Expert: Steven C. Scherr, D.D.S. - 8/27/2006

Question
Hi -

I am hoping you can offer me some feedback.  I saw my dentist back in January regarding pain in my lower last bottom molar.  It hurt when I would bite down as I released pressure.  The tooth had a very small filling in it.  The dentist opened the filling and saw no further decay - but said she saw a small crack.  She had great difficulty getting me numb (I actually reacted to the epinephrine) but finally did.  She bonded the tooth and refilled it.  However the pain got worse.

Next I saw an endondontist - but I also noticed that beginning a few months prior I was feeling fatique in my jaw at night and pain, headaches etc.  I have had a very stressful last year with a divorce - and in discussing all with my dentist we figured I was grinding which caused the crack.

I saw the endo who blew air on the tooth and I hit the roof in pain.  She said I needed a RC.  I also saw an Oral surgeon who said I had TMJ and he sent me for an MRI which showed some dislocation of my jaw joint on the same side as the tooth.  The first RC procedure was very rough, I got as numb as possible but still felt some pain in one of the roots - and she said there was a lot of inflammation.  For a few days I was in unbearable pain but eventually the tooth calmed down.  I went back for my 2nd treatment and she said I was done.  This was in end of February.

I went to my regular dentist for my crown prep and for the making of the gold crown.  I also saw several oral surgeons getting varying opinions on my jaw pain or supposed TMJ.  The crown has never been put on permanently because I continue to have discomfort and can't eat on that side of my mouth. Here is the odd part - the tooth gets worse as the day progresses.  In the AM when I wake up it is pretty calm.  But as the day progresses it gets sensitive - when I push on the sides of the tooth with my finger or tongue the tooth is sensitive.  I also have pain in my jaw all the way back throughout the end of my lower jaw.  It will pulse too - indicating it might be muscular?

I have had the crown ground down several times - twice by my dentist and once by the endo.  Last time I saw the Endo was in April and she told me to return if it continued but I really thought the pain was the TMJ.  So I have been seeing an OS who told me my TMJ is not bad and I just need a nightguard.  Been waiting for that to be ready and when I returned last week he gave it to me - but he said the pain I am experiencing now is NOT TMJ - that it must be the tooth and to go back to the Endo.

I know it seems like I am dragging this out but I am trying to keep the story somewhat short.  :)
I am going back to my Endo tomorrow - I am guessing this might be the crack in the tooth affecting my jaw?  Should I go for another RC, or have that surgery where they cut into the gum or just have the darn thing pulled? I am only 40 years old and have had excellent teeth all my life.  I don't know why this is happening but i just can't take the pain anymore.  It affects my neck, my jaw, my head, my eyes.

Any feedback is appreciated!
Beth

Answer
Beth,

I am sorry to hear of your unfortunate circumstances.  The pain you continue to experience may have several sources.  The following possibilities are listed in the order from most common to least common.

1. There may be nerve material remaining in the tooth that was not completely cleaned out by the root canal procedure.  The nerve system within a tooth is very complex, often having tiny flutes and side paths that are easy to miss and sometimes physically impossible to clean completely.  If there is enough nerve debris remaining or the body is extremely sensitive, soreness may remain.  If additional nerve debris can be located and removed, retreatment of the root canal may be successful.  Otherwise surgical treatment is often successful, especially if a surgical microscope is used to identify and seal offending areas.

2. There may be a crack in the tooth.  Cracks rarely show up on x-rays and may be located in places that are impossible to see, such as beneath the gum line.  Depending on the size and location of a crack, the tooth may or may not be able to be saved.  Sometimes the offending crack is not discovered until root canal surgery is done.

3. Grinding or clenching may continue to irritate the nerve blanket between the tooth and bone socket.  This nerve is not removed during root canal therapy because it lies outside the tooth.  Overwhelming compression of the tooth against this nerve blanket can cause inflammation and pain.  If the grinding or clenching is happening during sleep, a night guard will help.  If it happens during the day, behavior modification techniques must be learned in order to break the habit.

4. Muscle or TMJ damage may be referring pain to the tooth.  If this is the case, tapping on the tooth directly will not be painful.  If the offending muscle or joint can be located, direct stimulation of that structure will duplicate the pain symptoms in the tooth.

5. There may be another problem.  These include a neurovascular condition that is like having a migraine in the tooth.  Other possibilities include neuralgia and rarely, tumors.

Beth, it does sometimes take some time to get to the true source of the pain.  I hope you are feeling much better soon.

Steve