QUESTION: My general dentist referred me to an endodontist because he was not sure if my x ray showed the early start of an abcess. (Note that I do have a couple deep pockets for which I was being treated.) Even though I did not have any pain with this tooth, or any other, I visited the endodontist who performed several tests and took xrays. I did not have any sensitivity. He said that there was no abcess or need for any type of root canal but that tooth #18 has a crack in it and needs to be extracted; this was 6 months ago. I was always a "self pay" patient so I decided to enroll in dental plan but had to wait. During this time I again visited my dentist's hygienist for cleaning. I determined that her efforts with injecting an antibiotic in my gums was not bringing lasting improvement in the deep pockets (as shown by the measurements) and asked her to recommend a periodontist. At my first visit I told him about the endontist's recommendation but was not sure of the tooth number at that time. Periodontist did xrays and came up with a plan for gum/bone graft surgery on the deep pockets of both sides of my mouth. He did the gum surgery/bone graft on the right-side pockets about 3.5 weeks ago. In planning for the left side and during my surgery follow-up visit, I noticed that the tooth he is to operate on is #18. I reminded him of what the endodontist said and he examined the tooth again and had me bite down a couple times on something- no sensitivity and no pain. He said that it could be a groove and not a crack. I asked if he could do a diagnostic procedure; he said that would be "exploratory surgery". If he opens area and it is indeed cracked, he would just close it up and I could plan to have it extracted. But if he opens it and there is no crack, he would have to go ahead and laser it clean and to the bone graft- cost is over $2,000. Insurance only pays annual max of $1,500; I will cover the rest. But insurance won't kick in again until Jan. of 2015. I really want to deal with this ASAP but he agrees that as we are almost in October, I can wait until then. I also confirmed with endo's office that it was tooth #18 that he recommended extraction of. My questions are- which specialist should be the most knowledgeable about this being a crack or a groove? Have you seen cases where the tooth is cracked to the point of needing extraction but the patient has no pain or sensitivity with that tooth? Thank you so much.
ANSWER: Excellent question and great history, thank you for being so thorough. As far a who is more qualified to diagnose a crack both men are equally qualified but I would put a little more faith in the Endodontist as he deals with this situation often. As far as a tooth that has been cracked with no symptoms I have crowned these teeth and they've been very good with no complications. I am concerned about your periodontal condition and I'm not sure if I would risk the cost of a tooth that might be questionable. It is a second molar, which is not as vital to keep as a first molar but of course all are important. I think it might be wise to follow the recommendation of the endodontist and if you decided you needed a tooth in that spot then after your periodontal situation has cleared up you could consider an implant. Granted that would be more expensive but it is also with less risk than having all this periodontal work done and then probably a crown on the cracked tooth and then have it fail. Thanks for all your attention to detail, if I can be of more assistance please write to me.
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QUESTION: Thank you so much for your answer, Dr. Karmen. I do have a follow-up question. Like you, I am most concerned about my perio condition and want to correct it thoroughly. In fact, I am ready to just pay out-of-pocket now to extract the tooth then get the implant done when insurance kicks in again in January. In consulting with the perio, I asked him if the tooth turned out to be cracked and needed extraction, could he do the extraction and implant. He said that he could do the extraction and would pack it with some type of preparatory items but that a dentist(?) would then insert or "screw" in an implant. I am assuming that the dentist would also choose and prepare the actual tooth implant. I thought perios could perform the whole extraction/implant process. Is this the way it is usually done? If not, what type of specialist would be the most experienced with extracting tooth #18, then doing an implant? Lastly, which part of the process is more expensive- the extract and prep part or the actual implant? Thanks again and may your kindness be returned to you many times over!
Hello again Elle,
Often a periodontist will do both the surgery and the implant preparation. I think he might have meant that he would put the first part of the implant in and then your dentist would actually make the restoration which means he/she would place an attachment into what the periodontist placed and then restore the tooth part with a crown type of restoration. If he did not mean this then the people with the most experience in extracting teeth are oral surgeons and many of them do implants too. I would ask your dentist for a referral as to which surgeon they like to use. As fr as expense it is the actual implant that would be most expensive. Thank you for the follow up question, I hope all goes well for you and it sounds like you're in good hands.