Another Dental Thread...What To Do

[TrvlBug]

It has finally been determined by a specialist that the gum/bone infection at my last bottom molar is the result of a fractured tooth and not a freak infection. So the tooth needs to come out.

However, there is bone loss and the dentist is suggesting a bone graft at the time of extraction in the event I want to do an implant. He assumed I was going with an implant but I made it clear that was only if I had to. Based on my research including the recent 'Dental Crown' thread and 2 people who have lost back teeth, I should be fine without it. The specialist said my top tooth would come down!

Long story short, does it make sense to do the bone graft now? Why can't I wait and if I decide I absolutely have to have a tooth back there, do the bone graft at that time? I trust the specialist and his work, however, feel that because I live in the SF Bay Area and my regular dentist is located in Palo Alto, that I'm Ms. Moneybags and can afford to get the best of the best even though it may be throwing good $ away. Thoughts?

 

[fh2000]

It has finally been determined by a specialist that the gum/bone infection at my last bottom molar is the result of a fractured tooth and not a freak infection. So the tooth needs to come out.

However, there is bone loss and the dentist is suggesting a bone graft at the time of extraction in the event I want to do an implant. He assumed I was going with an implant but I made it clear that was only if I had to. Based on my research including the recent 'Dental Crown' thread and 2 people who have lost back teeth, I should be fine without it. The specialist said my top tooth would come down!

Long story short, does it make sense to do the bone graft now? Why can't I wait and if I decide I absolutely have to have a tooth back there, do the bone graft at that time? I trust the specialist and his work, however, feel that because I live in the SF Bay Area and my regular dentist is located in Palo Alto, that I'm Ms. Moneybags and can afford to get the best of the best even though it may be throwing good $ away. Thoughts?

My 2 implants both had bone graft done before the implant. My dentist said there is not enough footing without it. I remember adding bone graft costed few hundred dollars more.

One back molar implant actually failed after 3 months due to cracking below the anchor. Dentist pulled out anchor; reapplied and added more bone graft; re-did the implant and crown. So, the whole implant took 2 whole years with those 2 cycles. Three years later, it is still standing.

I think bone graft is important if you consider to have an implant later. It takes 6 months to heal and morph into your own bone to be strong enough.

 

[candrew]

I'm not a dentist and can only guess that doing the bone grafting at the time of extraction is to avoid having to put you in the chair a second time. If you decide to proceed with the implant and bone grafting, having a skilled specialist is key IMO to achieving the best possible outcome.

7 years ago I had an extensive amount of oral surgery done involving implants and bone grafting and I was glad to have a very skilled specialist doing the work. Yeah, it was costly.

 

[athena53]

I've had 5 implants over the years and every time the removal of the affected tooth (most had decay under a crown that wasn't detected till it was too late to save the tooth; the most recent was a cracked tooth), the bone graft and the placement of the implant were done in one surgery. I've had the same oral surgeon every time- he's an MD and a DDS. As long as he's in practice I'm sticking with him!

 

[travelover]

There at least two retired dentists here. I'd hang a bit for them to weigh in.

 

[gerntz]

I need a lower wisdom tooth removed shortly. Dentist says the upper needs to come out too due to the drop down effect you describe. So that part seems real to me.

 

[Bamaman]

My oral surgeon (Vanderbilt M.D.) pulled a tooth that'd broken off flush with the gum--and did a graft at the same time--$895. He wanted $2250 to to the implant, and later $895 for the abutment. Then my regular dentist would have to do the crown--$850ish.

I got the implant done for $900. Other than numbing me up, the implant only took about 6 minutes start to finish. It was easier of a procedure than a filling even.

I've had the abutment over a year, and have not taken time to get it installed and the crown completed. I use a dentist that has a CNC machine that carves crowns in 6 minutes after she does a scan of the teeth. One visit and 1 hour and I have the new crown installed--remarkable.

 

[OldShooter]

@TrvlBug, most dentists are effectively commissioned salespeople who really believe in their products. This does not make them evil but it does create a moral hazard. I strongly suggest that you go to a university dental school clinic (like https://www.ucsfdentalcenter.org/) to get a second opinion. They have no motivation to sell you anything but what you need and they have knowledge and access to the latest techniques and product options. An added benefit is that they may save you money. Our state university dental clinic typically charges half or less compared to the usual dental fees. I was talking to a friend who also uses a university dental clinic and in his state the care is free. (!)

