Can a tooth be crowned without canal treatment?

Run_to_da_hills

I had root canals done on two rear molars last November. The dental hospital gave me a XRay profile and stated that when I return they will crown the two teeth that had treatment plus two adjacent teeth that had not got canal treatment. Is this possible? I thought that teeth had to have their roots out before crowning.

I was also quoted a figure for this but I am afraid the hospital might exceed this figure should extra work be required. I wouldnt mind getting a second opinion to see if the two untreated teeth really need crowning as they haven't given me any trouble.

Cheers.

Bicycle

Hi,

I'm starting the process of having an "un root canalled" tooth crowned tomorrow (see my thread regarding Implant v Crown for my earlier deliberations).

My dentist thinks there is still some nerve activity in my tooth and therefore will not organise a root canal treatment unless absolutely necessary.

In a root canal, the pulp is filled with a resin to stabilise the tooth. The root remains and anchors the tooth in place.

Good luck. I hope things go well for you.

Run_to_da_hills

Bicycle wrote: »

Hi,

I'm starting the process of having an "un root canalled" tooth crowned tomorrow (see my thread regarding Implant v Crown for my earlier deliberations).

My dentist thinks there is still some nerve activity in my tooth and therefore will not organise a root canal treatment unless absolutely necessary.

In a root canal, the pulp is filled with a resin to stabilise the tooth. The root remains and anchors the tooth in place.

Good luck. I hope things go well for you.

Cheers lets know how you get on.

And good luck tomarrow.

Bicycle

Thanks for your good wishes. I'll let you know tomorrow evening how things go. Hopefully it will be very boring

Have a 60 min appt tomorrow, another 60 appt next week (when a mould of the stump will be taken - I'm sure there's a more technical term, lol!!) and then will have the crown installed the last week in January.

davo10

Run to da hills, I can't understand your reluctance to have treatment. If I have read your post correctly, you had root canal treatment done at a dental hospital and were advised to have crowns. If this is the case, you had your treatment done to the highest standards at a fraction of the cost you would pay a private practitioner, what exactly are you looking for?. If you do not want to take the advise of a dental tutor/professor at a dental hospital, move out of the way and let a more deserving and motivated person avail of the high quality subsidised treatment on offer there. I am certain that a high percentage of the people who have just lost their PRSI dental cover would be delighted to be able to have treatment in the dental hospital.

georgieporgy

I think the OP was querying the necessity of having crowns on the 2 teeth that were not root treated. He is not a dentist and wants further clarification before submitting himself unquestioningly to the staff at the dental school.

OP, most teeth that are crowned have not been root treated.. They are badly broken down but not so bad as to need root canal treatment. Very often the patient will not be experiencing any trouble from them. When you feel pain it is often too late! If the fine staff at the dental school have recommended crowns you can rest assured that it is a good recommendation. I suspect the teeth in question are heavily filled and are therefore structurally weak and in danger of breaking. Crowning them now will protect them from further damage.

res ipsa

Run_to_da_hills wrote: »

I had root canals done on two rear molars last November. The dental hospital gave me a XRay profile and stated that when I return they will crown the two teeth that had treatment plus two adjacent teeth that had not got canal treatment. Is this possible? I thought that teeth had to have their roots out before crowning.
Cheers.

All root treated back teeth need crown protection, but not all crowned teeth need prophylactic root canal treatment.

However in my line of work I see quite alot of teeth that have been crowned recently and were asymptomatic beforehand.

As a result I would myself be slow to get a crown on an asymptomatic tooth as iatrogenic damage is cumulative and irreversible.

davo10

rep, is it your advice that only painful, infected teeth should be crowned?. From a conservative point of view, is it not advisable in some instances to crown heavily filled teeth electively therefore guarding against future fracture/toothloss?. What do you advise us to tell patients when their teeth do eventually exhibit symptoms but are now unrestorable?, should I say "well it didnt hurt so didnt need to be protected with a crown, now lets take it out"?.

georgieporgy

As an endodontist, I think Res only sees the ones that go belly up so it may colour his reasoning?
A lot more teeth are lost due to not crowning soon enough. the problem with specialists, sigh!

Run_to_da_hills

davo10 wrote: »

Run to da hills, I can't understand your reluctance to have treatment. If I have read your post correctly, you had root canal treatment done at a dental hospital and were advised to have crowns. If this is the case, you had your treatment done to the highest standards at a fraction of the cost you would pay a private practitioner, what exactly are you looking for?. If you do not want to take the advise of a dental tutor/professor at a dental hospital, move out of the way and let a more deserving and motivated person avail of the high quality subsidised treatment on offer there. I am certain that a high percentage of the people who have just lost their PRSI dental cover would be delighted to be able to have treatment in the dental hospital.

