To extract dodgy premolar or not?

kayeb

I am currently undergoing dental implant treatment to replace my Upper Right premolar lost following an aborted root canal 18 months ago.  I was referred to the implantologist who visits my regular private surgery 2 or 3 times a month.  I also have a heavily broken molar on my left side (broken eating almonds), my regular dentist (2.5 years) had said it was on its last legs when I asked if it could be crowned or improved last year.  Eating has been difficult & I’ve lost 2 stone in the last year.  During the CT scan during the implant planning the implantologist observed that the left upper root filled premolar (next to the badly broken molar) had an area of chronic infection at the root tip.  I’ve had some twinges on this, but when I asked my regular dentist he said if it wasn’t bothering me to leave well alone.  Unfortunately at my regular check up a couple of weeks ago my regular dentist noticed that the upper left molar had broken further & could not be saved.  He suggested I discuss extraction & replacement options with the implantologist who I was due to see in a few days to remove stitches from my newly placed implant post on the right hand side.  The implantologist agreed the broken left molar was unsalvageable, but that having a chronic infection in the premolar next door was not conducive to implant placement in the soon to be extracted molar.  He excluded a bridge as it wouldn’t be going on sound foundations as the premolar has a large filling, incomplete root treatment, and apiosectomy wasn’t possible due to the proximity of my sinus to the premolar root.  He suggested either accepting the molar gap, or extracting both left molar & premolar & doing a double implant.  I don’t think he’s chasing fees as his consultations haven’t been pushy so far.  I’d agreed with my regular dentist that I’d discuss the recommendation on the phone.  He thought extracting the premolar seemed unnecessary & maybe a bridge would be possible, that I’d have to have the root canal redone by private endodontist then a post made to support a bridge (not sure which type) to the molar behind my soon to be extracted molar.  I’m not looking for a diagnosis, I know that’s impossible without access to my records, but would anyone be able to shed some light on the survivability of a 3 tooth bridge on a redone root canal with a big filling with a chronic area of infection please.  Any idea on costs?  I know implants are not an easy option.  Cost isn’t the issue, it’s about trying to weigh up the best option so I’m not running back to the dentist every year or two.  For the record I’m approaching 60 & I’ve improved my diet (after advice from this forum) limiting sugar attacks, & both dentists say my oral health is excellent now.  I haven’t got any gum disease & don’t smoke.  

Toothsmith

This is the problem when seeing multiple dentists. Newspapers often make much of 'investigative' articles where they send a reporter to several different dentists and come away with completely different treatment plans. Within dentistry though - we see these articles and collectively roll our eyes at the lack of understanding of the complexities of treatment planning! You see 3 dentists - you will get 3 different treatment plans! No one is right, no one is wrong. They are just giving the patient the benefit of their particular experience and training and the self-knowledge of what works best in their hands. We are not programmed robots - we all do things differently, and we recommend what we know we're good at, and steer away from what we're not so confident with.

Having said all that - this is a bit disconcerting when seeing 2 dentists who work in the same practice (albeit one just 'visiting') and obviously have some sort of professional relationship. They shouldn't really be leaving you stuck in the middle of two completely different treatments.

I cannot see you, or your records - and anyway, medical or dental advice isn't allowed on this site. So I can't say which you should go with, as I have no idea. I can see the implant dentists argument - and I would agree with you that I don't think he's just trying to rack up his fees. His advice sounds good, and I'm sure you'd get a predictable long term result from fixing the gaps his way. He is right that you shouldn't place an implant near any existing infection. That is a recipe for disaster.

As for your 'proper' dentist - I can see that argument too. But although I can't say i 'never' do it, making a root filled tooth the support for a bridge is only something you should do if you are very confident in it's long-term prognosis. The fact it's going to need a second root filling to deal with this chronic infection underneath it will make that prognosis slightly worse. I cannot see this tooth - so am not in a good place to make comment - your dentist is.

Having a specialist re-root fill this tooth, then the costs of the bridge and the post will mean that the cost of this option probably won't be that much less than the double implant? This is something that should be considered too. especially against how long each option might last you.

What I may be tempted to do here would be to ask that your dentist and the implant dentist actually have a coffee with each other and discuss the pros and cons of your case between them!! They are the experts, and they know the pluses and minuses. It would still; be up to you to make the choice, but if they can come up with a 'joint statement' - it might be more helpful?