Q: I am hoping you can give me some sound advice about dental treatment. I have been told that the slight pain I have when eating is caused by a root fracture (I had an X-ray taken). I am in my early 70’s and have no dental coverage so don’t want to do something unnecessary but, on the other hand, I don’t want to be foolish about dentistry needs either. What is likely to happen with that tooth which has no fillings in it?

P.S. I recently heard you speak at the Wenham Council on Aging; otherwise I would not have known of the amazing help you offer.

A: I am so glad that you enjoyed my dental discussion with your Wenham group. As you now understand, my entire emphasis is to educate the public regarding the field of dentistry so that each of you can become better consumers.

Regarding your question, I will say first that most of us in our 70’s do not have dental insurance and even if we did, we should never let that impact any decision regarding proposed dental treatment. One of the most heinous statements I hear from patients is when a dentist refers to the presence of dental insurance as a reason to consider treatment. Nothing else disgusts me as much. Dentistry is a health profession and as so ascribes to a very high level of ethics. It is most unethical of a dentist or any health professional to recommend treatment for any reason other than to eliminate the presence of, or prevention of disease.

In your case, the dentist has told you that you have a root fracture and that this diagnosis is based on an X-ray. Assuming the diagnosis is correct, you should be able to see this fracture clearly. If you have seen this and are comfortable that it is a fact, then the following should be considered.

You state that you have only slight pain when eating. This may be because you are avoiding that tooth when you chew or that your pain threshold is rather high. I say this because a root fracture that is clearly seen on an X-ray would usually cause significant pain and would most likely linger for minutes after. If this is the case, then I would tell you to not delay treatment very much longer as you are in danger of biting and causing the fracture to promote a very significant toothache. If this occurs at a time when you can not easily obtain treatment, you will suffer significantly. A root fracture is not repairable and the only treatment is extraction of that tooth or root. If it is a multirooted tooth, it is possible to salvage part of the tooth and continue to function without pain but you would still have to exercise great care in terms of biting pressure. If the entire tooth needs to be extracted, then the question becomes one of whether replacement is necessary. Contrary to what I often hear told to patients, it is possible to function without a full complement of teeth. I am saying that not every extracted tooth needs to be replaced. Many factors needs to be considered such as age, esthetics, finances, what affect it may have on other teeth, etc. All of this should be discussed with you or any patient prior to the extraction of any tooth.

I am somewhat suspicious of whether there is indeed a root fracture since you say you were told that this was the case but do not speak at all of whether this was shown to you as I suggest above.

If this supposed root fracture is difficult to see on a conventional X-ray, and that is often the case if the fracture is slight, then your dentist should suggest your having another film taken with a cone-beam technique. This is very new in dental radiography and has the advantage of being able to see much more than a conventional film. The conventional film is a two-dimensional picture of a three-dimensional situation. The newer technique is like the CT scan often needed in medicine as well. This degree of sophistication is not always needed so I feel that a conventional film should be done first, as was done with you, and if a diagnosis can not be made for certain, then the next level of a cone-beam film would be indicated. The conventional film is less expensive and exposes the patient to less radiation. That radiation will dissipate very soon so as long as it is not done repetitively at close intervals, it is not harmful.

Suffice it to say that a root fracture is a serious diagnosis and the treatment of such should be taken very seriously. You mention that there are no fillings in this tooth but that fact impacts a fracture of the crown of the tooth (the part you see) much more than the root.

I appreciate your confidence in me and hope that any others of you out there that need help with decision making in dentistry will also reach out.

Dr. Richard Greenberg of Ipswich practiced dentistry for 45 years after having attended dental school at Columbia University, where he was later an associate clinical professor of restorative dentistry and facilitator of the course of ethics. Do you have a dental question or comment about the column? Email him at dr.richard@nothingbutthetooth.org.