Article: 34722 of sci.med.dentistry From: joele@earthlink.net (Joel M. Eichen) Newsgroups: sci.med.dentistry Subject: Toothache? Date: Fri, 20 Aug 1999 00:08:29 GMT X-ELN-Insert-Date: Thu Aug 19 18:05:12 1999 X-Newsreader: Forte Free Agent 1.0.82 Organization: EarthLink Network, Inc. X-Posted-Path-Was: not-for-mail Lines: 567 NNTP-Posting-Host: sdn-ar-001paphilp017.dialsprint.net X-ELN-Date: 20 Aug 1999 01:02:11 GMT Message-ID: <7pi9ej$q6c$1@holly.prod.itd.earthlink.net> Path: news1.meer.net!news3.best.com!news2.best.com!news.maxwell.syr.edu!newsfeed1.earthlink.net!nntp.earthlink.net!posted-from-earthlink!not-for-mail Xref: news1.meer.net sci.med.dentistry:34722 Toothache? Here's an old file about what to do. Its a repost - you know. There's summer reruns when people are on vacation! Tom wrote: > This is an important question to me, because > my current treatment plan calls for crowning > all my teeth to protect them from fracture. > (I'm a pretty serious nighttime bruxer and > have lost several teeth already due to > fracture.) But if crowning doesn't offer much > protection, seems like I ought to just pull > them all and get dentures. > - Tom Cheers, Joel REPLY TO TOM: Hey Tom! All or nothing treatment plans lead to dentures far too often. Your own teeth are still better. Read below: ------- Root canal therapy ^^^^ ^^^^^ ^^^^^^^ Ouch! Is pulpitis reversible? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Somebody asked, "My dentist said the filling was very deep. I might need root canal therapy. What's the time frame between getting my tooth filled and knowing if I need the root canal therapy?" ANSWER: This is a pretty difficult and complex question. Its a pretty long post too! Sometimes its a month and sometimes its 12 years. The reason is that, acute problem ----> resolution or acute problem -----> chronic problem. This is well within the realm of cosmic consciousness, Budda, Jesus, Moses, ethical humanism, chakras, auras, and LGM (Little Green Men). In other words, prayer sometimes helps even more than homeopathic, allopathic or even naturopathic remedies. Really! * * * If the tooth hurts (sharp pain), wakes you up at night a lot, hurts to bite on it, and then becomes swollen, its definitely root canal time (or removal time). Its not going to get better by itself. If the tooth hurts, but its getting a little better, maybe it will be okay. Sometimes yes, sometimes no. What occasionally happens is that there is a sharp pain (known as the swan song) followed by "nothing!" This does not mean the tooth is just fine. Sometimes the tooth becomes non-vital and the abscess will develop a bit later (6 months to a year), frequently after a cold or bout with flu. The physical symptoms are what is most important in the diagnosis. Some dentists just go right ahead with the root canal as soon as possible, post and crown as soon as possible, while others do not. Read on! =============================== Is pulpitis reversible? Dentists are in two camps concerning the answer to this question. Its an important issue because it could affect what happens to your teeth years from now. This is kind of like the debate about the issue of social security when the baby-boomers retire. This is pretty much the "social security issue" of dentistry. I am concerned about this because I see so many beautiful root canal treated teeth where the entire top of the tooth is completely rotted off. With some teeth, the decay is even way down into the uppermost portion of the root. Beautiful root canal, but the tooth has got to go! Yes, I already know that this is the patient's own fault, but health care is not about "fault." I've already heard that I should trade my '95 Nissan plus the root canal care for the patient's 1998 Ford Bronco and then we will both be happy. But all of these bright ideas aside, our goal is to treat disease in the most beneficial and efficacious way possible. Even at this point, I could salvage that tooth with a post followed by a "root extrusion process." That is, I might want to "pull up" the root using an elastic band attached to an IntegraPost. Once the attachment heals, the ideal ferrule effect can be achieved. "Ferrule" is the metal piece that holds the wooden handle to a good shovel. A shovel without the ferrule is no good at all. A crown without a ferrule is even worse. Crown lengthening may be also indicated. You'll also need a crown to restore this tooth, meaning that this is a fairly complicated process and it is not cheap by any means. This is most likely the reason why you did not get your root canal tooth properly restored in the first place, so I bet that all of this knowledge is just like spitting in the wind. Next, I see so many fine root canal teeth where there is not any tooth structure left. Where do I attach the crown? I place a post and I hope and pray that it remains right where it belongs. How many times does the dentist see a crown come out, complete with a scary-looking post? Believe me, it happens! So, here comes my brand new emergency patient, no dental insurance, cute tattoo on one shoulder, and possibly a piercing the location of which you do not want to know. I do not mean to disparage the many wonderful tattoo shops and piercing shops that are keeping the Philadelphia economy alive and well, but quite frankly I hope that they are not propagating HCV (Hepatitis C) in their ink, while doing this. I hope to set this "achey brakey" molar right. It "aches" and I hope it will not "brake." I excavate the decay and I place a sedative dressing, which I hope will sedate the irritated nerve (pulpitis). If I am correct, (and many times I am), then I can