The Crown That Would Not Stay On
26 Months After Completion of Dental Work
[The only problem I had with my 28 new teeth was an incisor that kept on losing its crown.
The following posts tell about this problem, and its resolution. Many readers will find this TMI, but others might enjoy the level of detail I provide as well as some of the digressions.]
p.192, 3931
Chicago Dave#3931
Thursday Jun 27
[2013]
UPDATE. RETURN TO COSTA RICA.
Hi guys! I promised to post updates on any development, good or bad. So here goes.
It
looks like I'll be heading down to C.R. to see Dr. Prada again. The
crown on one of my front teeth (the upper-left lateral-incisor) fell
off. This was the second time in six months. Something isn't right.
Fortunately, this is the only tooth I've been having problems with.
There are explanations: the short prep (not Dr. Prada's fault), my bite,
whatever. I am *not* happy to have to return to C.R., but I don't trust
the local guys to fix it. The tooth doesn't hurt, which is a blessing.
But it could means that the pulp is nearly dead. I suspect that it may
need a root canal and a post.
Dr. Prada said he'd fix
it for free, charging me only for the lab work (about $300) if I need a
new crown. He has been unfailingly prompt in responding to my emails.
But I'm not a great advertisement for him with a missing front tooth!
Dr.
Prada said he could make a new crown in 7 days, but I’ll be staying a
little longer for some R&R and sightseeing. I’ll be arriving in San
Jose around noon on Sunday 7/28, and leaving Wednesday 8/7. PM me if you
plan to be in C.R. then. I'll be staying at the Villas del Rio in
Escazu, which is across from Dr. Prada's office. It's my fave motel. I
think this is also somewhat near Nova/Obando. (Euthie--you're gonna
have a great trip.
[Note: Euthie did see Dr. Obando, and it was a successful trip indeed for him.])
This
hiccup hasn't changed how I feel about Dr. Prada. (Skeptics should
note that the tendency is *always* for patients to love their dentist
even at the price of explaining away faults.) He made a full mouth of
crowns for me in 2011, which solved many problems I was having. I still
recommend him. In fact, one of my friends is also planning to visit him.
I'll try to persuade her to post progress reports. I've been to his
clinic four times already, so a report from fresh eyes might make for
interesting reading.
Thanks for all your great posts
Joe, Dog, Tamale and others! These are a great resource and
encouragement to others needing quality dental care. Let's make it a
custom to post yearly updates around May 1 so readers can find all our
progress reports clustered together.
-dave
TMI? For some Questions and Answers with Dave,
Press Here.
Or browse some of Dave's favorite dentists from "THE DENTISTS" menu.
[July 2013]
p. 205: #4186
Update #1 from Costa Rica...
My
posse arrived in Costa Rica Sunday, converging on the Villas del Rio
hotel, where we all crashed into bed and slept until Monday for lack of
sleep the night before. This is the hotel right across the street from
Dr. Prada’s Escazu office, where we’ve been camping out for most of
Monday and Tuesday. (This is a convenient location because some members
of my posse needed to be squeezed into Dr. Prada’s schedule. Being
nearby, it makes it easy to respond to new openings in his schedule.)
So I wanted to fill folks in on our first week of dental treatments with
Dr. Prada and his associates.
But first I wanted to
put in a good word about Dr. Obando (Nova Dental), Euthie’s dentist.
Euthie and his Mom came over to our place Monday night for socializing
and swapping stories about dentists. It was an odd conversation for
anyone not a part of the dental-patient underground. But it was great
to be able to speak freely about our dental experiences. Whenever I
post on this board I feel a need to self-censor myself lest I offend
some reader who might be skimming by. In face-to-face encounters, talk
flows more freely.
Euthie showed us his four new
upper front teeth. They looked great! The material was e.max and the
price was also great ($415/per). When I ran into Euthie Sunday night,
he had a conspicuous gap between two of his front temporaries (which
were cast to look like his original teeth). It must have been an eighth
of an inch wide. When I saw him Monday night, the gap was completely
gone! And the teeth on either side looked both symmetrical and
natural. I have no way to check the margins of the crowns (their fit
against the root), but everything that I could see indicated that his
dentist did a great job. He and his Mom had other work including
implants and composite fillings. We got together again tonight, and all
their work was completed. We hope he keeps us informed.
