Dental Q - Root canal and root amputation

[Melee]

Hi,

I will be starting my open water diving course next week. I'm concerned that a root canal that I had done a couple years ago that had complications where I needed a root amputation for one of the front roots (my second to last molar on my left upper quadrant) is going to give me problems while diving. Unfortunately, I have not gotten the crown fixed yet, so there's an enormous hole where the oral surgeon cut away the crown to amputate to the root. The gumline healed properly where the root was extracted and I'm not in any pain currently. Am I going to have major complications if I don't have the crown fixed? Thanks for any input.

Mel

 

[DocVikingo]

I will ask our diving dentist, Dr. Larry Stein, to respond to your injury.

Best regards.

DocVikingo

 

[Laurence Stein DDS]

Hi Mel,

DocV gave me the heads up.

For those of you who don't know, a root amputation is where a root or roots of a multirooted are sectioned off the associated tooth and the remaining tooth is then restored. In this way, it is sometimes possible to retain enough of that tooth to restore with an individual restoration.

The alternative is to extract the entire tooth and either place an implant or prepare adjacent teeth to support a fixed bridge, make a partial denture or simply go without.

The dentist/oral surgeon lifts a little flap of the gums surrounding the "lucky tooth". :cheeky: Then a drill is used to section across the diameter of the root to be removed and possibly some of the supporting bone of that root to allow it to be carefully extracted without removing the rest of the tooth.

This is often a last ditch effort to avoid extracting a tooth that may be supporting an existing bridge. Often the affected root has an infection of the gum or root tip. Frequently, this tooth has had a previous root canal and the root that is removed is the one that is "failing". A tooth without a root canal can also be amputated...the root canal is done following the surgery. Sometimes a muti-rooted tooth has a periodontal (gum) absess on one root or a pocket between roots...amputation of the appropriate root may make it possible for the pocketed area to remodel the surrounding bone and render the pocketed area more cleansable...improving the overall prognosis for that tooth.

A vertical fracture through one root would make it necessary to remove the affected root to help try to avoid a complete failure and loss of that tooth.

On occasion, a socket bone graft is done simultaneously to reduce the size of the post surgical "hole". The site will heal and usually has a bony defect associated with the amputation site.

Right now your biggest problem is the unrestored tooth and the hole in it. Following a root canal procedure the SINGLE GREATEST REASON FOR A FAILURE OF THAT ROOT CANAL IS THE FAILURE TO PROPERLY RESTORE THAT TOOTH IN A TIMELY MANNER!...There! I said it! :icosm12: Leakage from the oral cavity into and under the root canal filling material can take as little as 30 days.

From your description, this tooth sounds like a potential scuba diving problem. Problems can occur from trapped gases and from bacterial entering the remaining canals. Again, from your description, I am not able to accurately determine if the tooth had an existing crown prior to needing the root amputation. The hole you mentioned could be a root canal access hole or the hole left in the gum by the surgeon.

Anyway, if there is any type of hole into the nerve chamber, it should be sealed off as soon as possible to avoid contamination of the remaining filled canals.

Now, if the hole is simply the extraction site left by the removal of the amputated root, then there is less of a problem. If the root removal was "simple", then you only need a week or two. If its was difficult, requiring a lot of bone removal, you might have to wait up to 6 weeks.

You should be off all pain medications, antibiotics and be able to comfortably hold a regulator in your mouth. You should have no complications like an infection or dry socket or any dry socket dressing that is still being placed.

Your surgeon can advise you about this.

Finally, following the surgery, the opening to the nerve canal in the amputated root still exists and can be an entry site for gas or germs. This site is often under the gum and cannot be see directly. You want to make sure this hole is sealed as well.

One last thing. The prognosis for an "amputated" tooth is considerably less than the same tooth with just a root canal. While you may get a number of years out of this tooth, you probably won't take it to the grave with you. This is one of the reason single tooth implants should be considered as a resonable treatment option. It turns out that it is MORE economical once you factor in the fees for the original root canal, an endo post and core, a crown, root amputation surgery, replacing the crown, etc....and then you lose it!

