Removal/implant? bridge? or DME/root canal/crown?

[lcherteeth]

dear dentists. I am 38 yo F, healthy lifestyle, brush 2x a day, floss 1 x a day, sometimes ACT flouride mouthwash, normal cbc / cmp / vit d / tsh .
In Nov 2020 tooth 14 cracked spontaneously and because of the pandemic the dentist did a temporary filling but said eventually a root canal was needed. feb 2022 tooth 14 underwent root canal and a filling with zirconia. I do not know why a crown was not placed. a few months later the filling seemed loose and it was re-done. Dec 2024 while eating a soft piece of bread, the tooth and filling broke (attaching xray) which shows the root canal wasnt done well and temporary fill was placed. I was given these 3 options for tooth 14:
1) DME + root canal re treatment + screw and crown
2) surgical removal of tooth and titanium implant
3) the teeth adjacent to the broken one apparently need crowns anyway (see attached xrays), so a bridge with a floating crown was offered.

Q1: what is my best option in the long run of those 3 options? Since I am only 38 I dont want to have more surgeries on this tooth over and over in the next few years. I am doubtful that a tooth with so much damage and root canal could actually last me a few more decades, and my online search indicates a titanium implant has the most durability but the dentist says "if it was me I would try to keep my tooth." I thought root canal treated teeth were quite fragile.
Q2: I was told that teeth 4, 20, 13 and 15 also need crowns (15 is deep and may also need root canal). Do they all look like they need crowns? I was offered porcelain/ceramic in one place, but zirconia in another, and another dentist said he doesn't recommend crowns because that requires removing too much of my normal tooth. Which is best longer term?
Q3: why are my teeth so bad? is it true Dental Sealant can only be offered to virgin teeth with no restorations? what about Rx strength flouride tooth paste? is there some mouthwash I can use to help prevent further problems? what should i change in frequency or quality of how I brush and floss? use a water pik? I am so confused why my teeth always have new cavities. i'm a physician and cant think of any other labs to check on myself regarding teeth.
Q4: lastly and likely least important, i was offered laser gum restoration and told this will make my teeth less prone to cavities. i dont see anything wrong with my gums and they dont bleed when i floss at home. do i need this?
the overall quote is $12,000 so of course I want to make the right decision. thank you very much for your assistance.

 

[Dr Sunali dental Solution]

The best choice among these options depends on various factors including:

1. The extent of damage to Tooth 14
2. The condition of surrounding teeth
3. Your personal preferences regarding dental work

If Tooth 14 has enough structure left after re-treatment, Option 1 (DME + Root Canal Re-treatment + Screw and Crown) might be ideal as it preserves your natural tooth. However, if extraction seems inevitable due to poor prognosis or extensive damage, Option 2 (Surgical Removal + Titanium Implant) could provide a durable alternative. If you are concerned about preserving adjacent teeth while still addressing functional needs, Option 3 (Bridge with Floating Crown) may also be viable.

Answer to your 1st question
The best long-term option appears to be surgical removal followed by placement of a titanium implant. This option minimizes future interventions on Tooth 14 and provides a durable solution that aligns with your desire for longevity.

Answer to 2nd question
Between porcelain/ceramic and zirconia crowns, zirconia crowns generally offer better long-term durability, especially in areas subject to high bite forces.
Ultimately, discussing these concerns with your dentist will help clarify which approach best suits your specific dental needs while considering both aesthetics and functionality.

Answer to 3rd question

1. High sugar intake and acidic foods can contribute to tooth decay. Sugars feed the bacteria in your mouth, leading to plaque formation and cavities.
2. Inadequate brushing and flossing can allow plaque to harden into tartar, which can lead to gum disease and cavities
3. Saliva helps neutralize acids produced by bacteria in the mouth. Conditions that reduce saliva production (like certain medications or medical conditions) can increase cavity risk
4. fluoride toothpaste contains higher concentrations of fluoride than over-the-counter options and is designed for individuals at higher risk for cavities. Using this type of toothpaste can help strengthen enamel and reduce the incidence of cavities.
5. There are mouthwashes available that contain fluoride or antibacterial agents like chlorhexidine that can help reduce plaque buildup and prevent cavities
6. Floss daily to remove food particles and plaque from between teeth where toothbrushes cannot reach.

Answer to 4th question
if you do not experience symptoms such as bleeding gums or inflammation during flossing, it may not be necessary for you at this time. The decision should be based on a thorough evaluation by a dental professional who understands your complete oral health history.
the significant cost associated with laser gum restoration ($12,000), it is crucial to weigh its necessity against other preventive measures that might be more appropriate given your current gum health status.