By
the way, “Euthie” is a real person, a regular dental patient seeking
adventures and dental refuge in Costa Rica, just as I am. I first
posted in August 2011, a few months after finishing my dental work. For a
list of my earlier posts see p. 200, #4084. Euthie is a good example
of my idea of a successful medical tourist: He did his homework, and is
now reaping the happy results. He thanked me for my posts on this
board, which gratifies me. He found my post about how to use Google to
search the Topix board especially useful—I always thought that would be
one of my most useful posts. He invested a lot of time in researching—I
think this is necessary—and narrowed his search down to three
well-researched dentists whom he contacted for in-depth assessments.
I
like to have dentists other than Dr. Prada’s clinic to refer folks to,
and Dr. Obando might be a “keeper”. As most folks reading this board
are very value minded, and I don’t want to appear that I’m pushing my
own relatively high-priced dentist onto folks. Euthie said that there
were about ten folks back in Canada who are breathlessly awaiting his
return from Costa Rica with his new teeth. I suspect that many of them
will be following in Euthie’s footsteps to Dr. Obando.
In a future post, I’ll report on our progress with Dr. Prada.
-dave
p. 206: #4206
### Update #2 (Part 1 of 2) ###
Now
a wrap-up of what is happening to my sister and me at DDS, Dr. Prada’s
clinic this week, two years after my full-mouth restoration with him in
April 2011.
My friend (and her son) also saw dentists
at the clinic. She wants to report their experiences in her own post,
hopefully in a couple of weeks.
This post and the
next are going to be even more windy than normal—this is a feature not a
bug. Some folks appreciate the little details; they even appreciate
too much information if it is about an issue of interest. Just skip
over the parts that aren’t relevant to you.
APPOINTMENT
SCHEDULING. Dr. Prada and his associates run a typical clinic with
scheduled appointments. They bent over backwards to accommodate my
sister and my friends, who needed a lot more visits than they expected.
Getting dental work abroad requires flexibility on the part of both
patient and dentist. They fit us in during cancelled appointments and
for the first and last appointments in the day. Staying at the hotel
across the street allowed us a lot of flexibility to work into the
dentists’ schedules and to make appointments on short notice.
Dr. Prada told us to allow a week for all the work. We decided to stay
an extra couple of days, based on my previous experiences. We’re glad
we did because at the last minute we were joined by my sister and my
friend’s son. We lost Friday to a big national holiday, which was
unexpected. We could have made use of the additional day. A cell phone
is really useful in a situation like this, but we relied on one of us
four being in the room to answer the phone calls with appointment
re-schedulings.
<=== Continued ===>
p. 206: #4207
### Update #2 (Part 2 of 2) ###
THE
LOOSE CROWN. As I posted previously on this board, the crown on my
upper left lateral incisor has fallen off twice now. (It is one of 28
crowns made by Dr. Prada.)
I consulted with two local dentists in North Carolina who proposed three explanations:
(1) the “prep” (the little peg-like remainder of the natural tooth that serves to hold the crown) was too short,
(2) the crown was poorly fitted, and
(3)
the prep could be extended under the gum line to better support the
crown. Dr. Prada said that (1) was true, but not (2) or (3). It was
true the prep was short; this was obvious. My teeth were always
short. When a local US prosthodontist fit them with crowns in 1995,
there was only enough tooth length for short preps. I told Dr. Prada
that crown made in 1995 for the upper left lateral incisor had never
fallen off. But this newer crown was much longer than the older crown.
When the lower incisor contacts the upper incisor during eating, the
latter tooth is pushed outward. The additional length of the teeth
increases the leverage on the upper incisor, which can push the crown
off the prep.
Dr. Prada laid out two alternatives: (1) a
conservative approach involving re-doing the crown, and (2) a more
surefire approach requiring a root canal and a metal post to securely
anchor a new crown. I had two hours to choose.
