another opinion on multiple cavities?

[beastmaster]

Just had a strange dental visit. On first inspection the dentist said my teeth were generally in very good shape but with 2 cavities. Then he studied the x-rays while checking my teeth back and forth and said I had 10 cavities 😱
and now need fillings.

Could it mean that the ones he saw on the x-rays are smaller/minor? I thought it was kind of strange for that kind of reversal of fortune to occur. Should I try to get a 2nd opinion or just suck it up?

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[jmill0]

Caries (cavities) between the teeth cannot be seen from an oral exam (unless it is some gaping hole). Doc probably found two lesions on the biting surfaces of the teeth and 8-10 in between your teeth. You can either get a second opinion and start flossing or get the fillings done and start flossing.

 

[beastmaster]

Ah, that sort of makes sense.

What is the filling procedure like for in-between teeth with regards to time/pain/end-result? Are root canals involved?

 

[predentchick]

You can always get a second opinion, but the previous post is 100% correct. Xrays are taken to detect the cavitites in a front to back dimension and not for the "tops." So since you have only 2 on the top biting surface, your brushing habits are probably pretty good. But you are missing inbetween which means flossing is lacking... Good luck!

 

[toofache32]

Tangent (not really applicable here):

If only I had a nickel for every patient that said, "There was nothing wrong with my teeth and they never bother me but this dentist said I need a bunch of fillings. Does he just want my money?"

If your PCP tells you that you have hypertension, nobody says "he just wants my money." Hypertension doesn't hurt either and most people don't know they have it until someone tells them it's there.

OK, I'm done.

 

[predentchick]

Tangent (not really applicable here):

If only I had a nickel for every patient that said, "There was nothing wrong with my teeth and they never bother me but this dentist said I need a bunch of fillings. Does he just want my money?"

If your PCP tells you that you have hypertension, nobody says "he just wants my money." Hypertension doesn't hurt either and most people don't know they have it until someone tells them it's there.

OK, I'm done.

👍 Well put!

 

[beastmaster]

Tangent (not really applicable here):

If only I had a nickel for every patient that said, "There was nothing wrong with my teeth and they never bother me but this dentist said I need a bunch of fillings. Does he just want my money?"

If your PCP tells you that you have hypertension, nobody says "he just wants my money." Hypertension doesn't hurt either and most people don't know they have it until someone tells them it's there.

OK, I'm done.

Your comments are fair. But I have had first-hand experience with shyster PCPs, who schedule unnecessary tests, over-treat (when contraindicated), etc. You can never be too careful.

So what is involved in filling these interproximal lesions, if thats what they are?

Are root canals involved there somewhere?

Any good links I can follow (not getting very far with google on this one).

Thank you dental folks.

 

[jendent2008]

Your comments are fair. But I have had first-hand experience with shyster PCPs, who schedule unnecessary tests, over-treat (when contraindicated), etc. You can never be too careful.

So what is involved in filling these interproximal lesions, if thats what they are?

Are root canals involved there somewhere?

Any good links I can follow (not getting very far with google on this one).

Thank you dental folks.

They are called class II restorations. As long as the caries have not reached the pulp (and they probably haven't since you haven't had any pain), then there is no reason for a root canal. These restorations are routine, it'll involve the same amount of discomfort as other restorations. The other posts are right, these lesions are not usually apparent during a visual exam, but show up on radiographs.

 

[predentchick]

One thing to mention is if these teeth with the interproximal decay are the same as the ones with the occlusal decay, then a porcelain inlay MIGHT be needed. These tend to be expensive since they are a lab manufactured product. If your IP/Top Surface decay is significant then this MIGHT be suggested. These range in the $700 area whereas a 3 surface filling is around 250ish.But I'm sure the Dr. would have brought this up if it was a concern on your treatment plan.

 

[toofache32]

Given a choice, I will always go with amalgam for posteriors. I would rather do it once and forget about it rather than replace composite every 5-10 years. There is no good reason for posterior composite except vanity. I don't think composite preps are that much more conservative.

 

[DrRob]

If the interproximal lesions have not reached dentin then there is no need for a filling at this point. Chances are your cavities are small. I would get a second opinion - some dentists are more aggressive than others, not to say one philosphy is better than another.

