 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / General / Dentistry / August 2006Two dental puzzles...
I have two dental puzzles that different dentists have given me conflicting advice about. I suspect some combination of selling what they can do, not seeing the entire picture, CYA (Cover Your a.s), adherence to (dysfunctional) "standard practice", etc., etc. I am looking to the best and most appropriate long-term solutions and NOT what is "standard (CYA) practice", in other words, what would YOU do if this was YOUR tooth, and NOT what you would recommend to a patient. As with most other people, my financial resources ARE limited, though I have crummy Delta Dental coverage and live near the Mexican border so I can get ordinary procedures performed inexpensively. Puzzle #1: My lower right first molar is abscessed. It has apparently been so for a long time - looking bad on a 2-year-old X-ray. It has previously had a root canal and has a pin going into one of the roots - the one that looks the worst on a recent X-ray (with part of the tip of the root being eaten away), though all of the roots appear abscessed with darkened regions around them on the X-ray. At present, the tooth is firmly in place with no pain, though it did hurt a couple of weeks ago and had risen very slightly at that time. My endodontist is ready to charge in and retreat the tooth, replace the pin, etc., (for ~$2k), but my Mexican dentist advises against this procedure because of a combination of low success rate and the risk of spreading infection even if retreatment is "successful" and an even greater risks if it is unsuccessful. Complicating this is the next tooth over on the upper is broken off (see Puzzle #2), so that with both of these teeth missing my chewing will be seriously impaired on my right side. Also, I now have no shortage of strange heartbeat anomalies, some of which are "understood" and are probably benign, while others have been a continuing mystery, which might be blamed on a dental infection. Of course, the decision as to what to do is based on probabilities and costs. The costs are all too well known, but I really have no idea what the probabilities are. Can you help here? Puzzle #2: Like just about everyone else I know, I have a couple of broken-off teeth, that for various reasons were not suitable for crowning without extreme (read that "expensive") measures (root canal, pins, buildup, etc.), that my meager budget just wouldn't support at that time. They are tightly in place and not super-erupted. My Mexican dentist advises me that my gums have since receded around them and they are now unrecoverable - and is drooling over the prospect of installing bridgework for ~$1,200 each, or better yet, implants for about double that price. Some of the adjacent teeth are NOT crowned but have been extensively and deeply amalgamed, so I suspect problems in crowning them to install a bridge. Also, one of the adjacent teeth is a good incisor that I would sure hate to lose to a crown. What would seem reasonable to me (no, I am NOT a dentist, but I AM an engineer), would be to build up a rounded conical "nub" onto each of these broken teeth that would be high enough to engage the opposing tooth, but would NOT hang off to the sides to dislodge it from the tooth when biting down on something hard, so that no pins, etc., would be needed to secure it. In one case, the opposing tooth is an all-gold crown that would almost certainly be completely beyond any possibility of being damaged by this. This is somewhat reminiscent of the aboriginal tribes that chip the corners off of their teeth to look fierce, only in my case it would be built-up material instead of original tooth. This wouldn't look quite like original equipment, but these aren't front teeth. This wouldn't work quite as well as original equipment, but it would put these teeth back into at least partial service and hopefully preserve them for some decade in the future when some other solution might be more appropriate, e.g. when the adjacent teeth need crowns for other reasons, when my rich uncle dies and leaved me enough to install implants, etc. Certainly, this would be better than simply leaving them as they are to continue erupting, receding, etc. I have had my fill of "professional advice"!! What I appear to need now are ideas, suggestions, thoughts, experiences, or ~$20K to use traditional methods if your piggy bank happens to be overflowing. What do you think? Thanks in advance for your thoughts. Steve Richfie1d It's hard to tell without looking at them; if you could post xrays of the teeth in question it would be a great help. Puzzle 1: It all depends on how badly you want to save that tooth. Ask your endodontist to eyeball what the approximate chance of success would be in his opinion, considering all the complicating factors. You need to know not only if the root canal has a good chance of working, but also how easy it would be to restore the tooth to it former shape and function afterwards. Then you can weight this info with how much it's going to cost you