To pull or not to pull that is the question.

[pumpkins90]

Hello dental students,

I am starting dental school this fall, but i need some current students advice since i am uneducated at this point in time. I have an infected #2 tooth. The dentist told me i could either get a root canal and a crown done to save the tooth which would cost 1500-2000 dollars, or i could have it pulled for 130 dollars. He said he didn't know if it was worth the trouble to save it and if it was him he would have it pulled. I need to know how significant this tooth is. Can i live without it and how would it affect my everyday chewing. I really don't have the means to spend the money to save the tooth, but i hate the thought of loosing the tooth at 27. Any advice would be appreciated.

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[Yah-E]

Pumpkin:

It really depends on if you're willing to fork out the $$! My suggestion is this, I'm assuming the you had your #1 (3rd molar) extracted already and if you extract #2, then your lower right molar(s) will become non-functional (no opposing teeth to function with). You'll loose a big portion of your right chewing side.

At a young age, if you still have good supporting bone tissue, then I would try to save the tooth. If money is an issue, maybe you should try your dental school's Endo services by Post-doctoral residents and have a Pre-doctoral upper classmen make the crown for you. This should bring the price down.

I say save the tooth if you have the periodontium to support it!

 

[Meggs]

hey pumpkin, if you still got your #1, then the damage will be less if #2 gets extracted. But if you don't have your third molar, then by all means, try to get #2 saved. YahE's suggestion about going to a dental school is a pretty good one. Good Luck!

 

[pumpkins90]

No i haven't had my #1 extracted or any teeth extracted at this point. I was also told that if i had my #2 removed that my wisdom tooth may move slightly into some of the space, but he said there was no guarantee. I think i'm really leaning towards having it removed because i could end up spending all of this money and could still have to have it removed anyway someday.

 

[Meggs]

Originally posted by pumpkins90
No i haven't had my #1 extracted or any teeth extracted at this point. I was also told that if i had my #2 removed that my wisdom tooth may move slightly into some of the space, but he said there was no guarantee. I think i'm really leaning towards having it removed because i could end up spending all of this money and could still have to have it removed anyway someday.

Yes, the third molar will move at leat a bit towards mesial. But "someday" is not the same as today, when you're 27 years old. "Someday" might take years to come. Good luck.

 

[Frank Cavitation]

extracting your 2nd molar can have the following possible bad outcomes:
wisdom tooth becomes tipped and problematic
lower teeth overerupt leading to traumatic occlusion

these have the effect of reduced chewing/speech ability, periodontal problems and increased difficulty in cleaning. Yes, as previously mentioned these kinds of problems do not arise immediately but I believe once it happens it will be hard to stop.

Root canals and crowns do not have 100% success rate. Depending on the situation and the dentist, it may fail, become carious and/or reinfected and your money is down the drain. Of course this percentage is low, but definitely not inconsequential.

Another thing is to consider why you lost that tooth. Your treatment goals should take into account whether a bunch of your other teeth also have the same risk of getting infected.

If structurally sound, I think from best to worst the sequence is:
Endo+crown > implant > bridge > removable > hole.

I put implants in front of bridge because there is no gross reduction of adjacent teeth or alveolar bone loss of the pontic. Maybe if the endo needed post&core the prognosis is worse than implant?

 

[LateComer]

Save your tooth. Otherwise, you may have to do the bridges or implant that even cost you more. If you leave a hole there, you will end up with all kinds of problem that Frank has mentioned. Plus you may need an ortho later if the hole cause a dramatic effect of moving of the remaining teeth. That cost you more.

There is another way to make both ends meet. Ask your dentist to do a root canal and just an Almagam fillings instead of doing a crown. That can save you half. If your dentist does not want to do the fillings, go and check out with other dentists, especially the one that accepts Medical, they may do it for you.

 

[DrJeff]

Pros vs. Cons of saving vs extracted, they've all been well articulated so far, but one real question you need to ask yourself before you make the final descision, is how did it get infected? If it was a straight situation of decay(caries) then you have to look at your diet and also your decay risk on your other teeth since you may be inline for some more restorative work. Was the infection due to a fracture of the tooth and subsequent bacterial invasion/infection of the pulp(nerve/vasculature) of the tooth? I'd seriously bet that it was one of these 2 etiologies(likely caries), since they'll account for 95+ percent of all tooth based infections.

If it's decay, then you will have to make dietary changes(read that statement as reduction your daily sugar exposure to a limited few, get rid of the sugar in the coffee/tea(use equal instead), drink diet rather than regular soda(still not great but better than sugared), chew sugarless gum, not the real stuff, and stop sucking on peppermints/butterscoth candies. If it is decay and you decide to save the tooth, you'll be more at risk of having secondary decay around the final retsoration which will make it more prone to fracture and failure. I can tell you that most of my patients that have "failed root canals" will have the failure occur not due to re-infection of the root canal, but due to their inability to stop the very habits that caused the problem in the first place. If you're one of these folks, get your tooth extracted now, save your money and get an implant within the next year or 2. Since the implant is titanium and the crown is a combination of metal and ceramic, you can't decay it.