After a
brief Internet search, I decided that I didn’t want to risk a root canal
treatment (RCT) on a healthy tooth. I told Dr. Prada that I’d take
the RCT and post ONLY IF my x-rays showed that ANOTHER tooth also needed
a RCT. But otherwise I’d go conservative. Dr. Prada reviewed my
x-rays and said that everything was good. So, the conservative approach
it was.
Dr. Prada worked on building up the short prep
Monday afternoon. He works quickly, but he spent a full 45 minutes on
just this one issue. Time and again, he would apply resin (bonding) to
the prep, shine an UV light to harden it, and then shape it with his
drill. The new prep was a marvel to behold (if you’re into such
things): It was bright white, maybe three millimeters longer, a
millimeter thicker and with perfectly parallel sides to hold the crown.
The other trick he did was to make the new crown thinner to
“remove it from the occlusion”. An incisor on the jaw normally just
barely touches the back surface of this upper incisor when my jaw is
closed. By making the upper incisor a little bit thinner (a tenth of a
millimeter or so), the lower incisor would no longer touch it, thereby
reducing the lateral pressure against it. I thought it was a clever and
resourceful way to leverage the strong Prettau zirconia material of the
crown by pushing it toward its minimum limits of thinness.
All told, Dr. Prada spent at least an hour and half Monday on me
discussing and addressing this issue. The old crown was sent to the lab
to serve as a color guide. The new crown will be ready Monday, and Dr.
Prada will adjust my night guard too. Dr. Prada promised that he would
charge me only for the lab services to re-make the crown, about $300.
Woody: We'll miss you on this board. Please check back with news.
-dave
[QUOTE who="RJ of Oregon"]<quoted text>
Can
you explain to my novice self why you would gone for the RCT option
only if there was another tooth that needed it as well? [/QUOTE]
RJ,
Personal preference: I didn't want to do my first root canal treatment (RCT) on a healthy tooth.
I
did a little Internet research, and learned that RCTs are yet another
issue where some holistic-type dentists disagree with the dental
establishment. You can Google "root canal treatment" yourself and see
the types of charges and counter-charges that are being bandied about. I
don't know who's right, but I did respect the fact that some of the
dentists that I generally look to for advice (e.g., Mark Breiner) have
reservations about these treatments.
The root of the
tooth with the loose-crown problem was healthy. (Dr. Prada said that a
root is either viable or not viable; as long as there is circulation
it's fine even when the tooth has lost sensitivity like my tooth had.)
The RCT would have allowed a permanent fix to the problem of the crown
falling off. The metal post would be much longer than the little stub
of a tooth that has been trying to hold onto the crown. But to get the
metal post I would need an RCT since the metal post is stuck way down
deep into the root.
So, did I want to do a RCT on a
healthy root just to hold in a crown? I do not have any RCTs in my
mouth. My roots are very healthy, it was only the tooth enamel that had
problems (tetracyline staining, like my sister's, and also grinding). I
decided that I didn't want to have a *new* dental procedure in my mouth
if I could avoid it. However, if I needed an RCT for ANOTHER tooth,
then I would probably go ahead and do an RCT on this tooth too.
Convoluted
reasoning, but it's how I think about these things. I've had a lot of
problems with dentists and their treatments, and tend to shy away from
unnecessary risk.
####
It's good that you're
paying attention to the smiles that you see in the media. This counts
as research! Your fascination is healthy; I agree with OKJoe on that.
Many/most
of the photos are retouched to make the smile unnaturally white. It
becomes part of our visual culture to think of a nice smile as being
unhumanly white. Most dentists and physicians find this color
unattractive since they see real teeth all day long. But the rest of us
subconsciously accept the idea that nice teeth are refrigerator white.
Real teeth come in several different hues (yellow, bluish, gray,
reddish) and usually shade subtly from the root to the tip.
Photo-retouched teeth are bright white with no such shading. Just look
at your friends' real teeth and compare them with the "perfect" smiles
in your glossy magazines. They are totally different.
