Decay under a crown

[DavidN]

Hello, I wonder if some knowledgeable persons will give their views on this particular conundrum. I am 66 and recently attended my check up. Following an X-ray my dentist says that there is decay under the crown on my back upper right. The solution is to refer me to a suitably qualified specialist (She also mentioned that that tooth can be tricky as it's close to sinuses etc.) who will undertake root canal treatment et al. But she said that it wasn't definite that the decay would cause a problem immediately, although eventually the tooth would break at some point in the future. As the tooth is not causing any problems currently, she says that sometimes the body isolates the problem and doesn't cause trouble. I am going back in a week and have been asked whether I want treatment or not. To be honest I'm a little perplexed. This is first time (in about 55 years of visits) that I have been asked as to whether I want it doing or leaving. It is also the first time I have been referred to someone else for this type of treatment. This is not a great thing to say - but would my age have any bearing on her comments? In short, I haven't a clue what to do. This is the first time I have seen this particular (private) dentist. Any help or explanation would be very welcome. Thanks, David.

 

[honestdoc]

Please provide x-ray(s) and intraoral image if available. I'm more conservative than the average for profit dentist. If the decay is accessible, I'll clean it below the crown and repair it. It would be a marginal judgement call to replace the crown. If the tooth is vital, no root canal is needed. How you know is if it feels cold (cold test) and no swelling.

 

[DavidN]

Hi, Thank you for taking the time to reply. I'm afraid that I don't have the x- rays. It not something that I would think to ask for or, indeed, understand. As far as I am aware this particular tooth is completely inert and forgettable.Just normal, so to speak, without any swelling or sensitivity. To be honest, I felt communication was a little "unclear" during the appointment and l left with a lack of understanding and therefore confidence. A second opinion may seem the clever thing to do - other than the money already paid for exam, x-rays and cleaning.

 

[honestdoc]

All x-rays now are digital. Non-digital x-rays have been phased out with no technical support and no parts for maintenance and repairs. You can request a digital x-ray emailed to you.

It is hard to find an honest dentist because of the cost of operation and most young dentist have outrageous student loans in the US. If you live in an expensive location like California, NY, East coast, Pacific NW, it is even more difficult. Chances are, you need minimal work on that tooth.

 

[MattKW]

Hello, I wonder if some knowledgeable persons will give their views on this particular conundrum. ... Thanks, David.

If there's decay under the crown,the crown may have to be removed before you can tell if the tooth is salvageable.
there's no point going to an endodontist if you don't determine the amount of decay. It might be a tooth that's OK to do endo, but if you can't rebuild the tooth with a new crown, then there's no point starting an RCT.
If it's a 2nd molar, sometimes it's debatable whether it is a good idea to save these type of teeth. Not only do you have to do an RCT and a new crown, but you have to see if you will be able to keep it clean, and not endanger adjacent teeth. As honestdoc says, an Xray would be very helpful.

 

[Busybee]

You should get a second opinion. I had some awful decay because of a gap that developed in a seal of an onlay but you could not see the decay on any x ray because the crown material was too dense. When it was removed it literally just fell off even though I had hardly any symptoms. A lot of dentists prefer to leave something like that until it causes a problem because once you touch it, it can be difficult to fix and can start symptoms off. So quite often they will monitor it for a long time before doing anything.

 

[DavidN]

Well, I'm due back to see this particular dentist next week for just a 20 minute appointment - really to finish off the initial exam, polish and discuss the way forward. I intend to ask quite a few "probing" questions and you have really helped to gather my thoughts and to clarify things. Thank you for your replies and help. Cheers, David.

 

[MattKW]

... A lot of dentists prefer to leave something like that until it causes a problem because once you touch it, it can be difficult to fix and can start symptoms off. So quite often they will monitor it for a long time before doing anything.

I don't know how you surmise that dentists will, "leave something like until it causes a problem". I hope that would be very rare - it certainly would raiselagal and ethical questions. So, we tell patients there's a problem, give them the options with pros and cons, and guide them to a reasonable solution. If they don't take my advice, then I record their choice so they can't come back and blame me. The only time I'd advise them to "leave something" until it causes problem" is if:

1. the eventual problem will be minor, AND
2. the problem will not endanger other teeth or bone.