BTW the Dental Hospital is PRIVATE and at my own expense and is not in this country because I cannot avail of PRSI subsidisation here.

Not so much a reluctance, these guys run a business and like any business they are out for profit. I have heard of several cases where patients have gone for assessments abroad and were told that they needed unnecessary cosmetic surgery including implants.

My initial appointment was for 2 bad teeth that obviously needed root canal treatment and crowns, It was not until I flew out there that I was told that I needed extra work on two other teeth that I have had no trouble with in the past.

btkm8unsl0w5r4

Dental Hospitals run at about a quarter to a fifth of the cost of treatment with a private dentist . just for information. Usually they provide treatment far below cost as they are heavily subsidized by the universities and the HSE. Profit does not come into it in any way, the only thing they get from the patient is educational opportunities.

davo10

I think there may be a misunderstanding here. Run to da hills, "dental hospitals" is the term given to teaching hospitals such as Trinity and UCC dental hospitals. They are non-profit teaching centres and offer much reduced fees as you are often being used as a teaching case. Are you referring to a private dental clinic in a foreign country?

res ipsa

davo10 wrote: »

rep, is it your advice that only painful, infected teeth should be crowned?. From a conservative point of view, is it not advisable in some instances to crown heavily filled teeth electively therefore guarding against future fracture/toothloss?. What do you advise us to tell patients when their teeth do eventually exhibit symptoms but are now unrestorable?, should I say "well it didnt hurt so didnt need to be protected with a crown, now lets take it out"?.

No this is a clinical decision for you to make, I was talking about whether I personally would get a vital tooth crowned.
Do you see many vital teeth suffer catastrophic fracture because they were not crowned?

Unwilling

Hi

I have three crowns and NONE of the have had canal treatment!?
As long as it is cleaned properly.. happy days

By the way, can you PM me how much the dental hospital is charging you for the crown.?

Thank

res ipsa

georgieporgy wrote: »

As an endodontist, I think Res only sees the ones that go belly up so it may colour his reasoning?
A lot more teeth are lost due to not crowning soon enough. the problem with specialists, sigh!

You are quite right, we are all coloured by our experiences and prejudices, where you stand on something, depends on where you sit.
We even overestimate our abilities relative to others
http://en.wikipedia.org/wiki/Lake_Wobegon_effect
Would you personally prefer a cuspal coverage bonded amalgam or a destructive 2mm shoulder prep all ceramic crown on your own vital molar tooth?

georgieporgy

Res, it depends on how weakened the tooth is in the first place. I certainly favour onlays before crowns. Much less destructive. But on those bombed out molars with huge fillings I prefer a full crown. But 2mm shoulders would sure mean I'd be sending business your way. I feel guilty drilling 1/2mm shoulders.

davo10

Rep, I regularly see teeth that require extraction because they were not crowned when they should have been. this week I have seen 2 people whose first molars fractured. They both had large fillings and were asymptomatic. both were advised they needed crowns, in both cases the lingual wall fractured below level of bone, both now have Glass Ionomer fillings as a temporary measure and both have been told that teeth will have to be extracted when fillings fracture/tooth becomes painful. Effectively what you are saying is that if it isn't broken don't fix it, but experience has thought me and others that in some cases, not crowning a tooth when heavily filled is effectively allowing is to deteriorate to the extent yhat when it does eventually hurt, it may be too late to crown and the patient ends up having the more invasive bridgework/implant procedures. My belief is that your own teeth are the best teeth so crowning them to gaurd against fracture is appropriate and in the patient's best interest. I wonder how many of the endo patients you see would not require treatment had their teeth been protected by crowns previously, you don't know.

Bicycle

Well, I had my first appointment yesterday.

I was somewhat nervous - I'm an apprehensive patient at the best of times!! But was very reassured by my lovely dentist.

Had some serious anaesthetic, my tongue felt the size of my thigh (visualise a large bullock ). The drilling was fine. The only issues were (a) the slow drill that makes my head spin - but we got over that by it only being used in short spurts
(b) when the dentist had to cut one of the metal pins

But there was no pain - either physical or emotional. It took the full hour.

I was finished at 3, the anaesthetic started to wear off at 5.00pm and within an hour of that I was at work, in a job where there is a huge amount of talking involved. And I was fine. Could talk at length.

The only side effect was that while the anaesthetic was still present, I had difficulties talking because of the numbness in my tongue, but also interestingly had difficulties typing. Had huge issues spelling things correctly. Fingers worked but it would appear that either psychologically or more strangely physiologically, my language centre was affected.

The filling was in the lower jaw, rather than the upper jaw, so I find the whole language thing rather odd.

