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Medical Forum / General / Dentistry / January 2005Help--Should I get a crown?
About 8 weeks ago I had a root canal on a lower molar (the last one on the left, #18). Ever since, the tooth has a small sensitivity to touch--not exactly pain but not pleasant. Slight touch does it, such as with a soft tooth brush, or pressure from food that gets chewed on the reduced tooth. My periodontist examined the tooth last week and found: a deep pocket on the back surface, a small crack on the same surface. His X-ray didn't show it, but he still wondered whether there was a hidden root that wasn't removed. My general dentist wants to put a permanent, metal crown on the tooth right away. His argument is that the temporary filling that the endodontist applied is mostly gone, and that the crown will strengthen the tooth. If the tooth fractures while we wait for the tooth to feel better we have lost the tooth. My question is, why put in the crown when each bite will produce discomfort, if not real pain? The tooth hasn't gotten less sensitive in 2 months; why expect it to feel better any time soon? Any suggestions about other treatments that will safeguard the tooth while we see if it resolves? Or, is getting a crown the best step now? Thanks in advance for your help. A crack in your tooth will give you the symptoms you describe. When you bite down, the tooth seperates the adjoining pieces of tooth on either side of the crack. A crown will hold the pieces together and therefore not allow the flexion about the crack and thus, the pain you feel. On the other hand any residual pulpal tissues remaining in the tooth may be feeding some infection around the root tip and this could be the source of your pain too. Or, a combination of the two........ I would make a crown and seat it with temporary cement. Give it a month or so and see how it is going.If it is still giving you pain to biting then I'd take off the temporarily seated crown (not drill a hole through the top) and reinstrument the root canals and search for a second distal canal. Then reseat the crown temporarily. Also have the tooth thoroughly cleaned to eliminate the periodontium as the culprit of any pain you are feeling. A round of antibiotics may help here too. If after all that you still have pain on biting, then YOU must decide is it worth it to keep the tooth? If it is very minor then you may decide to keep the tooth and put up with it. If it bothers you enough then you can have it extracted. Ultimately the success of a root canal is determined by the patient keeping the tooth. It may never be 100% pain free and feel completely normal. Some teeth just don't respond to root canal therapy that way. Most do though, and feel absolutely, completely normal. Best wishes- > About 8 weeks ago I had a root canal on a lower molar (the last one on > the left, #18). Ever since, the tooth has a small sensitivity to [quoted text clipped - 20 lines] > while we see if it resolves? Or, is getting a crown the best step now? > Thanks in advance for your help. I agree with The Real Paul in everything he said. I would hold off sending any impressions to the lab until the symptoms disappear (I would remove the temporary filling, check for cracks and missed canals and make a composite core, then make you a temporary crown for the tooth to use for a few weeks). Good luck Dr. Jorge Bonilla Just to provide a different point of view..................I would not place a composite core. I would remove all filling material, and left over caries, lightly abrade any stain, then magnify about 10X on the monitor. This is the best way to look for cracks and missed canals.  Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > > I agree with The Real Paul in everything he said. I would hold off [quoted text clipped - 4 lines] > Good luck > Dr. Jorge Bonilla >Just to provide a different point of view..................I would not place >a composite core. I would remove all filling material, and left over >caries, lightly abrade any stain, then magnify about 10X on the monitor. >This is the best way to look for cracks and missed canals. Or you could just use your eyes. <hehe> -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE It should be pain-free before placing the final crown on it. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > About 8 weeks ago I had a root canal on a lower molar (the last one on > the left, #18). Ever since, the tooth has a small sensitivity to [quoted text clipped - 20 lines] > while we see if it resolves? Or, is getting a crown the best step now? > Thanks in advance for your help. I agree. A bonded composite build up that covers the cusps could be placed (and should be done before a crown anyway, IMO). This would take care of any worries about the temporary filling and 'buy' enough time to see if the pain will go away and the gums get healthy before investing in a crown. Fawks > It should be pain-free before placing the final crown on it. Even a fast SSC Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > > I agree. [quoted text clipped - 7 lines] > >> It should be pain-free before placing the final crown on it. >Even a fast SSC How do you do a slow one ? -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE You have watched me do the first few. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>Even a fast SSC [quoted text clipped - 6 lines] > wubbabubbazG@RBAGEyahoo.com > Take out the G'RBAGE >You have watched me do the first few. Heck, was thinking that you put Cerecs on the kiddies. -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE I have a patient's father that wants me to. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>You have watched me do the first few. [quoted text clipped - 6 lines] > wubbabubbazG@RBAGEyahoo.com > Take out the G'RBAGE >I have a patient's father that wants me to. I say go ahead. Don't forget to document. -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE >It should be pain-free before placing the final crown on it. We agree. Joel >>It should be pain-free before placing the final crown on it. > > We agree. > > Joel if the tooth is non vital, then why does cracked cusp cause pain? thanks >>>It should be pain-free before placing the final crown on it. >> [quoted text clipped - 5 lines] > >thanks Teeth have two sources of innervation. Internal = pulp External = periodontal ligament. -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE >>>It should be pain-free before placing the final crown on it. >> [quoted text clipped - 5 lines] > >thanks The cracked cusp may extend deep below the gum tissue ....... there are oodles of nerve fibers in bone and penetrating periodontium. But in general, you have expressed a valid point. Joel I've got to say that the logic of how the crack is so exquisitively sensitive worried me too. Just rubbing the tip of my finger across the top of the "crater" with _very_ light pressure produces sensation. I hope that the cause(s)-- and solution(s)-- will be clearer after Friday, when I'm getting a second opinion. Went for second opinion visit Thursday. Dentist used a high-powered microscope (displayed on a screen and printed out) to get a better look at the problem tooth. It showed one area that had been patched (amalgam) on the back surface of the tooth and a small hairline crack on the side of the tooth. This dentist proposed putting in a gold crown, but warned that it is not certain that the tooth will be saved in the long run. He didn't see any evidence in the x-ray that there was a hidden untreated root. Now here's another problem. This dentist has an excellent reputation as judged by a local consumer magazine and a report on dentists that other dentists recommend. He seems top-notch to me as well. However he will cost hundreds more than my regular dentist--who also seems OK, but not with anything like this guy's reputation. And, I think this dentist wants to use a porcelan crown. Is there much of a difference in these treatments? Is the gold crown a better approach with a tooth with one real and one minor crack? I know you don't know these dentists, but, in general, what hints can you give about making this sort of choice? Thanks, again, for your help. > Is there much of a difference in these treatments? Is the gold crown a > better approach with a tooth with one real and one minor crack? I know > you don't know these dentists, but, in general, what hints can you give > about making this sort of choice? Just for information, ask the two dentists if they will give you any warranty on their work. Provided you keep it clean and agree to get routine cleanings as needed, and wear an NTI (anti-clenching device that clips onto your front teeth, for sleeping) I don't see why the crown shouldn't last. You need the NTI, as the tooth is cracked. The crown will repair this RESULT, but it won't attack the CAUSE of the crack ( clenching/grinding of teeth, primarily at night). Note that it is rarely eating that cracks teeth; it is uncontrolled forces at night that cracks teeth. If this is a back tooth (molar) and there is evidence of a crack, I personally would want to go with an all-gold crown. The maliability of gold coupled with its resiliance and its lack of scratching of the opposite tooth makes it a better treatment, in my mind. I know there are lots of dentists who routinely treat molars with the newer porcelain crowns with the zirconium jacket inside, and they are probably as strong as gold, but gold will act as a _shock absorber_ as it tends to bend and deform under pressure, and it will bounce back again. Porcelains are getting better all the time, but they still cannot match gold for this. Thus, in conclusion, I personally would still recommend gold for the crown. Hope this helps. SP SignatureNot a real Addy, yet StovePipe- Thanks for your comments. Gold does seem to have the most valuable characteristics for this tooth. Did I say that this is #18, so appearance is not important? Also, I should have mentioned that the opposing upper