Getting to the root of a dental conundrum

November 8, 2012 3:46 PM

Is there an urgent, specific time frame when (if?) getting a dental implant after a tooth extraction? And is my new dentist being too helicopter-y and otherwise...not quite on-the-level? (Warning: looong backstory inside)

Yes, I've been a baaad dental patient and avoided seeing one regularly for a little over 10 years - partly because the dentist I'd seen since I was six years old retired in the meantime, and partly because I was variously too busy/had no insurance/afraid after X time elapsed that I'd be chastised for not maintaining regular visits.

Flash forward to late 2011 and I began to notice an occasional sensitive spot on one tooth and presumed it was a cavity. Ignored it (bad person, I know) and then in July 2012 Mr. Adams and I were on an extended road trip throughout the Western US when I felt electric-shock-type pain in that tooth and up into the gum (not when eating, just all the time). Bought some Ora-Gel and the pain subsided by the time we got home. I browsed online (Angie's List) to find a reputable pain-free dentist in my area and went to one with stellar reviews. The tooth in question was fractured and the nerve was dead from his POV, but he referred me to an endodontist. The endo removed the loose part of the broken tooth, applied a temporary filling and said a root canal was not possible, I needed to have the rest of the tooth extracted and then some sort of dental implant or bridge installed. I remarked to him that Dentist hadn't mentioned that things were so dire and went home with a packet of info. Later that evening Dentist called my home to say he'd spoken with Endo and then proceeded to comment on several points I'd mentioned to the Endo (like the fact that I'd mentioned I'd spent more time with the hygienist than Dentist during my appt). I was surprised that he'd been apprised of the details of my Endo appt so soon - in my experience it often takes a day or more for one medico to relay patient info to another.

Dentist (or, rather, his hygienist) had, at that initial appt, done a full set of X-Rays and a cleaning. She also measured the "pockets" in my gums. After Dentist's cursory exam he didn't mention anything about current cavities, just that I was in need of deep-root cleaning. At that time I scheduled (as instructed) a future appointment a few weeks hence. However, between that future appt and the partial tooth extraction I developed swelling and severe pain in the gum above that tooth and went back to see Dentist who diagnosed an abscess. He prescribed antibiotics and I returned 4 days later to have the rest of the bad tooth removed. He also took photos (not X-rays) of my teeth from various angles (full-face and then inside my mouth) and told me about tooth implants and recommended an oral surgeon, urging me to call ASAP for an appt. He also showed me the photos he'd taken and told me which of my current fillings would eventually have to be replaced and again mentioned the need for deep-root cleaning. No mention of any current cavities. As he guided me through the photos he said "We'll be maxing out your dental coverage for the year."

A few days later I received a letter from my insurance co stating that Dentist was not in their network and that I was paying possibly 45% more than necessary out-of-pocket for my co-pays as a result. To compound matters, Mr. Adams and I are moving to a new house and all of the physical and financial stuff associated with that started right after that last Dentist appt. Two days after Dentist extracted the second half of that tooth I received a voice mail from his office. Busy packing, I ignored it and received two more calls the next day, one of which said it was "urgent" that I called back. I did call back and the receptionist asked if I'd scheduled my appt with the oral surgeon yet to begin the implant process and I said "no." She then went on to say it was very important that I call him ASAP because my bone was shrinking as we speak and she gave me the impression that soon it would be too late to do anything about my missing tooth (it's the tooth immediately behind the canine on the right side, not a problem cosmetically). I told her about the letter I'd gotten from my ins co and she said that Dentist's fees were in line with reputable dentists in Oakland County and that the ins co's claim of "45% more" was an exaggeration.