I have another appointment next Tuesday for an hour, and will again have to work afterwards.

res ipsa

davo10 wrote: »

Rep, I regularly see teeth that require extraction because they were not crowned when they should have been. this week I have seen 2 people whose first molars fractured. They both had large fillings and were asymptomatic. both were advised they needed crowns, in both cases the lingual wall fractured below level of bone, both now have Glass Ionomer fillings as a temporary measure and both have been told that teeth will have to be extracted when fillings fracture/tooth becomes painful. Effectively what you are saying is that if it isn't broken don't fix it, but experience has thought me and others that in some cases, not crowning a tooth when heavily filled is effectively allowing is to deteriorate to the extent yhat when it does eventually hurt, it may be too late to crown and the patient ends up having the more invasive bridgework/implant procedures. My belief is that your own teeth are the best teeth so crowning them to gaurd against fracture is appropriate and in the patient's best interest. I wonder how many of the endo patients you see would not require treatment had their teeth been protected by crowns previously, you don't know.

This is an interesting debate.
In order of least to most invasive I would rather the following on MY VITAL tooth to prevent fracture:
1. Grind Sharp Cusps.
2. Grind cusps by 3mm and replace with bonded amalgam.
3. Grind cusps and replace with composite.
4. Ortho Band on tooth.
5. Gold Onlay.
6. 3/4Gold Crown.
7. Gold Crown.
8. White Porcelain FM Crown or All Ceramic Crown.

A vital tooth that is crowned will be root canal treated at a rate of 1% per year accordind to the Valderhaug study that followed vital crowned teeth for 25 years and at the end 25% were root treated.

Randow & Glanz showed us why it is important to preserve vitality to prevent fracture
http://www.ncbi.nlm.nih.gov/pubmed/3544657

georgieporgy

Res, I wouldn't draw that conclusion from the Valderhaug study. In the study it didn't state if the crowns were fitted in Santa Monica or Newcastle (if you get my drift).Otherwise,though, your list is pretty good.

res ipsa

georgieporgy wrote: »

Res, I wouldn't draw that conclusion from the Valderhaug study. In the study it didn't state if the crowns were fitted in Santa Monica or Newcastle (if you get my drift).Otherwise,though, your list is pretty good.

Fitted in Oslo Dental School by dental students.

http://www.ncbi.nlm.nih.gov/sites/entrez

georgieporgy

Best avoid Oslo if you want crowns then? ha ha.

seriously though, I still don't accept accept that 25% of crowned teeth end up needing RCT within 25 years. Just basing that on my own 35 years in general practice.
Indeed the number of crowned teeth that I have come accross that require endo is quite small. Negligible really. And those that did usually had big old amalgams under them. The dentist didn't remove the original ag prior to crowning.
It's like saying condoms work. I just don't believe it.

btkm8unsl0w5r4

georgieporgy wrote: »

It's like saying condoms work. I just don't believe it.

If you ask Big_G mum she would say they dont....:D

Big_G

Nice.

btkm8unsl0w5r4

There are other reasons to crown teeth apart from to prevent future fracture, vital need need crowns often IMHO because.
1. Extensive restorations.
2. Loss of bracing cuspal inclines.
3. Poor occlusal form or restoration.
4. Poor contacts.
5. Poor aesthetics.
6. As part of a wider treatment plan.
7. As RPD abutments.
8. As FPD abutments.

I think that a crown or onlay is a neater job than a bonded amalgam in a lot of dentists hands. And certainly indirect restorations have better control of the anatomy, contacts, and occlusal contacts than a direct restoration. Better looking and longer lasting also.

Crown now while you have something to crown is my motto, crowning intact teeth or periodontally involved teeth is not my bag however.

Conservative is doing what last longest not what costs least in time, money or tooth structure.

Second good debate of the week

ballsymchugh

Jayde Thankful Food wrote: »

If you ask Big_G mum she would say they dont....:D

Jayde Thankful Food wrote: »

Second good debate of the week

hmmmmmmm.

vishal

A girl in my class went to Oslo for her Erasmus. She was assisting a student who was placing a comp in a pool of saliva. I don't think I would go by that study. Most other studies are a lot lower than that.

ballsymchugh

http://www.boards.ie/vbulletin/showthread.php?t=2055744743

it's a conspiracy!

res ipsa

vishal wrote: »

A girl in my class went to Oslo for her Erasmus. She was assisting a student who was placing a comp in a pool of saliva. I don't think I would go by that study. Most other studies are a lot lower than that.