Another thing for most of us is that we have no way to judge the quality of the dental work we are getting. When I go to the clinic for work it is usually done by a student with a year or more of clinic experience and every single decision and step is inspected and approved by a teaching professor.

 

[HadEnuff]

retired dentist here.
If you are absolutely certain you never will have an implant, then you don't need the graft. If you change your mind later and want an implant, you can have the graft later, but it is more complicated and less effective than if you do it at the time of the extraction.

 

[RAE]

retired dentist here.
If you are absolutely certain you never will have an implant, then you don't need the graft. If you change your mind later and want an implant, you can have the graft later, but it is more complicated and less effective than if you do it at the time of the extraction.

I'm not a dentist, but this is exactly what I was going to suggest. I had one of my last lower molars pulled about 18 months ago (had a fracture in the root that was causing a lot of pain), and I told the dentist I wasn't sure if I wanted an implant or not after the extraction. As it turned out, I'm fine without the tooth, and don't plan on having an implant (unless something changes drastically). I don't know if I would have needed a bone graft for the implant or not (my dentist never said), but if you think you will probably not want an implant, then getting the bone graft now seems unnecessary to me.

 

[joeea]

However, there is bone loss and the dentist is suggesting a bone graft at the time of extraction in the event I want to do an implant. He assumed I was going with an implant but I made it clear that was only if I had to. Based on my research including the recent 'Dental Crown' thread and 2 people who have lost back teeth, I should be fine without it. The specialist said my top tooth would come down!

There is no need to have an unwanted implant. And there is no need for a bone graft.

Bone grafts are a cash cow for dental practitioners, and are very seldom actually needed.

 

[athena53]

Bone grafts are a cash cow for dental practitioners, and are very seldom actually needed.

Well, they're also "insurance". My late husband was the first of the two of us to need an implant and, being from the property-casualty insurance business, my first thought was how messy it could get if things went wrong. His worked just fine (he did have a bone graft) and it gave me the confidence to choose the implant route when I had to decide between an implant and a bridge. I HATE grinding down two perfectly good teeth on either side to prepare them for a bridge, I've had decay from UNDER a tooth supporting bridge that was hard to detect until it was too late, and bridges fail eventually. (Fingers crossed on my only remaining one; it's 15+ years old.) Anyway- maybe the bone grafts are unnecessary. I just know that both my oral surgeon and my dentist rave at how well the implants have integrated into my jawbone every time they see an X-ray.

And it saddens me to see an opinion that dentists are "commissioned salespeople" although I've seen enough horror stories on this and other boards to know it happens. Mine gives me options and explains costs, risks and benefits. I choose. There is zero pressure to take a particular route.

 

[Aerides]

I need a lower wisdom tooth removed shortly. Dentist says the upper needs to come out too due to the drop down effect you describe. So that part seems real to me.

This is true. If you're resigned to "eh I can do without" this one tooth, know that the top partner to it will be very likely to have issues. Dropping, infection, etc., can be possible.

I'm no dentist, but when I went 3 months between the implant base/plug and the top tooth being installed, I could feel something was up with the top partner, and the dentist was not surprised (and I was annoyed they didn't warn me - I only delayed the events to spread the cost over 2 years of insurance and would not have risked the 2nd tooth had I known. Luckily it was just a mild infection easily cleared up)

Personally I plan to take the pricey route on my teeth. It's not an area I plan to be frugal.

 

[athena53]

Personally I plan to take the pricey route on my teeth. It's not an area I plan to be frugal.

I watched a series on Netflix called "Botched-up Bodies" and some episodes dealt with people who had gotten cut-rate implants in dodgy places out of the UK. I'm well aware that there are good clinics in places such as Mexico and Thailand but I have no idea how you sort out the good from the bad. Some of the work looked like what I'd do if you gave me 2 hours of training and put me in a room full of dental instruments with a patient. Some of the implants didn't even get installed in the jawbone, just in the gum tissue.

I'll stick with my expensive guys in KS, thanks!

