“My Tooth is Still Hurting”

Dr. Al Danenberg Nutritional Periodontist

April 20, 2020

 

 

George contacted me by email a few weeks ago. He wrote, “My tooth is still hurting, and my dentist can’t find out why.” He lives outside of the US, found me on the Internet, and wanted another opinion.

 

I responded to him and explained, “I cannot make a diagnose over the Internet. But I will look at your x-rays and review your medical and dental history. Then, I should have some ideas and actions you could take that I will discuss with you.”

 

George emailed back, “That makes sense to me.”

 

He then filled out an online questionnaire and other information. George submitted them to me online. Also, he had his dentist email the dental x-rays. I took a look, gathered my thoughts, and we talked via Skype.

 

 

George’s Dental Problems

George’s acute problems centered around two recent dental procedures: a dental implant to replace his missing lower molar and a completed root canal on a tooth that was abscessed.

 

After we met via Skype, George explained the details of his dental fiasco.

 

He had an implant placed in his lower left molar area, which did not cause any pain while it was healing for several months. Then a crown was cemented onto the implant. Within a couple of weeks, he noticed some tenderness in the gum tissue surrounding the new crown. He went back to his dentist who took a new x-ray and told him, “That’s normal. You need to clean the area better.” George left thinking that it would get better. It didn’t!

 

In addition, the same dentist completed a root canal on his lower right bicuspid, which was abscessed and hurting. The root canal was done while the implant was healing on the left side of his lower jaw.

 

Shortly after the gum surrounding the implant crown became sore, the root canal tooth became extremely tender. George returned to his dentist to check it out.

 

The doctor checked that tooth, took a new x-ray, and made sure that the tooth had normal biting pressures when George brought his teeth together. The doctor tried to encourage him, “Your tooth will be fine. It just takes some time to heal after the root canal.” It didn’t get better.

 

George lost confidence in his dentist and didn’t know where to turn. That’s when he found my website and contacted me. Once he decided to schedule a consultation, George requested his new x-rays and sent them along with other documents for our Skype meeting.

 

 

Causes of the Pain

The sore gum around the implant crown

 

The x-ray of the crown on the implant showed a small amount of cement pushed under the gum tissue after the crown was cemented. Excess cement left under the gum tissue is unfortunately a frequent problem after the cementation of a crown.  This may be difficult to see on an x-ray. However, it is evident on an x-ray when someone looks for it.

 

I explained to George that the dentist or hygienist would need to take the time to delicately clean out the area. I suggested that, “the cement fragment is just like a splinter in your finger. It is an irritant. Your finger will not heal until the splinter is removed completely. And so, the gum around the implant crown will not heal until the cement is removed thoroughly. If the cement remnant is not removed, infection eventually will destroy the jawbone around the implant. That could cause the implant to be lost.”

 

George agreed with me and promised that he would schedule another appointment with his dentist.

 

 

The root canal tooth

 

The cause of George’s other problem was more difficult to determine. After his dentist completed the root canal on his bicuspid, the pain not only continued but actually got worse. I suggested that George see a root canal specialist to evaluate that tooth and take a three-dimensional (3-D) x-ray of the area. I suspected a crack in the tooth root. This specialized x-ray could show a crack better than a standard dental x-ray.

 

I pointed out to George my thoughts about a crack. It could occur if too much pressure was applied to the tooth by his dentist when he performed the root canal. Or, heavy chewing pressure could cause the fracture. If the root is fractured, it might have been present even before the root canal was started.

 

 

Tooth Pain Resolved

George was able to have the cement removed that was lodged under his implant crown. Also, George had an endodontist evaluate his root canal tooth and took the necessary 3-D x-ray.

 

The x-ray clearly showed a hairline fracture in the root of the tooth. Unfortunately, the only option George had now was to extract that tooth. And so, George had the bicuspid extracted. I told him that later on the space could be replaced with an implant or a bridge cemented on the teeth on either side of the missing tooth.

 

At last, George was able to get his pain to stop. But only after the cement was removed from under the gum and after his cracked root canal tooth was removed.

