Question about Deep Margin elevation

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I've just lost a 30 year crown on #15 upper left molar which also has deep decay below the gum line. No pain. My general dentist recommended extraction of the tooth, but I'm looking for an alternative solution. I moved to a new dentist who was willing to refer me to an endodontist and a periodontist. But I've heard that deep margin elevation is a relatively new procedure and that some specialists may lack the necessary skills. My question: Are there dental providers who specialize in deep margin elevation and if so how does one find them?
 

Dr M

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Do you have a recent x-ray of the decayed tooth? Deep Margin elevation might not even be an option if the decay is subcrestal.
 

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OK, Image attached.
2023:11:02 Jacques Levy #14 and #15 11:02:23.JPG
 

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Dr M

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The best option would be to see a specialist in your case. The root canal treated molar, almost seems like there is root caries present on the distal root, which makes the long term prognosis questionable in my opinion. I would also possible opt for an extraction in that case. The second molar does have deep decay. In my opinion the tooth would need a root canal before permanent restoration can be attempted, and even then the tooth seems like a periodontally compromised tooth.
In cases such as this, you have to think long term and not only short term. It is clear that you have some bone loss present between your teeth, which might be an indication of underlying periodontal disease. I would suggest seeking the opinion of a periodontist. He will do a tooth by tooth analysis and determine which teeth can be saved in the long run, once the perio has been stabilized. Might be better to extract if you are looking at the broader condition of your mouth.
 

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Thanks very much for your reply.

I have an evaluation referral to an endodontist the day after tomorrow. But just reading the posts in this forum gives me some hesitation about how to interpret his findings. I'm under the impression that the outcome may very well depend on how skilled he is and how cautious or conservative his approach might be.

I take note of your advice about keeping the "long term" in mind. Did I mention that I'm 86 and that "long term" has a different ring to it than it did when I was 50? My principal concern at the moment is the preservation of those teeth so I can keep chewing. An excavation of my mouth at this age presents me with a number of difficult prosthodontic problems which may not have easy or affordable solutions not to mention potential healing issues.

Since I was aware that #14 and #15 were compromised by decay at or below the margin, I looked at potential remedies other than extraction, which is why I raised the questions about Deep Margin Elevation and Crown Lengthening. A previous dentist did propose crown lengthening several months ago. In light of the above, my endodontist may recommend the more cautious remedy. I'm not at all sure what to do in that case given my reluctance to extract those teeth.

You speculated that the root canal treated molar seems to have caries on the distal root. My untrained eye doesn't see it. So far I don't have pain or sensation in either tooth. I suppose the endodontist will test the root canal treated molar (#14) for caries and then also test #15 to determine whether root canal is indicated? In the forum (Matt KW, Verified Dentist), I came across a case like mine which was recommended to be treated with root canal and subgingival amalgam as the most cost-effective solution. Another case (also recommended by Matt KW) involved treating the decay with an onlay, filling the pulp chamber with amalgam and utilizing a post/core buildup.

I appreciate your help and look forward to your insights.
 

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Dr M

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Taking your age into consideration, I then tend to agree that alternative options should be considered rather than extraction. The decay I mentioned is distal of tooth number #14. The endodontist will most likely take a 3D scan to confirm restorability of both teeth.
Deep Margin Elevation is a well documented procedure for teeth with decay below the gum line, although not all practitioners have the skill to perform this. Unfortunately this means that you will have to bring this procedure up during the consultation with the endodontist, and if he is not comfortable doing it, there is a chance he can refer you to someone in the area that can.
Subgingival amalgam is also a good option, but to do a proper filling, you will need to ensure adequate marginal seal, and either crown lengthening or deep margin elevation will be required to achieve this seal.
 

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Taking your age into consideration, I then tend to agree that alternative options should be considered rather than extraction. The decay I mentioned is distal of tooth number #14. The endodontist will most likely take a 3D scan to confirm restorability of both teeth.
Deep Margin Elevation is a well documented procedure for teeth with decay below the gum line, although not all practitioners have the skill to perform this. Unfortunately this means that you will have to bring this procedure up during the consultation with the endodontist, and if he is not comfortable doing it, there is a chance he can refer you to someone in the area that can.
Subgingival amalgam is also a good option, but to do a proper filling, you will need to ensure adequate marginal seal, and either crown lengthening or deep margin elevation will be required to achieve this seal.
Regrettably the endodontist yesterday did not see any alternative to extraction.

I mentioned Deep Margin Elevation to him, but he seemed unaware at first of the procedure. When I showed him a diagram, he acknowledged having seen something like it under a different description. I asked whether he knew another specialist who might help me but he demurred.

The endodontist I saw is part of a network served by the dental insurer which covers me. When I first mentioned DME, he called it a "heroic" procedure without much chance of success. It occurred to me (with no real evidence) that network dentists may not be paid enough to use procedures other than those which have been taught in dental schools for decades.

Extracting #14 and #15 is an undesirable outcome for me, but finding someone skilled in DME who would be willing to restore them is more difficult than I anticipated. Today I became aware of a supply house named Garrison Dental which hosted online webinars on DME so I called them and got a list of their customers in my county. Possibly one or more will know someone who is capable in the field.

The endodontist's report today said that I was asymptomatic upon presentation. It reminded me that I am lucky not to be in pain from #15 which lost its crown and that I may have "enough" time to locate a DME provider with the necessary skills.

Thanks again for listening.
 

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