When does a Tooth Need a Crown

               I got the idea for this post from teaching at the dental college. Different instructors seem to have different criteria for when its time to treatment plan a crown. I tend to crown teeth when there is sufficient tooth structure missing to put a tooth at greater risk for a future fracture. If such a tooth needs a replacement filling I usually recommend a crown instead, since this will tend to protect the tooth from the forces involved with chewing and protect the tooth from future harm. While replacing a large restoration with a new filling may be tempting, usually this is not optimal treatment. I believe that larger fillings fail more frequently than smaller fillings and when they do it places the tooth at an additional risk for the need of endodontic treatment or  tooth loss.

                  When treatment planning a tooth with a large failing restoration, I often find  that the tooth structure will not be sufficiently supported by another possibly larger new filling.When this is the case,  it's best to restore the tooth with a crown (or an onlay). I often explain this to my patient and add that when it's time to fix a restoration, it's best to fix it right and choose the best option available.

                  Patients sometimes counter that they cannot afford to  spend the money involved with having a crown made ( or would rather not). After hearing this I often point out that we can go ahead a place a large filling but if it may put the tooth at risk of developing a more significant problem. If their tooth later ends up needing a root canal or even needs to be extracted,  a significantly greater sum will be required.              I add this information because I need to confirm that my patient truly understands the reasons for my recommendation and that I have  informed consent to proceed with placement of a large filling. Often, after some back and forth conversation, my patient may change their mind and  have a crown made instead of a filling , but if  they don't, I can often place the large filling, with a clear conscience!

Why do my teeth keep breaking?

Some of my patients do seem to break a number of their teeth. There are probably a number of factors in involved. 
        First lets look at back teeth that break or crack. Often the teeth that break have fillings that undermine the existing tooth structure. Even a small filling placed close to the edge ( the mesial or distal of the tooth) can make a crack more likely to develop. Many of these teeth really should  have onlays or crowns placed to protect them.

             Another factor is the occlusion and frequency of night time clenching and bruxism ( many people do this at times while sleeping). Patients that have worn their teeth flatter so that there posterior tooth surfaces meet quite broadly during excursions often apply more force to their posterior teeth. These are people who have "cow bites" (Dentists term). Often when I examine these peoples teeth they have multiple posterior broad wear facets from their forceful grinding and chewing.

                Destructive habits , such as chewing on ice cubes, bones and other hard substances can also cause teeth to break. I had one teenaged patient who had no fillings in her teeth but kept breaking her teeth. It turned out she had a habit of chewing on to a pen top (kids do the darnedest things!)

              I have also observed that older patients, whose pulps have receded (no pulps in their clinical crowns) seem to be more likely to experience tooth fracture. This is especially true if the have a deep overbite involving their anterior teeth.

                Some dentists advocate changing the occlusion of patients by extensive tooth equilibration or by reconstructive dentistry. My solution is simpler.  For  most of these situations is to recommend that my patients wear a nightguard while sleeping that will protect their teeth and help eliminate destructive tooth to tooth contacts at night. This seems to be the least invasive choice and to my mind it is a "DO NO HARM" solution to the problem.

Why does my crown keep falling out?

Maybe it's not that into you.....? :)
              Being rejected by your crown hurts, especially when it was recently made and cost some serious money. Why does it happen? Usually either it has to do with the shape of the prepared tooth holding it or because the crown is ill fitting.

                For a crown to be retentive (resist the forces that may tend to remove it) the preparation has to be smooth and only SLIGHTLY tapered. It also has to be long enough to provide enough surface area to grab the cement. If the prepared tooth is too irregular, too short or too tapered, it may not have the proper shape to hold onto its crown.

                 Also, another possibility is that the crown can be cemented with a poor fit. In this case the crown does not hug the tooth well enough for the crown to stay put and since the crown is completely dependent on cement to stay. An analogy would be found in furniture making where most good furniture is made with dovetails, that increase the ability of the furniture to hold the wood together. Without dovetails, the pieces tend to work themselves loose more quickly. 
                 