A
few years ago, when the dental labs weren't as sophisticated as now,
many crowns for front teeth were made almost identical: the "picket
fence" effect. Once you knew what to look for, you could pick these
right out on Hollywood movie stars. Now, fortunately, the better dental
labs will make the crown for each tooth look like the natural tooth. I
mean, the incisors on the top are totally different in shape from the
incisors on the bottom. And the bicuspids (canines) are totally
different beasts than the incisors and premolars on either side of
them. And so on. Progress means that the picket fence smile isn't seen
as often. At least in Hollywood.
You really don't want white picket fence teeth, unless you don't mind those of us in-the-know snickering behind your back.
-dave
p. 207: #4225
#### UPDATE # 3 (Part 1 of 2) ####
# Day 8 in Costa Rica #
My
sister completed dental work with Dr. Prada this week. She scheduled
at the last minute and that for a consult only. But when she decided to
go ahead with work, Dr. Prada was able to fit her into his schedule on
short notice. (Just for the record, I don’t recommend doing this as a
matter of course: there might not be any appointments available to you.
Our ten-day stay across the street from his clinic allowed time for a
lot of improvising.) I’m encouraging her to post for herself.
“INFECTED”
IMPLANT. My sister was concerned about an implant on her left upper
central incisor. The dentist who implanted it and a second dentist.
both agreed that it was infected and needed to be replaced. (The
original implant operation was performed in Indiana, not California, as I
might have posted earlier.) Dr. Prada examined the implant and recent
x-rays. He said the implant was fine and did not need to be replaced.
There remained the problems of:
(1)
The high and somewhat unsightly gum line above the implant. The
Indiana dentist had badly misjudged the positioning of the implant. He
had to cut out at least one-eighth of an inch from the gums above the
incisor. This made the implant stand out. Worse, it made the entire
upper gum line very asymmetrical.
(2) The crowns on the four upper incisors were not well matched in color with either each other or the other natural teeth.
Dr.
Prada said that it would be possible to fix both problems. This would
require redoing the crowns on the four teeth and removing gum tissue
above the *other* upper central incisor to match the raised gum line
above the implant. He advised against this for cost-effectiveness
reasons. He noted that there were other aesthetic issues that were more
conspicuous that could be addressed more easily. (I’m paraphrasing
their conversation here. I want to show how pros and cons of different
alternatives were discussed.)
Later on, Dr. Gonzalez examined
my sister. He agreed that the implant was healthy and concurred that it
would be a complex and expensive process to fix the asymmetrical upper
gum line, though he could do it.
<=== continued ===>
p. 207: #4226
#### UPDATE # 3 (Part 2 of 2) ####
COST-EFFECTIVE ALTERNATIVE TO VENEERS.
My sister asked about improving the appearance of her lower front
incisors. These were her natural teeth, worn down by time and further
abraded by the crowns on the upper incisors. In color, they were
mottled brown. In shape, they were irregular with a lot of wear and
missing enamel. Dr. Prada warned against veneers, which wouldn’t last
very long on her short teeth. He suggested two options:
(1)
Crowns after gum surgery (“crown lengthenings”) to make the teeth
longer. (Dr. Gonzales performed crown lengthenings on all 28 of my
teeth in December 2010 and they look beautiful.)
(2) Bonding.
As a more conservative alternative to crowns, bonding would not require
the grinding down of the tooth. Dr. Prada applied some bonding to one
of the teeth to show what it would look like.
My sister chose
bonding on eight lower front teeth. This was the more conservative, less
expensive option, and she had had good experience with bonding years
before. The price was $285 per tooth in this case, but I’m sure the
price would vary depending on exactly what needed to be done. There are
different ways to bond teeth, and Dr. Prada had a technique I had never
heard about before. The work was performed in two visits totaling
about three hours in the chair.
