This post is not intended to teach you to diagnose your own mouth or to give you the ability to call out your dentist when he tells you you have a cavity. What this will tell you is what might be going through your dentist's mind when he looks at your x-rays. That way when you go to the dentist, you have a better idea of what's going on. First and foremost remember that every dentist is different, just like every doctor, teacher, and engineer is different. Many have different philosophies and approaches to dentistry.

Some dentists are very aggressive about treating anything that looks like it could be decay. There is such thing as a dentist who is too aggressive. Every dark stain and spot in the mouth doesn't need a filling. Every time you cut away tooth, you are creating a filling that will eventually need to be redone in anywhere from 2-30 years. You always hope that a filling will last a long time, and sometimes they do. I've had my silver fillings for over 20 years. But newer white fillings don't usually last as long because the material isn't as good. You can hope to get 10 years out of them, but with poor hygiene I've seen them need replacement in less than 3 years.

Some dentists are very conservative, and would rather watch most suspicious things rather than picking up a drill. There is also such a thing as being too conservative. The longer you watch a tooth that needs treatment, the larger the decay grows. Decay in your mouth doesn't just mean one tooth has a cavity. It means that your entire mouth has a higher number of the bacteria that create decay, and that you are at high risk for more cavities. The longer you let that sit there, the more the bacteria flourish.

When you visit a dentist for the first time, he legally must take enough x-rays to be able to diagnose your whole mouth. A full mouth series. Usually that's 4 bitewings and several more periapical x-rays, and usually a panoramic x-ray to diagnose any potential jaw issues. When you return for your next routine check up, there will less x-rays. The bitewings are used to diagnose decay between your teeth. A healthy tooth has an uninterrupted white shell around the outside, whereas an unhealthy tooth may have a small to large black triangle pointing toward (or extending into) the middle gray layer. On the periapical and panoramic x-rays, they are looking for signs of infection or lesions in the bone that should not be there.

Healthy bitewing:



Small cavity:



Large cavity:



You need a root canal:



The dentist is looking for spots that are growing in the enamel (the outer white shell) and are approaching or into the dentin (the middle gray layer). Typically, a conservative dentist will not treat decay unless it is through the enamel and at or into the dentin. However, if you are a patient with several other cavities, the dentist may make the decision to treat other smaller spots now rather than wait until they are through the enamel and to the dentin. Why? Because he knows you are high risk for more cavities. If the decay goes through dentin and into or near the pulp (the central black area that extends down the roots) you may need root canal therapy. You should always ask your dentist to show you the cavities he sees on the x-rays. Hopefully he does this without your asking. If you don't see what your dentist sees, tell him and ask him to enlarge the picture or make it clearer.

With adults, the treatments for a small cavity are pretty simple: a filling, silver or white. When they are larger the options become less clear. You may consider a crown, an onlay or inlay, or a large filling. It depends on the patient's budget, the philosophy of the dentist, and what esthetics are important to you and him. Still, any good dentist will work with any budgetary concerns you have to get you the best treatment for what you can afford.

If you are taking your child in for treatment, the options are more dependent on the age and behavior of the patient. In my office, if the patient is 6 or under and has decay in between the teeth (usually caused by diet), we recommend stainless steel crowns. When properly placed, the crowns will protect the entire tooth for its life until the tooth falls out. White fillings don't work as well, can fall out, and the tooth can still be exposed to decay since it is not fully covered. After the age of six, we consider white fillings more, though we still ask ourselves the following questions: How bad is the decay? How many surfaces of the teeth are decayed? Does the tooth already have a white filling? All those things and more go into consideration. Many parents don't like the esthetics of a silver crown, so my office only puts them on back teeth. On front teeth, we only do white crowns called strip crowns. For those with more money to spend, white zirconia crowns are an option for back and front teeth. However, they must be placed very very carefully to avoid them falling off down the road. If the tooth is going to exfoliate soon (within a year), we may consider not treating the tooth.