and how desperate you are for keeping that tooth and take a decision. Puzzle 2: It's not going to work. You will not gain anything and you might end up with more damage. Back teeth have that flat shape for a reason, they are designed to crush food. What you want to do is give them an unnatural shape and an unnatural function. If these teeth are truly unrestorable as you've said, there is no patch-up material that will stay there for the long term and even if it did the design you have in mind would not improve your masticatory ability. On the contrary, a poor design might lead to problems like food impaction threatening the wellbeing of adjacent teeth. Regards, George Thanks for your comments. I have some subsequent questions: > It's hard to tell without looking at them; if you could post xrays of > the teeth in question it would be a great help. I don't think we are allowed to post attachments, but I have a scanner that is supposed to be able to scan slides. I'll see if I can get it to work on the X-rays and email them to you if I am successful. > Puzzle 1: It all depends on how badly you want to save that tooth. Ask > your endodontist to eyeball what the approximate chance of success [quoted text clipped - 4 lines] > it's going to cost you and how desperate you are for keeping that tooth > and take a decision. Another factor that has my great interest is the effects of infection on my heart and other organs. I already have a variety of heart beat anomalies, some of which would seem to be consistent with some sort of infection, e.g. if I eat a bunch of sugar, then maybe 12 hours later (when my immune system has had a chance to be depressed by the sugar) I experience some atrial fibrillation. Of course there are other potential explanations, but there may be some major risks in "screwing around" with this, especially in my case. On a related note, a decade or so ago I attended a lecture where the speaker was recommending extracting ALL infected teeth! His explanation was that it was ever so easy for residual infection to escape detection, and in the process do long-term damage throughout the body. While this sounds a bit extreme to me, extracting teeth where simple root canals have failed seems more reasonable. Do you have any thoughts on this? > Puzzle 2: It's not going to work. You will not gain anything and you > might end up with more damage. Back teeth have that flat shape for a > reason, they are designed to crush food. These are both small top teeth - one just behind my left incisor, and the other is on the opposite side one tooth further back. In short, these are both small single-rooted teeth. My goal here was not so much to improve mastication, but rather to simply preserve the teeth and gums for possible rehabilitation sometime in the distant future when their neighbors have been lost, must be crowned, etc. > What you want to do is give > them an unnatural shape and an unnatural function. Yes - an unnatural shape but the only function is to preserve them indefinitely into the future. > If these teeth are > truly unrestorable as you've said, Not COMPLETELY unrestorable - one dentist gave me a $4K estimate for each with no guarantees. They aren't worth that when I still have most of my other teeth, but this situation could be VERY different in another 20 years. However, if I simply leave them as they are, they will probably either decay away or erupt in that time. Both still have their roots. What I am looking for is really a in-mouth STORAGE plan. > there is no patch-up material that > will stay there for the long term and even if it did the design you > have in mind would not improve your masticatory ability. On the > contrary, a poor design might lead to problems like food impaction > threatening the wellbeing of adjacent teeth. The obvious question then is: "What would a good design look like?" Any thoughts? This all brings up my primary beef with "modern" dentistry. Their goals are NOT my goals! My goal is to live a long life and eventually die with enough teeth to still chew fairly efficiently, whereas "modern" dentistry seeks to provide a 20 year solution (way too short) that looks pretty (when I don't). My most recent "failure" died 15 years after heroic efforts to save it. I suspect that most dentists would consider that a success, but that is just another tooth that I won't be dying with. Most dentists won't even fill a wisdom tooth, despite these being very effective anchors when 2nd molars are lost sometime in the future. To accomplish this very long term goal, I suspect that in-mouth "storage" of severely damaged teeth would be an effective tool. This would certainly be better than pulling and bridging them given the limited life expectancies of bridges and crowned teeth. Also, there are good bridging situations (e.g. where the adjacent teeth must be crowned) and poor bridging situations (e.g. where the adjacent teeth are still sound). Why not simply wait for the right situation? Also, the optimal restoration of often a function of what is happening with adjacent teeth, and this could