I'm completely confused by this, unable to make anything I've read on
the internet really fit.
Lower left molar with large filling and a cusp fracture dating back a
few years, had no money to repair it due to other medical expenses.
(Not mine.) Finally became infected (or clinically evident infection)
about 6 weeks ago. X-rays showed deep decay, but both the dentist and
endo agreed it could be saved.
Pre-RCT pain was exquisite when trying to sleep, and could be
periodically inflamed during the day by anything from cold or hot drink
to certain mouth movements that created suction. Tooth was sensitive
simply to light touch at some times.
Five weeks ago - endodontic appointment with a local group of
endodontists, supposedly the best in the city. Had trouble getting the
tooth numb, took quite a bit of time and anesthetic and trial and error
with pain. Endo said it was "hot." Once it was fully numbed, the
procedure seemed to go well. Endo has all the latest gadgets,
microscope, rotary drill, etc. Placed a post and did a build-up for
the crown. Post-RCT pain was minimal except for tenderness to contact
on the buildup.
Crown was placed two days later. Tooth was still tender, but nothing
too bad. Did a bite test that seemed largely okay.
After several days of staying off of the crown, I noticed when eating
(by accident) that I was able to chew on it.
I soon after, however, noticed that any jiggling movement elicits a
feeling of tenderness, almost soreness. This happens if I attempt to
"wiggle" the tooth, or with percussion, or sometimes when chewing if
the food pushes laterally on the tooth.
I can actually chew (straight up and down chewing force) with no
discomfort at all.
There is no pain upon releasing bite pressure. (Which I understand is
the hallmark of a fracture.)
The tooth does not hurt on its own. It is not sensitive to heat or
cold or palpation.
The tooth does not feel loose, does not wiggle that I can tell. It
feels pretty solid.
The tenderness varies throughout the day. Sometimes it gets bad enough
that the force of my tongue brushing it can elicit a sensation of
tenderness. Not shooting or stabbing pain, not even pain, just clear
tenderness. It has only gotten this bad after a lot of chewing on that
side one day of some pizza that had rather firm crust.
Sometimes the tenderness is all but entirely gone. The other day it
was gone when I awoke, but reappeared after a few hours even though I
had eaten nothing at all.
The dentist who placed the crown has shaved it down a bit once, but he
said it looked like there was just one spot where there may have been a
"little" contact, it did not sound as though the bite was very off.
Shaving it down did drop the frequency and degree of the tenderness,
but as far as I can tell now the tooth is not touching the opposing
teeth at all yet the tenderness remains.
My biggest fear is a fracture that could cause the tooth to need
extraction. I am in my 30s, have all of my teeth, but when the topic
of possible extraction of this tooth was originally raised my dentist
seemed hesitant, citing something about compromising function given
that I had several teeth extracted when I was young for orthodontic
reasons.
I suppose my questions are:
1. Does this sort of pain sound like a fracture? Again, there is no
pain on release of bite pressure, and it takes only the lightest
percussion to generate the tender sensation. I was under the
impression a fracture generally caused pain by allowing the tooth to
flex, but this light percussion wouldn't seem to be enough to cause any
flexing. Only lateral movement and percussion create discomfort, and
the lateral movement also does not create additional pain on release.
For example, if I press the tooth forward there is tenderness but then
it stops if I hold the tooth in that position, and there is no pain
when I release it. Same for pressing the tooth in a different
direction. And no pain at all pressing the tooth directly down.
2. It certainly feels like perhaps the ligament is inflamed, as it has
all the hallmarks of a 'squishing' sort of tenderness. Bite pressure
on this tooth probably presses it backward a bit, and it's my
impression that pressing the tooth backward manually elicits a lot more
tenderness than in other directions. Is it possible this is the
problem, even after 5 weeks? Note that I do not press and wiggle on
this tooth constantly, I've only done this to try to assess the nature
of the tenderness. I've even given that side entire days off from
chewing and have worn half of a night guard on -- on the opposite side
-- to try to limit unconscious clenching throughout the day or night.
3. Is it common for the endodontist to test for fractures during a
root canal w/microscope? Is there some sort of standard staining or
other process?
4. If this was a periapical infection, would its intensity vary this
way? Would there be other signs?
X-rays were taken of the tooth after the root canal, and after the
crown placement. The endodontist (an older man with a great deal of
experience) said he thought it turned out great, and the dentist (an
LVI guy) seemed to concur. No one has mentioned any sign of infection
or other issue with the tooth.
I simply don't have the money to spend for a lot of additional work
given the extreme financial hardships of my wife's cancer, and I'm
trying to make sure I'm as informed as possible before making any more
decisions. I have an appointment with my dentist next week to revisit
the issue. I like this dentist, I have no reason to distrust him, he
has actually been very helpful, but in the years of our struggle with
this cancer I've learned there is no better advocate than an informed
patient.
Any help would be appreciated.