Dr. Prada ground
off a thin layer from the front of each tooth to allow room to add the
bonding. He knew I was interested in the details of these dental
procedures, so he explained to me that this was a typical prep for a
“conservative veneer.” “Conservative” means that not much tooth
structure is removed. Then he applied coats of a special bonding
material. It applied as a blue ink-like liquid, but under intense UV
light, it solidified to white. He said that this bonding material was
very opaque and would help hide the brown coloration of the natural
teeth. It was as if he had given her thin, opaque, white veneers. He
spent time shaping each tooth with a burr (“drill”). In the end, each
tooth looked perfectly natural.
The newly treated
teeth were grayish, which was fine as they matched the other teeth. My
sister was very happy with the work and she has begun to smile with her
lower lip again. I think that it will take a few weeks or months for
her to get fully used to her new smile.
-dave in CR
p. 207: #4228
Yup. "Mooch the cat" is my sister, alright.
Mooch thinks my posts are too wordy, and she wanted to show me how to shorten them.
I
didn't realize she had tried bonding on her lower teeth before. She
said the earlier dentist used a yellow bonding material and the teeth
weren't shaped well. So she had it all ripped off.
By the way, the location on the post is correct. Our hotel is in Escazu, right near the clinic.
-dave
p. 207: #4231
### TMI on Crown Lengthenings (Part 1 of 3) ###
Woody
and RJ: Thanks for your nice compliments. I'm purposely detailed
because I think that's what people find most useful. I mean, if you're
interested in the topic, you just can’t get enough detail. And if
you're NOT interested in the topic, then you're going to skim the post
anyway, regardless of how short it is.
Now onto Woody's good question.
A
disclaimer: I'm just a patient, not a dentist, so I'm certainly not
qualified to give Woody or anyone else advice for a particular case.
However, I have learned a thing or two in my sojourn in the Dental
Underworld, a vast, bleak realm which certainly takes in much of the
U.S. too. So, let me try to pass on my story and what I've learned in a
way that might be of some use to readers.
AN EXCELLENT U.S. PERIODONTIST
My
crown lengthenings were a crucial part of the full-mouth restoration I
had in 2010. They were so important that they should have been done
back in 1995. I think that my US dentist in 1995 was very remiss in
never mentioning this to me. (He alluded to it obliquely and
obscurely.)
I would never have known about this
except for a great local periodontist: Dr. John Moriarty in Cary, N.C.
(His associate is supposed to be great, too.) Dr. Moriarty was the
long-time chairman of the Graduate Department of Periodontics at the UNC
School of Dentistry. He helped train a generation of
periodontists—-graduates of a 2- or 3-year, post-DDS program in
periodontics--and was partly responsible for the great reputation of the
department. So I'd like to give him a special shout-out. I asked him
why he was still practicing so long after "retirement," and he said that
he loved his work. He is certainly worth going out of one’s way to see
for a second opinion.
The purpose of crown
lengthenings in my case was to make the “preps” (tooth stubs) longer,
which would allow for better shaped and better fitting crowns and
hopefully ease the gum inflammation I experienced with the 1995 set of
crowns. (This plan worked.) My teeth had little enamel, but great
roots. If my roots were shallower or weaker, this plan might not have
worked.
Woody, my first piece of advice is to ask your
dentist about it and/or get a second opinion. You can’t just take the
word of people you meet on the Interwebs, you know!!!!!! You aren’t in
my area, but I’m sure there are excellent periodontists near you; it’s
just a matter of finding one. (Sadly, not all graduate periodontists
are top notch or even middle notch. Sigh.)
(Some
readers might be wondering why I didn’t let Dr. Moriarty perform my gum
surgery rather than Dr. Gonzales. Let me digress and answer that. I
would have been honored to have Dr. Moriarty operate on me, but I needed
to find a periodontist to work with my chosen prosthodontist. Dr.
Gonzales and Dr. Prada were associates with an excellent working
relationship. I didn’t think that Dr. Moriarty would feel comfortable
working with a non-local prosthodontist, although I never asked him.)
<=== Continued ====>
p. 207: #4232
### TMI on Crown Lengthenings (Part 2 of 3) ###
TO LENGTHEN OR NOT TO LENGTHEN?
