Crown issue

[Cassandane]

Hi All,

I had a large cavity on my UPPER RIGHT MOLAR back in 2014 which was treated with a filling. Filling is huge (pic attached). After the procedure as the weeks passed I noticed a jolt when i bite. It feels like biting on aluminum. Its like an electric shock. It only happens when i bite on hard objects like almonds etc .. the dentist said to give it time and see if it gets better. It never did. He did a bite test on me every time I came in to complain and I think he tried to file it down or something. Not sure what he tried to accomplish. I moved away and lived with it. The jolt only came on hard foods and it wasnt super bothersome. It still isnt bothersome. I can live with it if I have to. These days I can chew on it better than I did in the past.

Fast forward now 2018 the jolt now surfaces when I eat acidic foods (lemon, lime etc.) I saw 3 dentists for 3 different opinions. They did a bite test and concluded that their may be a fracture or brokeness on one of the cusps. They cannot prove it but when they put pressue at a certain angle with the hard tool they use for the bite test I raise my hand when I feel the jolt. If the tooth is really fractured on one of the cusps how is that possible since I felt the jolt right after the filling was done years ago. Theres no way I fractured it right after the filling.

All 3 dentists suggested a crown. They said the crown should solve the problem (98%) lol... and if it doesnt then a root canal is next.

The crown is gonna cost me $550 (my share) thats the exact cost as quoted by insurance. Do you think I should skip the crown and go straight to a root canal? I doubt that the nerve or root has anything wrong with it. Based on what i described about the jolt happening from hard foods and now acidic foods does it mean the issue is with the nerve or the issue is with a fracture? These days I dont notice a jolt on hard foods I notice it on acidic foods. My most recent dentist said a filling should of never been done on it, instead it should of had a crown immediately after discovering the cavity.

Why should I pay $550 now and get a crown only to be later told I need a root canal? Please explain this whole issue to me and why a crown is suggested first.

 

[MattKW]

You've got a deep composite on that tooth. As a first step, I'd suggest taking out the filling and looking at base of cavity prep - most cracks appear along base of cusp inside the tooth, and can be picked up with transillumination. Another possibility is that the composite is leaking, especially along deep back edge. After checking for crack in 1st step, if no crack found then line base of cavity with thin smear of Ledermix/corticosteroid paste for pain relief, then Dycal (CaOH) for insulation, and refill with amalgam. If the pain still continues, then consider RCT BEFORE a crown. An RCT can be done after a crown, but raises risks of difficult access/ poor visibility, and weakening of crown strength. I don't agree with crowning a tooth that is sensitive to see if that works - the pain must be resolved as first stage.

 

[Cassandane]

I forgot to mention that when I got the first filling in 2013 and moved to my current city my dentist here removed the first filling and put a new one in. But the jolt continued even with the new filling.

 

[MattKW]

Understood. But composites are much more likely to have post-op sensitivity than amalgams. If redoing a comp doesn't resolve the sensitivity (or if it's a huge cavity anyway), then I will change to amalgam. That usually does the trick as amalgams don't shrink/leak like composites. If changing to amalg doesn't work, then prepare for RCT, then crown.

 

[Cassandane]

Your suggestion is to now do a third filling with amalgam and see if it works and if it doesnt move to a root canal?

What if the nerve is healthy and viable though? Can Root canals be done on healthy teeth with good nerves?

 

[MattKW]

If the tooth settles down with the amalgam, then you won't need an RCT, just go straight to crown after a few weeks.The only reason that RCTs get done is when the nerve isn't settling down despite all simple attempts. If you go straight to crown with cranky nerve, the extra damage is likely to aggravate it further, and then you'll end up with an RCT that'll have to go through the crown. And that's a pain to do. It's much better to do a crown on a live tooth than an RCTd tooth because you'll have a stronger foundation (the natural tooth structure) - RCTs weaken teeth.

 

[Busybee]

I had a problem like this and it was a crack at the side of the tooth. I had an amalgam filling in the tooth at the time it cracked. The endo wanted to do a root canal & crown, but I went for a second opinion and that dentist suggested replacing the filling to seal the crack. He used composite. It's been successful for ten years. So instead of killing the nerve with RCT he saved the tooth.