Mark & Steven Bornfeld - 11 Nov 2006 14:16 GMT
> I'm completely confused by this, unable to make anything I've read on
> the internet really fit.
[quoted text clipped - 114 lines]
>
> Any help would be appreciated.
I wouldn't make too much of the "rebound tenderness" thing as
characteristic of fracture. Generally though biting on a fractured
tooth will elicit sharp pain.
It isn't possible at this time to tell (based on your description)
where the problem lies. I can tell you that symptoms after a root canal
often linger for quite some time. I personally had sensitivity and some
pain for a couple of months on a crown done for me by my brother, and no
root canal treatment was involved. I also think that rushing to put a
permanent crown on a tooth just a few days after a tooth with a
significant history of pain for a while is IMO rushing it. Where
fracture is suspected a temp. crown should be placed and then ideally
wait until the symptoms are gone. It's a lot of work on a tooth over a
short period of time. Relieving the bite on a temporary crown isn't a
bad idea either.
Having said that, it sounds like your dentists are conscienscious, and
there is no way I can second guess the judgement of a dentist who has
actually seen you. Most endodontists use operating microscopes these
days. It certainly makes seeing fractures easier, but no visual
inspection is foolproof, and x-rays only occasionally help in these cases.
I empathize with your battles with cancer; my family has had plenty,
and I agree that even the best facilities with the best people can make
amazing mistakes and missteps, and that constant vigilance is necessary.
This is however a very different kettle of fish in terms of complexity
of diagnosis, number of specialists, ancillary care etc. involved, and
an open discussion with your dentists should be able to lead you to a
good idea of what is going on. It may however take some time for things
to become clear.
Good luck,
Steve

Signature
Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001
C.J. Thomas - 11 Nov 2006 20:21 GMT
I wouldn't worry yourself over this tooth. Sometimes, a tooth that has had
a root canal done on it will never feel the same again. It happens. If the
pain was excruciating, then yes, worry...for your own sake. However, since
the discomfort seems to be rather mild, your body may get use to it over
time. Again, I would just keep an eye on it, but don't lose sleep over it.
:)
> I'm completely confused by this, unable to make anything I've read on
> the internet really fit.
[quoted text clipped - 114 lines]
>
> Any help would be appreciated.
An Endodontist - 12 Nov 2006 13:07 GMT
A couple of more points to this well-discussed topic:
Pain to bite release is pathognomonic of a cracked tooth only if the tooth is vital (alive with no previous root canal treatment).
The need to readdress a root canal that has persistent sensitivity will depend upon the degree of sensitivity and persistent or recurrent clinical/radiographic pathosis. This persistent sensitivity is sometimes caused by trapped apical pulp and retreating the root canal with wider instrumentation could help.
With a scope, staining for a crack is generally unnecessary. Cracks that are compromising the roots of a tooth are quite obvious under this type of magnification.
If this sensitivity were infection, antibiotics should change your symptoms. Antibiotics are sometimes useful as a diagnostic aid in cases like this. I suspect, however, from what you're describing, that they won't make a difference (especially since the tooth was vital prior to treatment)
C.J. Thomas - 12 Nov 2006 19:57 GMT
Why does the tooth have to be vital to detect a fracture upon biting
release? Isn't the PDL giving up the info, not the pulp? If what you say
is true, would u mind citing an article or two. Thanks :)
>A couple of more points to this well-discussed topic:
>
[quoted text clipped - 18 lines]
> --------------
> Posted via http://www.dailydentistry.com
Steven Bornfeld - 12 Nov 2006 20:23 GMT
> Why does the tooth have to be vital to detect a fracture upon biting
> release? Isn't the PDL giving up the info, not the pulp? If what you say
> is true, would u mind citing an article or two. Thanks :)
The only thing I've found as an ironclad pathognomonic sign in 30 years
is that there rarely are any pathognomonic signs.
I'm curious as to how far down a canal you can see a root fracture.
This is probably more idle curiosity than anything, since except maybe
in gross trauma cases most of these fractures can be visualized in the
pulpal floor or near the cervical line.
Steve
>> A couple of more points to this well-discussed topic:
>>
[quoted text clipped - 18 lines]
>> --------------
>> Posted via http://www.dailydentistry.com
Newbie - 16 Nov 2006 17:49 GMT
>> Why does the tooth have to be vital to detect a fracture upon biting
>> release? Isn't the PDL giving up the info, not the pulp? If what you say
>> is true, would u mind citing an article or two. Thanks :)
>
> The only thing I've found as an ironclad pathognomonic sign in 30 years
>is that there rarely are any pathognomonic signs.
Couldn't have said it better myself.
> I'm curious as to how far down a canal you can see a root fracture.
>This is probably more idle curiosity than anything, since except maybe
>in gross trauma cases most of these fractures can be visualized in the
>pulpal floor or near the cervical line.
With transillumination I'd say about 1/4 - 1/3 depending on the tooth.
