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Medical Forum / General / Dentistry / July 2007

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Pain after post and core

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Rob  Usdin - 28 Jun 2007 22:27 GMT
Recently had a tooth root canaled (I think it is #22 - pre molar on
lower left).

Yesterday the dentist did the post and core on this tooth.  While
grinding to tooth down in prep - using whatever the tool on the drill
does the grinding (big vibrations) it vibrated quite a bit and even
though I had novocaine I still felt sensitivity and pain as she put
pressure on during the grinding.  She also when prepping around the
sides of the tooth said she removed some gum overgrowth (which I also
felt).

She did the temporary fine, and it's on.  I am feeling pretty constant
pain right now from the tooth when putting pressure on it and constant
moderate pain in the jaw below.  I've felt similar pain on another
root canaled tooth after root canal but I don't recall much soreness
after a post and core being done.

So my question is this - is this even somewhat normal after a post and
core because the tooth is still sensitive?  It did hurt for a bit
after the root canal as well which subsided.  Is this just re-
irritation that will subside, kind of like a bruise?  Or would this be
indicative of a root fracture?

Thanks.

--*Rob
Steven Bornfeld - 29 Jun 2007 00:15 GMT
Rob Usdin wrote:
> Recently had a tooth root canaled (I think it is #22 - pre molar on
> lower left).
[quoted text clipped - 22 lines]
>
> --*Rob

    It sounds like she did a lot more than a post and core--she prepped the
tooth, and there may be gingival pain.  There are other possibilities as
well, of which root fracture is the worst (you would almost certainly
lose the tooth).  Most of the bad ones (fracture, root perforation,
overextension of the post) can be easily determined by an x-ray, and
significant pain should be checked.

Steve
REP - 29 Jun 2007 09:14 GMT
> So my question is this - is this even somewhat normal after a post and
> core because the tooth is still sensitive?  It did hurt for a bit
> after the root canal as well which subsided.  Is this just re-
> irritation that will subside, kind of like a bruise?  Or would this be
> indicative of a root fracture?

For real advice, please see your dentist. Every mouth/tooth is
diffferent; what I am about to post is an anecdote:

I recently had a root canal on #3 (upper right molar) due to nerve death
and fracture. The RC was largely painless ... then again, the nerve was
"dead" before the RC. A week later, I had the crown prep, build up and
casting for post - and it HURT!! Not just being in a bite block for 2
hours, ouch, but apparently there's plenty of nerves left in the gum,
etc! I was surprised at how much it hurt, and my dentist said that that
crown prep was the worst part of the whole thing. (A  bunch of xrays
were taken the following week when the post was placed - no root
fracture, and by then the pain had gone to just somewhat achy).

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"Did Father shoot him? I will eat Grandfather for dinner."
- Helen Keller, on learning of the death of her grandfather

email: aripee at inanna . com

Amatus Cremona - 29 Jun 2007 11:40 GMT
What is a post and core?  Temporary?

Why bother?

Signature

/

Amatus

/

>
>> So my question is this - is this even somewhat normal after a post and
[quoted text clipped - 15 lines]
> were taken the following week when the post was placed - no root
> fracture, and by then the pain had gone to just somewhat achy).
REP - 29 Jun 2007 12:14 GMT
> What is a post and core?  Temporary?
>
> Why bother?

It is entirely possible that, being merely an owner of teeth and not a
professional, that I screwed up some terms or used them improperly. I
had a broken tooth with a nerve that was not functional; that tooth had
a root canal; then that tooth was prepared for a custom-made cast-to-fit
post and crown. I am having quite a few crowns - years of poverty - and
my dentist wants to place them at the same time, so I currently have 3
temporary crowns and will have another in about 10 days. Why bother?
Need the temporaries to protect what remains of the teeth before they
are crowned, or so my dentist tells me. Personally, I'd rather have the
temps than be forced to sit on the porch and play my banjo.* Sure, the
work is all on molars, but same principle.

The point of my anecdote (which was labeled as an anecdote, and not as
gospel or full of correct jargon) was merely that one other person has
recently had a crown prep, that it hurt like f.cking hell and was told
that it was normal to hurt like f.cking hell.

*"Deliverance"

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"Did Father shoot him? I will eat Grandfather for dinner."
- Helen Keller, on learning of the death of her grandfather

email: aripee at inanna . com

Amatus Cremona - 29 Jun 2007 13:29 GMT
I am so sorry !  I should have been more clear.

I did not aim my comment at you.  :-)

I was simply pointing out to the professionals on this forum that we need to
find ways to reduce the amount of grinding we actually do on a tooth.  This
(in my office) means cores are not done and I do onlays instead of crowns.
Since I use a CAD-CAM system, I do them in one appointment rather than two,
so no temporary is needed.