                The same can be true with crowns, since their success is dependent on having a properly shaped tooth holding them and an intimate contact with it. The space between the crown and the tooth should be minimal (20-40 microns) in order for the cement achieve maximum holding power.

                   Most dentists faced with a permanent crown that comes out will first try to re-cement it. In my practice, I upgrade to a different permanent cement with more holding power. Unfortunately these cements do not always offer a long term solution and I am faced with the option of making the crown over.  When I do so I pay special attention to correcting any shortcomings in my tooth preparation and making sure that I take a perfect impression.

                  I should add a few  additional reasons that crowns can come loose. If the bite is high or just unfavorable, crowns can be more likely to come loose. Crowns do better when most of the occlusion is experienced along a  mostly vertical force vector and without much  of a horizontal component. Anterior teeth with deep over bites can experience a lot of horizontal forces on them and can sometimes be challenging to crown. Also some patients do have habits that are just not that friendly to crowns such as eating stale tootsie rolls or very hard and sticky candies. When chewed often these sweets tend to loosen even well fitting crowns


Dr. Pankaj Malhotra is a Periodontist & Implantologist in DELHI NCR region of INDIA, who maintains a practice in Noida. For more information about his Dental Practice please visit his website at www.dentalclinicnoida.in 

Sensitivity after a Crown placement

              There are two types of sensitivity that can commonly experienced after a crown is cemented. One is sensitivity to biting pressure and the other is sensitivity to cold (and or hot) liquids. If a patient is  experiencing either of these after a permanent crown is placed, then probably the best thing to do is to let their dentist know.

                  Sensitivity after a permanent crown is placed is not that uncommon. If a patient reports sensitivity, I check their bite, since a high bite can be irritating to the ligaments holding a tooth and can even cause pulpal sensitivity. A patient should be able to close there mouth comfortably without feeling any pain. If when they close their mouth (without chewing any food) they experience pain from a new crown, the bite should be adjusted.

              If a patient can comfortably close their mouths, but does experience pain on heavy chewing, I usually ask them to wait and see if the pain gets better with time. A crown cementation can sometimes irritate the pulp and with time this irritation can diminish. This can take months to go away and if a patient is willing, its usually best to wait. If I see them at their next recall, the tooth is still sensitive to chewing or when drinking cold liquids, I take a radiograph and if no pathology is evident, I usually try to get the patient to wait longer, since the only real other options are to perform a root canal on the tooth or to cut off the crown and place a temporary crown with a sedative filling. Which of these I would choose, if I feel the need to treat the tooth, is dependent on whether I believe the pulp has a reversible or irreversible pulpitis.

              Deciding whether a pulpitis is reversible is not always easy, but the prior history of the tooth has a lot to do with the decision. If a tooth was assymptomatic prior to me working on it initially, I am more likely to choose to remove a crown and place a temporary. If a tooth had a pre-existing crack in it or was symptomatic prior to me preparing it for a crown, I am more likely to recommend the patient visiting an endodontist and have a root canal done through the crown.

               I feel that the pulp is still vital and not infected, there is usually no harm in watchful waiting, since with enough time sensitive crowned teeth can calm down. I explain this to my patient and if the symptoms are bearable we often wait for the symptoms to slowly go away. If the symptoms are worsening instead, we can always choose the root canal option.

Why Dental Diagnosis are sometimes In-Exact.

              Even after after taking x-rays and performing a thorough clinical examination of a patient in pain, it is not always possible to make a definitive diagnosis in just one visit. Sometimes there are multiple possible causes for a patients discomfort. Often a patient having pain originating from one quadrant has multiple restorations and more than one can be  experiencing pain.

             Just last week a patient came in after a trip to Chennai complaining of pain. She hadn't slept all night. My clinical examination showed that the pain was coming mostly the area around lower back tooth , which had previously had a root canal, post and crown. The mesial papilla of the tooth  was swollen and painful. It had a pocket of 5-7 mm, and No drainage.  Clearly her pain could be due to a failing root canal or a fracture of one of her roots or also because of side teeth fillings. The x-rays taken were non conclusive.
                     To make the diagnosis more complicated the Patient had a bad cold and throat infection and fever. So the pain could have been worsened by Sinusitis or general malaise of the patient, which would definitely get better within 2-3 days with medication.