One
of my reasons for my fact-finding trip to C.R. in November 2010 was to
get second opinions on the necessity for crown lengthenings. For one
thing, it’s expensive. In the US, the quoted rate was $200/tooth, but I
think there is some flexibility in this. Dr. Gonzales did all 28 teeth
for well under $3,000, and the anesthesiologist was another $500. Both
did an excellent job.
But another reason is that, like
all dental and medical procedures, there might be health risks. I saw
seven dentists in C.R. in November 2010, and it turned out that all of
the general dentists advised against crown lengthenings. Most said they
simply weren’t necessary, and one dentist even sent me emails
predicting dental disaster if I went ahead. He compared my teeth to
fence posts and said that crown lengthenings were like removing the
earth around the base of the post. If you removed too much, the post
would just fall over. Well, it’s now two years after the procedure, and
none of my teeth have popped out. (Yes, I did have a CROWN fall off a
couple times, but that had nothing to do with the TOOTH, which has
remained anchored firmly in place.)
With the benefit of
hindsight, I know that the warnings against crown lengthenings IN MY
CASE were unfounded. But at the time, I was totally confused. I was an
unhappy resident of the Dental Underworld.
It’s also
possible that the general dentists didn’t realize how short my existing
“preps” (tooth stubs) were. Once the old crowns were removed, it was
obvious. But it’s not so obvious when the preps are covered by crowns. I
did try to tell them that my preps were very short, though.
Dr.
Gonzales understood the reason for the crown lengthenings, and he was
specially trained to perform them. He had excellent post-graduate
training at Baylor. Apparently, crown lengthening procedures aren’t
taught in every periodontics’ program, and I was fortunate to have found
Dr. Gonzales.
<=== Continued ====>
p. 207: #4233
### TMI on Crown Lengthenings (Part 3 of 3) ###
I
concluded that specialists and non-specialists approach dental problems
in slightly different ways. This realization startled me in 2010, and
it startles me still today. But otherwise, how to explain why some
general dentists do the things they do unless it is because—-as a
group—-they simply hadn’t been trained deeply enough in one or more of
the dental specialties?
I guess I’m saying that there
are complicated cases that general dentists and specialists—-in the US
and Costa Rica alike—-will approach differently. I don’t know how
frequent these disagreements are, but I suspect that general dentists
and specialists are working for slightly different purposes and/or
clienteles (again, in both countries). I think that general dentists
are trying to get things done as expeditiously and inexpensively as
possible, and that specialists may try to perform the “state of the art”
techniques on patients who can afford it. I expect that not everyone
on the Topix board will agree with this. And of course I could be
totally wrong; it would not be the first time. But it’s how I see things
now.
Woody, if you tell me the education-level and
alma mater of your dentist, I can predict where he stands on crown
lengthenings. From my experience, US-trained specialists in
prosthodontics or periodontists are comfortable with this procedure and
may recommend it or even require it. General dentists trained in C.R.
are less comfortable with this procedure, and may recommend alternatives
like laser gum shaping. There’s a new infrared laser that can help
reshape gums. I was pitched this machine by one or two CR dentists and
one US dentist. But no matter how great it is, I don’t think it can
replace a well-trained periodontist. (I don’t think that Dr. Prada or
his associates even have such a laser; if so, they’ve never mentioned
it.)
What else can I tell you? I suppose I can
review how crown lengthenings were used in my case. Dr. Prada removed
my old crowns and a week later Dr. Gonzales did the crown lengthenings.
I went home and let my gums heal for three months. Then I came back to
C.R. and Dr. Prada did a second “prep” on every tooth with the gums in
their permanent positions. It took him almost two full days. A month
later I had my new crowns. (As I mentioned in earlier posts, no other
dentist I found would have put in the time and effort to do a second
complete prep of my teeth.)
So, Woody, what does all
this mean for your particular case? First and foremost, I’ve tried to
make clear that I really can’t advise you here: I’m not a dentist.
I’m not even sure that permanent crowns will fit the gums like the temps
do. I suspect that they might, but you really need to ask your dentist
about these things.