I had a similar problem on the other side, which was at the time also filled with amalgam. That was fixed with a gold onlay. Maybe it was not necessary but good gold onlays last decades.

What you will find is that every dentist has a different approach on how to fix this. The trouble with a crack is that it can get worse if you don't protect it. If it goes to the root then you need an extraction so it's important to fix sooner rather than later. A crown can always be replaced if you need root treatment. Yes it's a waste of money if it doesn't work out but if it does, it might be all you need.

I've recently had a porcelain crown on a molar (which is not cracked) and I do think a gold onlay is better all round particularly if there is a heavy load on it.

 

[Cassandane]

My filling is white meaning its composite right? All the other fillings in my teeth are silver because I had them all done as a kid. So the problem is from the white (composite filling) as you are all saying?

I just feel like theres too much uncertainty...

It could be a million reasons why the tooth has a jolty feeling:

1. The tooth is cracked
2. The crack in the tooth reached the nerve
3. Composite is leaking
4. Theres no crack but a problem with the nerve
5. The filling should of been filled with amalgam instead
6.. more reasons
7. Etc...

How am I supposed to know why I have a jolt feeling? All the reasons I listed could be the culprit. I doubt a removing the composite and putting in amalgam will cure it. Again this is a huge filling. As you can see on the photo the parameters of the filling are from east to west on the tooth. Its pretty big no? The Dentist showed me a saturated photo of the xray which shows the filling is kinda sorta close to the nerve but not really. He said during the buildup of the crown he will be able to determine if the nerve is going to be affected and if it is then he will stop everything and suggest a root canal. Does his technique sound wise?

 

[Busybee]

When I have a jolt feeling it has always been a crack. It's like an electric shock and the real shock in my experience is when you eat hot food. I remember the agony of biting on a hot chip. A dying nerve is constantly painful in a different way. It doesn't react to temperature in the same way. Just hurts all the time. You can't pinpoint the pain and it can feel as though your whole mouth is sore. Can radiate beyond the mouth to the eye, jaw, depending on where the tooth is. With a crack that has not gone to the root it only hurts when you bite or chew. The clue is that it will linger after you have bitten into the food. The pain is not only sudden but develops in the seconds after biting.

 

[Busybee]

By the way a composite that's not properly sealed is a less intense pain that hurts when you eat sugar more like a sensitive tooth pain.

 

[Cassandane]

I understand. When I first got the filling a few years ago I got the jolt you described when I chewed on tough foods like nuts, maybe beef jerky, an unpopped popcorn kernel, stuff like that. The jolt would last maybe 2 seconds and go away.

These days I dont notice the jolt on hard foods as much. I have become immune to it because I have lived with it for these years that I have trained myself to use my other side of mouth to chew hard food. But these days I notice that jolt occurs when I chew sugary gum, have acidic salad dressing anything zesty and lemony. So my fear is that the acidic jolt is bad. Then pretty soon maybe Ill start getting sensitive to hot or cold. The jolt last a couple seconds and its just an annoyance, not really the aching nerve pain you describe. I know when all the dentists did the bite test they had me bite on a tool they put under the tooth and they would put it at a certain angle touching a specific point on the tooth. It only felt jolty when then placed the tool on a specific part of the tooth which they claim may be the cusp.

 

[MattKW]

Just to clarify in my experience of 35 years as a dentist: Any heavily filled tooth can crack, no matter what it is filled with. When you have pain immediately after a composite filling, then I would blame the composite sealing as a first inference. By replacing with a simple amalgam, you may take away any problem with the comp and relieve your symptoms. And then you may not need an RCT. That's how I'm looking at your history and how I would handle it, rather than jumping into a crown or RCT. Once you start a crown prep, you are committed to a crown. I don't believe that a crack has been justified at this point - ypou have to take out the filling and look at the base of the preparation for best chance.

