What to do about this tooth? Extraction was recommended

[ukw]

(you can click to enlarge)

The attached image shows my Left-Lower-Molar Tooth #18 which had a deep cavity and a couple of unsuccessful fillings. It's been in this current state for 3 years. I've seen 5-6 doctors who have given me divergent views on what to do.

1) The first 3 doctors were ready to do a crown. But somehow I didn't trust them because they messed up the filling and the tooth still hurt after their initial fillings. They seemed a bit naive or careless and I decided to check with other dentists.

2) To my surprise, the next 2 doctors took a really grim view of this tooth and told me the situation was drastic. They recommended extraction. They rejected the idea of a crown, because they pointed out decay under the bone on the right side. Doctor #4 said "It's not that simple: either an implant or crown lengthening will have to happen" -- and he showed me dark spots on the right side of the tooth under the bone. This image was the exact one where he showed the dark spots to me, and I saw them in his office too, but for some reason they're not that visible here (and maybe the other doctors missed them) -- or are they visible? Do you see dark spots on the distal (right) side? He sent me to an oral surgeon, Doctor #5. The surgeon, Doctor #5, only took a cursory look, and said "We're doing an extraction. That's what I recommend." He is friends with Doctor #4 and gets referrals from him and probably doesn't question the original referrals too much.

When I asked him if the tooth was in any way saveable, he said "No -- not unless you engage in some 'heroics.' " He also signed me up for an extraction and for a bone graft, with an implant procedure to follow after 6 months. He also mentioned as one argument, "There may be more decay that we don't see."

The thing is, after I researched what the extraction-with-graft/implant would entail, I feel like it would be true "heroics," rather than trying to save the tooth. For example, eating on one side only for 6 months would be "heroics" (his term) -- and he told me I'd have to do it. The bone graft can introduce immune issues or other problems. But I do agree dental implants are safe and isolated, whereas something like root canals are actually undesirable and can cause issues down the road.

So the situation has suddenly veered from regular dentistry to drastic measures, and it's because the last 2 doctors saw deep decay under the bone (unlike the first 3 dentists who didn't see it). This is the most recent image.

 

[DrTeeth]

You did not say how long the tooth was hurting after the initial fillings. I suspect that you have food trapping between that tooth and the next. Pain/sensitivity after placing such deep fillings is not unusual and does not mean that anything is wrong.

To me, it looks as if there is NO decay under the filling, from the shape of the darkness under the filling, it is likely to be the base of the cavity. It would be useful to know what the current filling material is.

I cannot see any indication for root treatment (RT) at this time.

The best ways to treat the tooth is as follows:-

1) Remove the current filling carefully. The cavity is deep and drilling into the nerve is a risk - then RT will be needed.

2) Check for the presence of decay.

3) Remove some decay if necessary. It is not necessary to remove all decay in all situations. You clinician will have to make that call.

4) Restore the tooth with a silver-reinforced glass ionomer cement. It is not necessary to do a good filling at this stage, though it is best to seal the cavity. This will last for a long time.

5) Observation for months or even years. This will be by way of x-rays and a clinical exam every 6 months. This will be to check to see if any decay left is progressing (it often does not) and to see if there is any sign of the pulp dying. Two different x-rays will be needed to check this. No need to worry about exposure to x-rays as the dose is VERY, VERY, VERY low.

6) If there is no sign of progressing pathology, I would see what YOU wanted to do to the tooth. If it is not bothering you at all and not paining you, it can be left indefinitely.

7) If you did want something doing to the tooth for some reason, I'd have to see the tooth from the top to decide what sort of definitive restoration would be advisable.

The above is the brief version. It is the cheapest and the best that I know of. Why the best? Because treatment is kept to a minimum and all options are left open. Each treatment has a failure rate and if several treatments are done, those rates add up.

Obviously, I have not seen you and have only seen the x-ray, but I am confident that the tooth has years of life left.

Cheers

DrTeeth

 

[ukw]

Thanks for the replies. You guys probably can't see it very well but there is a small layer of gum (above the bone) which extends to the top of the cavity. That little piece of gum would have to be removed regardless of whether I do crown lengthening or not, just to be able to access the cavity. It's dark and sits just above the white bone.

I've thought about removing the original filling but it's a huge risk to drill into that tooth.

Normally there's no pain on this tooth. I sometimes get gum inflammation when (my guess) food particles get through it. Extremely rarely I'll get some occasional sensation when eating potato chips or nuts.

I've been analyzing historic photos of this tooth for a very long time in order to assess whether the cavity is getting worse or not. My opinion is that it hasn't been getting worse and it's stabilized, but anything could happen at any moment.

I'm concerned about implants mainly due to the risk of permanent nerve damage. This is a lower molar, so it's very vulnerable to the Inferior Alveolar Nerve getting injured. The incidence is surprisingly high (no one told me that) and with implants usually permanent.

 

[DrTeeth]

Hi,

The gum is not relevant to my earlier post.

Cheers

DrTeeth

 

[comfortdentist]

To add to Dr teeth's comments

X-rays that are posted here are always low resolution so while it might look clear to you there is missing data.
If you were my patient I would take out the old restoration in tooth 19(36) and #20(35) as that filling is open.
I would restore with Activa. A BW type x-ray would show me how close the restoration was to the bone. I would then consider crown lengthening if needed. This is basic restorative dentistry with an excellent prognosis. We did this in dental school!
There is no way I would extract this tooth.

 

[ukw]

Thanks,

I don't believe there was ever a restoration on #20. #19 does have an old filling which is similarly chipped but much less than #18. #18/#19 are the only ones I've ever had fillings on up till now.

Regarding this tooth, how would the filling be safely removed since it's so close to the nerve? If I understand correctly, drilling into this tooth with a drill or "chunking" it is too much of a hatchet approach whereas what's needed is a delicate scalpel approach. But the material is hard and the drilling inevitable. You can't "soak" this filling and let it come off. Can dentists even remove fillings without making deeper holes? Are there very small drills? There would be no room for error here. If this were even contemplated, it would have to be an extremely calm and patient doctor, with a hand of steel and an eye for detail. Anything else could lead to disaster.