I have little doubt that some patients who visit a dentist and are told they have decay, but don’t experience any symptoms, are convinced that someone is trying to pull the wool over their eyes. There are probably several reasons for this. Possibly, they had been to some unscrupulous person in the past who suggested they had a problem, when they really didn’t.
I can see how that might create skepticism. I mean, it’s conceivable that sort of thing could happen.
But even if that were the case, I sincerely don’t believe it represents the behavior of a majority of dentists. Most of the dentists I know genuinely care about what they do and the people they treat. So maybe these skeptics are just people who don’t trust anyone. I don’t know.
The reality, though, is that these patients will eventually be in for a big surprise when the you-know-what hits the fan. Or – and let’s keep this a family column — when the decay hits the nerve.
But that could take a while.
And I believe that could be where some of the problem lies. A patient tries to use this to their advantage — they want to buy some time. After all, it’s not really being a “problem” for them in that they don’t perceive anything as being different. When the problem eventually does occur, I usually hear: “I never thought it would happen to me.”
A doctor detecting treatable decay usually recommends that the patient handle it at their earliest opportunity.
Why? Well, the patient can catch the problem when it is small, when it is less likely to cause post-operative discomfort, and when it will generally cost them a lot less.
But, first, let’s back up a little and explain why it’s possible to have a cavity – several in fact – and have absolutely no symptoms.
Most decay starts on the outer surface of the tooth called the enamel. It’s roughly 97% mineral in consistency and does not contain nerves. That means it has no feeling. Practically zero. Your dentist could DRILL on that part of the tooth and most of the time you won’t feel it.
Notice that in the earlier paragraph I mentioned “treatable” decay. Well, when would decay not be treatable right away? I can’t speak for other dentists, but I typically won’t treat decay when it is confined to the enamel. Why? It has the potential to re-mineralize. In other words, it has the capacity to fix itself – that is, if you don’t continue to do the things that led to the cavity in the first place. Usually, this is related to your diet, but it can be affected by hormones, or even medications.
Why not mention home care first? Isn’t that important too? Of course it is. It just may not be the most important factor.
Another time a dentist might not treat a cavity could relate to the age of the patient. For a much older patient, there are times when the pain or infection are not likely to come up before the patient passes. Of course, your dentist doesn’t have a crystal ball on that point. (Well, probably not.) But, it wouldn’t make sense to recommend treatment in the majority of those cases.
And this takes us back to the nature of a cavity. They often take a long time to get bigger. (But not always…. Again, no crystal ball here.) The reason has to do with the hardness of the enamel itself. Enamel, for you trivia lovers, is the hardest substance in your body. It’s harder than bone, and that property, along with the lack of sensation, can be problematic.
Here’s why: a cavity is often quite small on the outside of the tooth. It’s actually difficult for decay to work its way through that hard enamel. Most of the time it burrows a narrow channel down to the dentin (only a couple of millimeters away) and then it really starts to spread. Because dentin is softer than enamel, it’s just easier for it to spread more quickly there. By the way, this additional, and deeper, decay – very often still doesn’t hurt – as long as it is far enough away from the nerve.
Meanwhile, your enamel is, for the most part, continuing to hold its form. That stuff is hard. But things are generally hollowing out on the inside of the tooth now — out of sight and out of mind — as the decay continues to spread. Painlessly.
Eventually, your tooth can become very much like an eggshell.
Then one fine day you bite on something, and the hard enamel that was still doing its job holding the form of the tooth caves into the hole below. It just got too thin.
Now, at this point, does the skeptic understand that he got a cavity? Sure. Some of them finally get it. But for others –no! It’s more like: “Hey that blowhard dentist was obviously wrong because he talked about me having cavities years ago, and look – I did fine until now. In fact, I probably just lost a filling! Jeez, this hole just came out of nowhere. It’s probably the fault of some earlier dentist.” (Um, Mr. Skeptic never got the filling though. Remember?)
“Hey doc, how much is this going to cost me? $2,400?!!! (For a root canal, buildup and crown.) Are you insane? Just pull it.”
Now you are going to be missing a tooth, and may lose even more teeth as a result. Yet, when the doc first mentioned it, that cavity was only going to cost $150. How can it suddenly become sixteen times more expensive?!