radically change in the future. At the rate that I am now going, I will probably need a bunch of implants in another 20 years or so. However, I would like to put that off for as long as possible. Who knows, maybe I will be planted tomorrow with my present teeth! I would much rather enrich my kids than enrich my dentist. Thanks again for your comments. Steve Richfie1d > Thanks for your comments. I have some subsequent questions: > > I don't think we are allowed to post attachments, but I have a scanner > that is supposed to be able to scan slides. I'll see if I can get it to > work on the X-rays and email them to you if I am successful. You could post them somewhere on the Net, like one of these sites who offer image hosting (tinypic for example), and then post the link here. This way every dentist here will be able to see them and comment on them. > On a related note, a decade or so ago I attended a lecture where the > speaker was recommending extracting ALL infected teeth! His explanation > was that it was ever so easy for residual infection to escape detection, > and in the process do long-term damage throughout the body. While this > sounds a bit extreme to me, extracting teeth where simple root canals > have failed seems more reasonable. Do you have any thoughts on this? The speaker was probably a "biological" dentist relying on the focal infection theory that was discredited 70 years ago. If a RCT has failed, extraction of the tooth is certainly a viable option, but retreatment may also work. I wouldn't worry much about distant locations in the body becoming affected by infected teeth. To put this another way: there are people who have chronic ear infections or chronic problems with their sinuses, but noone has ever recommended they remove their ears or sinuses. > Yes - an unnatural shape but the only function is to preserve them > indefinitely into the future. > Not COMPLETELY unrestorable - one dentist gave me a $4K estimate for > each with no guarantees. They aren't worth that when I still have most > of my other teeth, but this situation could be VERY different in another > 20 years. However, if I simply leave them as they are, they will > probably either decay away or erupt in that time. Both still have their > roots. What I am looking for is really a in-mouth STORAGE plan. I see your goal here: it is to preserve some structure remaining in order to restore in the future. I don't know exactly how badly damaged these teeth are. If most of the crown portion has been lost and it's only the root that is remaining, you could have any current decay removed, root canal treatment if needed, and then the top portion of the tooth sealed with a material like glass ionomer to protect against further decay. This will not do anything to restore shape or function, but it could maintain the root there for a long time. Maintaining the root would preserve bone levels, which would be beneficial if you decided to restore with implants in the future. But all this depends on the individual teeth. Regards, George George, Thanks for taking your valuable time to help me, an obvious newbie. > The speaker was probably a "biological" dentist relying on the focal > infection theory that was discredited 70 years ago. If a RCT has > failed, extraction of the tooth is certainly a viable option, but > retreatment may also work. I wouldn't worry much about distant > locations in the body becoming affected by infected teeth. In my net browsing, there are plenty of sites that relate other problems, especially heart problems, to dental infection. Of course, this could be as you said based on long discredited information. > To put this another way: there are people who have chronic ear > infections or chronic problems with their sinuses, but noone has ever > recommended they remove their ears or sinuses. But, tooth roots are very different in two important ways: 1. They provide a protected site for infection to prosper indefinitely. 2. Teeth are MUCH easier to remove, and removing them doesn't significantly disable or disfigure the patient. > I see your goal here: it is to preserve some structure remaining in > order to restore in the future. I don't know exactly how badly damaged > these teeth are. They are broken off at the gum line. One had a crown and buildup that broke off and destroyed its margin on the way out. There isn't enough room to cut a new margin. The other one just behind my top left incisor had an amalgam filling and then lost its outer cusp - the inner cusp is still there. There is still plenty of surface area left on this one and I would think that it would be a reasonable candidate for a bonded onlay, but so far no dentist has wanted to attempt this somewhat unusual repair. When asked why, they explain that they are afraid of breaking off the remaining cusp and destroying the tooth. This doesn't seem quite logical to me, since by abandoning the tooth without repair, they are in effect sacrificing the tooth (and indirectly the opposing tooth) to avoid taking a gamble with it. This goes back to our differing goals