Your description could indeed be an indication that there is a fracture in
the root.  Posts are notorious for cracking roots.  Especially if they have
a taper or have screw threads.  Even smooth sided straight posts will crack
roots if the patient clenches at night.  A lot of us now feel that if we
could not restore the tooth unless we used a post, that the tooth probably
should not be restored, but removed.  In retrospect, teeth that survive for
decades with a post in them, never needed the post in the first place.

Do NOT have the finished crown final cemented on the tooth if it still hurts
! ! !   If it hurts with the temporary, it will still hurt with the finished
crown.  Find out why it hurts first.

Signature

/

Amatus

/

>
>> What is a post and core?  Temporary?
[quoted text clipped - 19 lines]
>
> *"Deliverance"
REP - 02 Jul 2007 10:46 GMT
> I am so sorry !  I should have been more clear.
>
> I did not aim my comment at you.  :-)

No problem. I was afraid I hadn't been clear enough that I was merely
adding an anecdote that was worth exactly what was paid for it.

> I was simply pointing out to the professionals on this forum that we need to
> find ways to reduce the amount of grinding we actually do on a tooth.  This
[quoted text clipped - 13 lines]
> ! ! !   If it hurts with the temporary, it will still hurt with the finished
> crown.  Find out why it hurts first.

The *tooth* never hurt. The tissue surrounding the tooth hurt like all
hell, due to the needle sticks, grinding, etc. I don't have a digital
xray of the tooth, but even if I did, it doesn't really show how damaged
the erupted areas were - it had large amalgam fillings, which fell out
when the tooth cracked diagonally, taking out the lingual side and most
of the back but the 'footprint' of the tooth was intact, and the roots
are strong and surprisingly healthy. A lot of remaining tooth had to be
removed as it was too thin to be of use (remember, it was honeycombed
with holes from former fillings) and the lingual side was broken just at
the gumline. After the tooth was 'cleaned up,' the casting was made for
the post - all this took some time, and no doubt being in a bite block
for as long as I was contributed to the post-poking pain.

By the time the post was to be intalled, the tissue had recovered and
stopped hurting; the tooth itself remains nonpainful, even with a large,
strange object in it. The only really thing I notice is that it's wider
and thicker than it's been for a year (since the temp is shaped like a
healthy tooth, and not my broken one).

It's been xrayed since the post has been placed (there is some concern
since #2 and #4 are absent) but the post is an excellent fit and so far,
it's fine. Once #30's crown is done - it had an RC due to absess years
ago but I couldn't afford the crown then - we'll all see how #3 does
with another tooth making full contact.

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"Did Father shoot him? I will eat Grandfather for dinner."
- Helen Keller, on learning of the death of her grandfather

email: aripee at inanna . com

Amatus Cremona - 02 Jul 2007 13:39 GMT
IF the lower tooth ahs not had any chewing contact for a L-O-N-G time, it
will probably be sensitive to chewing forces for the first few weeks, as the
ligament holding the tooth in place re-adapts.

Signature

/

Amatus

/

>
>> I am so sorry !  I should have been more clear.
[quoted text clipped - 57 lines]
> ago but I couldn't afford the crown then - we'll all see how #3 does
> with another tooth making full contact.
Rob  Usdin - 02 Jul 2007 15:18 GMT
FIgured I'd follow up with a post since I was the one who started all
this.

The tooth is down to a slight ache.  If it was still hurting as much
as it did last week I'd be at the dentist right now, but it may have
just been pain from the prep of the gum, as well as pressure to the
tooth "bruising" the tooth in the socket down to the jaw.  I can bite
and eat on it just fine now, I still have a slight ache but it is
controllable with one Advil so I'm thinking there's nothing adverse
going on. I will mention it all to the dentist though when I go to get
the permanent crown placed in 10 days in case she decides it is worth
an x ray just in case.

Also- just curious - are many dentists adopting digital x rays?  I had
another root canal early this year and the endodontist used digital x
rays.  For me as a computer guy, I thought it was pretty cool how they
could blow it up and get a better look.  My regular dentist though
still uses the standard x rays.  Just wondering what the adoption rate
on digital is.  Is my dentist behind the times or is the endo on the
leading edge?

--*Rob
Newbie - 02 Jul 2007 15:31 GMT
> Is my dentist behind the times or is the endo on the
>leading edge?
>
>--*Rob

Would guess that most endo's have digital and were
early adopters.

Many still use film, such as me, because of the expense
of going digital. It ain't cheap.  Mebbe when the price
drops a bit.
Amatus Cremona - 02 Jul 2007 19:29 GMT
I was digital before the local endo guys were.

