About Mark Bornfeld DDS Expertise I can respond to all questions dealing with the practice of dentistry, from both the dentist`s and patient`s perspective. I am knowledgeable about all dental disciplines, from cosmetic dentistry to surgery, from restorative dentistry to root canal treatment. I have strong opinions about controversial issues in dental practice, including those topics which directly impact on the reputation of the profession in the eyes of both the lay public and our health profession colleagues.
Experience
Past/Present Clients Editor, Queens County Academy of General Dentistry newsletter; contributor to Dentistry.com 29 years practicing general dentistry partnered with brother Steve as one-half of the DentalTwins®
I apologize for the long message; my story is complicated and unusual.
6 months ago I developed sudden onset of severe pain in lower right back
molars. It happened right after a long flight. After one week pain crossed
midline to left lower molars. Would not respond to usual pain meds. I have
seen 3 dentists who all have differing opinions and two neurologists at Mass
General who can't diagnose me.
The pain's quality is achy, however when ice is placed on the last lower right
molar (no wisdom teeth) a very strong electric pain is provoked. It also
happens with hot liquid. It stops after a second and then throbs painfully for
a long time. My teeth are tender upon eating the first meal of the day and
they hurt when I bite together.
The first dentist informed me the night guard I had been wearing for 4
months changed my bite. As a result I can no longer bite together
comfortably; I only bite down on my back molars. This also affects my
chewing. However, the pain started while I was still wearing the night guard
which kept my back teeth spaced apart. (It looks like a retainer)
I now wear a boil and bite nightguard which seems to have alleviated the pain
somewhat, in the sense it no longer feels like every tooth in my mouth hurts.
However I still have pain in the lower molars on both sides.
The first dentist told me I may need a root canal but that I probably have
myofascial pain. He gave me a shot of Marcaine which numbed the pain in
the lower right molars but not totally. I could still feel twinges of pain. The
second dentist told me I absolutely needed a root canal; in both lower right
molars.
The third dentist who I saw today told me I have a leaky filling in my last
lower right molar, a small cavity underneath said molar, and a cavity in
between both lower right molars. He did concede that none of this should be
causing me the pain I have been having, but that it's possible more decay
could be under the leaky filling. A cracked tooth was also considered but
could not be proven. All x rays (bite wings and apics (sp?) were normal. He
wanted to adjust my bite, but I will not agree to a permanent procedure until
the evidence to justify it presents itself.
The pain has spread to the whole of my face. My cheeks are always achy
when I speak or eat. My neurologist ruled out trigeminal neuralgia but says
it's possible an inflamed tooth could have set everything off. But then he
always ends with "but I'm not a dentist." It seems I am falling through the
cracks of medicine and dentistry.
I am very mindful of my oral health. Every medical text I have read says it's
impossible for pain to cross the midline, but I'm telling you, it did and it
continues to hurt on both sides. All blood work normal, MRI/MRA with
trigeminal protocol are negative for vessel compression. No Paget's disease.
Where do people like me go when they are in a shade of gray?
Thank you for reading,
Kristin
Answer Dear Kristin,
I usually refer my hard-to-diagnose patients to an interdisciplinary pain facility, where diverse specialties can be simultaneously brought to bear upon a diagnostic puzzle. Ordinarily, I would recommend the same for you, but there's something about your narrative that just intuitively feels like a problem resulting from bruxism (habitual jaw clenching and grinding). The fact that a night guard was made in the first place suggests that the suspicion was already there, and the fact that you saw an improvement when you changed your night guard is further evidence that you're on the right track. (For the record, I'll say that I don't recommend boil-and-bite appliances, because the way they're shaped is too unreliable; they can easily introduce forces that are far more damaging than those they're meant to treat.)
Bruxism can definitely account for the bilateral pain, and can cause injury to the periodontal supporting tissues, as well as fracture of the teeth. Be advised that tooth fracture is almost never conspicuous on x-ray, because the fracture line is always oriented parallel to the x-ray film. Fractures can often be inferred by serial challenges to the individual tooth cusps. Fractures can also sometimes be seen by transilluminating the teeth under high magnification, or removing any fillings in the teeth so that the trajectory of any surface cracks can be followed into the deeper tooth layers. Especially in light of the presence of a cavity, the severity of the pain, and the fact that it has been refractory to diagnosis, it's time to approach the diagnostic process a bit more aggressively, take out the fillings, and see what's under them. It may seem a bit extreme, but I suspect it will be more productive than further exploration of the neurological possibilities.
Hope this helps...
Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY
