Is this crown necessary?

May 30, 2008 9:33 PM

My girlfriend's dentist is pushing her to get a crown on a tooth with several fillings. I'm skeptical because she has no pain, he doesn't see anything wrong with it, and he pushed her last year too. Should she listen to him, get a second opinion (any suggestions for Portland, OR?), or ignore him?

His argument is simply that there are a lot of fillings in this tooth, the fillings are old (10 years), and it will hurt a lot if it breaks. She describes the tooth as "one big filling." Cost would be $1000, she has no dental insurance, and she works full time in theater so money is not super flush.

posted by msalt to health & fitness (26 answers total)

The dentist is probably correct (I am not a... you know...). If the dentist has been trustworthy, then he is probably not pushing for it to make his boat payment. He's just trying to get ahead of the problem instead of catching up with it later, when it may indeed turn into a painful emergency.

However, who knows, really? My dentist put a gold grown on a molar and told me it wold probably not last more than a year or so, and at that point I would need a root canal and more major work. That was 30 years ago, and I have never had a bit of trouble with it, even though the teeth around it have needed work.

A second opinion wouldn't hurt, of course, but it might be an unneeded expense, especially if the current dentist has been trustworthy so far.
posted by Fuzzy Skinner at 9:41 PM on May 30, 2008

Good dentists do tend to suggest preemptive maintenance on things like this. They want to help their patients avoid unnecessary pain and discomfort and inconvenience in the future by nipping things in the bud early on.

But a doctor's good intentions definitely feel more pushy when you don't have insurance, and I assume the dentist knows that she doesn't. She should feel comfortable asking about all the possible alternatives, and about setting up a payment plan if it comes to that.

After years of neglecting my mouth due to both a lack of insurance and a general phobia though, I'm firmly in the "TAKE CARE OF YOUR TEETH" camp. I wouldn't just blow it off.
posted by padraigin at 9:54 PM on May 30, 2008

I guess the thing that set me off was that the dentist really had no basis whatsoever for concern. If she had complained of pain, or an x-ray showed something, or he saw some evidence of a crack, then sure...

I also think it's safe to say she wouldn't have asked me if she completely trusted the guy. She's a relatively recent transplant to Portland, so it's not a longtime caregiver situation.
posted by msalt at 10:00 PM on May 30, 2008

Fillings also may not last forever. I had 10 year old fillings that were beginning to come loose, and had to be replaced. Maybe that is part of the the dentist's concern as well.
posted by All.star at 10:12 PM on May 30, 2008

Not a dentist, and a lot of variables here, but it does sound likely that your girlfriend will need some dental prosthetic at some point. Since money is an issue, if she doesn't get the crown now, why not at least start trying to save for it?
posted by owhydididoit at 10:13 PM on May 30, 2008

Just checked -- fillings are not coming lose at all.
posted by msalt at 10:27 PM on May 30, 2008

I actually had two fillings in a tooth and a large junk of the tooth chipped off because the tooth's structure was weakened. I didn't even bite on anything, I only noticed because I felt a sharp edge in my mouth, so no pain (but I think I got really lucky, the dentist couldn't believe I didn't come running for pain meds). It cost a little over $1000 when all was said and done to get a cap (fillment? the name is escaping me, they basically replaced the top half of my tooth). So it can definitely happen. It's probably a case of pay now, or pay later (with a lot pain possibly) or she gets lucky and the tooth holds.
posted by whoaali at 10:46 PM on May 30, 2008

I'd advise getting a second opinion, especially if she doesn't have a long and excellent relationship with the dentist. Dentists do have different styles and different judgments; she may get a different answer from a more conservative dentist.

I'm fairly sure I had a drill-happy dentist once, many years ago, and I regret not having a second opinion on his recommendations before letting him at my teeth. The guy swore up, down, and sideways that I was going to need a crown right away pronto. I dithered and never got around to it; truth is, my intuition's alarm bells were ringing and I was just starting to listen to them.

