Wednesday, May 20, 2009

Root canal and crown

Hey all,

I don't know if you know this but it has been raining for 3 straight days here. I am not talking about drizzling, it is pouring on and off all day and night.
We lost power at my house for a couple of hours on Monday. When the power came back one of my thermostats failed to work. Now I don't know about other states but if you don't have air conditioning in Florida you are one sweating miserable individual.
So I went to Home Depot and bought a thermostat and tried to install it.
You know the thing that on the outside of the package it says "EASY TO INSTALL".
Yeah, well I forgot to read the fine print and it says, "easy to install" alright but I guess some on the package it must read, "if you are an electrical engineer".
So after my third trip to Home Depot and my third attempt to install a thermostat myself, I called the air conditioner guy.
He came out the next day and told me I did it right I just didn't program the thermostat properly.
So I paid $80 for a house call to have the air conditioner guy program my thermostat.

But one of the reasons I didn't write on Monday was because of the power outage, the air conditioner and my neighbor.
Yeah, during the storm I heard two booms. I looked outside and I think the first boom was from lightning hitting a branch of my neighbors tree and the second boom was the tree branch hitting his house.
By the time I saw it it had fallen to the ground. Not really any damage to the house.
I called another dude that lives in my neighborhood, goes to my church, lives just down the street, and has a chain saw.
I told him, "let's bless my neighbor and get this huge branch off his house and clean it up."
He said okay and was down the street in about 5 minutes with the chain saw.

We did it in about an hour. We stacked up the big pieces and piled up the tiny branches.
I didn't tell him it was us. I just wanted to bless him and not get any credit for it.
But I have to tell is killing me. Not being able to tell him it was me that did it.
I have talked to him a couple of times since Monday and I am dying. I don't even know if he even knows the branch fell.
My neighbor came home and things were clean and there were piles of stuff in the lawn.
I am dying right now. I want credit. I know, I know, I know I am not suppose to want it but I do. Man do I have a long way to go.

In my younger days I hated to read. I read but only when my teacher told me to.
Now I am going back and reading the classics.
In the same light I am going back and watching the classic movies. I watched Casablanca this weekend. It was okay. Nothing that blew my socks off. I think for the 40's it was very well done. But, what can I say, it was done in the 40's.
I followed this one up with Bedtime Stories. It was good. Nothing great...just good.

I am reading a book called The Glass Castle. I think I told you a week ago or so. It is very good.
I will recap later.

Today's topic.
I wanted to talk about crowns after root canals.
Mainly I want to talk about posterior root canals and crowns (premolars and back).
I have to tell you, and I don't want you to think bad about me....I don't crown every root canal tooth.
I don't know if there has been any studies in the last 15 years about bonding teeth and root canals but I have done my own.
My studies are a little less technical than the scientists.
I have a 17 year old patient that has a very good DO resin on #13. If I did the filling I know it is conservative but it still could have been deep. I know the filling is good. But now she comes in with an abscess. I do a very conservative access on this one canal tooth.
The patient can't afford the crown.
I do an access filling. Thus starting my study.
I have been "studying" this way for 14 years. I can count on one hand how many times this way has backfired on someone. Now if it backfires I don't remember even one where we had to extract the tooth. It is more like they broke the tooth and it now can't be fixed with a filling. So we just do a crown (and now usually a better financial time than before).

Let me show you a picture.

All the decay removed and pulpectomy done. I think this patient was saving money for each step.

Root canal what?

Are you going to tell me this is wrong? Are you going to tell me that I need to do a $1200 onlay to save this tooth? I don't buy it.
And I don't want to shock you but I do the same thing on molars.
If I do a MO resin on #18 and it just a little deep. The tooth abscesses and I have to do a RCT. Well I just fill the access filling. Tooth is fine.
And since we are being honest with each other I will tell you more. I don't care if it is a conservative filling or not.
I don't care if I put a build-up on the tooth. It is going to be okay in my hands.
Sometimes I will put a big filling on a tooth and tell the patient. "This is what dental school told me, that you need a crown. I don't know if I buy this anymore. I put a big filling on this tooth and I think it is going to be fine. When I see you every six months we will revisit this tooth. I don't think you are going to any problems. If you do then we will do a crown."
Now I have just saved this person at least 10 years without a crown.
Now again I don't know if this has been studied. I know that a non-vital tooth is weaker and that is why supposedly the tooth needs a crown but maybe there is study that shows that a bonded tooth is better than a tooth with an amalgam build-up.
It is for me.
Maybe the thought process has changed and my thought process is right on. Sometimes practicing dentistry feels like you are doing it on an island all by yourself.
I guess this is what the AGD and this blog are trying to alleviate.
Does anyone else have there own study going on?
Have a good Wednesday,


Anonymous said...