 

[OldShooter]

... And it saddens me to see an opinion that dentists are "commissioned salespeople" although I've seen enough horror stories on this and other boards to know it happens. Mine gives me options and explains costs, risks and benefits. I choose. There is zero pressure to take a particular route.

As I said, there is moral hazard. It's certainly not limited to dentists. Veterinarians are right up there, since virtually everything they recommend including drugs ends up on the customer's invoice. Chiropractors probably excel, in many cases stepping over the line into quackery IMO. MDs in large groups, less so because they generally do not financially benefit from the recommendations they make. But moral hazard is out there and hard to avoid.

... I'll stick with my expensive guys in KS, thanks!

Agree totally. Mexico, Thailand, .. many of the medical tourism choices are pretty off-putting. But to your last point, I have not found that price is a reliable indicator of expertise or quality. This is particularly true in situtations where I cannot independently judge the efficacy or quality of what I am buiying.

That is why I am so happy to have found our university dental clinic. In addition to not buying from commissioned salespeople, I get the expertise of the professors and their meticulous attention to both treatment decisions and inspection of the work as it progresses. The lower-than-market prices are just icing on the cake. I would pay higher prices for what I get there.

 

[Z3Dreamer]

My 2 cents. Had an implant 10 or 12 years ago. It didn't hold and had to be redone. Not a problem as those can happen. I have two complaints. The dentist's office did not give me enough info to make an informed decision regarding costs on the two paths they could have gone. They should have said: "Path A has a total cost of xxx and Path B includes our fee of xxx. You need to ask the Oral Surgeon for their fee". They said: "Path A costs xxx and path B costs xxx and since they are about the same, you should do B". I understand that they don't know what the OS charges but an reasonable person would conclude they did not provide good guidance.

Second complaint is that there is a massive gap between the crown which is installed on top of the implant and the gums. After every meal, large amounts of food are stuck in this food trap. Current dentist says there is nothing that can be done. I have to carry dental brushes everywhere I go. Does anyone else have this?

I wish to weigh in on dentists being some sort of salespeople. I found that every time I went to see this young dentist, he wanted to do something that was costly. For example, he redid a filling and wanted to use gold. His argument was that the gold would last forever. 2 problems: cost is about $700 more than any other procedure and the color is not natural. After I had the gold filling, DW had a filling redone by a different dentist. His argument was that in people our age, a normal filling will last for the rest of your life. No need to spend the extra money on gold. Whoops!

In discussing with an older dentist, he says that they teach "aggressive dentistry" in school these days. They teach them about cosmetic dentistry, they teach them about devices that help patients sleep better, and finally, they are taught to replace old fillings, even though they are not cracked, broken, falling out, etc.

 

[Teacher Terry]

My dentist partners with a oral surgeon so can quote me accurately for both.

 

[rpguy4]

My 2 implants both had bone graft done before the implant. My dentist said there is not enough footing without it. I remember adding bone graft costed few hundred dollars more.

One back molar implant actually failed after 3 months due to cracking below the anchor. Dentist pulled out anchor; reapplied and added more bone graft; re-did the implant and crown. So, the whole implant took 2 whole years with those 2 cycles. Three years later, it is still standing.

I think bone graft is important if you consider to have an implant later. It takes 6 months to heal and morph into your own bone to be strong enough.

Same boat - I got an infection after my 1st bone graft and had to start the whole process over again. Each bone graft takes about 6 months for it to build new bone, and provide a good anchor for the implant. It was about 2 years from start to finish. No issues so far.

 

[Potstickers]

That is why I am so happy to have found our university dental clinic. In addition to not buying from commissioned salespeople, I get the expertise of the professors and their meticulous attention to both treatment decisions and inspection of the work as it progresses. The lower-than-market prices are just icing on the cake. I would pay higher prices for what I get there.

Nothing wrong with university dental clinics...but if you're so certain dentists are commissioned salespeople, why would you trust a dental clinic that is training people in these techniques?

Personally, my (and dental insurance's) payments have, in the aggregate, purchased the equivalent of a very nice sportscar. Growing up in a town with unfluoridated water and having braces for years really set me up for major dental issues down the line. I'm extremely thankful to have had really good dentists and only one stinker.