             I placed the patient on Antibiotics and it was decided that the best course of treatment was to do nothing more for the present but to speak with her in the following week to see if she was experiencing any improvement. If there was no improvement he could then check her again to see whether there was an actual tooth problem that required treatment.

                  Although patients in pain often want immediate relief, sometimes the best way to handle  a problem is to do nothing. This is especially true when the dentist is not sure what is causing the problem and there is a possibility that the symptoms will go away if the patient is given enough time. If the problem persists for more than a week or two , the patient should come back to the dentist in order to have him better diagnose the cause of the symptoms and often the source of the problem may become more apparent if given additional time.

What Should you do if your Filling Falls off...

If your filling falls off it is generally the time to call and schedule a dental visit. If your tooth is not hurting, it usually not so important to call your dentist, but you would be wise to seek an appointment within a week. Absence of pain is not a reason to delay seeing a dentist, since patients who report that a filling has fallen out can often have decay present or may have a piece of the tooth broken as well.

Once you visit your dentist, he will most likely need to take a dental radiograph or two so that he can diagnose the extent of the problem. If there is no decay present your tooth may just require a new filling. If decay is present, the dentist will need to clean it out prior to refilling the tooth. Bear in mind that in the event that the decay  has compromised the pulp, your tooth may require a root canal procedure and teeth with extensive missing tooth structure may be candidates for a crown instead of a filling.

Toothaches : What to do..?

Aching tooth

Although there are many causes for "toothaches", the correct procedure is to call your dentist. If you do not have one, call a friends dentist. If its after hours, call and take the appointment. Ok, but what to do until then?

The first thing to try is to take a pain killer such as Ibuprofen (Combiflam or Flexon) or Crocin. Both of these medications are not only good at cutting down inflammation but also provide pain relief for mild and moderate pain. Both are excellent to be used as first line medications for tooth pain. Do not take a stronger narcotic medication without trying one of these two. The sole exception would be for someone who  has a bleeding  problem or an allergy that can be caused by either of these drugs.

              It is not advisable to place tablets or clove inside the mouth in an attempt to alleviate the pain. Some patients try and holding this against the tooth in an attempt to stop the pain, but the medicines can cause burns in the gingiva. Rinsing frequently with warm saline solution can help in the event that a patient has a swelling in the gum.  It is not advisable to place a hot compress on the outside of the face, since this can draw an infection toward the skin of the face and can cause more swelling.

              Sometimes patients experience toothaches immediately after eating. Usually these people have a tooth or teeth with deep caries and eating can cause the teeth to throb. For these patients I advise not letting food come in contact with the painful tooth (teeth) since it can cause a worsening of the tooth ache. Often teeth with deep cavities and vital pulps will calm down on their own if left alone for a short period of time (an hour).

            If you are experiencing an "after office hours" tooth ache and cannot reach your dentist, a trip to the hospital emergency room is an option, since many emergency rooms have oral surgeons on call.

Ask me no questions, and I'll tell you no lies.

               The title of the post is a saying by Oliver Goldsmith which personifies the subject i am writing upon.. 

           It seems like some of the patients that we see, read this quote before coming to the doctors.. Well as hard nuts as we are, we do ask questions and a lot of them at that.. 

            The details of the patient or as we call it the Case History of the patient which involves a set of questions to be put forward to the patient - starting from Name, Age, Address, occupation to the Complain and the the details about it and also about the other parts of the body and sometimes about the parents and children too.. 

          I dont understand why do some patients have to lie about these things and that also to a doctor.. the noble profession as we call it.. We are here to alleviate your misery not to gain some vital info about your house or family.. 

           Each and everyone of these questions is necessary to us for forming a diagnosis to your disease and to  treat you well. And if you tell lies about any of this you are hampering your own health and treatment and God forbid if some complication occurs, you shall never be able to forgive yourself.. 

         Even a phone number or your correct and full address is necessary sometimes.. We arent here to spam your phones with msgs or to flirt (female patients look astonished when we ask their age) so better we get all your details correctly and well informed then to play with your own lives..