A well integrated implanted will generally outlast a tooth with a root amputation. That being said, I have seen root amps that have lasted more than 20 years.

Good luck. Contact your surgeon if you have any concerns about the surgical site. You might want to ask if a small hole or perforation was left where the root used to be.

Please remember that I have never examined this site and am not privi to information and reason for selection the root amputation procedure.

Regards,


Laurence Stein, DDS :doc:

Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)

 

[Melee]

Hi Dr. Stein,

Thanks for the information. I had the surgery done about maybe a year ago. The oral surgeon told me that he wanted me to wait six months for the area to heal before considering a modified crown. Of course, being stupid, I've waited this long to get to this point. I was unfortunately hassled by Blue Cross because they thought that my root amputation was "medically unecessary" (long story) so I've delayed getting the crown fixed. When I went in for my follow-up with the oral surgeon, he mentioned that the area where the root was extracted had tapered off and healed quite nicely. Yes, you are correct that the "hole" is from the Crown. He cut a quarter of the base of the crown to get to the fractured root. My friend is a dentist, so I will make an appointment to see her regarding this.

Again, thank you very much.

Mel

 

[Laurence Stein DDS]

Hi again,

Hey, fight those sons of guns at Blue Cross. Your procedure is nearly always "medically necessary". There is no way a person is going to put themselves through the procedure just to cheat this insurance co. The dentist and/or surgeon will most likely have to submit the pretreatment x-ray and may be asked for a post operative one as well.

Either your tooth needed it or it didn't. Repeated unsuccessful root canal attempts will render this tooth non-restorable. The simple fact that you had previous root canal treatment and you had an existing crown basically obligates you and your dentist to re-restore this surgically treated tooth.

Remember, the squeeky wheel gets the oil.

Many insurance companies automotically deny a claim and hope you won't fight it. Do this 1000 times a day for $1000 a pop and the insurance can save themselves a bundle...especially if the patient and doctor don't fight it.

Good luck.

Larry Stein

 

[Melee]

Hi Dr. Stein,

Thanks for the advice. I will definitely fight it if they deny my claim for the work that needs to be done to my tooth, and this time, I'll be more dilligent about it. It took over a year before they would pay a portion of my initial work, and by that time, it went to collections, so I was forced to pay the residual. I guess that's what insurance companies are also hoping, that they defer payment until your credit goes bad and then you're obligated to pay.

Mel

 

[Laurence Stein DDS]

Hi Dr. Stein,

Thanks for the advice. I will definitely fight it if they deny my claim for the work that needs to be done to my tooth, and this time, I'll be more dilligent about it. It took over a year before they would pay a portion of my initial work, and by that time, it went to collections, so I was forced to pay the residual. I guess that's what insurance companies are also hoping, that they defer payment until your credit goes bad and then you're obligated to pay.

Mel

Hi Mel,

It's important to understand that your contract for dental insurance is between you and your insurance company. Any services provided to you is by your dentist and as such, if you owe him money, then it is between you and him.

The insurance company's only obligation is to honor their contract with you. If your dentist provides services that are not covered by the insurance company, the bill is still yours to pay in a timely manner...no matter if you think the insurance should have paid.

This is one of the great misconceptions about dental coverage. Unless you are a member of an HMO, and even they have exceptions like copayments, your insurance contract and you dental provider are different entities and neither is responsible for the other.

If your dentist cannot receive payment from your insurance company, YOU, are responsible for the entire bill. Any copayment to your dentist is collectible at the time service is rendered...not after insurance has paid. Your dentist has overhead and lab bills due each month for treatment rendered to you and other payments. If he had to wait 3-6 months for any payment, he would be out of practice very quickly.

Try to get your car out of the mechanics shop without paying when you pick it up following repairs. Even if you have a service contract or warrantee work, you have to pay any non-covered expenses before the mechanic gives you the keys.

When possible, we would like to get preauthoriztions indicating that the insurance company will pay for a portion of treatment. This is not always the case. Even with pre-estimates, the insurance company may change its mind and they tell you this on the pre-treatment estimate.