An example might be a lone-standing tooth with an RCT that is failing, but the either the patient cannot afford a crown, or a crown offers no benefit.
So, as I said in earlier post to DavidN, the decay has to be sorted out first, and if this means removing the crown (usually) then so be it. If the tooth is still salvageable, then the decay is removed and a temporary crown is cemented in place.The endodontist will not be happy if the decay and salvageability of the tooth has not been sorted out before his consultation.

 

[Busybee]

It's not rare in the UK MattKW. These days there is a policy of watchful waiting if a tooth doesn't have symptoms or obvious root failure. It's a big shift from how they used to work, but I guess dentists are worried about litigation these days. So even if there is sensitivity and some pain there are many dentists who will not want to open up the tooth if there is a big filling or potential of complications. Or they refer on.

 

[MattKW]

I don't doubt that some dentists do it that way. I take issue with the statement that "there is a policy", and that there are "many dentists" that do this. Unless you have hard stats, then that would appear to be a very personal and anecdotal observation that misleads people and casts a slur on most dentists. With regard to avoiding poss litigation, I consider that to be a furphy, again with no evidence. It should be the opposite, as a dentist leaves themselves open to litigation if they do not take the steps as I suggest in previous post, including possible referral.

 

[Busybee]

What evidence can I give you Matt? I'm not going to dig up scientific studies on the subject. Minimally invasive and preventative dentistry is becoming the norm in the UK. This is a seismic shift from the 1970s NHS dentistry where even the hint of a cavity was filled. The absence of pain was irrelevant. It's not a slur to focus on prevention and a conservative management approach to old restorations. It's an opinion that litigation plays a part in a cautious approach. We have a compensation culture. This is just the way things are.

 

[MattKW]

What evidence can I give you Matt? I'm not going to dig up scientific studies on the subject. Minimally invasive and preventative dentistry is becoming the norm in the UK. This is a seismic shift from the 1970s NHS dentistry where even the hint of a cavity was filled. The absence of pain was irrelevant. It's not a slur to focus on prevention and a conservative management approach to old restorations. It's an opinion that litigation plays a part in a cautious approach. We have a compensation culture. This is just the way things are.

No, perhaps you misunderstand why and how these changes are occurring.
When I was a student, it was certainly "if in doubt, drill it out" as in the 70s.
The presence of early decay can now be treated with fluoride applications, toothpaste, mouthwashes etc, and monitored over time with a well informed patient so unnecessary intervention can be avoided.
That is not to say it is left alone, "...if a tooth doesn't have symptoms or obvious root failure...", we simply don't need to be as aggressive as we once were. I don't drill anywhere as much as following the principles that I was taught, and I have seen the benefits.
I know what they teach nowadays and why, I have seen the lecture notes, the scientific literature, the clinical changes over my 36 years, and have young dentists working with me.
It is all about the better understanding and science of decay, and has absolutely nothing to do with litigation/compensation. It is all about handling the patient and the disease process more appropriately.

 

[Busybee]

Matt what I am referring to is being termed by the profession as "defensive dentistry". There's been quite a bit of discussion and research into the subject in the UK.

I am glad that you agree with my other points ref the changes in approach from invasive to conservative.

 

[DavidN]

Matt ,
You mentioned:- "advise them to leave the decay if the problem will not endanger other teeth or bone". This is a worry of mine (I have a brother who ignored a problem with his back, bottom right molar and ended up have a operation where his jaw needed to be cut away due abscess and infection....). Surely it impossible to tell how something like this will play out and therefore it's better to address the issue directly rather than wait and monitor. Who knows what may lurk under the crown and where it might lead. Thanks for your help, David.

 

[MattKW]

It has to be monitored, i.e. regular checks and X-rays. You don’t simply leave anything until the patient feels a problem. It is the dentist’s responsibility to advise the patient of this requirement, and I record the warning. But not all patients heed advice, as did your brother.

 

[DavidN]

O.K I understand thanks. I can't grumble really. I had my first amalgam fillings back in the 1960's and, give or take the odd implosion, they are still being worked on and giving service nearly 60 years later. Onward and upward!