Phantom Tooth Pain?
Most dentists have encountered the patient who complains of an unlocateable tooth pain.
Sometimes it is a sharp pain that causes a reflex reaction when chewing or when eating crunchy foods or sweets. Oftentimes, a radiographic and clinical examination reveals nothing except healthy teeth with small fillings.
In other situations it is quite obvious when you see a tooth with a large filling. Usually what we are looking for, based upon the symptoms presented, is a cracked tooth. The cracked tooth can be difficult to locate and sometimes goes undiagnosed until the tooth fractures and is more symptomatic.
Usually, when a tooth fractures, the cusp breaks off in a diagonal direction at the level of the bone. If there is enough tooth structure remaining, the tooth can be saved but may it may involve doing a root canal (RCT), post core build-up and crown lengthening. If there is not enough tooth structure remaining, it would probably be best to remove the tooth and place an implant.
The obvious candidates for sensitive teeth pain are previous treatments that have large fillings. Large fillings weaken the tooth and as we bite, the cusps of the teeth are flexed in a lateral direction which can lead to cracks and fractures.
When there is pain associated with a crack, it occurs because the crack has propagated far enough that the crack itself expands and closes with biting pressure. This opening and closing of the crack affects the nerve within the tooth and creates the pain and sensitivity.
There have been numerous times that I have removed an old amalgam filling from an asymptomatic tooth only to find cracks within the tooth structure. In those circumstances we can preventively restore the tooth to prevent the crack for getting any worse.
There are different restorative options for cracked teeth. The main objective is to prevent further cracking of the tooth and fracturing. The most common restorative options can include:
- 100% Porcelain Crown
- PFM (Porcelain Fused to Metal)
- Acrylic Crown
- Porcelain Onlay
- Gold Onlay
Sensitivity Yes - Cracked Teeth No
But what if the sensitivity is not from a cracked tooth? What could cause an individual to wince when eating something hot or cold or chewing something crunchy? What else would cause sensitivity?
Enamel erosion or abrasion can lead to sensitivity. Abrasion can occur at the gum line from over zealous brushing which abrades away the enamel, creating notches near the root and exposing the underlying dentin.
Erosion occurs from a combination of acid and bruxism. The acid weakens the enamel and the bruxing or even normal function wears away the enamel exposing the dentin. Enamel erosion can be seen on the biting surfaces as small craters.
Dentin is composed of tubules that extend out from the pulpal area of the tooth. There is fluid in those little tubes and every time the fluid moves it stimulates the nerve in the pulpal tissue. Hence the wincing reaction.
Treatments for this type of sensitivity can be include:
- Sensodyne Toothpaste
- MI Paste
- Composite Resin Restorations
- Dental Crowns (Caps)
Sensitivity caused by Dental Treatment
What about sensitivity after having restorative work?
Sometimes patients have sensitivity to biting after placement of composite restoration. The reason this occurs is because a small micro gap exists between the composite restoration and the underlying cut dentin.
Every time the patient bites, the composite flexes enough to create a pressure change in those dentinal tubules and tug on the pulpal nerve. The micro gap can occur because of polymerization shrinkage of the composite or poor bonding technique. In any event, replacing the filling properly should help.
Sensitivity can be experienced after a tooth is prepared for a crown, onlay, or a veneer. When a tooth is cut, you are exposing those dentinal tubules. If the tubules are not sealed with a bonding agent or a good fitting temporary, sensitivity will occur.
In addition, without a good fitting temporary, bacteria can get under the temporary and into the dentinal tubules resulting in sensitivity as well, and quite possibly an irreversible pulpitis resulting in root canal treatment.
Lastly, sometimes a permanent crown, when placed, does not fully cover the cut tooth structure which can cause annoying sensitivity.
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