Expert: Mark Bornfeld DDS - 7/19/2007

Question
QUESTION: Dear Dr. Bronfeld,

About four months ago I had a full set of digital x-rays taken and was told by the dentist that there were no problems. Today, I had x-rays taken again by another dentist who says I have substantial decay under a crown connected to a bridge and that I need a root canal as well as a bridge replacement. Could that much decay have occurred in so little time. And do I really need a root canal if I am experiencing only slight discomfort with cold. This dentist also says I should have two other crowns replaced with Cerec crowns. He says the cost for all this, minus the root canal which will need to be done someplace else, is over $6000 (my cost. My insurance is supposed to pay all but a $50 co-pay for bridges and crowns.  By the way, the previous dentist told me my teeth were okay, but told my husband that he needed a crown replaced. And now the new dentist says my husbands teeth are okay, but I need work. What's going on? I need to make a decision on this right away, and I feel a bit upset, not knowing who to trust. I'd appreciate any help you can give.

Thanks.

Susan Sudbury

ANSWER: Dear Ms. Sudbury,

Quite naturally, I am at a disadvantage in determining which of your dentists is coming closer to the mark of diagnostic accuracy. Apart from the fact that I am slightly irked by what I feel is an over-emphasis on high technology (both dentists are guilty of this-- the first with digital x-rays, the latter with Cerec crowns)-- either dentist could be correct. It is unlikely that significant tooth decay could have occurred in the span of four months, so one of two things might have happened:

1- your first dentist failed to discern and identify the tooth decay, which was already present. Those high-tech digital x-rays don't quite have the same image resolution as conventional films, so it's possible they didn't show the tooth decay, which can easily be obscured behind a metal crown margin. It's also possible that your first dentist just dropped the ball when interpreting the films.

2. Your new dentist may have misinterpreted his x-rays, which can sometimes display artifacts (erroneous parts of an image due to exposure, development, or film emulsion defects) which can be mistaken for real decay.

That $6K bill is substantial-- no doubt your dentist must support that tremendous capital expenditure he made in purchasing the Cerec system, which comes in at over $80 K. For the record, crowns of equal or superior quality are available using established old technology.

As for your skepticism regarding the root canal-- it is entirely possible to have a pulpal infection without any symptoms, so you can't assume your dentist is wrong in this regard. Diagnosis of pulpitis or abscess is relatively assured if it is demonstrated that tooth decay has breached the pulp.

So whom do you believe? You can either obtain a third opinion from yet another dentist, or perhaps you might wish to consider returning you your original dentist and challenging him on missing the tooth decay. He will either sheepishly concede he missed it, or declare your new dentist to be wrong. He is unlikely to maintain that there is no decay if it is demonstrably present, since a failure to diagnose dental disease is professionally negligent, and he will be eager to be given the opportunity of correcting his mistake.

Good luck!

Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY

---------- FOLLOW-UP ----------

QUESTION: Dr. Bornfeld,

Thank you for your quick response. Both dentists used digital x-ray technology, so they should have been looking at the same thing. Also, that dentist was subsequently removed from our dental insurance program for trying to charge us for things that should have been covered by the insurance. I am worried that the same thing is happening again, because, as I said, we have 100% insurance on crowns and bridges except for a small co-payment of $50. The new dentist also said that I need two other  traditional crowns replaced with the new Cerec Crowns. He says the digital x-rays show gaps. I don't know if I have a real problem with those crowns or if I'm being sold a bill of goods.

Don't know if you have any additional ideas for me. By the way, I saw the digital x-ray and it the decay didn't extend all the way to the pulp. Is there some other test to determine if I really need a Root Canal?

Thanks again.

Susan Sudbury
ANSWER: Dear Ms. Sudbury,

Although both of your dentists used digital x-rays, they were not necessarily looking at the same thing. Subtle differences in the angle at which the x-rays were exposed can make a significant difference in whether tooth decay is visible or not, especially adjacent to a crown margin, where it is all too easy to obscure significant decay. More importantly, the dentists were seeing the x-rays with two different sets of eyes, and with diagnostic skills that are not necessarily equivalent.

As for your dentist's removal from your insurance panel-- this is something that may or may not have any bearing on either his professional skills or integrity. Suffice it to say that doctors and insurance companies play a kind of game with each other, and neither party necessarily holds the moral high ground. There are many dental services that have merit, but are not covered by insurers. The fact that benefits are not available for a particular service does not necessarily mean that it is inappropriate treatment or that the fees are excessive.

With respect, there are sometimes difficulties in reliably determining whether tooth decay has reached the pulp from any x-ray, digital or not. This is especially the case at a crown margin, where the full extent of the decay is partially obscured by the metallic substructure. There are several different ways of diagnosing pulpal injury-- radiographically evident signs of infection, palpable swelling, symptomatology, and others. One thing is certain-- it will be far easier to determine the need for root canal therapy AFTER the bridge is removed. Once this is done, the decay can be carefully excavated to see where it goes. Although it's nice to know the full extent of treatment before starting, it's not always possible. There's no sin in deferring conclusive determination of the need for root canal therapy until after more diagnostic data is available.