Frankly, I have to wonder if the guy knew how to read an x-ray. Because fifteen years later, my dentist and I agree that I still don't need a crown.
posted by sculpin at 10:48 PM on May 30, 2008

I guess the thing that set me off was that the dentist really had no basis whatsoever for concern. If she had complained of pain, or an x-ray showed something, or he saw some evidence of a crack, then sure...

I've had a tooth split before because fillings weakened it. No pain, no early warning. This is when I had dental visits every 6 months with someone my family trusted. The evidence he sees is that the tooth is structurally weak, and that in his experience similar teeth have cracked. There may not be any other evidence available.

That being said, your girlfriend should do a cost/benefit analysis. Ask the dentist how much it would cost to have the reconstruction after the tooth split. Compare that to the $1000 they're asking now, weighted against how likely she feels the tooth is to fail.

Also, is there a chance either you (assuming your plan allows for committed couples) or she'll have dental insurance in the foreseeable future? Does she have any health insurance at all? One of my options is what's called a Medical Savings Plan (IIRC). Basically, I can spend up to $2000 from this account over the course of a year. The trick is that I have to declare each year how much I want available (from $200 - $2000) and then the amount is removed from my paycheck pre-tax. People I work with use this system for all sorts of things that wouldn't be covered, like LASIK and cosmetic dental work. Sure, you still pay, but it lowers you taxable income, it's spread out evenly, and you aren't charged interest.
posted by sbutler at 10:52 PM on May 30, 2008

On one hand, none of my cavities ever hurt before the dentist found and filled them, but I trusted that he was the expert and knew what he was doing.

On the other hand, my dentist has been recommending I get my wisdom teeth removed for a few years (I *have* had pain, but only every couple years when I get an infection that I'm able to fight off in a few days; they aren't impacted, they just aren't fully erupted) and I've decided not to do it until it becomes utterly necessary. (When either the infection doesn't go away and the pain makes me crack, or if I get a bad cyst, or whatever.) It's just damn expensive and I kind of take pride in having all my teeth. Maybe if I find myself ultra flush with cash one year I'll have the bottom two removed. I just have *so* many other places I can spend that money.

So, I'm in the "wait and see" camp. (Or, "ignore til later.")
posted by iguanapolitico at 10:54 PM on May 30, 2008

"I guess the thing that set me off was that the dentist really had no basis whatsoever for concern."

Except, you know, that he's a dentist and has probably seen the consequences of NOT doing what he's recommending. Heck, he might even tell you what those consequen-- wait a minute...

"His argument is simply that there are a lot of fillings in this tooth, the fillings are old (10 years), and it will hurt a lot if it breaks. She describes the tooth as 'one big filling.'"

Ahh... there we go. Trying to keep your friend from being in pain. What a money-grubbing jerk. I must have missed the part where he "had no basis whatsoever".

If your friend wants to wait until she's in intense pain and then pay an emergency dental rate, then I think doing nothing is a great idea. If you wait until there's pain (or a crack, for goodness sake) it's too late for "preventative" maintenance. You're now talking about fixing a problem. Tell her to get a second opinion. While she's doing that, she should start looking for was to save the cost of the crown because, even if she doesn't get it now, it would be stupid to not take the preventative measure AND not plan for that risk to come to fruition.

(Also: if she has as little faith and trust in her dentist as you seem to, she should find a new one... but it sounds like you might just be a little over-protective)
posted by toomuchpete at 10:59 PM on May 30, 2008 [1 favorite]

I could be over-protective, granted. I was also harassed by my dentist pushing the amalgam replacement thing hard, a while back, which shades my judgment. Medical savings plan -- I'd have to marry her to get her under my plan, though I think she may be amenable to that.
posted by msalt at 11:49 PM on May 30, 2008

To look at this another way.

I think you've already decided that the crown is not necessary; you're just looking for verification. Otherwise, why would you be asking the medical advice of random internet strangers rather than getting a qualified second opinion?