As I remember, you are going to
the Cavallini clinic. I VAGUELY remember from my visit in November 2010
that they have the infrared laser I mentioned. The laser is quick and
quite inexpensive, by the way. And it wouldn’t surprise me if they had
seen a LOT of patients with issues very similar to yours. Your dentist
can certainly give you a more informed answer than anything I could
offer.
I don’t think you should worry. But if you
are worried, get a second opinion from a good--hopefully
great--periodontist. And if his answer should differ from your CR
dentist’s, well, welcome to the Dental Underworld! Now you will have to
decide for yourself who’s right.
Hope this helped!
But, honestly, I think that your dentist has successfully handled many,
many patients with whatever is troubling you.
Please keep us all informed.
-dave
P.P.:
By the way, my sister took her nom de blog “Moochthecat” from one of
her pets. I don’t think she ever heard of “Morph the Cat,” but I’ll ask
her.
p. 207: #4246
Hi from Costa Rica, LadyD!
I'm
writing this from my dentist's office as I wait for my friend to wrap
up. My sister also came down to C.R. in part to consult about a botched
implant from a U.S. local dentist. (See our posts above.)
Yes,
you can save money by getting your implants in Costa Rica, even with
traveling expenses. The implants including crowns are from about $1,000+
to $2,000. You won't save much or even anything with just one or two
implants due to travel costs. But more than two should be a very
significant cost savings. (If you choose your C.R. dentist carefully,
you can afford to get better care than the dentist around the block.)
As
for a recommendation for the best dentist, that is a personal decision.
There are a few excellent dentists that are perennial stars in our
discussions. It's a good idea to read the last 30 pages or so of this
blog (and the accompanying blog) to get an idea of the lay of the land.
Today
is my last full day in Costa Rica, and the weather was lovely for most
of my current visit. Yeah, it rained in the afternoon most days, but it
didn't inconvenience me. Low 70's most days, and today and yesterday it
didn't rain at all. Glorious.
-dave
p. 208: #4248
#### UPDATE FROM C.R. # 4 (Part 1 of 2) ####
My
posse is leaving for home tomorrow, so this will be my last dispatch
from C.R. I have a little update to add to my story. I went in
yesterday to take delivery of the new crown—only to find out that I
needed a root canal treatment (RCT) after all. I got the RCT yesterday
and the new crown today—the same crown I tried on yesterday—on a metal
post. It certainly wasn’t what I hoped for or expected when I got up
Monday morning, but such is life.
THE BEST LAID PLANS
Dr.
Prada worked for over an hour last week on a beautiful “build-up”
treatment for the short “prep” (tooth stub) on my upper left lateral
incisor. He would not have invested so much time unless he fully
expected it to hold the new crown. In my visit Monday morning, he spent
almost half an hour adjusting the crown—pushing it onto the prep and
taking it off—time after time. Somewhere in the process the build-up
became detached from the prep. He had a sly way of breaking the bad
news to me. After finishing the adjustment, he handed me a mirror and
said that there was good and bad news. I looked in the mirror and saw
the new crown which blended in beautifully with the other teeth. He
pointed to two minor imperfections—which were scarcely noticeable—and
mentioned that the crown would be sent back to the lab to fix the
imperfections and for final polishing. Then he took the crown off and
let me look in the mirror again.
Instead of the big, white prep
of last week, I saw the old dark mahogany prep. My heart sank. It was a
wordless let-down. He said the only remaining choice was to get a root
canal to prepare the tooth for a metal post. He scheduled me for later
that same day with his endodontist for the RCT, and for the following
morning (today) for the post insertion and crown delivery. It was great
that he could work me into his schedule on such short notice, but I was
still philosophically opposed to a root canal—my first—and on a healthy
tooth no less.
