[33M] Root canal, extraction only, or extraction + implant? (tooth 31, x-ray attached)

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Hello! I'm a 33-year-old male, located in the US, non-drinker, non-smoker.

I've been having some pain chewing with my 2nd lower right molar (tooth 31). My dentist thinks that it can be root canal'ed, I went to a second dentist who thought that root canal has a poor prognosis and recommended extraction + implant, and I went to an oral surgeon who thought that I could go either way, and also gave me the option of extraction + bone graft only, or extraction + bone graft + implant in the same session (he said that my tooth looks like it's amenable to doing the implant in the same session).

I like my oral surgeon (he also did my wisdom teeth last year and did a great job), but with so many options, I'm honestly confused on what to do here. I've heard that extracting a 2nd molar without replacement is usually fine for chewing, but risks the upper 2nd molar erupting, and I don't want to lose so many teeth (especially with the 2nd molar on the left side also having some issues that will probably need RCT/extraction down the road - it's just got a filling on it for now).

I'm also not sure if doing an implant in the same session is a good idea - my oral surgeon said I could wait 4 months and come back for the implant if I wanted to take a wait-and-see approach to see if I really want to replace the tooth, and I'm also wondering if doing the implant in the same session has a worse prognosis than waiting for more bone to grow back after the extraction? Or, it doesn't matter, and I should consider myself lucky that I can do it in one session instead of multiple like most situations?

Lastly - I'm quite anxious when it comes to dental work, so I've asked for valium for the extraction (+implant) since he only wants to do local anesthesia. It'll be my first extraction while awake (he did my wisdom teeth with IV sedation), so I'm a little nervous about how this extraction would go? He said he'll do a "surgical extraction" that takes ~30 minutes (implant an additional 20 min), which sounds rather... scary.

Would love to hear your thoughts. Thank you all so much!

X-ray attached is from Feb 2023.
 

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MattKW

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  1. Whilst an RCT is technically feasible, the real issue is the final "restorability" of the tooth. The RCT access hole will come in from the top of the tooth; add to this the large hole in the back of the tooth (which will be a bugger to fix), and you will be left with a structurally very weak tooth. Even planning a crown at the end will not improve your long term chances - I'd give the tooth a 5 year life after you've spent a fair amount of money. So, I'd go for extraction.
  2. A surgical extraction for that??? What tosh! The extraction will be dead easy - the tooth is upright, there's quite enough to get a good grip, and it has nice conical (ice-cream cone) roots. A competent dentist would have the extraction done within a couple of minutes. I would suggest just simple local anaesthetic, maybe some "Happy Gas" if available, or at most a smallish dose of a short-acting benzodiazepine (triazolam is great, temazepam is good, diazepam ("Valium") is good but lasts much longer). If taking an oral benzo, you need someone to transport you. Certainly don't need IV.
  3. After such a simple extraction, I would wait 6 months for bone to heal, and to see if you feel you need to replace it. If you then decided to go ahead with the implant, I doubt you'd need bone grafting - this should reshape nicely and leave sufficient bone for an implant.
  4. The opposing upper would become redundant if you don't place an implant, but waiting a mere 6 months won't cause significant over-eruption.
 

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MattKW

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Good-o! Let me know how it goes.
If you are in the US, then talk to oral surgeon or dentist about taking triazolam. It is marketed under the name "Halcion" and comes as 0.125mg tabs. See Wiki for a bit more info.
The best way is to plan the extraction first thing in the morning. Take 1 tab the night before to help you relax and get to sleep. In the morning, have a light breakfast and have someone drive you to the dentist, arriving at least 30mins early and take 1 tab 30mins before the appointment in the reception area.
If you don't have some food in your tummy before a stressful situation, you are more likely to get even more anxious and faint. I always carried fruit juice in my fridge to give to patients who hadn't eaten before an extraction.
 

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