Nerve pain surrounding root canaled & crowned tooth-need crown lengthening?

[Leslynn]

My #14 tooth was diagnosed as needing a root canal and crown.  So the dentist put a temp tooth on and thereafter I had the root canal performed by an endodontist. Then I returned to the dentist for the crown fitting and I told her during that visit that I had slight discomfort on that tooth (and couldn't understand why if the nerves were no longer there).  She attributed the discomfort to sensitive surrounding gum tissue that would be relieved by proper oral care procedures which I followed and the crown was eventually placed.

But I continue to have discomfort surrounding that tooth which has become more like a zinging, nerve pain whenever I floss. I went back to the endodontist for his review and was shown that the root canal was done properly.  However, he did reveal that the crown was ill fitted (i.e., was not meeting the gum correctly at a point and food could get lodged under the crown).

So I returned to the dentist and she removed the crown and put the temp back on.  She also reworked cavities on the #13 and #15 teeth.  Also, I continue to follow her dental regimen (proper flossing, rinses, use Sensodyne, etc.) to try and improve the discomfort but it has progressively gotten worse. It really zings and hurts when I floss on the backside of that tooth and now also hurts when I chew on an edge of that tooth.

I went back to the endodontist to review the root canal again but he convinced me that his work was done properly. He was perplexed as to my problem since there is no evidence of an infection or fracture, and the temp seems to have a good seal now. He recommended along with my dentist that I see a periodontist.  

So I saw a periodontist who recommended crown lengthening surgery.  He said there is no guarantee that this procedure will alleviate my pain but is hopeful since it will allow better room for the crown placement.

Consequently, I am really unsure about proceeding with this surgery.  I have definite NERVE PAIN surrounding the back side of this tooth.  Could it be that the temp is ill fitted in some way?  Should I seek another periodontist for a second opinion or some other type of dental professional.  This whole process so far has taken over a year (there were a couple months setup during that time due to a family death).

What should I do from here?  I will appreciate any help.

[scottma]

Try to remove temporary crown and see if your symptom persists or not. If symptom disappears after temp off, you symptom is probably caused by occlusal interference. If problem remains, it may be periodontal tissue related or non-odontogenic toothache, in which condition, you may need to see an Orofacial pain specialist.

[Leslynn]

Thank you for your suggestion.  Yesterday my dentist called me to discuss and reconfirm that I need this crown lengthening procedure.  She said my situation is very uncommon and that I have an impingement on a thin biologic width.

I did not read your message until after my dentist called to advise the above.  If I follow your suggestion to remove the temp crown, how long can I go without wearing that?  Would I have to go without wearing it for awhile to know if that process will alleviate the pain?  Or do you believe the pain would go away right after the temp removal?

[Leslynn]

I forgot to mention that the dentist also said yesterday that "the fitting is too close to the bone".

[scottma]

Symptom will disappear in minutes after removal of temporary crown, if occlusal interference is the culprit. Violation of biological width by temporary crown is an unlikely event. If the pain is indeed caused by periodontal issue, the periodontist can confirm source of problem.

[Leslynn]

Thank you for your reply.  What is odd to me as that I did not have this flossing discomfort until AFTER the root canal and the first crown was cemented.  What would cause this impingement of biological width?

[Leslynn]

Hello, Dr. Ma.  I appreciate all your feedback so much.  

Would you recommend seeing another dentist or periodontist for review and if so, which one?  I asked my dentist about taking another look at the temp fitting but she said she is certain that will not help and that it sits too close to the bone, and too make an appointment for periodontal surgery.  So I do not think she will take the temp off for me to try your suggested test above.  This temp feels like it is "squeezing" my gum line and bulky.  

I did not have this pain before all the dental work began on this tooth.

[Leslynn]

Thank you so much for all your help, Dr. Ma!  I will seek a second opinion from a another periodontist or prosthodontist as advised.

[Leslynn]

Hello, Dr. Ma. I hope you are doing well!

I have visited with a prosthodontist, periodontist and endodontist (all new dental experts to render opinions) since my last contact with you.  They are all in agreement that the prep margin does not violate the biological width.  However they are not sure of my discomfort.  They suspect that my tooth is cracked but it is not showing up on visual/x-ray examines.  

The endodontist said another possible cause for my discomfort is that not all the pulp was removed during my root canal. So he is proposing to take a closer look by removing the packing material.  He said then hopefully his camera can capture a crack or he will find residual pulp left behind.