 

[lnn2]

If the interproximal lesions have not reached dentin then there is no need for a filling at this point. Chances are your cavities are small. I would get a second opinion - some dentists are more aggressive than others, not to say one philosphy is better than another.

I second that 👍

 

[J2AZ]

😱

Given a choice, I will always go with amalgam for posteriors. I would rather do it once and forget about it rather than replace composite every 5-10 years. There is no good reason for posterior composite except vanity. I don't think composite preps are that much more conservative.

I disagree. Even though you may have to replace the composite filling in 10 years it is better than having to get a crown. Amalgum fillings have a much different rate of expansion and contraction and often lead to cracks and tooth fractures. This is especially true for large posterior occlusal fillings.

If I were you I would get a second opinion. It will not hurt. The filling of the decay located between the teeth will be a bit more involved than the decay found on the biting surfaces. However, it is still straight forward.

The doc will go in from the top of the tooth and drill down until he cleans out all the decay. He will probably go back and forth between his high speed and slow speed and may use a decay detector to verify all decay is out. He will then place a small piece of metal between the teeth and hold it in place with a small metal ring. This allows the doc to reform the contact. He will then place the filling material, cure it, check your bite and contact, adjust and polish.

He will probably sch you for multiple visits.

You should know that for billing purposes there really is no such thing as a one surface filling when the decay is located between teeth. You will always be charged for two surfaces if the doc has to go in from the top (occlusal surface) to reach the decay on the mesial or distal surface of a tooth. So, even though you have ten cavities you will be billed for 20 fillings! 😱

 

[beastmaster]

Appreciate all the responses.

What are the disadvantages for long-term tooth health in the doc going aggressively after interproximal lesions when perhaps it could be debatable if it is necessary. Can it do more harm than good is what I'm asking.

As far as multiple visits, he said it would take 3-4.

 

[airvent]

Chances are that those interproximal lesions will need to be filled eventually. Waiting until you really REALLY need the work is not the best policy. You can ask your current dentist if you can wait on the fillings. He may decide to wait and watch. Dentistry is also part prevention. Depending on your own Dental hygeine fillings may be the smart thing to do.

 

[toofache32]

I would get it done now unless you're really motivated and will really get xrays every 6-12 months to follow for changes. Also, a more conservative treatment (filling) can be done now, while something more drastic may have to be done if you wait (crown). It's kind of like "you can take insulin now or dialysis later."

 

[predentchick]

Can it do more harm than good is what I'm asking.

YES! If you don't get them taken care of, then you WILL have pulpal involvement (ie... root canal). The sooner the better because even the most disciplined person can lose (most do) when it comes to the remineralization game (turning the decay back into mineralized tooth by great hygiene, xylitol, etc without getting it filled).

 

[12YearOldKid]

There's a lot that goes through the dentist's mind when deciding to drill or not. If a 50 yr old patient walks in with one or two small interproximal lesions (cavities in between your teeth), good oral hygiene, only a few previous restorations - more than likely the dentist is going to just "watch" those. On the other hand, if a 25 yr old med student comes in with those same interproximal lesions, bad hygiene, sips mountain dew all night to keep him up studying, a dozen previous restorations -- there's going to be some enamel flying.

But yes, more cavities are typically found on x-rays than during the visual exam.

 

[12YearOldKid]

One thing to mention is if these teeth with the interproximal decay are the same as the ones with the occlusal decay, then a porcelain inlay MIGHT be needed. These tend to be expensive since they are a lab manufactured product. If your IP/Top Surface decay is significant then this MIGHT be suggested. These range in the $700 area whereas a 3 surface filling is around 250ish.But I'm sure the Dr. would have brought this up if it was a concern on your treatment plan.

I like your online treatment planning. Actually, he'll probably need endo, core buildup, crown lengthening, and PFMs on all those teeth. Several of them will fail within the year so he might as well plan on 3 or 4 surgical extractions, some bone grafting, implant surgery and implant crowns too.

... although those of us with more than nine months of dental school under our belt are probably leaning towards some good old fashioned silver fillings. 😀

 

[aphistis]

I like your online treatment planning. Actually, he'll probably need endo, core buildup, crown lengthening, and PFMs on all those teeth. Several of them will fail within the year so he might as well plan on 3 or 4 surgical extractions, some bone grafting, implant surgery and implant crowns too.