 

[OldShooter]

... so certain dentists are commissioned salespeople ...

Sigh. ... I'll try one more time and then quit. A dentist is in a position where sometimes a thing he can recommend is in his best interest but is not his patient's best interest. This is called a "moral hazard." Look it up.

... why would you trust a dental clinic that is training people in these techniques?

I am quite sure that the students and professors are not compensated based on what products or services I purchase. So no significant moral hazard exists.

That, too, is the reason that we should prefer Registered Investment Advisors. They are fiduciaries and at least in theory their duty of "loyalty" eliminates the moral hazard. This is in contrast to "Registered Representatives" who are commissioned salespeople and hence there is the risk of moral hazard.

 

[dixonge]

Long story short, does it make sense to do the bone graft now? Why can't I wait and if I decide I absolutely have to have a tooth back there, do the bone graft at that time?

If you get the bone graft now and you need an implant later, you will get the post, then wait six months, then get the tooth (depending on the technique used)

If you don't get the bone graft now and you need an implant later, you will have the bone graft, wait six months, then get the post, then wait another six months, then get the tooth.

Also keep in mind possible changes in your dental coverage.

Additional thought - your bone graft should be cheaper while your gum is already open due to the extraction. More hassle/expense if performed later as a separate procedure.

 

[MichaelB]

A quick question regarding bone grafts and implants. Can a dentist determine if there is enough bone for an implant before removing the offending molar, or is that assessed only after removal?

 

[HadEnuff]

As a retired dentist I can tell you that the line between over-treatment and under-treatment is a fine one. Even with the best, most honorable intentions, a dentist's ability to know what the future holds for a raggedy looking tooth full of raggedy looking fillings is a guess. I've seen small innocent looking cracks turn into tooth destroying vertical fractures, and I've seen restorations I thought wouldn't last a week last for years.
I've seen the smallest of holes in teeth, barely big enough to stick the sharpest of explorer tips, turn into deep decay as I got into them, wondering to myself if I was "over-treating" just by endeavoring to undertake the most conservative of treatments.

It is definitely an issue that could lead to a loss of trust. I can't think of a dental care delivery system that would eliminate the conflict, however. The vast majority of patients are not within a practical distance of a dental school.
And don't think that there is no scenario for conflict in the dental school environment. Schools need to graduate dental students, and dental students need to do a certain number of procedures to graduate. That can lead to an influence on treatments.

 

[athena53]

A quick question regarding bone grafts and implants. Can a dentist determine if there is enough bone for an implant before removing the offending molar, or is that assessed only after removal?

My oral surgeon always did a panoramic scan first and then viewed it in 3-D, rotating it at all angles, before he decided on treatment. I think that would give the surgeon an answer although, as I said, mine always used a bone graft and I was OK with that.

Another point I wanted to make: the last implant was one done when I said I wanted it handled that way- no hard sell at all. Dentist had been "watching" that tooth for a year because he saw a thickened ligament and thought it might eventually need a root canal. When I started developing pains he couldn't find anything in the X-rays and thought it might be a hairline crack in a root. He was going to go in and drill to see what was going on but the more I thought about it- if it was a crack in a root he couldn't fix it and it might need a root canal anyway...I said I'd rather just replace it with an implant. The oral surgeon reported that it WAS a cracked root. I made the right decision.

 

[mn54]

i am a retired dentist who teaches at a local university. when you say it is your last tooth, does that mean it is your 3rd molar, 2nd molar, 1st molar? this would make a difference in deciding if you need the implant. also realize that that opposing tooth on top will drop down, as was mentioned, and may eventually be lost. but since you do not chew with this tooth it may only be a cosmetic problem. while there are bad apples in every profession, i have a problem with old shooter saying that a dentist would recommend treatment not in the patients best interest. it is in the dentists best interest to treat their patients well to keep them as patients for the long haul. i, and all the dentists I know, would never recommend treatment that was not in the patients best interest. maybe you had a bad experience with a dentist, i don't know, but i am truly offended by this statement.
as far as Michael's question, on a regular x-ray it can sometimes be misleading to tell how much bone is there. on a cbct x-ray it is much easier to tell this information. of course if there is any infection present this must be removed which can effect how much bone is left.