Patient presents with deep cavity (April 2011)

This patient presented to my office with a “hole in his tooth”.  The tooth was not painful except when cold water or food touched the tooth.  I took an x-ray of the tooth and tested it for vitality.  The x-ray shows a very large cavity that is close to the nerve.  The blue outlines the cavity and the red outlines the nerve.

It was important for me to test the “vitality” of the tooth.  To do this I placed a ice cold cotton swab on the tooth.  One of four things will happen:

1. Patient feels cold (Normal).  Treatment: Filling
2. Patient feels more cold then normal and or pain. (inflamed, pulpitis, possibly reversible).  Treatment: Filling +/- medicated liner
3. Patient feels extreme cold and or pain and it lingers afterwards (Inflamed, pulpitis, non reversible).  Treatment: root canal.
4. Patient feels nothing.  No cold.  No Pain.  Tooth is already dead (necrotic).  Treatment: root canal

For this patient it was scenario one.  It was a deeper filling so I would still place a mediated cavity liner to be on the safe side. The patient declined treatment and said he would have tooth fixed at a future date.  I advised against this.

Patient returns to office with swelling (December 2011)

The patient presented approximately 7-8 months later with swelling and pain around the same tooth.  To the left is the new xray taken.  Can you see the difference?

The bacteria travels from the mouth into the cavity (hole) and now into the nerve and down the root of the tooth.  You can see a shadow on the bottom of the root, this is an infection starting.  The bacterial infection eats away at the bone and eventually spreads and will form an abscess.  There are only two options for this tooth:

1. Root canal and eventually a crown
2. Extraction and either a bridge, denture or implant if he chooses to replace tooth

Treatment

The patient decided that he wanted to save the tooth.  The x-ray on the right shows the tooth immediately after root canal treatment.  We will bring the patient back in a month to assess healing and at that appointment we may build it up.  Within 6 months I recommend that the patient crown the tooth to protect it from cracking or chipping.

Conclusion

This post was to illustrate what can happen if cavities are left untreated.  A simple filling has now turned into an infection, root canal, build up, and eventually crown. The prognosis of a filling is much better then that of a root canal and filling.