So this random internet stranger says NO, the crown is not necessary. For various meanings of the word necessary.

Will your girlfriend die if she doesn't get a crown? Almost certainly no. Will delaying the crown have a permanent impact? Almost certainly no.

Will it prevent discomfort? Possibly yes. Will it be cheaper? Possibly yes.

People crack and brake teeth all the time and they continue on just fine.
posted by sbutler at 11:54 PM on May 30, 2008

Get a second opinion. Dentists do recommend unnecessary work sometimes, either due to playing it very safe, or making an honest mistake, or the boat payment thing. Having unnecessary work done is disruptive, stressful, expensive and may require some amount of healing, and anytime you have something medical done, unexpected consequences are a slim possibility, so it isn't like there is no harm in getting the work "just in case" if it isn't warranted.

I had a dentist do the big tsk-tsking thing in a checkup and sadly announce to me that I had seven cavities and he was going to need to do a lot of drilling and we'd need a new appointment for all that work. I ended up breaking the appointment because I had a bad feeling about it, and went to a new dentist, who said he saw nothing cavity-like in my teeth. That was 11 years ago, and it's the same every year: no cavities. It's really harmless go to see someone else and see if their diagnosis corresponds or not, and talk to them about whether they would make a similar recommendation and why or why not. Worst case scenario is that you're better informed and out the money for one consultation.
posted by Your Time Machine Sucks at 3:49 AM on May 31, 2008

She is not flush with cash.
It does not hurt now.
It will cost about the same if it later breaks and she needs a cap.
hmmmmm.......
posted by caddis at 5:35 AM on May 31, 2008

Do it. The cost will be much higher in both money and pain (and possibly vanity) if that tooth cracks, and there is rarely any warning before it cracks. Does she want to risk losing a tooth and needing a $3000 implant to replace it, or go toothless because she can't afford an implant? This tooth has been drying out since the fillings (and you say it's mostly filling, so in effect it's like a root canal and they absolutely need crowns) and it's a prime candidate to crack all the way down to the bone. She does not want to go there; I've been there and it sucks. Playing it safe with your teeth is the smart thing to do.
posted by zarah at 5:42 AM on May 31, 2008

I have had a coupla3 teeth capped due to excessive fillings. I've never had any reason to regret this; of course I have no way to know if they would have been fine left alone. I do know that old fillings need to be replaced every several years, and that tooth will just get weaker and more vulnerable every time. In the long run, she's not going to save any money just getting it capped.

Is this her regular, long-time dentist? Does she have any reason not to trust him? If not, I'd follow his advice (medical/dental advice is what you pay these guys for).
posted by nax at 7:48 AM on May 31, 2008

I would absolutely get a second opinion. We've moved around a lot and seen many different dentists, and I am always amazed at the variety of recommendations I've gotten. Another dentist can tell you if wait-and-see is a reasonable approach.
posted by selfmedicating at 8:06 AM on May 31, 2008

I hate this 'if the cost of care > you can afford == greedy doctor trying to buy a boat' attitude'. Have you discussed sliding scale charges or a payment plan with him? Have you asked if there is a low income clinic you could be referred to?
posted by pieoverdone at 8:06 AM on May 31, 2008

I'm with pieoverdone - but for a few unscrupulous ones, dentists do NOT create trumped up problems so they can "pay for (their) boat". There are simply way too many people with actual dental problems for that to be necessary (oh, and also it's ILLEGAL and immoral).

I say get a second opinion. It may set your and her mind at ease one way or the other. But ultimately the crown will probably be necessary. Waiting on it puts her at risk of much more expensive procedures, like crown lengthening surgery (depending on how the tooth breaks, etc). I know, because it happened to me. And I also have no insurance. Thousands of dollars later, it's paid off. But some preventative care would have saved me most of that. So waiting is a risk, but it's hers to take, of course.
posted by FlyByDay at 8:41 AM on May 31, 2008

I used to manage dental offices. I'm chiming in with the crowd that says if you don't trust your dentist, find another one. Whether he's honest or not matters little, if you think he's trying to screw you financially, get out of the relationship.