Other considerations include whether the dentist just met you and doesn't know how regularly you'll return for routine care and exams. He may be more aggressive in treatment. Or if you are a regular patient, he may be more conservative and willing to watch the small cavity. He will also consider your socio-economic status, knowing that certain statuses are higher risk than others. He will also consider your insurance, knowing that some families don't always qualify for Medicaid-type insurances and so if he doesn't treat your decay now, you may not get treatment in six months or a year. Often, a simple thing you can do is ask "Does it need treatment right now, or can we watch it until next time?" That may make the dentist more willing to watch it. However, if he says, "No, I think it needs treatment now," you should probably follow his recommendation.

If a tooth is ignored due to a parent's refusal to treat for a variety of reasons, it may eventually need to be removed. The space between the remaining adjacent teeth begins to close and the child loses room for his or her adult teeth. They may come in crowded, needing more orthodontic (braces) work to correct the issue. In some cases, the problems may be irreversible and lead to the extraction of adult teeth to make room for the child to have an esthetic smile. You may say to yourself, "Well, my child had a small mouth." The dentist will agree while thinking, "Yes, and you caused it." A pediatric dentist will likely have more training in determining early intervention with children who will need orthodontic care. Under the pediatric dentist's care, your experience with orthodontics will hopefully be easier and simpler. However, general dentists can have very good training as well and their opinions and treatment options should not be discarded, especially if their career has focused more on child care. Like with anything in life, the more you do something the better you become at it.

Your child's behavior is also an important consideration for a dentist. He may recommend some level of sedation based on the age, attitude, and anxiety level of your child. While some tragic accidents to occur (and usually make big news), anesthesia is generally very safe at multiple levels. An older child may only need nitrous gas to help them remain calm. A smaller child may need oral or conscious sedation to help manage their anxiety. And some children, and teens, may need deeper sedation either through IV or general anesthesia at a hospital to complete all their treatment. A good dentist will recommend what he thinks is best and usually the least amount of anesthesia to accomplish all treatment in one visit on a small child, and a quarter to half of all treatment on an older child, teen, or adult who needs a lot of treatment. However, if a parent insists on less sedation, a good dentist will usually try to accommodate. However, he may trust his experience with such matters and either refuse to treat a child with less sedation (and recommend you try elsewhere) or politely encourage you to trust him on his recommendation, with a good explanation as to why.

There are some signs that your dentist is trying to make a buck: If you recently moved or switched dentists, and you suddenly have a high uptick in cavities on your first visit, you should seek a second opinion. If your dentist tries to tack on other purchases like marked up toothbrushes and toothpastes (or copies of his book) that he conveniently offers in office. If he insists on replacing old fillings just because they are metal; if he pressures you into making a decision immediately; if he seems to only offer crowns, veneers, or onlays and inlays. If you dentist has recently converted to a new religion, and is always getting redressed after you wake up. These are all signs that you may want to consider a second opinion. Most dentists who give you a second opinion will do so at a minimal charge, though he may (rightly) insist that he take his own x rays rather than using the ones you brought. If you are constantly having issues with treatment like post-treatment pain or sensitivity. If the work your dentist does consistently needs to be replaced after a few years, those are all signs you may want to try a new dentist.

I hope this helps. Please feel free to ask questions. I hope this helps.

Edit: Dentistry in Utah is a whole other ballgame. Because so many dentists are willing to work at reduced rates, insurances pay 40-60% of the average rates for procedures. That means many dentists in Utah make less than the national average. And dentistry in Utah is cut-throat. Group-ons, mailers, billboard ads, and promotions are the norm here more than anywhere else. A dentist may over-conservatively diagnose you to get you to come back (because your last dentist said you had 4 cavities.) A dentist may aggressively diagnose you because he's desperate to make the money. However, the same principles apply. Go with recommended dentists that people who you trust also trust. Don't go somewhere just because they have a deal for a free cleaning and toothbrush and whitening on your first visit. Don't hop around from deal to deal every six months. You want a dentist who knows you and who can give you care from year to year if possible. Stay away from corporations who have offices in every town. Their dentists are far more likely to be production oriented, not patient oriented. Again, these are all guidelines, not hard rules.