Cold Test positive and X-ray negative: a painful time dilemma

[Brause]

Tooth #36, X-rayed today. No radiographic anomaly found (yet), but cold test failed.

Most dentists would diagnose irreversible pulpitis, but mine is skeptical...he thinks cold tests are not conclusive. The tooth has no caries and only a small restoration. It had to take on a lot of the chewing work since #46 had been extracted 3 months ago.

What does not support advanced pulpitis:

1. First sensitivity recorded with an electric toothbrush one month ago.
2. Some bite/chewing sensitivity for the last 3 weeks.
3. Real toothache only crept up in the last 2 weeks.
4. Toothache not present at night.

Dentist thinks it is some kind of orofacial pain.

The question is: how conclusive is the cold test? Are we waiting for the "rarefying osteitis" to appear 2-10 months after the start of the pulpitis?

P.S. No root canals for this one for the case it needs them. I'd go for extraction and implant considering the chewing stress #36 has to handle.

 

[MattKW]

A cold test (or an EPT) has to be measured against other teeth to gauge overall sensitivity. I see that you have had significant enamel erosion on the 36 and slightly less on 35. This is usually indicative of an acidic diet, e.g. soft drinks, fruit juices, ... and would lead to sensitivity. Is this a fair statement?

 

[Brause]

A cold test (or an EPT) has to be measured against other teeth to gauge overall sensitivity. I see that you have had significant enamel erosion on the 36 and slightly less on 35. This is usually indicative of an acidic diet, e.g. soft drinks, fruit juices, ... and would lead to sensitivity. Is this a fair statement?

Great observation. Likely bruxism*, and maybe my diet is acidic (oats, brown rice, blueberries, 1 can of Coke Zero per day...but no fruit juices, processed meats). But why would it affect only selected teeth...unless it is bruxism + acidic foods?

Coffee definitely aggravates it, black tea less so.

Tooth 33 showed very little cold sensitivity in comparison.

One possibility is that tooth 36 was traumatized during the extraction of fractured tooth 46 just before Christmas. I had to bite on a mouth prop whereas there were wild vibrations during the extraction...which lasted for over an hour. This could have traumatized tooth 36 (which was felt 2 months later). Or is that too far fetched?

The other possibility: since mid November, I have been chewing mainly on tooth 36 (35, 37) as tooth 46 was hurting/missing...and it is somewhat stressed.

My dentist advised against endodontic treatment.

From the literature, I learn that false positives in cold tests are rare. I still think it could be advanced pulpitis through trauma (though I wonder how the bacteria could have entered without fractures).


* received a mandibular nightguard in early February.

 

[Brause]

Teeth 36 and 35. Is the yellow material dentin underlying an overly thin enamel?