This is a good summary from my mentor:Georgieporgy will see how I have been "coloured" by him:D


http://www.nature.com/bdj/journal/v192/n6/full/4801365a.html
Pulp morbidity in crowned teeth

Dental pulp is the highly vascular, richly innervated soft tissue structure whose principal role is tooth formation. But even after teeth are erupted into the mouth and fully formed, the dental pulp is not a redundant organ. Pulp tissue retains the important function of supporting its secretory odontoblasts which lay down reparative dentine in defensive response to dental injuries throughout life. There is also some evidence that the pulp may be involved in a pressure-receptive function, limiting the possibility of damaging functional overload on teeth.1
If this were not sufficient justification to preserve healthy pulps, then the desire to do patients no harm and to avoid the pain, swelling and suffering which often accompanies the injury and demise of a pulp surely must be.
An insulating coverage of dentine and an impervious layer of enamel protect the pulps of healthy, intact teeth from injury. Crown preparation places the pulp at risk in a number of ways. High speed stripping of hard tissue poses the threat of pulpal overheating, with disturbance of microcirculation, vascular stasis, thrombosis, reduced blood flow and internal bleeding.2 It also opens a multitude of dentinal tubules that communicate directly with the pulp. The deeper the dentine is cut, the more permeable it is,3 and the more vulnerable the pulp becomes to chemical, physical and microbial irritants. The microbial threat presented by the oral flora is by far the most serious, and is capable of heralding intense inflammatory changes, with micro-abscess formation and progressive pulpal necrosis.4, 5
Although the pulp shows considerable resilience and is often capable of recovering from irritation, the injuries induced can become significant in the long term.5 Scarring as a result of inflammation and repair interferes with the nervous and vascular supply to the tissue6 and jeopardises its resistance to further insult. It is important in this respect to recognise that crowns are rarely made for pristine, intact teeth. Rather, they are made to protect and restore teeth which have been damaged by wear, trauma, or cycles of caries and repair. After a lifetime of cumulative insult, crown preparation can be the final straw, bringing pulpal breakdown (Fig. 1a), and the need for root canal treatment.7
Figure 1a: Pulpal breakdown and acute apical periodontitis affecting a recently crowned mandibular first molar


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It is uncertain how many teeth lose vitality as a direct consequence of crown preparation. Bergenholtz and Nyman's8 much quoted study showed that 9% of crowned teeth, compared with only 2% of uncrowned controls lost vitality during long-term review. None of this was attributable to caries or other obvious causes, but the crowned teeth in this study did have advanced periodontal destruction, and were involved in extensive, cross-arch bridgework.
Extrapolation to the case of uncomplicated, single crowns is therefore difficult.
Even higher levels of pulp death were recorded by Felton et al.,9 where 13.3% of teeth restored with full coverage crowns, compared with 0.5% of unrestored controls lost vitality during the 3–30 year review period. But it was not possible to derive from this report how many teeth had suffered further pulpal insult, such as recurrent caries, which may have artificially inflated the adverse effects reported.
A more realistic estimation may be in the order of 4–8% in the 10 years following active treatment.10, 11, 12, 13 This estimation does, however, assume that efforts were made to identify and manage all obvious pulpal pathosis before crowns were made; an assumption that cannot always be taken for granted in practice and which increases the likely incidence of unexpected endodontic problems that need attention at a later date.

The dangers of root-treating crowned teeth

Extra-coronal restorations do not rule out root-treatment or retreatment (Fig. 1b), but it should be noted that working through a crown is always more difficult, and that damage can be done.
Figure 1b: Root-treatment completed through the crown without serious damage


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Just piercing the glaze of a porcelain crown dramatically reduces its strength,14 whilst cutting through a metal ceramic crown can weaken the porcelain bond and predispose to fracture. Vibration can disturb the cement lute of a casting and predispose leakage or loss, whilst rubber-dam clamps may crack and pit cervical porcelain15 and occasionally cause a crown to debond.
Once through the crown, the search for the pulp can be hazardous. Metal copings and cores obscure the pulp and prevent its location and assessment from preoperative radiographs. The alignment and rotation of the crown may also not correspond to the underlying tooth, causing loss of orientation and misdirected cutting. Added to this, problems are compounded by limited entry of light and poor visibility.
All of this can leave the operator severely weakening the core and vertical walls of the tooth in search for the pulp chamber and canal openings (Fig. 2a). Catastrophic errors such as perforation are also possible.


Figure 2a: Overcut and misdirected access through a crown grossly weakens the vertical walls of the preparation


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Figure 2b: Disorientated by the presence of a crown which had modestly realigned the tooth, the access cavity into this lower molar completely bypassed the pulp chamber to the mesial and lingual. There were no less than five separate perforations


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Of equal importance is the damage that can be done to patient confidence and trust if a recently crowned tooth becomes troublesome and has to be accessed or the restoration removed for endodontic treatment.16 As the complexity of the crown and bridgework increases, so the consequences become more serious. Replacing a single crown damaged during access is one matter; replacing a large bridge which has suffered irreparable damage to one of its abutments is quite another.
It is certain that a small number of teeth will always develop unexpected endodontic problems after crowning,11 but it is also certain that many such instances can be avoided by careful preoperative workup.