What's the best of three unappealing options?

April 17, 2012 7:52 PM

I will be having a root canal soon, but the dentist has told me that the damage to the tooth may not be treatable by the root canal, and that other action may be necessary. He's given me a few options to consider, and has asked me to pick one.

The options I've been offered are crown lengthening, implant, or extraction + denture. From a perspective of simplicity and cost, I'm leaning toward the denture option, but I'm concerned that I will come to regret it. I know only that the other two options are considerably more invasive and expensive. If you've been through any of these, what is your experience? What do you recommend I do?

posted by smilingtiger to Health & Fitness (18 answers total)

considering some similar options myself, and everyone i have spoken to about dentures or bridge work say in the longer term it has significantly deteriorated their ability to eat and enjoy food. it is hella pricey, but i am leaning towards an implant. that said, i have some time -- i got the root canal and a temporary "long term" crown (cheaper) so my soon-to-die tooth can fill the gap while i scrimp and save.
talk to people you know in your area -- see if anyone recommends a dental surgeon you could consult with about implant options.
posted by tamarack at 8:11 PM on April 17, 2012

I have one implant and one bridge, both in areas where root canals failed dramatically. Lots of drama with both but at the end of the day the implant is far better than the bridge.
posted by elizardbits at 8:24 PM on April 17, 2012

I've had a crown lengthening (at a periodontist) and a crown on one tooth. I can't tell it from a "normal" tooth at all, so it's definitely way better than a denture. The only bad thing is that I had some decay under the crown after 3 years and the crown had to be yanked and replaced. If this happens again the tooth probably won't survive and I'll need an implant.

Based on the total cost, especially if I have further trouble, I probably would have been smarter to get the implant in the first place. On the other hand if money's tight, a crown will work fine for a few years, maybe more.
posted by mmoncur at 8:25 PM on April 17, 2012

Can you describe the nature of your tooth damage a bit more? The one time I had a tooth problem where a root canal wouldn't work, I had to have an apicoectomy instead. But that is WAY different than a crown lengthening so perhaps our conditions are not really that comparable. As for what that entails, it is genuine surgery, but it's done in a couple hours, you come back a few weeks later to get a stitch or 2 removed, and that's it - no long term deterioration of anything.

Anyway, may be something to ask about. If it's manifestly not applicable, then my apologies.
posted by Joey Buttafoucault at 8:26 PM on April 17, 2012

I have experience with an implant, and also with a denture.

The implant was more than 10 years ago and I have been extremely pleased with the result. I remember it being a long process with multiple visits, and not exactly pleasant... but not worse than a root canal. Today I'd be hard-pressed to point out which tooth is the implant. It looks and feels exactly like one of my natural teeth. I don't remember the cost, it was fairly expensive, but given the long-term results I think it was definitely worth it. Plus, my SO had a lot of fun telling everyone I "had implants done - but only one side."

More recently I lost a tooth and decided on the denture this time. Reasons: an implant would be riskier this time since this one is on the lower jaw, and there is some risk of damaging the nerve that runs through the jawbone, which could leave me with a droopy face for life. (They require a CAT scan or MRI just before the implant surgery, to locate the nerve and minimize the risk.) Have also developed allergies to many antibiotics, which are needed with an implant. The denture is ... well, OK. I don't like it, but it's not horrible. Some foods (like sushi rice) can pull it up in the middle of eating - surprise! - and it gets food underneath so I make a little trip to the bathroom after meals to rinse. But it's not so horrible. Other than making me feel really old at bedtime.

One additional factor in favor of the denture was that my dentist explained I could always go ahead with the implant later, if I ended up hating the denture. (Not sure how much later, though, as you start losing bone where the tooth was, due to lack of pressure on it, leaving too little bone to anchor the implant in.)

I recommend making sure your dentist takes time to fully explain the options, benefits and risks of each as they pertain to you personally. Obviously these vary with the location of the tooth and other individual factors. Get a second opinion if needed. Good luck!
posted by evilmomlady at 8:27 PM on April 17, 2012 [1 favorite]

Before you write off the tooth consider seeing a specialist in root canals, i.e. an endodontist. Such a person would have a lot more training and practice with the procedure than a general dentist and might have a different opinion on whether the tooth is salvageable or not.
posted by Runes at 9:59 PM on April 17, 2012

I have two implants replacing congenitally missing adult teeth (some people's baby teeth will last forever in this situation, mine didn't). Like evilmomlady, it'd take me some effort to figure out which teeth are the implants. I've had them, I think, eight years.

It was done in two stages. The first was done simultaneously with having my wisdom teeth out and I was knocked out, so no real opinion on the pain there. That was to remove the baby teeth and place the posts the anchor the implants. I think I went back a second time to do a cast of my mouth to make the implants. Then a third visit to actually put the implants in. I don't remember that being particularly painful. It wasn't pleasant, but I don't remember it hurting.
posted by hoyland at 5:46 AM on April 18, 2012

I think an important question to ask you is how old are you? The younger you are the more conservative the treatment should be in terms of tooth structure preservation.

The second question is, which tooth is it?
posted by Under the Sea at 6:28 AM on April 18, 2012

I had a crown lengthening procedure last year, when there was so much decay on the tooth that there was not enough height left for a crown without it. My dentist and periodontist did not even consider an implant, since a crown + root canal + crown lengthening procedure was an option. They would recommend an implant only if the tooth cannot be saved.

The crown lengthening was more trouble, more pain, and more expense than just a root canal, but far less trouble and expense than an implant, and far less damaging to the mouth than an extraction followed by dentures.