So, finally on to my two-part question. Is there a crucial time frame involved from time of tooth removal to dental implant if that is the preferred route? Will it matter bone-wise that much if I wait six or eight months? (Ins doesn't cover implants, so I'll be paying out-of-pocket and we've got all these moving expenses right now...) And, since I haven't visited a general dentist in so long, I'm basing my experience on my previous dentist, who traditionally saw me twice per year for a cleaning and exam and then told me whether I had cavities that needed filling. Is it out of the ordinary for this guy to not have mentioned thus far whether or not I have any cavities? And is it unusual for his office to get immediate and detailed feedback from the offices he's recommended (endo reporting back my comments, oral surgeon apparently confirming that I hadn't yet scheduled an appt)? If I decide not to go the entire deep-cleaning route (which I probably need, but right now am concerned about taking care of more immediate dental needs like cavities for the time being, for the sake of time and money saving) and I decide to do so with another practitioner, is Dentist obliged to send my X-rays to the new person I select to save me the cost of new films? (NOTE: I do brush and floss regularly, but I'm nevertheless prone to cavities due to Sjogren's Syndrome.)

posted by Oriole Adams to health & fitness (7 answers total)

This doesn't directly answer your questions but maybe it will help a bit. When I had a dental implant I first received a bone graft to build up the bone so that the implant had better footing. The oral surgeon recommended the graft even though there was no wait between removing the tooth and starting the implant process. So, maybe the dentist is trying to avoid the need for a bone graft. An oral surgeon can tell you more, I'm sure.

One downside to waiting, as my dentist told me, would be that the remaining teeth would crowd in to fill the empty space where the old tooth was.
posted by exogenous at 4:47 PM on November 8, 2012

*Not a dentist but play one on TV.

There might be root fragments still hanging around in the socket. You should get the extraction finished right away, and then you can think about other things while it heals. You don't have to start the implant process right away.

If the extraction is complete, I believe you can wait to put in an implant or a bridge. Speaking of which - what about a bridge? Did nobody talk about that with you? Bridges are often covered by insurance.

Did your new dentist take a complete medical history, and/or ask you about your Sjogren's Syndrome? I'm guessing no.

Sounds like you and this dentist aren't a good fit. You should get a second opinion ASAP. Your records belong to you, and while they might charge you a duplication fee, they're legally required to send your records to you or to your new dentist.
posted by overeducated_alligator at 4:47 PM on November 8, 2012

Oooh oooh! I was just at the periodontist this very afternoon, and I asked the very same question as part of your part two (Can I wait 6 or 8 months to do an implant?). So, I am not a -dontist or doctor of any kind, but this is what I was told:

It depends. (Sigh.) I had a tooth extracted by my general dentist, a second molar, in an emergency setting 3 months ago and it has been healing very well. Periodontist said that in that way-back position (at the widest part of the jaw) bone loss is likely to be minimal over a year or two, but will occur eventually. And of course, everyone is different and he can't guarantee anything. He'd prefer I do the implant there ASAP, but thought it wasn't likely to be a giant issue if I waited a little while longer. [Note: he had me to wait 3 months after the extraction for the bone to heal before beginning the implant process. Dunno what other periodontists like to do in that regard.]

The reason I asked to wait a while longer is that while waiting for that first extraction to heal enough to have the implant, I developed a second problem tooth that needs treatment. Since it's not an emergency, I have a little time to plan the treatment. As exogenus said above, the periodontist recommended that he do the extraction on this one so he could do a bone graft at the same time as the extraction. (As opposed to going back to my general dentist for the extraction.) He said in this position (first molar) a bone graft (to shore up the area where the implant will go) will definitely be necessary.

So it sounds like having a consult with a periodontist or oral surgeon very soon might be good so that you can plan your treatment. But it doesn't seem like you'll necessarily have to have any actual work done right this very minute.

Also: this stuff is crazy expensive. Crazy. No insurance and I'm looking at about $4700 for extraction/graft/implant/crown on this second tooth, and about $3600 on the implant/crown for the first tooth I lost (since no graft is likely to be needed - will be more if it is). Ouch ouch ouch ouch ouch. (this is in Ann Arbor)

Also: sounds like you might do well to shop a little more for another dentist. I didn't think anything you said he did sounds shady, but it does sound like you might appreciate someone with a different style.
posted by agentmitten at 5:13 PM on November 8, 2012

There was a two year period between an extraction and one of my three (!) implants. I'm not going to say your dentist is lying to you, but they appear to be making things a little more emergent than they actually are.

