problem free, your choice could be a good one. I wonder though whether instead of a composite restoration perhaps a more long lasting crown might be an option to consider. Some composites can last quite a long time, but with cracks present, I'm just fearful of a large fracture which a crown might be able to prevent. It is more costly, but sometimes the investment is worthwhile. That being said, one does have to gamble that the remaining nerve does not act up, but if it has been fine for many, many years, the chances can be good that it will continue that way as long as the crack is not allowed to progress.

You certainly can try the filling for the time being, and look at a crown in the future as one other option. Whew, that's got to be one of the longest replies I've made for quite some time!
 
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annie778

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Thanks ZZ. The tooth lasted 24 years with a large filling and no symptoms. I think the crack is very recent (well there are two vertical cracks close to each other on the inside of the tooth and there is not much tooth left on that side). I think the crack was caused by crunching polo mints because I went through a phase of eating them just before the heat sensitivity started. So I think because the cracks are recent there has not been enough time for the seepage to cause an infection. I am getting the work done today so will report back on how it feels later. I think he mentioned putting a thermal seal on it and also giving it a good clean (mentioned ozone too_ before placing the bonding.
 
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annie778

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Ok Ive had the filling. Was a bit of an ordeal as I had an injection in between my jawbone and it was totally numb but now I understand how people feel when they panic because they can't swallow properly and you feel a bit like you're choking. Then I had a dam put on and I was a bit panicky about not being about to swallow but it was ok....

The base of the tooth is not cracked and the dentist managed to save the entire remaining tooth structure as the bit that is cracked is still very robust. So he has sealed it and he did some ozone treatment on it to disinfect it before bonding a white filling to it. He thinks the composites around these days are pretty much as robust as amalgam and have the added advantage of bonding to the tooth so less chance of seepage. I've touched it with a q tip dipped in hot tea and it does not seem to have that searing pain it had before so I very much hope this will work out and that I won't need a root treatment. Feels fine when I'm eating too. If I do need more work at a later date then I will feel that I have at least explored the other possibilities before rushing into the last option.

So this just reinforces my belief that if you get told that you need some radical work done, then you should ALWAYS get a second opinion and then choose the opinion that you feel more comfortable with.
 
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