 

[Cassandane]

I ran this idea by my dentist but he thinks the amalgam filling wont work since the "alleged" fracture on the cusp is too big and too detrimental. He says this upper molar is used for chewing and bears alot of stress and pressure during eating etc..so he still believes a crown would be the better option. I noticed something else: When i floss that tooth (#3) i notice the jolt sensation only arise when i floss that tooth on the side that it is touching tooth #4. When I floss that tooth from the side that it touches tooth#2 i dont feel anything. I attached a photo showing a red line which represents floss and that is the side of the tooth at which i feel the jolt. Perhaps the fracture is on that particular cusped side and not the other side.

 

[Busybee]

Did you discuss a gold onlay? You remove less tooth that way and it does the same job, if not better. There seems to be a lot of marketing for composite and porcelain vs gold and amalgam these days. You generally remove less natural tooth for both gold and amalgam. The restorations for the latter also last longer. Dentists these days seem obsessed with composite and porcelain. Is it cheaper I wonder?

 

[MattKW]

Did you discuss a gold onlay? You remove less tooth that way and it does the same job, if not better. There seems to be a lot of marketing for composite and porcelain vs gold and amalgam these days. You generally remove less natural tooth for both gold and amalgam. The restorations for the latter also last longer. Dentists these days seem obsessed with composite and porcelain. Is it cheaper I wonder?

Gold onlays don't necessarily remove less tooth structure because it is an indirect restoration. By that I mean you have to take an impression and it means there must be no undercuts, the preparation must be flared outwards, unlike normal fillings (comp or amalg) which are direct. An indirect restoration will always have more tooth removal than a direct restoration. Not saying there's anything wrong with inlay/onlays, but there's lots of pros and cons to different ways of restoring teeth. Each case is different.

 

[MattKW]

I ran this idea by my dentist but he thinks the amalgam filling wont work since the "alleged" fracture on the cusp is too big and too detrimental..."
My point is not that a crown won't work, in fact a crown is probably the best option in the long run. My issue is that your dentist is assuming it's simply a crack because or the "bite test" alone, and doesn't seem to consider that the composite could be the problem. As I said in last post: to find the crack, remove composite and physically LOOK for crack with transillumination. If no crack, then refill with amalgam and see if that settles pain. If THAT works, then go for crown. You will hopefully avoid need for RCT. I think too many dentists don't accept the potential shortcomings of composites when issues like this arise, and rush to judgement based on limited testing and reasoning.

 

[Busybee]

Matt I meant that if you're going for a crowned option then a gold onlay would remove less tooth than a ceramic crown. I've been told by more than one dentist that a ceramic requires slightly more tooth removal and that although gold is best patients don't like the way it looks. From an end-user point of view, I do feel happier chomping on gold than ceramic, feels indestructible (like Jaws in James Bond). On that tooth you'd probably see it in the smile.

 

[Busybee]

My point is not that a crown won't work, in fact a crown is probably the best option in the long run. My issue is that your dentist is assuming it's simply a crack because or the "bite test" alone, and doesn't seem to consider that the composite could be the problem. As I said in last post: to find the crack, remove composite and physically LOOK for crack with transillumination. If no crack, then refill with amalgam and see if that settles pain. If THAT works, then go for crown. You will hopefully avoid need for RCT. I think too many dentists don't accept the potential shortcomings of composites when issues like this arise, and rush to judgement based on limited testing and reasoning.

It seems very sensible to test it this way, but IMO most dentists wouldn't be patient enough to do that Matt. Depends on temperament and approach to work of course. Most dentists are focused problem solvers and like to find the fastest route to the solution so don't always want to try different things. Wouldn't it also mean disturbing the nerve twice which could lead to root failure in a tricky tooth and more tortuous dental visits and injections?

 

[MattKW]

It doesn't take much time to do this, and if you truly want to get to the base of the problem it's the only way to go. Otherwise you're simply treating symptoms. The tooth is already disturbed - if you go straight to a crown with all the damage that'll cause, then you're much more likely to end up with an RCT than if redo with amalg first and allow pain to subside. I don't like to think my dentistry is tortuous to that extent, and if it avoids an RCT....

 

[Busybee]

Matt - all dentistry is tortuous for the patient!