All this being said, I understand how it is possible for an expected insurance payment to screw everything up. It is to the insurance companies advantage to delay payment or deny a covered claim just to see if it "falls through the cracks". The best that can happen is nobody complains and they don't pay. The worst that happens is they have to pay using a portion of the premium they contracted with you for to cover the expense you hoped you wouldn't incur. In the process, they don't care if they screw up the doctor/patient relationship.

I hope you were able to patch up things with your dentist.

Regards,

Larry Stein

 

[Melee]

Hi Dr. Stein,

I have definitely learned my lesson with insurance claims from my last experience. Don’t want to do that again. I am going to a different dentist than the one that did my root canal treatment or hemisection. Hopefully, she'll be able to evaluate the situation or refer me. A couple questions for you before I go on my visit:

1) You mentioned that “Finally, following the surgery, the opening to the nerve canal in the amputated root still exists and can be an entry site for gas or germs. This site is often under the gum and cannot be see directly. You want to make sure this hole is sealed as well.” How will the dentist fill the hole (if there is one) if it is under the gumline? Is this a post-operative procedure? The oral surgeon never mentioned this to me.

2) Would you then not recommend that I take the open water diving class until I get this fixed? (Cringes, I’m guessing your answer is yes.)

3) I realize that this tooth will sooner or later need to be replaced by an implant or extracted for a bridge, but say, even if I get the work done, am I going to have future problems diving? I’m thinking the worst case scenarios here. So if that’s the case, then I might as well get the darn thing extracted.

Again, your knowledge is very much appreciated.

Mel

 

[itziar]

Hi Melee,

I sympathize with your situation. I had a root extracted a couple of weeks ago. My doctor said it was an "endodoncia" (in Spanish), which I am not quite sure if is the same that you have had done, although the description sounds pretty similar. I had half of the tooth removed, the nerve was killed and they filled the nerve hole with posts and some sort of resine. All this in three sessions. I am not aware of their opening any hole, maybe because I did not really have an infection in the tooth: it was just in very bad condition.

In any case, I was diving just one week after the last session and before the crowns and final restorations were in place -- I am still waiting for a good time to go back to the dentist to do this, but after reading Dr. Stein's comments, I will make sure I do it by next week at the latest. I briefed my doctor on all possible nasty things that change of pressure can do to trapped air, but he did not seem concerned that anything could go wrong while diving. He X-rayed the tooth and showed it to me to demonstrate that there were no holes left. I was already off medication and made sure that I could hold the mouthpiece in my mouth without pain.

Do not give up on the hope of your first dives, but do check with your dentist and wait for Dr. Stein's answers, who will know best.

Good luck,

-- Itziar

 

[Laurence Stein DDS]

Hi Melee

Yes. By magic. Doesn't surprise me. Usually. Probably not. :icon10:

There may be a hole in the base of the pulp chamber which leads to the nerve canal in each root. Simply removing the root from the remainder of the tooth doesn't mean there isn't an opening. This hole is simply the connection of the canal with contains the nerve in the root with the nerve in the pulp chamber.

This can be plugged up at the time of root amputation or by reentering the top of the tooth through the remaining cap and filling the opening. The oral surgeon may not have thought about it...if he didn't know you planned to scuba dive.

If the tooth is properly plugged, then you may dive...even if it is a tempory filling...just make sure there is no cotton in the pulp chamber...ask your dentist...there should be no way for gas to enter the remaining tooth.

You will probably never have a dive problem related to this tooth because the condition is very rare. Having never examined your mouth it is impossible to say how long this will last and it is not prudent for me to speculate on treatment options...I'll leave that to the insurance companies who never seem to have a problem coming to a conclusion about a given treatment and then recommending benefits accordingly.

It might, however, be reasonable to discuss this matter with your dentist. He would be in a better position to recommend alternate treatments.

You could take the position that if everything feels OK and the tooth and restoration is solid, go with the existing treatment plan. If and when a problem does occur, then you can fall back onto the other treatments options...having already discussed them.

Let me know how it goes.

Regards,


Larry Stein
:doctor: