Straight to root canal?

[AmitC]

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I attend a university with a world-class dental school. Students of this university get discounted dental treatment from post-graduate fellows.

In January 2004 one of these dentists did a filling on a side surface of #3 (adjacent to #4) that, upon drilling, proved deeper than it seemed on the x-ray. "I see pink already," she warned as she drilled, but eventually was able to but in a base and composite filling without touching the pulp. By September, however, an x-ray showed fresh decay had begun BENEATH that filling on #3. I was told this came to within 2 mm of the pulp, but it's impossible to tell exactly without opening it up. Clearly, the composite didn't hold up, or it wasn't put in quite right.

Now they want to open up, take out the failed composite filling, and put in amalgam, with warnings of a high likelihood of hitting the pulp, emergency root canal, and a trip to the endodontist. Given how much of the tooth they're going to have to take out to fill it with amalgam going so close to the pulp, are all these steps even worth it? Shouldn't I just put up my hands and say, "I surrender -- let's just go straight to the endo"?

I mean, she saw pink just setting up the composite restoration. Doesn't that guarantee they'll hit the pulp the next time around?

Thanks.

 

[DcS]

I don't think it's worth it to just give it up. What I do question is her choice to put a resin on something that close to the pulp, fully knowing leakage and polymerization shrinkage. This is a whole separate topic, but is a good example of why I think offices with no amalgam whatsoever is failing to provide proper standard of care. Trust me, I love and use resin as much as I possibly can, but there are just some situations where they absolutely are not the best treatment. In a case such as yours with encroachment of the pulp, I personally would not have felt comfortable placing a resin there for the exact outcome...the possibility of recurrent decay close to the pulp. If anything, why not place amalgam and let it rest for a little bit to see how the pulp reacts. If things look good in 6 ms or a year, then replace it with composite. If I were you, let them open it up and take a look, hopefully they can place medicament, get a GOOD seal with amalgam and let some reparative dentin form. Time will tell but I would not surrender just yet.

Any other thoughts in general about the whole "amalgam-free" office?

 

[AmitC]

Wow, you guys are quick! Thanks a ton. Here's the ironic thing: Before I lay down, she said the size of the filling required amalgam. When she saw its depth, oddly, that's when she switched to the base + resin!

I'm going to try and ask the department if, because of this "mistake," they'll help me cover the cost of any resultant root canal.

Thanks again.

 

[DcS]

Wow, you guys are quick! Thanks a ton. Here's the ironic thing: Before I lay down, she said the size of the filling required amalgam. When she saw its depth, oddly, that's when she switched to the base + resin!

I'm going to try and ask the department if, because of this "mistake," they'll help me cover the cost of any resultant root canal.

Thanks again.

It's not necessarily a "mistake", it certainly is a valid treatment. Now had she put an IRM in there and left it as a permanent restoration, now that is a different story. I think you'll probably hit a dead-end as far as that goes, but questioning for "learning" purposes might be the better approach.

 

[Blue Tooth]

Having been down this road enough times already, I'm in favor of doing the prophylactic endo. I agree with DcS in that that's one reasonable way to go, but II'm being a bit more pessimistic here. hIt's highly likely that at some point in your life the tooth is going to go devital and need the endo anyway (I'm guessing that you're a lot closer to 20 than 50). So I'd say do it now. Also, considering that you have recurrent decay 9 months post-op, there's something else going on. Sure there's potential problems with polymerization shrinkage and having an open margin, but don't forget that you're doing something to feed the bacteria and not cleaning them out so they can get into the margin. So put down the mountain dew, and pick up some floss.

Another option is to do a keyhold preparation from the lingual. That way you leave the old restoration in and just remove the decayed area. It's worth considering.

 

[DcS]

Another option is to do a keyhold preparation from the lingual. That way you leave the old restoration in and just remove the decayed area. It's worth considering.

Is that approach taught at Mich?

Good points as far as the preventative endo is concerned.

 

[AmitC]

Yup, I'm 29, which is why I too was convinced it would have to be done at some point. No Mountain Dew, really, and I do floss nightly, use a Braun/Oral-B electric toothbrush, and even apply Oral-B's Rx-strength stannous fluoride 0.4% in gel form (though I'm much less disciplined with that than I should be). Bottom line, I seem to be prone to decay between the teeth. It's rather frustrating, really.

Thanks for your opinions. I'll be asking the dentist better questions as a result.

 

[Blue Tooth]

Yeah we're taught the keyhole but you hardly ever do it. I think I've only done it once. As for the recurrent decay, there's always room to "blame" the patient for inadequte oral hygeine. Even though you say you're flossing you might not be doing it right. Then again, the dentist could have just as easily left decay or an open margin.

 

[1-16-17-32]

By September, however, an x-ray showed fresh decay had begun BENEATH that filling on #3. I was told this came to within 2 mm of the pulp, but it's impossible to tell exactly without opening it up.

Something doesn't add up. If she was able to "see pink" when she was drilling originally, she was closer than 2 mm to the pulp at that point. Then why would the x-ray show new decay that is within 2 mm of the pulp? The original decay which should have been removed would already have been that close to the pulp.

 

[AmitC]

Because these are post-grad fellows, as soon as one graduates, you get another. The one who did the initial filling wasn't the one who later looked at the x-ray. The way the later doctor explained it to me was that it *looks* like a 2 mm distance, but that when it's that close, the pictures have limitations and can often conceal decay that is *already* at the pulp. Does that sound right?

Alternatively, couldn't it be that the portion of the flawed filling that hit up against pink is still fine, but the new decay is about 2 mm away? The reason they've given me for why there's risk of hitting pulp is that to get at the new decay, they need to take out all of the old filling and do it over again with amalgam.