Digital is "an expense" to purchase initially, but is paid for entirely by
what you would have spent with film.  Depending on how busy the office is,
the break-even point is 2-3 years.  After that, it is much cheaper to use
digital.

Signature

/

Amatus

/

>
>> Is my dentist behind the times or is the endo on the
[quoted text clipped - 8 lines]
> of going digital. It ain't cheap.  Mebbe when the price
> drops a bit.
Newbie - 02 Jul 2007 19:53 GMT
See, that was a perfect set up by me.

Good job AC !

>I was digital before the local endo guys were.
>
[quoted text clipped - 14 lines]
>> of going digital. It ain't cheap.  Mebbe when the price
>> drops a bit.
Amatus Cremona - 03 Jul 2007 11:51 GMT
Gee,,,,,,,, thanks

Signature

/

Amatus

/

>
> See, that was a perfect set up by me.
[quoted text clipped - 19 lines]
>>> of going digital. It ain't cheap.  Mebbe when the price
>>> drops a bit.
Amatus Cremona - 02 Jul 2007 19:29 GMT
It should not be hurting at this point.  Something is wrong.

Signature

/

Amatus

/

> FIgured I'd follow up with a post since I was the one who started all
> this.
[quoted text clipped - 18 lines]
>
> --*Rob
Steven Bornfeld - 29 Jun 2007 15:53 GMT
>> What is a post and core?  Temporary?
>>
[quoted text clipped - 16 lines]
> recently had a crown prep, that it hurt like f.cking hell and was told
> that it was normal to hurt like f.cking hell.

    You were misinformed.
    As for Amatus, forgive him.  We have a running inside joke, and you got
caught in the crossfire.
    Apologies,
Steve

> *"Deliverance"
Steven Fawks - 30 Jun 2007 12:01 GMT
> The point of my anecdote (which was labeled as an anecdote, and not as
> gospel or full of correct jargon) was merely that one other person has
> recently had a crown prep, that it hurt like f.cking hell and was told
> that it was normal to hurt like f.cking hell.

I would not like such pain to exist in any tooth that I have plans
to cement a permanent crown on top of.

If it does not feel pretty good by the cementation appt., I would
not place that crown (or any of the 'neighbors') until the pain
problem is corrected.

Was the root canal just recently done, or was it older treatment?

As far as posts being 'notorious' for cracking roots, that statement
could be a little inflamatory.  I have placed many posts over the
last 28 years of dentistry, and the failures have been low.  Of those
failures, most have been failures of the build up around the post or
the post itself.  Not very many have been root fractures.

These posts have been mostly size #5 pre-fab, cemented posts.  Stainless
steel in the early days, then titanium (I tried the fiber posts for
a few years and they failed at an alarming rate, so I'm back to
titanium).

JMO,
Steve Fawks
Newbie@bix.nex - 30 Jun 2007 23:33 GMT
>> The point of my anecdote (which was labeled as an anecdote, and not as
>> gospel or full of correct jargon) was merely that one other person has
[quoted text clipped - 3 lines]
>I would not like such pain to exist in any tooth that I have plans
>to cement a permanent crown on top of.

Agreed

>If it does not feel pretty good by the cementation appt., I would
>not place that crown (or any of the 'neighbors') until the pain
>problem is corrected.

This is why I rarely prep for the crown on the RCT appt.

>Was the root canal just recently done, or was it older treatment?
>
[quoted text clipped - 3 lines]
>failures, most have been failures of the build up around the post or
>the post itself.  Not very many have been root fractures.

Agree here but am placing less posts and have eschewed placing
pins altogether.
AC plans for future and ultimate failure, his practice is much
different from mine.
One of us dislikes prostho, both are masters of the craft.

>These posts have been mostly size #5 pre-fab, cemented posts.  Stainless
>steel in the early days, then titanium (I tried the fiber posts for
>a few years and they failed at an alarming rate, so I'm back to
>titanium).

Titanium is an interesting metal.  Strong, light, yet a bit flexible.
Very difficult to forge and a bit rare, compared to iron (steel)
There are some firearms with titanium parts, it's too flexible
for the frame.

Am using gold plated Dentatus, post space prepared with the
four sided prep instruments that are part of the kit.
Cement them in place, use an explorer to coat the walls,
seating the post counterclockwise with a vibrating motion.
Usually give a 1/4 to 1/3 clockwise turn after full seating
Using Fuji 9 as the core/luting agent. Often done
in two steps.

Most posts IME fail due to cement failure of the build-up
material/post/tooth structure interface. Micro-leakage at the
crown margin/cement/tooth interface is the starting point of failure.

Bonding  PFM's with a material such as Calibra
may become standard, but material science needs to advance
a bit further.

