Heavily filled tooth persistently painful, but temperature sensitivity improving. Prognosis?

[ToothPatient]

Last worked on 8 weeks ago, the temperature sensitivity is improving, but the nerve has began to hurt constantly without provocation.

It just pulses, sometimes refers pain into the jaw.

Does this indicate irreversible pulpitis?

Dentist at the time said try and give it 6 months before committing to a root canal, but maybe he was referring to temperature sensitivity, not spontaneous pain?

Can this type of spontaneous pain ever subside?

When I do the "tap test" using a piece of metal against the tooth, it doesn't elicit pain or sensitivity.

It's perhaps the nerve is just still traumatized from all the work/drilling that was done on the tooth, and needs more time to settle down?

 

[ToothPatient]

Actually let me correct that, it was consistently painfully pulsing, but perhaps has either become more noticeable, or got to the point I'm finding it difficult to tolerate.

 

[ToothPatient]

Finally, I'm curious whether this consistent pain could actually be an infection?

Whether anti-biotics could help resolve it?

Or as above, it's been drilled on very heavily recently as per the x-ray, maybe the nerve is just acutely traumatized.

But again, temperature sensitivity which was the main initial complaint, is showing very good signs of improvement, to the point it's almost gone? (unless that means the nerve is just dead now)

 

[Dr M]

The spontaneous pain, is consistent with irreversible pulpitis. There is a high chance you will need a root canal. Antibiotics will maybe help, but it is never a solution. The pain will return as soon as the antibiotics is out of your system. Consider doing a follow-up with your dentist.

 

[ToothPatient]

The spontaneous pain, is consistent with irreversible pulpitis. There is a high chance you will need a root canal. Antibiotics will maybe help, but it is never a solution. The pain will return as soon as the antibiotics is out of your system. Consider doing a follow-up with your dentist.

Had a review yesterday.

Pretty sure the nerve is dead now. Prior it was super sensitive to temperature, now it's unresponsive to temperature.
Just getting pulsing/pain higher up in the gums.

Any idea how long would I have between now and the nerve totally dying, an infection/abscess potentially happening? Cause obviously that's what I want to watch out for now.

Root canal is definitely up next (provided it's viable).

......

Also, the "bite test", biting on cotton roll, releasing that is quite painful = possible cracked tooth?
An the buccal side, there is a horizontal crack across the tooth I can kind of put my finger nail in.
Unsure if that would again affect the possibility of a root canal being successful?

 

[ToothPatient]

Also in terms of after the root canal, getting a core (hopefully not a post), and crown placed, is it typically advised to see a restorative dentist or restorative specialist, for best results?

Or is that something a general dentist would typically look after?

 

[Dr M]

You can see a general dentist for this. You will need to make sure there is no crack first, since if there is a crack, and it runs too deep, then a root canal and crown, won't be a solution.
Unfortunately there is no specific time line from when a tooth becomes necrotic, until it forms an abscess. The best advice would be to sort it out as soon as possible.

 

[ToothPatient]

You can see a general dentist for this. You will need to make sure there is no crack first, since if there is a crack, and it runs too deep, then a root canal and crown, won't be a solution.
Unfortunately there is no specific time line from when a tooth becomes necrotic, until it forms an abscess. The best advice would be to sort it out as soon as possible.

I meant to clarify also, the thinking on having a post to hold a crown in place, after the RCT?

In modern dentistry, is it considered preferable of undesired to have a post?

The alternate being, a core exclusively.

I had read a post can act as a wedge, weakening the tooth, but may need more clarity on this.

 

[Dr M]

It depends on how much sound tooth structure is left after the RCT has been completed. If there is enough sound tooth structure, you can consider a core with a crown only. If there is not enough sound tooth structure, you will need to consider a post, and sometimes even more than one post.

 

[ToothPatient]

The spontaneous pain, is consistent with irreversible pulpitis. There is a high chance you will need a root canal. Antibiotics will maybe help, but it is never a solution. The pain will return as soon as the antibiotics is out of your system. Consider doing a follow-up with your dentist.

First, I've been been popping questions about this tooth on and on, I apologize for that, but it seems I'm at a juncture where I have to have faith in one position or another.

The temperature sensitivity is gone as mentioned prior.

The spontaneous pulsing (not in the tooth, but more toward the tip of the root in the gums), is improving each day.

If it keeps improving, in about a month I'd imagine it may have resolved entirely.

My concern is that if the absence of pain is just a dead nerve, then that pain may return much worse in the form of an abscess if left untreated.

