What else do I Need to Consider? (The ‘nitty gritty’ dentist stuff)

Whatever the situation, there are a number of things that need to be taken into account when making any decision.

I am going to discuss the patient considerations that directly relate to you- your expectations, your finances, your mouth and associated dental factors.

This information is meant as a guide, not specific detailed individual advice. This will only be available from the dentist examining you.

Every single case is different and must be assessed on an individual basis in order to provide the most suitable treatments.

Let’s outline the treatment planning process together. All dentists should take these factors into consideration when planning treatment.

Patient factors

• Your expectations 

Ask yourself…

How quickly do you need it done?

How important is the look to you?

How long you do want it to last?

How much are you wiling to spend?

• Your health

Your medical history can have an impact on the treatment that can/should be carried out. Certain conditions may make particular treatments unsuitable. 

Aside from your medication and the conditions that you may be suffering from, we need take into account your age, general fitness and ability to tolerate treatment. On paper an implant may seem the best option but if you are unable to lie back in the chair, stay still for more than 10 minutes at a time, then an hour long surgical procedure doesn’t sound so feasible.

• Your mouth

(i) Access

How much space does the dentist have to operate i.e. how wide you can open the area that the dentist needs to see. We generally measure this in terms of fingers- one finger wouldn’t even allow the drill and the bur to get inside your mouth and four fingers would make you like the cartoon in the ‘reach’ advert-

(ii) The number of missing teeth

The more teeth you have missing, the more complicated a fixed solution becomes. A removable option for restoring 4 missing teeth is hardly any different in terms of time, cost and procedure than to replace 6 teeth. With fixed options this is a different story and requires much more careful consideration.

(iii) The position of the missing teeth

If the tooth that is missing is the last molar tooth on that side of your mouth, then there will be fewer consequences from not filling that space, than for example, if it were your front tooth. If the tooth opposite a missing tooth is also missing then you should not get over- eruption. You may find that chewing isn’t a problem to you and you may decide to simply leave the space.

(iv) The prognosis of the remaining teeth

If certain teeth have a poor prognosis, whether that relates to the state of the nerve, or the supporting bone and gum for the tooth, it must be considered when planning treatment. If a tooth is likely to be lost in the near future, it may be an appropriate time to extract it now. You could select a treatment that would allow you, if necessary, to add a tooth later on, something that is quite easily achieved with a partial denture.

(v) The level of gum you show when you smile

This is related to your aesthetic demand and how important the finished look is to you. If you have a high smile line i.e. you show a lot of teeth and gums then aesthetics will be much more crucial to get right. If you have a very low smile line you may even be able to have metal clasps near the front of your mouth on a partial denture that nobody (apart from your dentist) will ever know about.

(vi) The appearance of your remaining teeth

A removable option will not change the appearance of the other teeth, but may be carried out in association with other cosmetic procedures. Same goes for an implant with a dental crown. Other crowns, cosmetic bonding or veneers may also be needed as well if a smile makeover is the goal. A bridge however could help- it would not only support a heavily filled tooth, but help re-shape and re-colour the teeth involved either side.

(vii) The condition of the support for your teeth

This is very important in restoring spaces with fixed options and must be carefully assessed so as to ensure the solution is a long term one. If the tooth supporting the bridge is weak, then having it take the the pressure off the missing tooth as well, will only cause it to fail sooner. If it does, the whole bridge becomes useless and must be removed and a new option for the space found. Given the time, money and process- you can see the importance of ‘treatment planning’.

When placing an implant, it is important that sufficient bone exists to support the implant. If there isn’t enough good quality bone, it may be necessary to have a grafting procedure prior to the implant placement to give it the best chance of success. This will increase the cost and may or may not be something you wish to have done. If not, I would rule out an implant as an option.

(viii) The quality of the teeth remaining

Are they heavily filled? Have they had a root canal or a post placed? What is the prognosis of the nerve? Are they perfectly healthy? All these questions must be considered.

In general, a root treated tooth with a post isn’t an ideal supporting tooth for a bridge. That said, it is a frequent finding and something that is done fairly regularly. It is, as always, a matter of weighing up each of the options fully and going with the best option for you.

For a bridge, having two perfectly healthy teeth either side of the space is not ideal either. Whilst providing great support, they would still have to be filed down and this would be considered in many cases overly destructive. This removal of a naturally healthy tooth may be avoided by placing an implant or denture that would leave them untouched. The bridge is essentially two crowns with a fake tooth attached in the middle. So it can be considered either destructive or protective, depending on the state of the teeth on either side.

The prognosis of the nerve is another important consideration. As with a crown, if a nerve inside a tooth is rather suspect, it is, in most circumstances best to do a root canal treatment before making the bridge. This avoids having to destroy the integrity of the bridge afterwards, which of course is a good thing. Unfortunately, it is not always an easy thing to predict and teeth under bridges do play up, so sometimes we do have to go down that road of doing a root canal through the top of the bridge.

• Your bite (or as we say ‘occlusion’)

This is very important and needs careful analysis. There are two approaches dentists can take:

(i) A conformative approach; where dentists accept the current occlusion or bite and fill the space(s) to ‘conform’ to your current teeth.

(ii) A reformative approach; this involves changing the way you bite together. If you have worn your teeth down your bite may need to be opened up to allow space for crowns and bridges. The way you move your teeth across each other as you chew may also need changing. We call this ‘guidance’ and by adjusting it we can help to protect the remaining teeth more effectively, allowing forces of eating to be more evenly distributed. It may also help relieve the symptoms of TMJ.

• Your level of oral hygiene
  

If your plaque control is poor, anything placed in your mouth will make cleaning even more difficult, so it is vital to get this under control first, otherwise you may end up in a worse situationthan the one that you started with.

• Your habits

Grindingplaces undue extra stress on teeth and often leads to increased wear and more frequent broken restorations. Getting this under control with a suitable night guard is essential.
Smoking will affect the success of implant placement and can cause a worsening of gum disease that may in turn affect other supporting teeth.

• The Dentist

(i) The dentist’s level of skill and training
The dentist’s preference and level experience regarding the various treatments.

(ii) Cost
Don’t be afraid to ask questions! As dentists we want to do what is right for you and for you to be happy- this involves a two- way conversation. It is our job to answer your questions and concerns and give you sound appropriate reasons why something ‘is’ or ‘is not’ advisable; or indeed possible.