The fact of the matter is if you can see a lateral vertical root fracture
through the pulp chamber or at the orifice(s) the tooth likely non-restorable.
There are sometimes radiographic signs that may give you a hint.
Mark & Steven Bornfeld - 16 Nov 2006 18:46 GMT
>>>Why does the tooth have to be vital to detect a fracture upon biting
>>>release? Isn't the PDL giving up the info, not the pulp? If what you say
[quoted text clipped - 15 lines]
>
> There are sometimes radiographic signs that may give you a hint.
Sure. I think I've heard some of the endos with operating microscopes
claim they can see much further down the canal than that. Might be
true, or may be macho posturing.
Steve

Signature
Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001
Newbie - 16 Nov 2006 21:14 GMT
>> With transillumination I'd say about 1/4 - 1/3 depending on the tooth.
>> The fact of the matter is if you can see a lateral vertical root fracture
[quoted text clipped - 7 lines]
>
>Steve
One must justify the expense one way or the other.
Then there is the: 'you're not able do do endo without it' guys.
Whatev ;-]]
An Endodontist - 12 Nov 2006 13:12 GMT
A couple of more points to this well-discussed topic:
Pain to bite release is pathognomonic of a cracked tooth only if the tooth is vital (alive with no previous root canal treatment).
The need to readdress a root canal that has persistent sensitivity will depend upon the degree of sensitivity and persistent or recurrent clinical/radiographic pathosis. This persistent sensitivity is sometimes caused by trapped apical pulp and retreating the root canal with wider instrumentation could help.
With a scope, staining for a crack is generally unnecessary. Cracks that are compromising the roots of a tooth are quite obvious under this type of magnification.
If this sensitivity were infection, antibiotics should change your symptoms. Antibiotics are sometimes useful as a diagnostic aid in cases like this. I suspect, however, from what you're describing, that they won't make a difference (especially since the tooth was vital prior to treatment).
http://thisblogexperiment.blogspot.com
Andy.J.Droel@gmail.com - 12 Nov 2006 17:13 GMT
Often in these cases the diagnosis will become clear after much
waiting.
For now, you might still just be experiencing pain related to the
recent treatment. If there is still pain after several months, or if
"something just doesn't feel right", make sure you go back to the
endodontist (ideally the same one, but a different one if you feel it
is necessary to make a change) and let them know what's happening so
there can be a greater chance of discerning between vertical root
fracture, reinfection, persistent bite trauma from an occlusal
interference, or something else.
These situations present themselves to all of us dentists several times
a year and it can be very frustrating for patients and dentists alike
as we wait for things to begin to make sense for a particular
situation.
Even from your long and well-informed narrative it is impossible for us
to help you beyond that without a thorough exam and x-rays. Best of
luck!
Andy Droel, DDS
www.droelfamilydentistry.com
> A couple of more points to this well-discussed topic:
>
[quoted text clipped - 9 lines]
> --------------
> Posted viahttp://www.dailydentistry.com
Steven Bornfeld - 12 Nov 2006 20:24 GMT
> Often in these cases the diagnosis will become clear after much
> waiting.
[quoted text clipped - 19 lines]
> Andy Droel, DDS
> www.droelfamilydentistry.com
Welcome, Andy. I admire a guy who can work with his wife. ;-)
Steve
>> A couple of more points to this well-discussed topic:
>>
[quoted text clipped - 9 lines]
>> --------------
>> Posted viahttp://www.dailydentistry.com
JimSocal - 13 Nov 2006 19:59 GMT
>I'm completely confused by this, unable to make anything I've read on
>the internet really fit.
...[edited]
>The tenderness varies throughout the day. Sometimes it gets bad enough
>that the force of my tongue brushing it can elicit a sensation of
[quoted text clipped - 12 lines]
>but as far as I can tell now the tooth is not touching the opposing
>teeth at all yet the tenderness remains.
I have a similar problem, I have discussed here before, though it
sounds like mine is not quite so senstive or painful as your's. Mine
is a very mild sensitivity to chewing or percussion, after a root
canal and crown on my front right lower molar (#30).
I have asked many dentists and endos about it and no one knows the
answer. Mine is still sensitive after almost one year.
The consensus is that it may have a small root that the endo did not
get when he did the RCT, one that is not visible on xrays, and that
there is really nothing to be done about it. It would cost a lot to go
in there again, not to mention the pain, and still they might not find
it, and who knows if it might get worse from the trauma?
Most everyone says I should just try to live with it and hope it does
not get worse.
However, if your's is not "livable", and since it has only been a
month, I wonder if maybe you shouldn't have the endo take some more
xrays and see if he can find a root he missed, or go back into it and
poke around...? Is this a good idea, dentists/endos?
The worst thing about mine is that it hurts a bit when I brush it and
that makes me not want to brush too close to it, and is actually
negative reinforcement for me to brush my teeth.
Just fyi, I was told that sometimes these things calm down after a
couple months, so with any luck, maybe your's will be one of those.
Mine was not.