Conversely, it would be far from ideal to have an unnecessary root canal treatment.

.......

I've followed up with two dentists who've adopted entirely opposing positions
1) wait and see
2) root canal ASAP (this dentist mentioned patients can often make it through the final phase of nerve death, dull, barely noticeable ache........ until the abscess forms and it becomes an emergency).

I guess that's why I'm personally trying to scrutinize the symptoms and try and reach some kind of conclusion (watching a lot of reversible versus irreversible pulpitis videos outlining corresponding symptoms etc).

........

Based on all that........ any further thoughts/perspective are welcome?

 

[ToothPatient]

It depends on how much sound tooth structure is left after the RCT has been completed. If there is enough sound tooth structure, you can consider a core with a crown only. If there is not enough sound tooth structure, you will need to consider a post, and sometimes even more than one post.

Actually, you raise the very issue I'm now confronted with.

Apparently a crack has been identified on a distal cusp as of yesterday.

So in addition to the occlusive, mesial, lingual and buccal surfaces being filled, now the distal area has a crack apparently.
There may be a crack across the buccal surface? The inverted curve shadow I can fit my fingernail into.
And constantly inflamed/bleeding gum just above that large buccal/mesial surface filling (angry red looking).

I'll just post these pics again real quick:

After drilling out the core for a RCT........ might trash what little is left of that?

If it were a case where a post was necessary, I understand extraction might be preferrable.

I don't know, it may be impossible to say, only feasible to find out by doing it and seeing what happens.

But I'm on the precipice of having to make that decision, extraction or RCT.

Thoughts/experiences are welcome.

 

[MattKW]

It seems it has gone irreversible and it is only a matter of time before it becomes painful. An RCT (or extraction) is inevitable. It would be better to plan for it at a convenient time rather than pain to force you to seek treatment.
As for post or no post, I completely agree with Dr M; it will depend upon how much tooth structure remains. It's not easy to judge based on Xrays alone; I would firstly take out all old filling, do the RCT, then see what remaining natural tooth structure is left. I attach a simple decision-making tree that I teach (ETT = endodontically treated tooth)

 

[ToothPatient]

It seems it has gone irreversible and it is only a matter of time before it becomes painful. An RCT (or extraction) is inevitable. It would be better to plan for it at a convenient time rather than pain to force you to seek treatment.
As for post or no post, I completely agree with Dr M; it will depend upon how much tooth structure remains. It's not easy to judge based on Xrays alone; I would firstly take out all old filling, do the RCT, then see what remaining natural tooth structure is left. I attach a simple decision-making tree that I teach (ETT = endodontically treated tooth)

Thanks for that clarification.
As of next week it's going to be either the extraction or RCT, just trying to decide on which.
Wasn't expecting this onset of seriously acute pain that woke me Friday morning however, and forced me to take anti-inflammatories every 6 hours since (which had no effect on the pain that was there before Friday). Pain went from "moderate" to "severe" in an instant, unsure if that's typical of an abscess?

Perhaps you can clarify also:

Prior to this Friday, I could chew on the tooth fine. Now it's WICKED painful, impossible to chew on, I can't clench down fully at all.

What I'm trying to determine, could the nature of this new onset pain be attributable to abscess formation?
Or an emergent crack, as the inspecting dentist on Friday thought possible?
Or perhaps a crack that's aggravated the abscess, so like a double barrel effect?

 

[ToothPatient]

Can answer this question myself now.

Three full days on anti-biotics, that insane pain on chewing has subsided

= it was attributable to abscess formation/infection, not a crack as had been put to me by an endodontist.

........

It seems it has gone irreversible and it is only a matter of time before it becomes painful. An RCT (or extraction) is inevitable. It would be better to plan for it at a convenient time rather than pain to force you to seek treatment.
As for post or no post, I completely agree with Dr M; it will depend upon how much tooth structure remains. It's not easy to judge based on Xrays alone; I would firstly take out all old filling, do the RCT, then see what remaining natural tooth structure is left. I attach a simple decision-making tree that I teach (ETT = endodontically treated tooth)

So really this question could only definitively be answered by the restoring clinician? (a prosthodontist in this case)

During the restorative procedure?

Based on that linked chart, there's more filling than tooth in this tooth, so at least one post, based on that?

This x-ray doesn't show the opposite/lingual side, which looks heavily filled to me?

And where a post is necessary, I understand oftentimes an extraction becomes preferrable?