“Rip-off artist. Seems you can’t trust anyone. . . .”
This is a reprint of a column I recently wrote for our office newsletter. While it is only mailed to existing patients, it contains sentiments I wanted to share more broadly. Hopefully, it will help you consider a few things about your dental health and maybe even save you some trouble down the road. While this was directed to the patients in my practice, if you aren’t a patient of mine and haven’t seen your dentist in a while, please reach out to him at your earliest opportunity. Read on and I think you’ll understand why. At least I hope so.
You can save your teeth. How do I know this? After more than 25 years in practice, you get to see a few things.
The two main reasons people give for not taking care of their teeth are time and money. Typically, people will swear they have neither.
I believe that they believe it.
But, here’s the funny thing: when the emergency happens (and it will given enough neglect) most of these same people find the time and the money to handle their problem. Sometimes, it even costs more than it would have to prevent the problem to begin with.
So, what’s that about?
It’s actually pretty simple. One patient summed it up concisely: “I never thought it would happen to me.” You see, I know that most people — deep down — really understand that neglecting their dental health can lead to trouble. But a couple of other things come into play.
First, is this classic error: “If I don’t have dental pain, then everything must be OK.” Here is why that’s just not true. Cavities usually start on tooth enamel. Tooth enamel — being about 97% mineral and not containing any nerves — doesn’t feel pain. Trust me on this. Once you actually do feel pain, it’s bad.
Second, the number one cause of tooth loss (worldwide) isn’t even cavities. It’s periodontal disease. More than half of American’s have it and most don’t have any clue that they do.
Sometimes the first symptom they notice is that their teeth are getting loose.
I can’t tell you how many times a new patient has come in and told me, my front tooth just fell out. (Naturally, it was loose for a while, but that’s the thing — they expected that maybe it would get better or, if they didn’t think about it, they could just ride things out a little while longer — or … they just didn’t think it would happen to them.)
One panicked lady absolutely had to leave the office with all her problems handled that day. After all, she couldn’t let people see her with missing front teeth. It didn’t matter that she let it go for years.
It doesn’t work that way. But you can take care of your teeth. Ask us for help. That’s why we’re here.
I haven’t written anything to the blog for some time now. Like so many people I know, I have been busy with other projects. Every now and then, though, something will come up and I find I tell myself, “I need to write about that”. Recently, an exchange with a patient prompted me to write on the subject of how much time a patient might expect from a crown or a bridge.
What I found interesting was this patient’s viewpoint about something that was happening with her relative. It seems that this relative was experiencing a problem that required she/he have a crown re-made. My patient, made an off-hand comment to me along the lines that her relative’s dentist might not have been so great because the crown was having to be redone.
I’m thinking: Oh, it must have just been placed recently.
She’s thinking: After about twenty years.
Granted. My patient has not (yet) had to replace any of her dental work and she has been with me nearly twenty-five years.
But here’s the thing: as a dentist when I hear that a crown lasted twenty years, I think – “Sounds like that dentist did a pretty good job.” It seemed to me, my patient had an entirely different impression.
I asked her: “Did you realize that the average life for a crown or bridge is only between 5 and 15 years?” My patient seemed a little alarmed by that, but acknowledged she did not realize it.
There are so many factors that can go into how long a crown or bridge may last, that this can be really difficult to predict. The five- to fifteen-year figure often cited by dentists is based upon university studies and insurance company estimates of how frequently they need to be replaced. Most insurance companies will pay for a new crown after five years, although, a number of them have recently extended that replacement date to 7 or even 8 years.
In all fairness, sometimes crowns can fail due to manufacturing errors. But the reality is that this is very seldom the case. More often it is the patient that fails the crown.
How so? There are two main reasons: decay under a poorly maintained crown and tooth clenching and grinding.
But here are a few other ways a crown can break –
Removing bottle caps
Cracking crab claws
Holding roofing nails
Tearing open cellophane packages
Inappropriate use can cause porcelain that is veneered onto a metal base to break off. Using common sense is important.
Provided a crown is manufactured to high standards, after choosing the right material for you, and having it fitted correctly to your bite it has the potential to last a lifetime.
Home care has something to do with it too.
