Pain and cold hot sensitivity after white composite filling on molar 1 month ago


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I need advice on pain and hot & cold sensitivity on my lower left first molar Tooth 19, a month after white composite filling. This tooth was absolutely painless and symptom-less before the filling, and had had no trauma. I am healthy and not on any medications. First I will upload links to the relevant X-ray images.

Image 1: X-ray of Tooth 19 before filling. The yellow circle marks tooth 19, while the red box indicates the “cavity” that the treating dentist (Dentist #1) saw and tried to fix
http://i.imgur.com/VssVF2c.jpg

Image 2: X-ray of Tooth 19 before filling from different angle (taken by Dentist #1)
http://i.imgur.com/YEbhu5p.jpg

Image 3: Actual picture of Tooth 19 after filling (taken by Dentist #2)
http://i.imgur.com/LQega48.jpg

Image 4: Actual picture of Tooth 19 after filling, with surface area of filling marked in yellow (taken by Dentist #2)
http://i.imgur.com/vrhR2Yq.jpg

Image 5: X-ray of Tooth 19 taken a month after filling, first angle (taken by Dentist #2)
http://i.imgur.com/GmKFefv.jpg

Image 6: X-ray of Tooth 19 taken a month after filling, second angle (taken by Dentist #2)
http://i.imgur.com/X8HmUuI.jpg

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THE STORY

In early February 2017, I visited the treating dentist (Dentist 1) for an oral exam. He seems competent and highly experienced, with a very busy office with advanced equipment.

Dentist 1 observed decay in Tooth 19, as indicated in the red box in x-ray Images 1 and 2. He performed an exploratory excavation using laser (no drill) and then filled it with white composite restoration. One week later, Tooth 19 became sensitive to hot and cold, and also very painful when biting. The sensitivity and pain were concentrated in the area where the filling is, at the corner of the tooth facing the cheek and Tooth 18, as shown in Images 3 and 4. Image 3 shows the actual picture of the tooth, and Image 4 marks the surface contour of the filling in yellow. Pressure on the rest of Tooth 19 yielded zero pain, but pressure applied to the filling surface area was so painful that I had to use my other side of the mouth to chew. Even pressing on the filling area hard with my finger yielded soreness. Swishing hot and cold liquids also caused high sensitivity in the filling area, but no sensitivity on other parts of Tooth 19.

3 weeks later, the pain from chewing lessened to the point where I could chew using the filling area of Tooth 19 with little pain. However, sensitivity to hot and cold liquids remained. I returned to Dentist 1 to have my bite adjusted. He used a colored carbon paper for my teeth to bite and grind on, and then used a drill to revise the bite. For the hot cold sensitivity, he used ozone gas to spray the tooth for about 1 minute, claiming that this would help. 1 week after the followup visit to Dentist 1 (so 1 month after the filling and 3 days before this post), the hot cold sensitivity has not improved. While chewing food using the filling area was still tolerable, during empty mouth clenching, the filling area still felt sore from biting pressure. I went to a different dentist, Dentist 2, to check if there’s anything wrong with the filling. The x-rays taken by Dentist 2, Images 5 and 6, show that the filling is far away from the nerve and not deep. No cavity around the filling could be observed. Dentist 2 again revised the bite using carbon paper and drill without Novocain. She said the filling was well done and there is nothing wrong with the pulp nerve, based on the fact that if there were a problem with the pulp nerve, when she fixed my bite with the drill I would’ve found it unbearable without Novocain. She also prescribed oral dexamethasone (0.75mg, 6 tabs, all taken in one day), claiming that after her bite revision and the dexamethasone, I would feel much better.

Dentist 2 also hinted that there may have been no cavity at all in the first place, as the “decay” spanning almost the entire height of Tooth 19 in Image 1 was nowhere to be found in Images 4 and 5, which were x-rays taken by the second dentist. Her reasoning is that, the filling covered only the top half of Image 1’s supposed “decay” vertically rectangular block. If the decay in Image 1 in fact existed, then the bottom half of the “decay,” which the filling did not cover, should still be observable in Images 4 and 5, but no decay can be seen in areas where the filling did not cover. But when I specifically asked her "so do you think the filling was unnecessary because there had never been any decay?" she avoided directly responding and said something like "oh that's not necessarily true as there may have been something there and Dentist 1 opened it up, went in there, removed it, and closed it up."

3 days after, which is today, the biting pressure pain and hot cold sensitivity have stayed the same despite Dentist 2’s bite revision. I have not taken the dexamethasone since I’m weary of the systemic effects of an oral corticosteroid. I also don’t want to merely hide the pain symptoms using dexamethasone especially when I am suspicious of something else going on in Tooth 19. The pain alerts me that there's something wrong.

Needless to say, I regret to have let Dentist 1 perform the filling without seeking a second opinion, but what’s done is done.

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CURRENT SITUATION

My goal is to resolve this asap through accurate diagnosis and proper treatment while keeping this tooth alive without crown or RCT. The last thing I’d want is for this simple filling to turn into a root canal or crown necessity. Cost is not an issue as I have a generous dental insurance so I'll do whatever it takes to make this tooth healthy again.

I would greatly appreciate any advice on what could be possibly happening to Tooth 19, given that I am feeling biting pressure pain and hot cold sensitivity despite the filling being far from the nerve and done by an experienced dentist using a supposedly precise laser. During empty mouth clenching, Tooth 19 is the only tooth that feels pressure pain. One thing that did improve is pain while chewing: 1 week after the filling, it was so painful to chew with Tooth 19 (with pain coming from the filling area) that I had to rely on my other side to chew. Now the chewing pain has gone down to the point where I can chew with both sides.

