Expert: Frederick R. Liewehr DDS, MS, FICD - 2/24/2009

Question
My tooth #19 has had a long, sad history. One of the many sad parts was that three endodontists and five dentists who examined the tooth over a six month period were unwilling to advise me to get a root canal until a fistula erupted and made it obvious.

I don't fault anyone for this, it's just a very serious indication of what I'm up against as to diagnosis.

Now that the root canal has been done and I've had a well-fitting temporary crown on for a month (following an ill-fitting, painful temporary I had for a week), it is proving equally impossible to make the determination why the tooth continues to have an intermittent low-level ache and sharp pain on biting.

The endodontist felt sure there was not a crack in the roots because she didn't feel one, though of course that doesn't mean for certain that there isn't a crack.

The Xray of the root canal shows all four canals filled neatly out to the tips of the roots. So it seems to me that repeating a root canal is nothing more than shooting in the dark.

My gut sense is that it is going to come down to me making a "personal decision" about extraction. Hence I am trying to make that as educated a decision as humanly possible. Here are my questions.

1. It seems from this article  (http://www.mynewsmile.com/dental/root_canal_pain.htm) that the problem could be persistent infection in the bone (outside the tooth itself). So I'm strongly inclined to ask the endodontist to try antibiotics before attempting another root canal. Does that seem reasonable?

2. Given a well-fitting temporary crown and my own good sense not to chew anything that could break it or pull it off, what is the absolute longest that it is reasonable to leave the temporary in place? Is the primary risk that it's not sufficiently sealed against invasion of bacteria? What other risks are there? My thinking is that the only way to rule out the possibility that the pain is really coming from another tooth is to have the work done on those other teeth first. In terms of finances, that could take a year.

3. Given the appropriate precautions against breakage, and the intention to make the decision whether to go ahead with a permanent crown, what is the definitive level of "normality" I'm looking for with a well-fitting temporary? Should I be able to chomp my way normally through toast, almonds and pork chops without provoking symptoms?  Or is that just too much to expect from any temporary crown?

My next appointment with the endodontist is Thursday. I hope you'll be able to reply before then so I'll have some extra perspective when I discuss options with her.

Thank you so much!

Gail

Answer
I can't tell you much without seeing you. You may need yet another dentist. Your endodontist should have been able to see, stain, and test for a cracked tooth.

As for your questions:

1) No, it is not reasonable. If you have an extraradicular infection, the bacteria will be in a biofilm, and you will need surgery to get rid of them.

2) Temporary crowns are rarely "well fitting" or sealed. If your problem is sharp pain on biting, your endodontist should certainly be able to determine which tooth produces the pain.

3) Temporary crowns vary from poor to excellent. What you ask depends entirely on the quality of the crown.