Whatever you do, use this a learning experience, not only for why it happened and how to prevent it, but whatever treatment modality you choose, experience it to the fullest, remember what each part of the proceedure is like, and you'll have a great adavntage at being able to tell your future patients what it is like to have it done. I can tell you, that I've had many more patients opt for implant restorations ince I had mine done about 1 year ago and when I'm explaining it to them and I can pull back my cheek and say "look at this tooth, it's an implant, and here's how it felt when I had it done....." Case sold, here comes the titanium, please pay on the way out.

 

[ddstothecor]

DrJeff--Do you do your own implants, or do you refer out to the prosthodontist?

 

[DrJeff]

Originally posted by ddstothecor
DrJeff--Do you do your own implants, or do you refer out to the prosthodontist?

I restore my own implants, but have an area oral surgeon do the placement for me.

With proper occlussal analysis and a surgical stent fabrication prior to placement surgery, implant dentistry is actually easier and quicker than standard crown and bridge. I also have the utmost faith in the surgeon I use(heck I've got 1 piece of his titanium in my mouth and I'll be adding a second later this summer). If he sees that the bone isn't there to place the implant where I need it to restore it properly, he's grafting/ augmenting bone and not just placing it wherever he wants to put it. With the system I'm using(ITI), my part of it is as simple as removing the transmucosal healing abutment, snaping an impression coping onto the implant body, taking a final crown and bridge impression(the coping comes off in the impression) and then torqueing the abutment onto the implant and quickly relining a pre-made temporary crown(Literally 20 minutes start to finish and most of that is getting the temporary relined and cemented)

The problem and expense with implant dentistry is when the implant is placed in the wrong location/wrong angulation, then a custom abutment(lab bill of $100-300 ) is often needed verses a standard abutment(normal cost of $25 to 50+ )

In my residency I placed about 20 implants(most of them edentulous cases for overdentures on 2 or 3 mandibular posterior 1 tooth replacements). It's not a difficult procedure, granted I wouldn't do any sinus lifts/rib grafts prior to placement, but it really isn't much more difficult than say prepping a crown or doing a rotary endo. My partner and I look at it this way, ultimately who would be better for our patients, us doing 75-100 a year with no IV sedation license for patient comfort, or the surgeon who does 600+ a year and can sedate?? Really a no-brainer in our book.

 

[ddstothecor]

I find it interesting that you refer to an oral surgeon. Do prosthodontists install implants also? If they do, do they procure sedation for the patient? If not is that why you send the patient to the OMFS instead?

 

[LateComer]

Personally, I think placing an implant is even easier and less time consuming then doing an endo on a molar tooth. However, a successful implant that can last many years without losing it due to bone absorption is a little bit more tricky.


Implant is good where it has a good solid support of bone. Otherwise, it needs to have a bone graft before placing an implant. If you're going to have an implant on #2, it's very likely you need to have a bone graft in the sinus around that area, i.d., sinus lift. It will take several months upto a year for the graft generating the bone before an implant can be placed. Due to extra cost of possible sinus lift plus the implant itself, it's a good way to go if time and $$ is not your concern.

 

[DrJeff]

Originally posted by ddstothecor
I find it interesting that you refer to an oral surgeon. Do prosthodontists install implants also? If they do, do they procure sedation for the patient? If not is that why you send the patient to the OMFS instead?

Any licensed dentist is allowed to place implants. Most of them (sheer volume of the numbers placed) are placed by the GP's, Oral Surgeons, and Periodontists. Many prosthodontists, and even some endodontists will place them, and about the only fields where you won't see the docs placing them are pedodontists, and orthodontists(all though I suppose that a few orthodontists may place them for palatal anchorage situations.

The sedation issue, atleast in my circumstance, is based on what offer it would do to my malpractice insurance premiums. I'm eligible to obtain my IV sedation certificate, I've taken the didactic portion, I've done the requisit # of cases under supervision, I have my ACLS certification. I don't want to pay the extra $10-15,000 that my yearly malpractice insurance premiums would be(to put it in perspective, my premium is currently just over $2000). I also look at iut from the standpoint of how many patients would I really use the sedation ability, and do I really want to attract the type of patient that typically wants sedation on a regular basis(i.e. very nervous, typically in moderate to severe dental neglect, and often with some psychological issues). I can say that after having an implant placed in my owm mouth, that most folks won't need sedation for this procedure, however my tolerance for the procedure may be very different than some of my patients, so i want them to have the option for sedation if they so desire. Rarely(I'm talking twice in the last 4 years) I've used the services of a dental anesthesiologist how came to my office and administered the IV sedation to my patient while I did the dentistry. I like sedation in certain circumstances, I just don't personally want to deal with the extra expenses and issues that surround it.

 

[pumpkins90]

I just wanted to thank everyone for their useful information. I will take everything into careful consideration before making my final decision.