I will appreciate your thoughts on this.  I am suppose to have this endodontic procedure this Friday.

Also, the periodontist did remove the temp tooth in March and it has not been in place since.  My gum tissue is now much improved (thank you!).  However, I continue to have sensitivity on this tooth when I bite down, chewing food.

[scottma]

If tooth #14 is sensitive to chewing or biting after removal of temporary crown, possible cause of symptom is apical periodontitis resulting from incomplete canal debridement and/or obturation. Cone beam CT may reveal root fracture or Endodontic incompleteness better image. In addition, mb2 of tooth#14 tends to be missed easily. It appears your endodontist is equipped with Endodontic microscope, which can do a better job. If there is no Endodontic fault, you are probably having non odontogenic tooth ache, most commonly muscular toothache. In that case, you may need to see an Orofacial pain specialist.

[Leslynn]

Once again, thank you so much!  So to make sure I understand you correctly, you believe that the endodontic microscope will give a better image than a cone beam CT to view potential causes for my discomfort?  

[scottma]

Both endo microscope and cone beam CT will be basic equipment in the near future, just like x-ray, which was indispensable equipment for dental office in the old days. I believe endo microscope is essential for endodontist who were trained after 2001. Cone beam CT may detect early apical periodontitis and missed mb2 canal. Endo microscope helps endodontist see canal orifice and obstructed canal. If there be apical periodontitis detected by CT, and clinically mb2 or mb1 is non negotiable, apicoectomy and retrograde filling of MB canal may rescue the tooth, instead of extraction. It appears that you are reluctant to have the offending tooth extracted. The status of the tooth does not look hopeless to me, based on provided information.

[Leslynn]

Thank you for your reply.  I am hesitant to have the tooth pulled and an implant placed if not necessary.  I would really like to know the cause of my pain and to confirm that is the most appropriate remedy before doing so.  Tomorrow I will share your thoughts with the endodontist, and let you know any findings from there.

Your feedback and support is so appreciated!  

[Leslynn]

Hello, Dr. Ma.  I had the endodontic excavation procedure done yesterday. The endodontist cleaned out the canals (I believe he said I have 3; 2 of the canals each have 2 roots and the 3rd canal has 1 root; I have a radiograph of tooth 14 if you would like to review it - I don't see how to upload it here).  After examining with the microscope, he found calcified pulp at the tooth's service which he removed.  He confirmed that the Mb2 was not missed and there is no fracture. The calcified pulp was all he found.  He then resealed the canals with a temporary filling. Although he did not sound optimistic that removing the calcified pulp would help my discomfort, he said let's review in 2 weeks to see if there's improvement.  If the pain is gone, he will then refill the canals with permanent resin.  It the pain persists, then he suggested I either see my original endodontist to request a gratis root canal retreatment.  Otherwise, it looks like I would be taking the path of having the tooth pulled and have an implant placed there.

Any thoughts?  If seeing my x-ray (it is prior to having the calcified pulp removed) will help you render further feedback, please let me know the email address on where to send that.

Thank you!

[scottma]

It appears that the Endodontic treatment is optimal, and your presenting symptom is tooth sensitivity upon chewing and/or percussion. All endodontist know your symptom probably results from apical periodontitis, however, there is no radiographic evidence of apical periodontitis. Assuming there is no apical periodontitis, your problem may come from periodontal dysesthesia, the is coined by me and not appeared in existing literature. Periodontal dysesthesia is a type of peripheral sensitization of trigeminal nerve. After canan obturation, if your symptom persists, you may request your dentist to administer intraligment injection of lidocaine or mepivacaine without epinephrine once a week. If the culprit of your dental problem does result from periodontal dysesthesia. Your symptom tends to resolve or decrease. One or two more injection may eliminate the problem. If first injection does not help. Further injection is probably not helpful. In that case, administration of neurontin  and/or amitriptyline is warranted.
I believe my dental colleagues are honest and they can see the same thing as my eyes do. Your descriptions are adequate for me establish a dental image in my mind. Therefore, no need to send me x ray. You may present my opinion to your endodontist. The important thing is, when we don't have clinical and radiographic evidence to explain patient,s pain, we need to consider non odontogenic toothache.

[Leslynn]

Okay, Dr. Ma. Thank you for your feedback. I will share your thoughts with the endodontist upon my revisit, and appreciate all your time and help.