Replace filling or just go with a crown?

[VallartaLad]

Should I replace an old large filling on #18, or replace it with a crown?

Have attached Xray images (along with neighbor #19, which had an AstraTech implant and zirconia crown put in this past winter and spring). The symptoms improved but didn't go away. I still get some occasional (and rarely severe/long-lasting) pain in my lower left when eating something chewy, cold or sweet. My newly acquired general dentist, who installed the #19 crown, thinks #18 could be at issue now. Its old filling may have a small leak or perhaps there is a small crack which isn't yet too significant.

He says I could:
a) Go to endodontist; have an eval and probably a root canal, and then come back for a crown.
b) Skip (a) for now. Just have the general dentist put in a crown. That might trigger the need for a root canal but odds are it would not. It might stop the symptoms for good. If later it needs a root canal, just drill through the zirconia crown and patch it. (Is it that easy with solid zirconia, which I know can be quite hard?).
He didn't mention a 3rd option of just replacing the old filling with a new one and I didn't think to ask. But I thought I'd ask on this forum as a possible 3rd option. That seems the most conservative route certainly.

Any thoughts?

 

[Dr M]

Good day

Replacing the filling with another filling, or even perhaps an amalgam filling, might be a good option to consider as a first option. It does look like there might be some micro-leakage mesially, which could lead to sensitivity. Crown placement is more destructive, so I would consider this only after replacing the filling. I would not consider root canal treatment at this stage, unless you start experiencing more severe symptoms.
Also make sure to check the occlusion on the tooth, after replacing the filling.

 

[VallartaLad]

Thanks hugely! I guess this replacement filling would also be called an onlay filling then? (or inlay?).

You mentioned amalgam. But is there any reason NOT to request composite material? I know it doesn't have the longevity of amalgam. I'm in my mid 60s if that helps answer this. Should I perhaps be concerned that my dentist may have a tougher time keeping the area dry so it can bond, and layering the composite in an ideal way?

 

[Dr M]

Moisture contamination is one of the main risk factors, which influences the bonding of the resin composite to the underlying enamel and dentine. Any poor areas of bonding might lead to micro leakage and sensitivity. With any composite material, it is critical to keep the area dry, with a rubberdam and suction.
Amalgam on the other hand is a lot less moisture sensitive.

 

[VallartaLad]

Got it! Thanks!

If I do go for a crown after chatting with the dentist, I think I'd choose a full cast gold alloy (highly noble).

Since this needs less tooth reduction than other crown types, this should reduce the chances that I'd trigger a need for a root canal. Plus I suspect the crown's core integrity will stand up well, if I do ultimately need a root canal and the endodontist drills a hole thru the crown. And I don't mind the esthetics that far back in my mouth.

So my last question: Are most dentists willing to provide a pretreatment estimate for the cost of a gold crown up front? Or does the variable price of gold and the inability to predict how much gold is needed until the impressions are taken, just make this simply impossible to estimate?

Might PFM with metal (i.e. gold) occlusal be a good 2nd choice?

Thanks!