Extractions followed by dentures allow an amount of jaw bone loss that is completely unacceptable, to my mind, if you can afford a less damaging procedure. Dentures do not provide the stimulation that the jaw needs.
posted by artistic verisimilitude at 6:54 AM on April 18, 2012

Implant worked great for me, and my dentist helped me find a legit 0-interest way to get it on a payment plan.
posted by yeahyeahyeahwhoo at 7:08 AM on April 18, 2012

Implant. Preserves the integrity of teeth on either side, is a permanent measure, less likely to require additional work later on (that winds up leading toward the implant anyway.)

It costs but really there are few things more worth the money than your teeth.
posted by A Terrible Llama at 7:22 AM on April 18, 2012

Don't get a root canal. It's a barbaric procedure that, IMO, should probably never be done -- the tooth is *dead*, just get rid of it and get an implant or denture. I think the only reasons they are still done are 1) dentists make a lot of money from them and the inevitable future work they will cause and 2) there's somewhat of a stigma against losing teeth and/or having dentures so people want to keep *their* teeth at all costs.
posted by imagineerit at 8:37 AM on April 18, 2012 [1 favorite]

Response by poster: To answer a couple of questions that have been raised - I'm in my early forties. The tooth in question is the very back molar on the upper right side. I'm a little wary of dentists wanting to perform the most expensive procedure, which is why I don't trust my dentist's recommendations. I've been getting advice from family and friends (and you - thank you!) and while I recognize that the best long-term move may be an implant, I'm still thinking about a denture. If it can be worn at night only (since the space where the tooth had been would not be visible during the day), thereby doing whatever it needs to do to keep my other teeth where they should be, would it be more than a slight nuisance?
posted by smilingtiger at 10:59 AM on April 18, 2012

I'm a little wary of dentists wanting to perform the most expensive procedure, which is why I don't trust my dentist's recommendations.

There's is your problem, right there. Your dentist has given you a range of options with different costs, financial and physical. But you either won't or don't trust him enough to pursue the more expensive but potentially more satisfying solutions.

You need a dentist you can trust and with whom you can speak frankly about all of your concerns. If you're detecting a subtle up-sell vibe from your current doctor and its eroding your confidence, then you really need to see someone else.
posted by R. Schlock at 11:18 AM on April 18, 2012

To give another perspective, do you need the tooth replaced?

I had a tooth removed last December (second premolar) and I can eat perfectly normally on the missing tooth side. It takes a little time to adjust but I don't even feel a difference these days!
posted by Wysawyg at 2:09 PM on April 18, 2012

Best answer: The answer to your question lies in the condition of the tooth itself and your bone structure. Definitely get referrals now to seek professional recommendations, first from endodontist (for root canal advice). If the tooth has good prognosis, strong structure and good bone support then a root canal with proper restoration is the most conservative treatment at this point. If your endodontist advises a number of procedures are needed, then the extraction followed by implant seems suitable. For recommendations, call your Dental Board, ask for dentists in your area with strong portfolios of upper molar implant surgery. Dont have an everyday dentist do your root canal+restoration, honestly some dentists are just barbaric hacks wanting eagerly to try the latest surgery.

Follow up with the periodontist on the implant and discuss any risks see here of upper molar implants regarding lack of your bone structure, and keep in mind success rate should be plus 90%. This is why the periodontist expertise is paramount as they will be doing any implant. Mostly likely the periodontist will have a prosthodontist they work closely with, for the implant itself.

If I were you, and the canal restoration doesnt have great confidence, then I would get an implant hands down - its only a single tooth replacement and you have a good 20-30 years here to consider. The initial cost and surgery will pay itself back tenfold in that time. In comparison to a denture the implant is simple, it maintains integrity of surrounding teeth (reducing their maintenance cost), it reduces gum degradation and bone loss and it contributes positively to your overall experience. It will be worth every penny to see professionals if you go this route.

Your molar teeth are considered the foundation of the bite. Total loss of this tooth will cause neighbour teeth to tilt and there will be drop of the jaw which will alter your bite. This can lead to muscle stress, temple headaches, earaches, tightness in the mouth and sore throats over a long period of time. Its just something to be aware of.

Having said all of that, the procedure should be chosen based on predictability and success rate, not what is most expensive.
posted by Under the Sea at 4:25 PM on April 18, 2012

Oops, periodontist wil be doing any implant prep work, sorry!
posted by Under the Sea at 4:26 PM on April 18, 2012

So the tooth is the very last one on that side? Are there other missing teeth on your upper arch? If this is the very last tooth, does the opposing (farthest back)lower tooth bite against the second to the last upper tooth even a little bit?

Breaking it down by treatment option: If you have a root canal on a molar, you must get a crown placed as quickly as possible. Without nerve/blood supply, teeth become very brittle and are in danger of fracture. A fracture which goes below the bone level or through a root means the tooth will need to be extracted and the cost and time of having the root canal is wasted. So if you cannot do Root Canal, Crown Lengthening, Core, and Crown, don't even get the Root Canal.

For nearly the same cost, extraction and implant and crown has a much higher predictability of success. You will have a functional tooth which will never decay.

Now, if this tooth is the only tooth on the upper that you will be without, and the very back lower tooth is biting against the second to the last tooth on the top, you may never miss the tooth after it is removed. Teeth usually only drift forward, so if you lost the second to the last tooth, the last tooth will drift forward and look like it's falling into the gap left. So filling in the space becomes a much bigger concern.

If there are other upper teeth missing already and for the price of one partial denture, you could fill in other gaps up top, then the denture(partial) option looks a lot better. But using partials/dentures are a poor substitute for fixed one-to-one tooth replacement options.

If this were me, I'd probably remove the tooth and see how it goes. Financially, you can space out the treament by having the extraction and maybe bone filler placed. Wait six months or so to see if you even care that the tooth is gone. If you want to then pursue implant option, it's always there.
posted by Jazz Hands at 6:19 PM on April 18, 2012