            

          Here I would give you 3 examples of patients giving me wrong / incomplete information in the last 1 month and putting their lives or their children lives in danger..

1. A Female scheduled to undergo a surgery didnt tell us about her pregnancy until it gained a complication 1 week after the surgery was done.. She put herself under the stress of surgery, put herself under the Xrays and the complication later and then decided to abort the child..

2. A 8 yr old child who was scared to visit a dentist and had very little medical history suffered a Brain Stroke on the dental Chair and had to be immediately shifted to the hospital and underwent a Brain surgery..

3. A 28 yr old Patient fills up a form and details of all his brother and gets his treatment done just for faking a bill and getting reimbursed for it.. 

              So i request you to kindly give all your details as they are in your full knowledge to the doctors and we shall treat you to the best of our capability.. Remember we are all under Hippocrates oath and your information remains with us only..

Lastly, I pray to God that you dont have to come to us at all.. 

Keep Smiling.. 

Why Is Dental Treatment Expensive?

So am back after some hibernation with a sensitive topic which is on every patients lips whether in pain or not…

While Dentists are fortunate to be involved in a helping profession, they are also small businessmen who run a private for profit business.

Getting started in dentistry is expensive and can leave young dentist's with a large debt load of Lacs of rupees in debt. Opening a dental office is also expensive with real estate at all time high and rentals. Dental offices are costly to build and even well established dentists can feel financial pressures.

Fees are of intense interest to many people shopping for a dentist on the internet and often patients seem to be shopping for affordable dentistry. This is all well and good, but usually it is wise when seeking ‘bids’ to stay away from the low bidder (unless you’re our government?)

As one of my wise dental assistants once pointed out ‘Jitna sugar daaloge utni meethi cheez milegi”. Similarly where dentistry is concerned good work takes time and usually has a fee that properly reimburses the dentist for his time. And operating costs being the same in an area, quite naturally the ones doing at a low cost are cutting corners somewhere.

Most patients demand that their dentist stay current both with their continuing education and expect that their dentists use first rate materials. Similarly dental laboratories that dentists employ to achieve create beautiful and well fitted dental restorations are not inexpensive either. It is not surprising that that a high percentage of any dental fee goes to paying operating expenses. Most dental offices have operating overheads of 60-70 percent or more.

Salaries and benefits for well trained dental staff can be expensive since they expect compensation that is competitive with the market place and they most talented employees can easily find work with other dental or medical facilities.

Although dentistry can be treated like a commodity just like any other, it is an ART and also a science. Often in dentistry as in life, it not what you do that’s important, it’s how you do it! An excellent filling is better than a poorly fitted crown. Many dentists do things differently and invariably some offer better results than others. 

My crown broke, What should I do?

               If your crown breaks, you should call a dentist and get an appointment as soon as you are able. Hopefully your dentist will see you within a day or two. If they can't see you within a week, I would call a different dentist or better yet ask them 'nicely' if they can refer you to a good dentist who will be able to see you sooner.

               It is best to see a dentist soon, because it is often hard for a patient to evaluate the extent of his damage. Sometimes, a patient without much pain has sustainned a significant injury to a tooth. Fortunately, most times having your crown break isn't such a big a dental emergency. Most times when the patient is seen the crown either needs to be replaced or smoothed.

                Some times the remainder of the crown is sharp and can irritate or cut the tongue.
If the underlying tooth is exposed, sometimes the tooth is sensitive to air or cold liquids. That means the pulp inside the tooth is still alive(a good thing!). Although this is anoying and can be a pain, nothing will happen to the tooth in twenty four to 48 hours. Teeth do not decay in one week. It takes time for decay to develop

               Occasionally, when a patient calls and says "my crown broke", what actually has occured is the tooth under the crown has broken off and the crown has come out. This can be a bigger emergency. When the patient does come in, the remainder of the tooth has decay and sometimes it requires endodontic treatment. Often these teeth do not hurt, since the pulp is already dead. Some teeth have sustained vertical fractures and in a worst case scenario the tooth needs to be removed.