I’ve had my bite checked and revised twice by two different dentists. The tooth is much more sensitive to cold (eg. iced coffee, ice cream) than hot, and after it comes into contact with cold, within 3 seconds the tooth would be unbearably sensitive that I am forced to remove the cold stimulus quickly. This sharp sensitivity would dissipate after 2-3 seconds, but a dull minor ache would linger for longer. There is also an occasional throbbing dull ache in the tooth without stimulus.

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A FEW QUESTIONS

1. Could this be a cracked tooth?

This is my top concern due to Tooth 19's symptoms and the ramifications of cracked teeth. Nothing in the x-rays indicate a cracked tooth. However, I’ve performed a bite test on tooth 19 with a dental chewie, and there is indeed soreness upon moment of pressure release but it is not a sharp major pain. This soreness disappears within 2 seconds after moment of pressure release. Besides the bite test, what diagnostic tests should I request the dentist to perform to definitively confirm or rule out the possibility of a cracked tooth?

2. Could this be a bonding failure, or a cracked filling?

How can a dentist differentiate between a cracked tooth vs cracked filling / bonding failure?

Should I have the filling removed and redone assuming the filling is flawed, and see if the tooth would feel better?

3. Do I still have problem with my bite as a result of the filling?

I know my bite was perfect before this filling, as I've had thorough orthodontic work done and wear my retainer every night. I've read that a high bite could also cause my current symptoms. Should I continue to try to have my bite revised?

4. What are the chances of this being simply normal post-op pain and sensitivity after a filling where further intervention is unnecessary and the best course of action is to just wait it out?

I’ve had composite fillings done before and never have I experienced this level of discomfort – all of them were symptomless right afterwards. I suspect something’s wrong with the tooth or the filling as something’s off with the symptoms remaining for so long post-op.

5. Based on the x-ray images, in your opinion, do you think I got ripped off by Dentist 1 because there was no decay in the first place?

I’ve tried to provide as many details as possible, but if you have any questions or need further clarification, please don’t hesitate to ask. You're also welcome to PM me.
 
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svor1988, thanks for the comment. I've read your response in the other thread. Sounds like I have an incomplete cure, debonding failure or open margin issue?

I'm planning to have the dentist replace and redo the entire composite filling -- would that be a reasonable next step from here? If yes, what sort of precautions or requests should I ask of the dentist to ensure a successful and long-lasting filling replacement? For example, using a specific type of bonding agent and composite material? As for curing technique, should I request the dentist to use incremental cure instead of bulk cure?

My dental insurance will pay for everything so I seek the best materials and techniques available.

I know my post is long. It's challenging enough for you guys to "diagnose" my issue remotely online so I tried to be as descriptive and clear as possible with all the explanations and relevant images. Your time to read my thread and comment is greatly appreciated.
 
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I've uploaded a clearer set of pictures here. I was unable to edit my first post.
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Image 1: X-ray of Tooth 19 before filling. The yellow circle marks tooth 19, while the red box indicates the “cavity” that the treating dentist (Dentist #1) saw and tried to fixhttp://i.imgur.com/d9zL1eu.jpg
http://i.imgur.com/d9zL1eu.jpg

Image 2: X-ray of Tooth 19 before filling from different angle (taken by Dentist #1)
http://i.imgur.com/2YMB03A.jpg

Image 3: Actual picture of Tooth 19 after filling (taken by Dentist #2)
http://i.imgur.com/Qt9wFkZ.jpg

Image 4: Actual picture of Tooth 19 after filling, with surface area of filling marked in yellow (taken by Dentist #2)
http://i.imgur.com/MEE1oyu.jpg

Image 5: X-ray of Tooth 19 taken a month after filling, first angle (taken by Dentist #2): http://i.imgur.com/2rW201M.jpg

Image 6: X-ray of Tooth 19 taken a month after filling, second angle (taken by Dentist #2): http://i.imgur.com/sFPfwJR.jpg
 
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> He performed an exploratory excavation using laser (no drill) and then filled it with white composite restoration. One week later, Tooth 19 became sensitive to hot and cold, and also very painful when biting.

Was it etched with acid between the laser excavation and filling?

If it was not etched with acid:
From https://link.springer.com/article/10.1007/BF02133162:
"The results obtained indicate that the bond strength of laser-etched enamel was significantly lower than that of acid-etched enamel."​

Though that paper is from 1995. I'm not sure what current state of the art is. I did see another recent paper saying no bonding difference was found. Food for thought for you I suppose. You could try asking what model the laser is, determine the wavelength & intensity from that, and do a literature search. Sometimes the reading material put out by manufacturers puts their device in the best light possible while omitting or minimizing important details.

In a non-related paper I did see in SEM photos significant differences between acid etched and laser etched enamel; the acid etched looked far better in terms of bonding ability.

The bond would be more important in fillings on the chewing surface.​

In the event there is decay forming in a crevice between the composite and enamel (due to the poor/insufficient bond), avoid all sugary and acidic foods/drinks in the meantime, and rinse (with water) after meals. Minimizing food for bacteria means minimizing lactic acid produced, and thus minimizing further decay.​

I'm not done reading yet. You could also try seeing advice elsewhere, like reddit or telemedicine services- you should be able find more knowledgeable advice than mine.
 
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I recall that it was indeed acid etched, since he applied something sour to the tooth before filling it.
 

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