When you get an implant, there are four basic steps (assuming the tooth is already gone):

1. The implant post is placed. This is fairly invasive, and I was under twilight sedation when it was done. Basically, it's a double threaded screw that's drilled into the bone of your jaw. It's a lot less painful than it sounds.

2. Some weeks later, the healing abutment (an attachment to the post that allows the gum to heal and provides a spacer for the hardware that's going in later) is placed. This is less invasive, and usually is done within minutes using a local anesthetic.

3. Some weeks (or even months, depending on whether the implant is in the lower or upper jaw) after that, the temporary crown is placed. This is usually done by your regular dentist, and they take a mold to be sent off so your permanent crown can be made. This takes from four to six weeks depending on the lab that makes the crowns.

4. Finally, the porcelain crown is attached to the post. This final bit may happen as many as four to six months after the initial surgery, depending on scheduling and whatnot.

Thing is, this is a time intensive process anyway, and a dentist who pressures you to spend between three and seven thousand dollars (depending on the tooth and the surgeon) immediately is not your friend.
posted by Mooski at 5:30 PM on November 8, 2012

It is difficult to address your specific case without certain additional information, but I can offer some explanations that might help based on what you've said so far.

First off it would be in your best interest to make this decision as part of a comprehensive plan to get and keep your mouth healthy. some people lose bone rapidly, others do not, some areas that need extensive crown and bridge work anyway are better treated that way than with multiple implants, for other mouths the opposite is true. find a good gd, build a relationship based on trust, ask lots of questions and get second opinions if necessary



Secondly, you have mentioned the need for deep cleaning, from which I infer a history of past or active periodontal (gum) disease) which usually means there has been some bone loss around some of your teeth. this may impact whether you even have enough bone to use to support an implant or a bridge if an implant cant work. Periodontists also do implants, so it might be reasonable to see one and have that specialist address your gum disease and the implant. ask your gd about this option before you see the oral surgeon.



Finally, your dentist has recommended that you see a surgeon for the implant. Your first visit with them will be to see if the extraction site is suitable for an implant, now or in the future, with or without additional treatment (grafts etc). The sooner you get the initial consult, the more time the surgeon has to determine whether or not there is urgency in placing the implant immediately. many surgeons actually want to wait several months for the healing to occur before going back in. if you are going to wait you should have something placed in the space to hold it open (some temporary tooth of one kind or another).


Best of Luck
posted by OHenryPacey at 6:04 PM on November 8, 2012

I had a cracked molar extracted last year and have also been 'catching up' on dental health with a deep cleaning and 4X/year followup cleaning for about a year (which will then drop to 2X). My dentist has been super communicative and very focused on ensuring the restoration of dental health, but at least in my case he's said that an implant (which would have the same timeframe/steps mooki outlined) was both crazy expensive and totally optional. I understand that depending on the tooth/your mouth sometimes an implant is highly encouraged, buy: Get a second opinion.
posted by donovan at 9:15 PM on November 8, 2012

First of all, why don't you make a list of your questions and call the practice and ask them all you want to ask them. If they don't like that ask them about the x-rays being transferred to a new dentist and find a new dentist.

As somebody who's blessed with teeth they can take liberties with I'm all for waiting most of the time. But you're trying to make decisions based on incomplete information. So you need to ask your dentist about cavities and any other expected treatment and cost for it. And you need to see somebody doing implants about your specific implant requirements and how much that's going to cost and how time sensitive it is...you cannot make informed decisions about these things by talking to people on the internet..

And I totally can see where you're coming from in terms of finding it weird to be chased about the referral for example. Personally I'd be looking for a new dentist at that point because I'd find that very patronising but you have to work out what's right for you.
posted by koahiatamadl at 8:23 AM on November 11, 2012