Bonding an all ceramic restoration, including silanation and an
*absolutely* dry field may be the ultimate cure
but not always achievable.

When any restoration can be truly bonded in a 'wet' field,
then failures may be a thing of the past.

Of course the cause of cuspal fractures must be addressed,
and a preventative must be implemented. NTI is my choice
but any other device is better than nothing.

Damn, my soap-box just collapsed;  whacked my noggin
and hurt myself <g>

>JMO,
>Steve Fawks

OK TJ,  have gone on too long,,,

Time for a nap ;-]]
REP - 02 Jul 2007 10:23 GMT
> > The point of my anecdote (which was labeled as an anecdote, and not as
> > gospel or full of correct jargon) was merely that one other person has
[quoted text clipped - 9 lines]
>
> Was the root canal just recently done, or was it older treatment?

I meant the prepping was quite painful. The tooth itself is 'dead' - the
nerve had 'died' before the RC had certainly hadn't recovered after it
(and yes, the RC had been done the previous week). It didn't hurt at all
until I had spent 2.5 hours in a bite block, getting many, many
needlesticks, a lot of grinding and some work done on the gum. The tooth
still didn't hurt - but everything around it sure as hell did. A lot.

Again, just an anecdote from someone who had recently had it done to
someone else who recently had something similar done - and please note,
my anecdote began with "see your dentist for real advice."

Signature

"Did Father shoot him? I will eat Grandfather for dinner."
- Helen Keller, on learning of the death of her grandfather

email: aripee at inanna . com

Steven Bornfeld - 29 Jun 2007 15:52 GMT
> What is a post and core?  Temporary?
>
> Why bother?

    You're slipping.  I figured you'd be in within the hour.
    Seriously, you never use posts?  I'm aware that accepted guidelines
have changed, and I assume your Cerec will create in effect an integral
core/restoration.  But in order to create a path of draw, won't that
sometimes require you to remove extra tooth structure?

Steve
Amatus Cremona - 01 Jul 2007 14:58 GMT
>> What is a post and core?  Temporary?
>>
>> Why bother?
>
> You're slipping.  I figured you'd be in within the hour.

You caught me napping  :-))

> Seriously, you never use posts?

I will use a fibre-post when I have no supragingival tooth to bond to, and
the patient understands that this is only an effort to get another year or
three out of the root before implants.  The forces which broke off the tooth
at the gum-line will still be there.  I want the next gfracture to be
supra-gingival which is less likely to be an emergency with pain and
swelling on the weekend I drive Strad up to Interlochen.  I threw out all
the metal posts (actually donated them).

>I'm aware that accepted guidelines have changed, and I assume your Cerec
>will create in effect an integral core/restoration.

The machine will replace whatever is missing.  You are free to use your
imagination during preparation and clean out the tooth as you see fit.  The
technology simply replaces what was removed by caries and dentisty.

> But in order to create a path of draw, won't that sometimes require you to
> remove extra tooth structure?

Line of draw is visual.  Whatever the camera can see, is what will be made.
The technology CANNOT make an internal undercut, because the camera does not
see it.  Slight internal undercuts of the preparation are simply filled with
the luting agent.  Larger ones,,, you have to decide how thick of a core of
luting agent you are comfortable with.  More than a full mm, and I will
generally reduce the enamel above it slightly.  I like more porcelain in the
tooth and luting agent. My big concern is the side of the tooth, not the top
of it.  I want the thick enamel on the buccal and lingual walls to remain
intact at all times.  This enamel is generally very well supported by dentin
and is important to the inherent flexibility of the tooth.  Abfraction and
fracture are reduced when you keep this part of the tooth.  If I see
fracture lines in the base of a cusp or the floor of the preparation, After
imaging the fractgures for my record, I will reduce the height of the cusps
on that side (or both sides) by 3 mm.  The porcelain then covers this much
of the cusp in order to prevent spreading the cusp tips apart during
isometric bruxism and further fractgure.  I always show the patient the
fractures on the monitor and explain that prognosis is reduced.

Steve, also
Steven Bornfeld - 01 Jul 2007 15:37 GMT
> You caught me napping  :-))
>
[quoted text clipped - 37 lines]
>
>  Steve, also

Thanks for the clarification.

Best,
Steve
Amatus Cremona - 02 Jul 2007 13:37 GMT
Should have been " I like more porcelain in the tooth and LESS luting agent.

Signature

/

Amatus

/

>>
>> You caught me napping  :-))
[quoted text clipped - 44 lines]
> Best,
> Steve
Newbie - 02 Jul 2007 15:17 GMT
>Should have been " I like more porcelain in the tooth and LESS luting agent.

We knew that.
 
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