MY FIRST ROOT CANAL
Dr. Caranza,
the endodontist, did the RCT Monday afternoon in the same clinic. Her
examination room seemed well equipped. I asked her if she had a
microscope—I thought all RCT procedures used microscopes—and, sure
enough, there it was. She wouldn’t use it on me that day, but she did
use an ultrasound gadget. The RCT procedure was anticlimactic. It was
97 percent painless: I think I felt a couple sensations when we began,
which I used as an excuse to ask for additional doses of lidocaine as I
always do. Later on, I felt a moment of uncomfortable pressure. The
entire procedure took about 25 minutes, and Dr. Caranza was very
efficient and thoughtful. Upon finishing, she put back the temporary
crown and cautioned me to treat it carefully. (I think I read a post on
this board years ago where another endodontist installed a metal post
and sent the patient out for the evening without a temporary crown.
That wasn’t the case here.)
People sometimes wonder
about sterilization procedures in Costa Rica—there must have been some
awful reports years ago—but I can say that everything was autoclaved and
placed in separate packages. This is not atypical—the other clinics I
visited in November 2010 were the same way. After the RCT was finished,
I paid the bill and immediately left for a tour of San Jose with my
friends. There was no pain, so I did not take any pain relievers. (I’m
feeling a little bit of tenderness in the gums in that area now, so I
might take some pain relievers later on tonight.) The procedure cost
$270, but this was for a simple tooth, an incisor. I suspect that
molars might cost more, but I didn’t ask.
===== Continued ======
p. 208: #4249
#### UPDATE FROM C.R. # 4 (Part 2 of 2) ####
MISGIVINGS ABOUT ROOT CANALS
I
was more concerned about the possible ramifications of the RCT than the
procedure itself. As I mentioned in an earlier post, I was very wary
of trying any new dental procedures, a fear arising from previous bad
experiences. I also did not want to kill an apparently healthy tooth. I
discussed my concerns with Dr. Caranza before the procedure. She was
very patient with me and took about 15 minutes allaying my worries. I
also learned a few words of endodontist-speak. Endodontists talk about
“saving the tooth” which means to leave the enamel and dentin of the
root intact but removing the nerve and pulp at the center of the tooth.
They talk a lot about this nerve. The nerve can be healthy, dead,
dying, infected or in some other state. In reply to a question, she said
that the enamel and dentin surrounding the nerve and pulp are already
dead, even in a tooth with an intact and healthy nerve.
Dr.
Caranza said that the nerve in my tooth was mostly dead already. The
grinding of the tooth for a crown is thought to be very hard on roots.
She explained that the x-ray of that tooth showed no enamel and only
half a millimeter of dentin, which wasn’t enough to protect the nerve
from bacterial infiltration. The fact that the tooth had no sensation
even when the prep was exposed to air and liquids was also a bad sign,
as I had expected. I don’t know whether this story was completely frank
or not, but it made me feel better. Dr. Caranza thought that the nerve
was dying anyway, and would be dead within a few months anyway even with
an intact crown. So, I wasn’t sacrificing a healthy nerve to an RCT
after all! I was merely killing the nerve before it had a chance to die
naturally and get infected. After drilling into the pulp, she said
that the nerve was 90 percent dead already. She stuck to her story for
the rest of the procedure, so at least I give her credit for
consistency.
So I felt better about my first RCT.
But now I’ve begun to wonder which of my other 27 teeth will be the next
candidate for an RCT....
POST AND CROWN
At 9:30
today, Dr. Prada: removed the temporary crown; drilled a hole in the
gutta percha in the RCT’d tooth and inserted a metal post; fit and
cemented the new crown, just back from the lab; adjusted the bite
(“open, close, bite down, move your jaw forward”); and adjusted the
night guard he made for me in April 2011. He works very quickly, but it
still took him almost an hour. Probably more than that if we include
all the time he spent answering yet more questions.
Twelve
hours later, the bite feels good. But my gums are slightly tender for
some reason. It was probably take me a few months to accept my new root
canal. I hope that my 27 “good” teeth can hold out for a few more
years because I’m not looking forward to a Costa Rican RCT trip every
year.
-dave
For some Questions and Answers with Dave,
Press Here.
Or browse some of Dave's favorite dentists from "THE DENTISTS" menu.