as mentioned earlier. > If most of the crown portion has been lost and it's > only the root that is remaining, you could have any current decay > removed, There is no significant decay. > root canal treatment if needed, The roots seem to be OK. > and then the top portion of > the tooth sealed with a material like glass ionomer to protect against > further decay. This is new to me (oops, I am showing my vast ignorance). Can you tell me a little about glass ionomer? What is it generally used for? Can other materials, e.g. as might be used to build up a tooth, be placed on it, or would it have to first be removed? > This will not do anything to restore shape or function, > but it could maintain the root there for a long time. Maintaining the > root would preserve bone levels, which would be beneficial if you > decided to restore with implants in the future. But all this depends on > the individual teeth. Remember, we may be talking decades here. Wouldn't the tooth still erupt over time, and wouldn't gums eventually recede from non-use? Also, the opposing teeth are threatened by having nothing to bump up against. How about something that pushes when biting while limiting force, e.g. a thin elastomer sandwich bonded between a hard surface and the tooth? Of course, a simple buildup that would have to be replaced every year or so would also seem to be an option. Perhaps a simple do-it-yourself blob of marine epoxy applied as needed? There is some stuff that remains slightly flexible that I could envision working quite well if you don't mind blue teeth (obviously an engineer's and not a dentist's point of view). The laptop computer that I am writing this on was smashed and broken, and I glued the pieces back together with this stuff! Its slight flexibility allows it to give rather than break under high stress, e.g. under screw heads at points of attachment. Any thoughts? Thanks again for your patience and help. Steve Richfie1d > George, > > T > In my net browsing, there are plenty of sites that relate other > problems, especially heart problems, to dental infection. Of course, > this could be as you said based on long discredited information. > But, tooth roots are very different in two important ways: > 1. They provide a protected site for infection to prosper indefinitely. > 2. Teeth are MUCH easier to remove, and removing them doesn't > significantly disable or disfigure the patient. The only dental problem that has been linked to heart disease is periodontal disease and the relationship between the two is tenuous at best at the moment - more research has to be made since there are many complicating factors. As to roots providing a protected site for infection, they shouldn't if a RCT is successful. Your body has the ability to deal with certain bacterial loads. There are billions of bacteria not only inside your mouth, but inside your whole gastrointestinal tract. Bacteria also frequently enter your bloodstream through injuries as well as simple things like brushing. If you couldn't deal with them, you would be dead! > Remember, we may be talking decades here. Wouldn't the tooth still erupt > over time, and wouldn't gums eventually recede from non-use? Also, the [quoted text clipped - 4 lines] > course, a simple buildup that would have to be replaced every year or so > would also seem to be an option. Buildup materials do not have the necessary strength to remain on a compromised tooth indefinitely. I would guess you need SOMETHING (glass ionomer, amalgam, composite, whatever, I mentioned GI because it's probably the easiest to apply) to cover the root for protection issues and then a partial overdenture that will prevent eruption (a simple design would do and you won't have to wear it all the time). Those materials will be removed when the tooth is ready to be restored. I would agree with most everything that "George" has written. However, it really is impossible to give you any meaningful diagnosis/prognosis/treatment plan without examining you in person, or at the very least, seeing your radiographs. I work as a volunteer at a free clinic that has a large proportion of Hispanic patients, many of whom have had dental work done in Mexico. To be very honest, the quality of the Mexican dentistry that I've observed is extremely poor. If you do decide to go to Mexico for dental care, which I would not, be VERY careful in selecting your dentist. Some of the treatments that I've observed have been FAR off the scale of what would be considered the standard of care in the USA. If cost is an issue, I would definitely recommend going to a dental school clinic -- there are several dental schools in Texas, and you will find the fees MUCH lower and the quality of the work would be outstanding. Good luck! >I have two dental puzzles that different dentists have given me conflicting >advice about. I suspect some combination of selling what they can do, not [quoted text clipped - 72 lines] > > Steve Richfie1d |
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2009 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.