... although those of us with more than nine months of dental school under our belt are probably leaning towards some good old fashioned silver fillings. 😀

You forgot the orthognathic surgery, fool! 😀

 

[predentchick]

I like your online treatment planning. Actually, he'll probably need endo, core buildup, crown lengthening, and PFMs on all those teeth. Several of them will fail within the year so he might as well plan on 3 or 4 surgical extractions, some bone grafting, implant surgery and implant crowns too.

... although those of us with more than nine months of dental school under our belt are probably leaning towards some good old fashioned silver fillings. 😀

What the hell? There is nothing wrong with my explanation. I don't need to explain my work history with someone who posts comments like that. Troll.

 

[drhobie7]

By and large, what was said here was correct. You should keep in mind that most people replying are 1st, 2nd, and (maybe) a few 3rd year dental students. Are there any 4th years in the house? While we do know quite a bit at this stage, our knowledge is not equal to that of a practicing dentist.

It's difficult to say anything meaningful without conducting a full oral examination with radiographs. I would not feel comfortable recommending specific restorative materials such as ceramic ("porcelain") without knowing your occlusion. The best restoration for you could be amalgam, composite, gold, ceramic, or none at all. When used as indicated and done properly, each of these treatment options is excellent and will last a very long time.

If you are concerned about being taken advantage of by a clinician (and I don't think you should be because dentists generally have plenty of work and are honest) you can seek a referral from the restorative dentistry chairpersons at Columbia or NYU.

 

[beastmaster]

What the hell? There is nothing wrong with my explanation. I don't need to explain my work history with someone who posts comments like that. Troll.

Don't be offended. I'm sure he was only teasing (the sarcasm is clearly a gag on 'medical student syndrome').

Thanks for all the responses.

 

[predentchick]

Don't be offended. I'm sure he was only teasing (the sarcasm is clearly a gag on 'medical student syndrome').

Thanks for all the responses.

I guess. Its just hella annoying! I mean come on people. Since when is an inlay not a possible treatment option when there is IP and O decay? We don't know how deep this decay is. We haven't seen the pt's radiographs. I was throwing around tx options that may be brought up at a second opinion IF this is an appropriate route. Some people just love to put out the "I know so much more than anyone else cause I am a DS-whatever." Get over it.

 

[aphistis]

I guess. Its just hella annoying! I mean come on people. Since when is an inlay not a possible treatment option when there is IP and O decay? We don't know how deep this decay is. We haven't seen the pt's radiographs. I was throwing around tx options that may be brought up at a second opinion IF this is an appropriate route. Some people just love to put out the "I know so much more than anyone else cause I am a DS-whatever." Get over it.

You know, you're the only one who's still hanging on to this. Who needs to get over it, now?

And, like it or not, nobody knows jack after one year of dental school. You don't, I didn't, and 12YOK didn't. Don't get so worked up about it.

 

[ISU_Steve]

Tangent (not really applicable here):

If only I had a nickel for every patient that said, "There was nothing wrong with my teeth and they never bother me but this dentist said I need a bunch of fillings. Does he just want my money?"

If your PCP tells you that you have hypertension, nobody says "he just wants my money." Hypertension doesn't hurt either and most people don't know they have it until someone tells them it's there.

OK, I'm done.

Damn, I'll have to remember that one Toof.

 

[predentchick]

You know, you're the only one who's still hanging on to this. Who needs to get over it, now?

And, like it or not, nobody knows jack after one year of dental school. You don't, I didn't, and 12YOK didn't. Don't get so worked up about it.

Remember your OWN sig quote when you run your mouth.

 

[drhobie7]

Remember your OWN sig quote when you run your mouth.

Um, are you calling yourself an idiot?

 

[aphistis]

Um, are you calling yourself an idiot?

You might want to retype that in one-syllable words.

It *is* pretty entertaining, though, how often people try to throw my signature back in my face without any idea what they're declaring about themselves.

 

[predentchick]

When people throw his sig in his face we are pointing out that HE thinks we are "idiots", yet he takes the time to single me/us and start running his mouth. Notice a pattern? He even admits it happens more than once. People wouldn't throw it back at ya if you didn't have it there when you're doing exactly that. No more posts from me on this thread. Not worth my time.