 

 

My Recommendation

Pain is a terrible thing. Especially when professionals you trust can’t make it go away. It is not wrong to get another opinion from another professional. I always encourage patients to seek other ideas from other medical and dental experts if there is a concern or an unresolved question. Sometimes the cause of a dental problem is very difficult to determine; sometimes the problem is the result of poor dentistry.

 

At times, the dental problem is related to other problems occurring in different parts of the body. The mouth is intimately and intricately connected to the rest of the body. Whatever affects one cell will ultimately affect all other cells. The mouth is not an island unto itself.

 

Whenever there is pain, it could be the result of uncontrolled inflammation and infection. If infection and inflammation become systemic, many other parts of the body will be affected. The source of the problem must be discovered and treated appropriately.

 

 

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Inadequate Dental Exam
Results in Continued Pain

Dr. Al Danenberg Nutritional Periodontist
June 25, 2018

 

 

 

Inadequate Dental Exam

 

Last week a friend of mine, whom I will call Craig, called me. He lives about 300 miles away from where I live. He told me about his dental problem. His story is a recurring concern I have about some dentists performing an inadequate dental exam. A lack of an in-depth exam can result in continued pain for the patient as well as expensive, unnecessary, and possibly harmful treatment.

 

 

Craig’s Problem

Craig told me that several weeks ago he had pain in his upper left molar area. He had so much pain that he could not sleep. Ibuprofen was not taking care of his pain. So, he went to his dentist, who took an x-ray.

 

Craig is a healthcare professional, but not a dentist. So, Craig understands medical terminology and the process of correctly diagnosing a problem.

 

His dentist explained that he saw an old filling in the last molar that could be causing the problem. The doctor recommended to remove the old filling and replace it with a new one. Craig accepted the dentist’s conclusion, and the dentist proceeded to remove the filling and place a new one at that appointment.

 

My friend believed that the dentist knew what he was talking about and left the office after the procedure. Craig thought his problem was solved. However, the pain was not gone. It just got worse.

 

He returned to his dentist the following week and explained the problem was getting worse. The dentist then suggested that the tooth probably had a crack and would require a root canal and crown to save the tooth. At that point, Craig was concerned about his dentist’s diagnosis. So, he called me for my opinion.

 

 

My Opinion

Craig emailed the digital x-ray to me, so I could explain what I saw. It was a standard, two-dimensional dental x-ray. When I looked at the x-ray, I noticed changes in the bone density around the roots of his molar teeth. These changes suggested the teeth were in trauma. The trauma was typical of a clenching or grinding habit. Tooth trauma like this could wiggle the teeth and damage the jawbone. This could cause pain in the tooth area, pain in the muscles of the jaw, and pain in the jaw joint.

 

After I explained to Craig what I saw in his x-ray, he told me that he clenches his teeth most of the time. My next question to my friend was, “Did your dentist ask if you were aware of clenching or grinding your teeth?” Craig told me his dentist never discussed it nor questioned him about it. He also said the dentist never explained what he saw in the x-ray other than the old filling.

 

I told Craig a 3D x-ray of the area might help identify if there was a cracked root or other damage around the tooth that could not be seen from a standard dental x-ray. I also suggested that he purchase a soft bite guard from the drug store to cushion his bite while he slept. If the pain was only from clenching or grinding, then the soft bite guard might be able to lessen the severe pressure and possibly relieve the pain.

 

Craig immediately went to his drugstore and purchased a soft bite guard for about $20. He called me the next day excited, “Last night was the first night in several weeks that I had no pain and could sleep all night long.”

 

 

Closing Thoughts

I know that diagnosing problems in dentistry can be difficult. But, a well-trained dentist should be able to look at an x-ray and see what I saw.

 

When there are obvious changes in the bone suggesting tooth trauma, then one of the first questions the dentist needs to ask the patient is, “Are you aware of any habits of clenching or grinding your teeth?”

 

Certainly, the first thing a dentist should not do is replace an old filling before a thorough evaluation is done. An inadequate dental exam often results in a misdiagnosis and continued pain as was the case for my friend Craig.

 

To completely correct Craig’s problem, he may need to have various chewing surfaces of his teeth smoothed and polished to “even out” his bite pressures. Also, Craig may need a customized bite guard.

 

 

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