teeth are a partial denture, so nighttime clenching hasn't occurred for over 20 years. However, I think I do a certain amount of daytime clenching and tapping, so your guess about the source of the crack may be right on. If I get the crown I'll have to break myself of that awful habit. Then you're probably clenching during certain stages of sleep also. You might want an NTI to stop that <G>. There is no reason your regular dentist can't make a gold crown for if you just ask. JMO, Fawks However, I think I do a certain amount of daytime clenching and > tapping, so your guess about the source of the crack may be right on. > If I get the crown I'll have to break myself of that awful habit. Interestingly, my "regular" dentist didn't want to use an all-gold crown because he said the tooth preparation was different and more of the tooth would have to be removed to fit it. (The tooth had a metal+gold crown on it before the root canal.) He said it would be easier to use the same type of crown again. I'm going for another 2nd opinion tomorrow and I'll be raising the issues of type of crown as well as getting the crack(s) thoroughly analyzed before any additional work is done. I want to save the tooth, of course, but I want to avod installing and paying for a crown if the tooth is going to fail soon anyway. I'll keep you posted on the diagnosis. > Interestingly, my "regular" dentist didn't want to use an all-gold > crown because he said the tooth preparation was different and more of > the tooth would have to be removed to fit it. (The tooth had a > metal+gold crown on it before the root canal.) He said it would be > easier to use the same type of crown again. That is not correct. If anything, an all-gold crown will require less reduction of tooth structure, not more. But if the tooth was properly prepared for the previous porcelain/metal crown, not much additional reduction should be necessary in any case, with the possible exception of the marginal area. Steve > I'm going for another 2nd opinion tomorrow and I'll be raising the > issues of type of crown as well as getting the crack(s) thoroughly > analyzed before any additional work is done. I want to save the tooth, > of course, but I want to avod installing and paying for a crown if the > tooth is going to fail soon anyway. > I'll keep you posted on the diagnosis. SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 > > Interestingly, my "regular" dentist didn't want to use an all-gold > > crown because he said the tooth preparation was different and more of [quoted text clipped - 9 lines] > > Steve I agree... One should be able to place an all-gold crown with LESS preparation (reduction of tooth structure) than with a porcelain fused to metal crown: it's thinner, so less tooth has to be filed away. I don't see why your dentist would say that, but maybe there is something we're not seeing here... Cheers SP SignatureNot a real Addy, yet >> > Interestingly, my "regular" dentist didn't want to use an all-gold >> > crown because he said the tooth preparation was different and more of [quoted text clipped - 17 lines] >Cheers >SP Even less preparation to place a bonded porcelain onlay, .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. I have not been asked to place a band prior to crowning a tooth with a suspected fracture in years. Q. If you do it your self: just jam it on place separators reduce the M & D prior to placing it? carabelli > I have not been asked to place a band prior to crowning a tooth with a > suspected fracture in years. [quoted text clipped - 8 lines] > > carabelli If'n ya don't mind my asking: what do you mean by separators? Do you mean matrix bands on the adjacent teeth so they don't get bonded to the band? And while we're on this subject: can you not use plain old copper bands in place of the ortho bands? I have a ton of those things here. If I ever had a fractured tooth case, I'd have a reflex reaction to try those. Thanks SP SignatureNot a real Addy, yet "StovePipe" <StovesNewAddy@sympatico.DOTnet> wrote ......... > If'n ya don't mind my asking: what do you mean by separators? ..... an elastic encircling proximal contacts to open space mesial and distal to a tooth - movement is usually adequate in about 7 days. carabelli > "StovePipe" <StovesNewAddy@sympatico.DOTnet> wrote ......... > [quoted text clipped - 4 lines] > > carabelli Got it, thanks SP SignatureNot a real Addy, yet Thanks, Steve, for your comments here and on the other thread. The continuing story.... Yesterday I went to my general dentist--or should I say, to two dentists. My dentist confirmed that there was a crack in the lower molar, but neither an x-ray picture, the magnifying imager, or dental explorer could determine exactly how deep the crack was. (It is on the back surface of the tooth.) He called for a second opinion (actually the 4th, including where this started and all the dentists who have seen it), from a periodontist colleague. The latter confirmed the problem, and the uncertainty of just how bad the crack was. They came up with the following treatment plan. The tooth will be prepared for a porcelain and gold crown, but for now a precision-fit temporary will be put in place. We will carry on with that for 2-3 months to see how the tooth behaves--especially what happens when it again takes part in chewing. (Remember, the tooth was reduced when the root canal was performed, so it's been out of action for 8 weeks now.) In addition, we'll see whether the sensation (I don't want to call it pain at this point) gets better or worse. After that, if things are OK, the permanent crown will be installed--but shaped so it's not quite as high in my mouth, and will therefore get less force in chewing. In terms of what has been discussed before, he argued that the added weight of the gold crown, and the smaller amount of remaining tooth to hold it, were factors that argued for the porcelain-gold crown. (He would do either--the final choice being up to me--but the porcelain-gold appeared better for this tooth.) The decision to wait before the permanent crown is installed was largely not to waste money on a procedure that turns out unsatisfactorily in 3 or 4 months. I was told that the temporary will strengthen the tooth enough for now, and in any case, would be put in while waiting for the lab to make the permanent crown. The only difference is that we'll keep the temporary a bit longer than usual. How does all this sound? Fred > Thanks, Steve, for your comments here and on the other thread. > [quoted text clipped - 35 lines] > > Fred Sounds about right. Obviously this tooth is a question mark, but this is the best you can do. After a couple of months, it should be considerably clearer how serious the fracture is. Good luck, Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 Steve-- Thanks again for your comments, help, and encouragement. Fred >Thanks, Steve, for your comments here and on the other thread. > [quoted text clipped - 35 lines] > >Fred Everything sounds fine except for the BS about weight. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. > >How does all this sound? > > [quoted text clipped - 6 lines] > > I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. I agree.... I'd still opt for an all-gold crown for the added resiliancy that gold can furnish. SP SignatureNot a real Addy, yet Cracked tooth .......... parafunction .............. new crown . . . . . . . . . , , , , , , ,, S N A P !!! Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> >How does all this sound? [quoted text clipped - 12 lines] > that gold can furnish. > SP > Cracked tooth .......... parafunction .............. new crown . . . . > . . . . . , , , , , , ,, S N A P !!! Cracked tooth .......... parafunction .............. new crown . . . .NTI . . . . . , , , , , , ,, NO S N A P !!! Providing he/she wears it... And they must... parafunction is why the tooth is crackde in the first place.... SP SignatureNot a real Addy, yet >> Cracked tooth .......... parafunction .............. new crown . . . . >> . . . . . , , , , , , ,, S N A P !!! [quoted text clipped - 5 lines] >tooth is crackde in the first place.... >SP Think fusible link. If an all porcelain crown is over-stressed, the porcelain will chip and require polishing, repair or replacement. Over-stressing a gold crown will break it off at the CEJ, and require RCT and post, or extraction. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. I'm going in for the prep and temporary crown tomorrow, as previously discussed. But I don't understand some of the terms in the following paradigm. Please explain. Cracked tooth .......... parafunction .............. new crown . . . .NTI . . . . . , , , , , , ,, NO S N A P >I'm going in for the prep and temporary crown tomorrow, as previously >discussed. But I don't understand some of the terms in the following >paradigm. Please explain. > >Cracked tooth .......... parafunction .............. new crown . . >. .NTI . . . . . , , , , , , ,, NO S N A P Try this. A cracked tooth probably is a cracked tooth because the patient has parafunctional habit. If the parafunctional habits are not interrupted, the new crown results in the tooth breaking off at the gum-line. If the patient makes a commitment to wear an NTI every night, and perhaps during some of the day time hours, the tooth would probably not break off. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. > >I'm going in for the prep and temporary crown tomorrow, as previously > >discussed. But I don't understand some of the terms in the following [quoted text clipped - 14 lines] > > I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. Check it out at www.nti-tss.com SP SignatureNot a real Addy, yet I want to thank all of you for your discussion and advice. I had an appointment for the crown that I have now cancelled, and another dentist is going to examine the situation and give a second opinion after examining all the circumstances (and the tooth!). I'll let you know what happens. |
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