 

[aphistis]

When people throw his sig in his face we are pointing out that HE thinks we are "idiots", yet he takes the time to single me/us and start running his mouth. Notice a pattern? He even admits it happens more than once. People wouldn't throw it back at ya if you didn't have it there when you're doing exactly that. No more posts from me on this thread. Not worth my time.

Really? Just where did I call you an idiot, now? See, the way *I* remember this thread, I went out of my way to mention that everybody spends time in the position you're in, and that it's not a unique, personal failing of yours, in response to which you flew positively off the hook. So does that make me an...

"idiot"

...or maybe a...

Troll.

...or could it mean that maybe, just maybe, I'm not the source of the problem here?

 

[gryffindor]

Since when is an inlay not a possible treatment option when there is IP and O decay?

When the patient can't afford it. In that case, you do a really big filling.

 

[jmill0]

I've done ZERO inlays since boards. Don't plan on doing one again either. Sure, they're nice, but there's no insurance company that will pay for an inlay when a Class II restoration will work. You can sit and do them all day long until your insurance company downgrades it to an amalgam or (if you're lucky) a composite and you're stuck holding the lab bill for all that work. Don't plan on getting that from the patient either. They'll just want to know why you didn't do the fillings in the first place.

Show up to your patient with a treatment plan of $10000 to fix 10 Class II lesions and they'll be out the door down at the next guy getting the $1500 composites done.

Treatment plan them that way if you want, I'll be happy to take the $1500.....

JMHO

 

[DrJeff]

I've done ZERO inlays since boards. Don't plan on doing one again either. Sure, they're nice, but there's no insurance company that will pay for an inlay when a Class II restoration will work. You can sit and do them all day long until your insurance company downgrades it to an amalgam or (if you're lucky) a composite and you're stuck holding the lab bill for all that work. Don't plan on getting that from the patient either. They'll just want to know why you didn't do the fillings in the first place.

Show up to your patient with a treatment plan of $10000 to fix 10 Class II lesions and they'll be out the door down at the next guy getting the $1500 composites done.

Treatment plan them that way if you want, I'll be happy to take the $1500.....

JMHO

Alot of truth to this post. I've done a number of inlays in private practice, but to be honest with you, I end up doing way more of the BOF's (Big 'ol fillings) and full cverage crowns that inlays/onlays.

For example, I have 4 new patients in the last month whose caes really stick out in my mind over all the others. First off, they're all between the ages of 17 and 23, and they are absolutely loaded with decay. One of them is 17 and has decay in 26 of his 27 present teeth(somehow #25 is decay free 🙄 ), another on is 17 and has decay in 10 teeth, and the second one's older sibling is 19 and has 18 decayed teeth. The last one who I saw today is 23 and matched his age with 23 carious lesions 😱 . Out of the 4 patients and 77 carious teeth, if memory serves me correctly I'll be doing endos on atleast 7 of them, and then of the remaining 70 teeth, I could justify 15 to 20 inlays/onlays. But in this situation where I'm already talking treatment plans between $1600 and $8000(conservatively) already, I'd love to do in the inalys/onlays, but actually treating these teeth and not running up such a huge balance their accounts that could potentailly end up written off as uncolllectable debt is more important to me.

In my personal experience, I'm way more likely to have the patient agree to an inlay/onlay when I'm looking at having to a single tooth. I'm also now seeing clinically that I can very often place a direct composite with result just as good as an indirect restoration that 3 and 4 years out are functioning and looking just as good

 

[UConn_SDM]

I don't think composite preps are that much more conservative.

I completely disagree. There are times when a composite prep will look similar to an Ag prep but how can simply doing CR not be considerably more conservative than having to go into dentin on the occlusal, breaking contact around box, and adding retention?

I've seen many class II lesions on premolars that mesially and distally only required a slot prep interproximally and some composite be turned into MOD Ags buildups for a crown.

 

[drhobie7]

I was under the impression that composite was as conservative as it gets. Definitely more than amalgam and definitely more than an inlay. Are we still talking about inlays? I like ggggooooooooollllllllllllllllllllldddddddddddddd. (That was a reference from Austin Powers Goldmember). 🙂

 

[beastmaster]

*** CAVITY UPDATE from OP ***

So I went back to the dentist for the fillings and she decided to do the right side of my mouth (4 of the 10 cavities, 3 bottom 1 top). Here's some random thoughts (in case anyone might be curious!)