Mark Bornfeld DDS

---------- FOLLOW-UP ----------

QUESTION: Dr. Bornfeld,

It's been a few weeks now and it turns out that the tooth (#15) under the bridge was unsaveable and needs to be extracted. It was crumbling away so badly there is no way to save it. The new dental office (a third one) was unable to make an immediate referral to a specialist who could extract my tooth, except to someone who is not covered by my insurance. So I am waiting until next Friday to have it removed. It has already been a week that my bad tooth has been exposed (except for a little filling that's kind of holding the whole thing together). What I am wondering is if I should be taking antibiotics or something to prevent any kind of infection over the next week or if you think it should be okay for another week. The reason I am concerned is because I had rheumatic fever as a child and recently have been told that I have a "hole in my heart" which I guess is something that may or may not be related to the rheumatic fever. I did take amoxicillin 2000 mg at the time they removed the crown and discovered the unsaveable tooth.

By the way, I am not having any pain with the tooth, so I guess the nerve is dead and I am not experiencing any fever.

Can I ask one more question? What is the going price range for dental implants, as that is the next decision I must make.

Thank you so much for your help.

Susan
ANSWER: Dear Susan,

The protocol for managing heart defects is in a state of flux, primarily due to policy changes that were published by the American Heart Association in April of this year. It their latest revision, many of the predisposing heart conditions that were previously considered to merit antibiotic therapy have been removed from the list. Broadly speaking, the categories of heart conditions that still will require preventive antibiotics are:

-patients with artificial heart valves
-patients with a history of bacterial endocarditis
-patients who have unrepaired, unsuccessfully repaired, or recently repaired congenital cyanotic heart defects

It is unclear whether you fall into one of these categories, so I advise you to consult with your cardiologist for more specific recommendations customized to your current diagnosis.

Be advised that using antibiotics "just to be safe" is not necessarily the right thing to do; the inappropriate use of antibiotics introduces its own risk, and your doctor must chart a course that provides the best risk/benefit balance.

The fee for implant service varies considerably, so it's not possible to offer an estimate that is applicable to you. Not only are there regional variations in the fee ranges, but an implant is not an implant; there are different types of implants, with different types of devices that interface with the implants. They may be used to support a single-tooth prosthesis with a stock abutment and a crown, with a custom abutment and crown, or be used to support a fixed bridge in combination with additional implant fixtures, or perhaps be used with a bar connector or other overdenture attachement-- it's a lot more complicated than just "implants", which technically speaking only refers to the artificial tooth root that is buried under the gum. For a realistic estimate of the entire cost of both implant and prosthetic device, you must consult with your prosthetic dentist. There are usually several different options available, so you should consider getting several estimates to determine the type of treatment you feel comfortable with.

Hope this helps...

Mark Bornfeld DDS

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Bornfeld,

The plot in my implant journey thickens. Here is my question. Is there any contraindication for doing a sinus lift when there is a mucosal cyst in the maxillary sinus of the same side? Also, is there any known association between severe dental decay and mucosal cysts? And finally, do you know of and do you have an opinion about studies which show spontaneous bone formation of the maxillary bone after the removal of a mucosal cyst where a "pocket" is left in the sinus? I'm not sure exactly what this refers to, but maybe you do. I have seen at least four references to different studies that report on this. I guess the idea is, that the spontaneous bone formation precludes the need for the sinus lift.

Thanks again for your help.

Susan

Answer
Dear Susan,

Questions about cysts or other abnormalities within the sinus are, strictly speaking, better answered by an ENT doctor rather than a dentist; anything within the sinus is beyond the expertise of a dentist and beyond the legal scope of a dental license. This may seem to be at odds with a dentist's prerogative regarding sinus lifts, but these procedures never actually enter the sinus; they merely lift the sinus membrane. Once you get into the sinus itself, it's no longer dentistry. However, based on my limited knowledge of sinus cysts, they are not associated with dental disease, and tooth decay does not play a role in their occurrence.

You'll need to speak to an ENT doctor to see if a sinus lift would be contraindicated in the presence of a cyst. I suspect it would depend on the size and location of the cyst, since it is conceivable that it could be displaced by a sinus lift so that it obstructs one of the openings that communicate between the sinus and nasal cavities.

I am unaware of any studies that deal with bone regeneration after removal of a cyst in the sinus. It makes intuitive sense that some bone would re-grow, since the same response usually follows the removal of an odontogenic cyst in the mouth. However, the probability that bone would grow in precisely the right location and in the right amount that it would help to accommodate an implant would be very low, and I think it unlikely that cyst removal would eliminate the need for a sinus lift.

Mark Bornfeld DDS