Don't know if you have less stress in Fla but in Indiana, doing RCT on a maxillary premolar and no cuspal coverage is asking for trouble. I have a high rate of intact teeth splitting M-D and thus unrestorable. Once a restoration is in place, the odds are even higher for a break. Most of the teeth requiring RCT in our practice have DEEEP restorations, usually not placed first by us. We have many bruxers and flat teeth from reflux acid erosion which increases occlusal contact/stress. The only other thing I have to go on is if I have recommended a crown post-RCT and the patient declines treatment. I have them sign an informed consent. I have to say that the fracture rate on these teeth (restored with large restoration either resin or AR) is around 30% as the patient continues to delay cuspal coverage. I think you are very lucky. Also, you have not been practicing for 26+years, so maybe you havent seen some of these teeth come back to haunt you (unrestorable fx, sorry ms jones, get an implant) as yet. How transient is your patient base? I have patients that have seen me since 1984 that I am still following so I have a long track record here. If you truly can duplicate this record consistently, put together a seminar and teach the rest of us.....I prefer to save the patient money.

Anonymous said...

Just a dentist passing by!

The question is whether you believe in the process of science.
or you lay claim to homeopathy.

You know studies show that crowning a RCT tooth greatly increases the chances of success.
So from this, it is general consensus that we crown them.

You're advocating 'alternative medicine'. Thats fine, if the patient is aware of you're maverick solution. But this is asking for a lawsuit should a tooth crack and the patient sees another dentist and is told... "should have been crowned".

And they will crack.. maybe assymptomatic for now but they will crack. Ive seen it and science proves it.

Cusp coverage is science.

Anonymous said...

well i do agree to your philosophy..some times we treat our patients more about the future possibility of law suit..and that does affect the way we believe in our my opinion..every case with RCT needing a crown should be left to the jugdement of that individual dentist...and usually that gives the best judgement then just following research and science all the time...we are humans..and science and research does not always work the same for every person....if i were a staunch believer of crowns after a rootcanal...i should have got it done on my tooth..i have a root canal in central incisor and a second molar..both if i have any doubt i should have been the first to get the crown....i mean i know there are long as i know the fact that i have to be careful....i think i should be fine without crowns...especially for my front upper central incisors..i know for sure that my tooth was non vital since 10 yrs only recently i got my rct done..because it was how did my tooth stay fine all this should have been in half long time ago..after all it was non vital all these yrs..and if we are not careful with how we chew or grind we can even split a vital tooth also...i usually believe in crowning when i know it has a huge restoration or a situation where i know patient might split this is just my opinion...when i tell this to my patients..i usually get more compliance and they understand the situation better rather than making it a law.."you have to get a crown after root" canal....nah..not always

another dentist who believe that you should sometimes believe in your jugdement

root canal said...


i don't know where you live and i didn't hear a news about nonstop rain in 3 days at your place.

which one i believe you guys? you don't have any names.

maybe root canal first after the crown well it should be based on experience.

Jess said...

I know this is an old post but this is the study I bring up to my patients when I'm telling them that my professional advice is to crown the RCT tooth.

Salehrabi R and Rotstein I (2004). Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. Journal of Endodontics 30:846-850.

Kind of hard to argue with those numbers!!

gatordmd said...

I did a Google search of that article and I found it.
The article you refer to talks about the validity of doing a root canal and how the success rate of a root canal and the success of an implant are the same. I did not see where it talked about crowning a tooth at all.
Root canals and saving teeth are an integral part of my practice but crowning all of them is not.
If there is another article I would love to read it.


handy said...

Dear gatormd:

I also currently have two upper molar teeth that have been treated with root canal. Due to the high cost of crowns, and limited skills from local doctors I am feeling forced to follow up with composite fillings instead. Do you think it is safe for me to follow your step of skipping the crowning? Thanks.

Jess said...

Hey John,

I think we are reading different articles. I just went and skimmed through the article again and to me half of it is about crowns (I also did a Ctrl-F for implants and got 0 hits).

I have got a pdf of the article I am referring to and will send it to your email address. Hope I have not totally lost my mind and that we're talking about the same thing. Otherwise, plenty of articles out there talking about full coronal coverage and RCT outcomes.



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