That said, I never worked for an office that supported making treatment plans just to rake in the cash.

I have, however, taken voicemails off the machine in the morning from people who didn't take the doc's advice and found themselves in "unbearable" pain in the middle of the night. You absolutely do not want to be the patient experiencing that kind of pain. Personally, I wouldn't take the gamble.

There is a program called CareCredit that your dentist may accept. If it looks like you qualify, you can likely find a dentist in your area that does accept that plan. Yes, it's credit so there is interest, but unless you default on the payments in many cases the doctor eats the interest in exchange for getting paid up front. (But beware, the penalties for missed payments are...penalties.)
posted by bilabial at 10:46 AM on May 31, 2008

Dr. Beck at Mount Tabor Dental would be a good choice for a second opinion.
posted by cmonkey at 11:57 AM on May 31, 2008

Modern dentistry advocates strongly for the preservation of the natural tooth when possible and safe to do so, because regardless of modern science's advances in materials technology* we still can't implant living tissue and nerves into a dead tooth. But there comes a point where the advantages of a live tooth are far outweighed by the risks of structural collapse; at that point, you have to be pragmatic. Teeth do not regenerate. As long as you keep eating and drinking, your teeth will be wearing out (even if you brush religiously, since brushing contributes to wear on the enamel).

(Warning: car analogy ahead...)

You ever watch those TV shows where they restore classic cars? Invariably there's a scene where they strip off the paint and reveal that the car is covered in bondo from previous accident and rust repair. Some panels can be patched. But there comes a point where there's nothing more you can do but junk the section and replace it with a donor or a new part.

Same thing goes for teeth. If your teeth are nothing but bondo, you're cruising for a serious bruising.

I think you would benefit from hearing from anyone who has had the experience of a cracked tooth. I know a few people here have already mentioned that you "don't want it." But I think perhaps more descriptive language is needed.

* I don't know about anybody else here, but I personally find osseointegration to be a fascinating subject.
posted by Civil_Disobedient at 4:07 PM on May 31, 2008

I would also save up for the future - for a trip to Mexico, Ukraine, India... I can't believe that one tooth could be so crazy expensive, mama mia! A full root canal at a sterile, modern dentist's office in the Ukraine costs about $65. Don't be a chump.
posted by Meatbomb at 4:31 PM on May 31, 2008

Would it be possible to get a second opinion and then maybe discount crown at OHSU?
posted by Lesser Shrew at 5:07 PM on June 1, 2008

Second opinion -- get one. It'll not only give you a second person's experience and viewpoint, it'll also give you reassurance of whether you need this work done or not.

I've had my mix of dentists. Some are very aggressive (too much so) in terms of so-called "preventative" maintenance, while others are very passive, only repairing things that have broken or about ready to fail. I went to the one dentist who supposedly had the best training, all of the latest technology, etc. He wanted me to do close to $15K of dental work. Saw two other dentists, both leading researchers @ NYU's dental school. Both of them saw what he wrote up and said 90% of it was totally unnecessary. AND, that overpriced dentist and all of his "latest" equipment missed that I had one filling which had failed and a tooth which definitely needed a root canal. The NYU dentist took an old analog x-ray of the suspect tooth and I could clearly see the root had become or was close to becoming compromised. With the digital x-ray, you couldn't tell. Sometimes "old school" isn't a bad thing.


Civil_Disobedient's correct. The best tooth material is still what your body made and there's no modern equivalent for that. It's in your best interest to keep it for as long as possible. (S)He's not the only one I've heard say this. I know several orthopaedic doctors for some of the major sports teams in the USA. ALL of them state that, with very few exceptions, the repairs they do aren't as good as what the body originally had.
posted by OTA at 7:18 PM on June 1, 2008