In my twenty-five years of practice, I have seen this repeatedly. For me, two cases have illustrated it best:
Earlier in my career, I had a patient who needed a lot of dental work. He already had quite a bit done, but much of it was pretty old and, frankly, it didn’t look very good. It’s actually uncommon for me to see work that I believe wasn’t done carefully, but if any situation fit that bill, this was it. His crowns fit like “socks on a goose.” I don’t know where he had it done and, at this point, it really isn’t the moral of this story. The important thing is that this work was, apparently, what he could afford at the time. What amazed me was that these crowns were still functioning after more than twenty years. There was no reason they should have. They fit that badly. So, why were they working? This patient’s home care was excellent. He brushed and flossed after every meal. He knew that getting new dental work was going to be costly for him, so Mr. Flosser he made sure that what he had lasted him. I was impressed.
Not too many years thereafter, I saw a different patient for a new patient exam. This man had bridgework from ear to ear. Honestly, it looked great. Pretty much everything about his crown and bridge work was technically correct. The bite was good, they were esthetic, and when I took his diagnostic x-rays, I noticed that the critical areas fit perfectly. Someone obviously took a great deal of care to make sure that they delivered a great product to this patient. I would have gone to that dentist.
But another thing that I observed when I reviewed the films was that there was decay all over the place. So much, in fact, that the only way to correct it would have been to remove the bridges, clean out the decay and replace everything.
The likelihood that his dentist would have left behind that much decay is nearly zero. No one who took that much care into crafting his work would have allowed it. But the real reason I know that is this: during the course of my exam, I observed that this patient has so much plaque and garbage in his mouth, I doubt he ever brushed his teeth. It looked like he had just finished eating cottage cheese before he came in. The plaque was that heavy.
This man’s dental work was only between two and three years old. He probably paid a small fortune for it. It was that extensive.
Now, I had the unpleasant task of telling him my findings. To make a long story short, I never saw him again. Mr. Cottage Cheese probably thought I was trying to put one over on him. Nothing bothered him (yet!), and it was most likely inconceivable to him that he should have anything wrong in so short a time. And yet, it was not a promising scenario.
Today, however, an equally common cause of crown or bridge failure is tooth clenching and grinding. I have written about this epidemic elsewhere. But, if you grind or clench your teeth, things are just going to wear out a lot faster. It’s just common sense. If you had a choice of parking your car in the middle of a golf driving range or outside of the driving range, under which conditions is your car likely to end up with the better paint job?
Some people can place amazing forces on their teeth. When they do, if a tooth was in really bad shape before it was restored, the crown probably won’t survive the weak tooth. You need something of a substrate to support and retain the crown. The cement can’t be relied upon to do the entire job.
Also, to put things into perspective, the average force on a back tooth is typically around 75 pounds per square inch. When we chew, that goes up a little – maybe, to 80 or 90 pounds per square inch. Remarkably, some people have been recorded as having applied as much as 3,000 pounds per square inch on their teeth while sleeping. That can crack a virgin tooth, let alone one that has had any work done to it.
In the end, there really isn’t a simple answer as to how long a crown should last. It can vary. With all other factors being equal, I would hope for no less than seven years and consider anything beyond fifteen years “good.”
Many of my patients who are still with the practice after 25 years and that I still have the opportunity to examine, continue to have their original crown and bridge-work. But some have moved to other states, and others have passed away in their older years. Yet, much of what I can see looks pretty good. Some old crowns and bridges could use a face-lift. That usually means replacing it.
Every now and then, I wonder about those two patients I mentioned above: Mr. Flosser and Mr. Cottage Cheese.
Mr. Flosser may still be running around with those old crowns. Mr. Cottage Cheese is probably wearing dentures by now. . . .
It is not without purpose that dentists repeatedly herald the fact that your mouth tells us a great deal. Yes, it will communicate — and without words — whether you have been brushing or flossing. But it will also tell us a story of your overall health.
For centuries, even the physician began his examination of the patient with a look at the head, ears, eyes, nose and throat. He would ask you to “Say aah.”
Ever wonder why?