- I saw an elongated/pyrmidal wooden stick and some "clampy" metallics so I presume there was at least one cII restoration (perhaps exactly 1). Two shots of anesthetic and I didn't feel a thing. Entire procedure lasted 30 minutes.

- Anesthetic wore off exactly 3.5 hours later, over about 15 minutes while I was watching poker on TV.

- Had a nasty headache in the evening, but woke up fine.

- She said one tooth was "deep" and she gave it "a lot of medicine," explaining that it would have heightened sensitivity for weeks. 16 hours later, I'm drinking my cold drinks (it's hot) with a straw as indeed the tooth (#31 I think) is very sensitive. I wonder what is causing this.

- Coworkers think I'm crazy, drinking everything with a straw. They are calling me straw man.

- I heard the word analgam used but the fillings looks dark whitish.

- As I rub my tongue over one of the teeth (one of the bicuspid premolars I believe it is) it feels super sharp. When I look at it in the mirror with a flashlight it seems as if there is a narrow hole in it from the top (think sci-fi movie where the ground starts splitting in half and moving apart). As if the fillings fell out and left a gaping hole. Not sure what to make of this one, will ask about it during the next visit. The tooth itself feels fine, but I sure wouldn't want foodstuff getting stuck in there...

- Rinsed my mouth before bed and a few minor bits of silver looking chunks would end up in the sink. Probably residuals from the fillings that the nurse failed to suction off. Didn't think too much of this.

- Didn't eat last night, just drank my protein shake with a straw. Didn't brush this morning, just rinsed with water and protein shake with straw. Will have first meal in a few hours -- I brought spaghetti with some garlic and sauce, which I will eat while listening to Italian music. Will probably still chew with my other side out of paranoia.

 

[DcS]

When the patient can't afford it. In that case, you do a really big filling.

PDC asked when it was not a treatment "option", not the only treatment offered. Regardless of your perceptions of your patient's ability to pay for treatment, it's technically against the law if you don't at least offer all available treatment options (which, in this case includes an inlay). It's the same as offering no treatment at all. Of course none of us will endorse that, but you still have to present the patient with that option.

 

[drhobie7]

Hey there,
When drilling close to the pulp (center of tooth where the nerves and vessels are) you can irritate the nerves. There's probably a mild inflammation of the pulp that follows. Nerves are picky little buggers. They don't like being bothered and it takes them a while to settle down and get back to normal. The nerves in your tooth will be hyperresponsive for a few days. They've got all these inflammatory mediators around them that are making them excited. Interestingly, pupal nerves only yield the sensation of pain regardless of the stimulus.

Regarding the loose amalgam in your mouth afterwards. I guess it's not a big deal, but it could have been prevented by using a rubber dam.

As for the hole and sharp thing, beats me. I'd have your dentist take a look at that. Take care.

 

[toofache32]

Regarding the loose amalgam in your mouth afterwards. I guess it's not a big deal, but it could have been prevented by using a rubber dam.

As for the hole and sharp thing, beats me. I'd have your dentist take a look at that. Take care.

Am I the only one here putting these 2 things together as maybe being the same problem?

Just trying to invoke Occam's Razor.

 

[drhobie7]

Am I the only one here putting these 2 things together as maybe being the same problem?

Wow, that'd be bad if the acutal amalgam filling was what he felt in his mouth! Um, I guess I just assumed a practicing dentist would know enough about retention form to make sure the amalgam would stay in place. Definitely possible, but I hope it's from miscellaneous amalgam debris during condensation/carving.

 

[DrJeff]

The likely explanation (of course I've NEVER seen any of this in my patients before 😉 ), is the extra amalgam was exactly that, just residual pieces that were "hiding" from the assistants hi-vac suction either under the tongue and/or way up/down in the vestibules. The sharp edge/gap is likely a sign of an amalgam fill just short of the cavo-surface margin, and as long as that edge is in enamel only, a quick pass or 2 with a sand paper disc is all that's need to keep the tongue happy when it explores over there. The other possibilty is that while still anesthetized, some grinding around on that tooth caused a small fracture of the amalgam likely around the cavo-surface marging and/or the marginal ridge. If this is the case, the restoration may need to be replaced.

All I can tell the restorative dental folks on this board is if either of these sceanrios haven't happened to you yet, they will 😱 😀