The specific reason is that the sound you make elevates the soft palate and allows for a clearer view of the back of the throat, but it also tests the function of the vagus and glossopharyngeal nerves. Doctors have an abbreviation they use to describe this evaluation: HEENT (head, ears, eyes, nose, throat). More recently, health professionals have been pushing for a modification to that standard evaluation, changing it to “HEENOT” instead (head, ears, eyes, nose, oral cavity, and throat).
Thus, health professionals can work together in the best interest of their patients. By performing a thorough oral exam, the dentist will often spot systemic problems and refer their patient to a physician for further evaluation. The family doctor can, in turn, evaluate oral health and alert the patient to the fact that it is time to see a dentist in order to get better.
Anyone following our blog or newsletter for any length of time has already been acquainted with the fact that what goes on in our mouths can affect the health of the rest of our bodies. Studies continue to show the links between oral and general health. By way of review – periodontal disease has been linked to complications with diabetes and pre-term labor in pregnancy. There is also a strong connection between poor oral health and rheumatoid arthritis, cardiovascular disease, strokes, and Alzheimer’s.
The fact that we perform an oral (and oral cancer) examination during your bi-annual checkups and “cleaning visits” does not excuse you from seeing your doctor for general health problems, and vice-versa. We are professionals in oral health and regular maintenance in our office helps you to stay healthy. So you want to be certain that each time your family doctor ask you to “say aah,” they then say “good job – everything looks great!”
If you have any questions about your oral health, please contact us! We love hearing from you.
The posting below is actually taken from our Weird Dental “Facts” section. It’s an assortment of dental trivia and facts — some true, some we’re not so sure about 😉 — but either way, we hope to entertain, as well as educate you, with our postings.
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This dental fact was prompted by a recent television program I watched that discussed three of the top life-threatening emergencies. We hope you never find yourself confronting this type of problem, so here is the Weird Dental “Fact”:
A dental infection can kill you.
But also true.
A toothache left untreated can, over time, develop an abscess. (An abscess is an infection that fills with pus and debris.)
Periodontal disease, left untreated, can also develop an abscess over time.
The trouble with many dental problems, though, is that in their early stages they are seldom painful.
In fact, sometimes, they aren’t painful even after they become more advanced. So people tend to put off treating cavities and gum disease hoping it will just go away or get better on its own. Then, when it does get worse, they will often put that off as well This is where it can get really dangerous.
One complication of a dental infection is called Ludwig’s Angina. It’s a type of infection that can travel from the roots of the teeth to the floor of the mouth and under the tongue. The infection can spread very quickly, creating a swelling that can block your airway or prevent you from swallowing. This can be life-threatening.
It can be cured with quick treatment that gets the airway open and with antibiotics, but sometimes surgical intervention is also necessary.
The better solution is to never let your oral health become so neglected as to allow the possibility of this type of infection.
You go to the dentist every six months to have your teeth cleaned. Well, hopefully you are getting regular dental visits. Right? But, just what is the dentist doing when he cleans them anyway?
We’ll get into that shortly. And maybe you can even recall the dentist pointing out places where you had some tartar. But if you are like many patients, you nodded your head and he went on cleaning.
On the other hand, possibly you were thinking: “Just what the heck is tartar anyway? Isn’t that a Russian thing? Or, maybe, it has something to do with that white sauce. No, that doesn’t make any sense. Oh well, I don’t want to embarrass myself by asking.”
And it went in one ear and out the other.
Let’s try to clear it up a little. Tartar is basically hardened plaque. And plaque is the sticky mix of bacteria, food particles and proteins that forms in your mouth — pretty much every day. It sticks to your teeth, it gets under your gums, and it builds up on your dental work. The trouble is that when plaque hardens, it builds up – actually, very much like a coral reef.
And like a coral reef it can spread out over a broad area. But the damage it causes hits you in two ways. Firstly, the bacteria that cover the tartar damage your gums from the toxins they secrete. This can cause the gums to become inflamed and to bleed. In its mildest form, this is called gingivitis. But secondly, the tartar acts as a foreign body. Get the idea of having something stuck in your teeth – say, a shell of popcorn. It won’t take long before the gums get puffy, red, and irritated.
The thing is, if it’s popcorn, you notice it pretty much immediately. After all, one moment everything is fine, and the next you’ve got this thing stuck in your gums. And until you pick it out, your gum stays puffy and protests its presence with bleeding and, sometimes, pain.
The difference with tartar is that it generally forms more slowly. So, in most cases, people don’t even notice it growing. Nor do they notice what it is doing to their gums and the surrounding bone. Because when gingivitis is not gotten under control, it gets worse. Pockets form between your teeth and gums and get filled with more bacteria and more tartar. This leads to an infection called periodontitis.
Over time, your immune system kicks in, trying to use stronger methods to fight this problem that just isn’t going away. The result: it starts to work against you and breaks down your own bone. What’s more it usually does it painlessly. So many people don’t even realize they are losing bone until their teeth get loose. That’s why this is the number one cause of tooth loss worldwide.
So what is the dentist doing when he cleans your teeth? He’s removing the foreign body (the tartar) and what is basically a condominium for your harmful bacteria. But don’t feel too bad for your evicted bacteria. They will try squatting in a new home under your gums in less than twenty-four hours. And they are associated with such nasty effects as heart attacks, strokes, Alzheimer’s, pancreatic cancer, and more.
For the sake of your health, when it comes to tartar, you should care. Steps you can take to get matters under control include brushing after meals, daily flossing, and eating a healthy diet. Oh, and if you smoke, chances are you will build more tartar as well. There’s one more reason to quit.
Once tartar has formed on your teeth, only your dentist or hygienist can remove it.
So, be sure to visit your dentist at least twice a year to remove any plaque and tartar that has built up and to prevent more serious, and costly, health problems.
OK. So let’s say it has been decided: you are a candidate for an implant.
You may have heard that getting an implant can take a long time. By contrast, you can have a bridge to replace your missing tooth in about two weeks or less. Isn’t that better?
Not so fast. It all depends.
Let’s look at a couple of scenarios. If you are replacing only one tooth and have two adjacent teeth here is what you should consider:
In order to place a bridge, you have to shave down those teeth so that they will support the bridge. This limits their longevity and may open the door to the need for additional work, such as root canal therapy in the future.
You should also understand that bridges don’t last forever. The national average, according to university studies and insurance company estimates, is only five to fifteen years. If, you are in your twenties, a bridge can turn out to be much more costly over your lifetime.
Let’s see how this plays out:
For the sake of argument, consider that a person has lost their first molar. The 2013 national average price for crowns (the individual units that make up a bridge) was about $1160. Since our hypothetical bridge has three units, that adds up to $3,480. If existing fillings need to be replaced due to decay, it could cost another $500. And if a root canal is needed because the filling is now closer to the nerve, this can cost as much as another $1,100 for a molar. Suddenly, the total bill can exceed $5,000 using our example.
In five to fifteen years the bridge may need replacement. Let’s be generous and say it lasts fifteen. Between the ages of 25 and 85, that’s four replacements – nearly an additional $14,000 – if nothing else is needed.
In the long run, replacing one tooth using a bridge can cost nearly $20,000 over your lifetime. And that’s assuming it is still in a condition that permits a new bridge.
What if instead we replace the tooth with an implant? At today’s rates, a traditional root form implant runs between $1,800 and $2,000 in my area. An abutment (that’s the part which ties the implant and the implant crown together) will range in price from an average of $850 to $1,200. Prices for implant crowns vary widely – though many dentists charge the same fee as they do for regular crowns. In this example, we’ll use the fee given above, so $1,160.
If we take the higher estimates here, we’re up to $4,360. That’s only $880 more than our bridge in the earlier example’s “best case” scenario.
The difference? That implant (barring situations like an accident causing physical injury to the implant) has a good chance of lasting a lifetime. That’s a lot less than $20,000 over time if you go the bridge route.
I have had patients react in various ways to this analysis. Some tell me “I really don’t want to wait three to nine months, while wearing a temporary partial, for the implants to be ready.” Others have said, “Well, if I’m going to have to replace a bridge down the road, or even end up with an implant later anyway – I might as well just do it now.”
Both arguments have their merits. But at least now you have some information that can help you make an informed choice.
Dr. Richard Walicki is a dentist practicing general and cosmetic dentistry. While we hope you find the information contained herein interesting and useful, this blog is for informational purposes and is not intended to diagnose any oral disease. Dental conditions should be evaluated by your dental health professional or a qualified specialist.
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