avoid destruction of excessive tooth structure, root canal therapy, and some of the complications described above. In other words, I am trying to keep it simple right into the next millennium. Of course, there are no guarantees when we work with human beings. Most times, the patient is appreciative. Others might prefer to go right ahead with the "whole ball of wax" but that's what I'm trying to avoid. I don't like seeing "a whole ball of wax" where a tooth should be! Is pulpitis reversible? I do not have any evidence at all that pulpitis is reversible. Quite possibly, the nerve dies and becomes mummified. This in itself is not a bad thing as long as the mummification process seals off the apical foramen (hole in the tip of the root) in some sort of a physiologic manner. As long as there is no entrance for bacteria, then all will be well in toothland. This last paragraph is pure speculation on my part. Perhaps there are studies which demonstrate that root canal - post - crown is the only route to success. I do not know. This seems to be the belief of many dentists. I've seen too many small fillings proceed onto root canal, crown, post and extraction, way too soon. Further, my observations are not done within any controlled clinical setting. They are only observations which seem to be generally true when observing the dental health from various populations - that is, my loyal patients! [What follows is a repeat post about pulpitis.] ================================================= P U L P I T I S ================================================= Pulpitis means "inflamed pulp." This is not "infected pulp," although an infected pulp will most likely include some inflammation. Heck, it is always so! Bacteria generally cause inflammation of the tissues (inflammatory response). Tooth------(trauma)-------->Hyperemic pulp (pulpitis). Hyperemia means "increased blood flow." This means the tooth is sensitive to cold and hot, and just doesn't feel right. There might be some sharp pain. Classical signs of inflammation are "calor, rubor, tumor, dolor." This means "heat, redness, swelling, and pain." Sounds better in Latin, doesn't it? Ahhhh, these dentists. They know what they are doing! Inflammation is widely studied so that the practitioner is keenly aware of what he is looking at. You might want to become aware too. It is the exact same process as when you get too much sunburn, a bruise, or assault from a noxious substance. "Calor, rubor, tumor, dolor." No infection (no bacteria), just inflammation. (Dermatitis: derma- = skin, -itis = inflammation). There are two possible conditions. The tooth either heals spontaneously or it does not. Some dentists will tell you that pulpitis ----always ------> abscess. I do not believe that this has been shown to be true, but I do stand to be corrected if there is evidence to that fact. I have seen many times that, pulpitis ----sometimes-----> normal. A hyperemic pulp may respond with sharp pain when cold water or ice cream hits it. Sometimes, something weird happens. There is an unusually intense pain, and then the next day, nothing. Do not relax just yet. If the hyperemic pulp expands too much within the pulp chamber of the tooth, it "strangulates" the blood supply and nerve tissue and cuts off the venous return. This means that the engorged tissue inside of the pulp chamber has impeded the blood flow back out of the pulp chamber. Remember, the arteriole, the venule and the nerve all pass through a fairly small apical foramen (hole at the tip of the root of the tooth). The nerve tissue "dies." Louis I. Grossman, one of outstanding pioneers in endodontics (root canal dentistry) graduated the University of Pennsylvania in 1924. He referred to this intense pain the pulp's "swan song." This means that the pulp is now non- vital. By the way, Dr. Grossman graduated dental school in 1924. Not undergraduate. You did not need an undergraduate degree or even have a need to step foot into a college classroom in 1920 when he first matriculated into dentistry. These dudes went from high school right into dental school. They were fine dentists but made plenty of errors in other areas such as chemistry. A dental abscess (bacterial infection) means that a process occurs which allows bacteria to proliferate around the apex of the root. This is called, "periapical (around the apex) abscess (collection of pus)." Periapical abscess. A non-vital pulp is vulnerable to attack from bacteria which may be circulating in the blood stream from time to time (transient bacteremia - temporary circumstance of bacteria circulating in the blood). The bacteria lodge inside the now non-vital root canal and proliferate. The dentist looks at the x-ray and observes a dark shadow around the root. "Ahhh, you have an abscess. We have to perform root canal therapy." You have a dull pain, and you have some swelling. Your tooth might feel raised up. This is the result of the bacteria trying to push the tooth right out of your mouth. If you wait for 5 or 10 years without the dentist, the tooth will spontaneously exfoliate (come out all by itself). The tooth will be gone. I do not advise waiting that long, unless you are auditioning for Stoppard's new film, "Shakespeare in Love." If that's your thing, then missing teeth are an advantage for employment. This entire scenario may be further complicated by the fact that some teeth have 3 roots, some have 2 roots but 3 root canals, and some teeth have 4 root canals. Other teeth have only one! This is why we have to go to dental school for so long! We got to memorize how many canals! I personally have jotted it down on the sleeves of my dental coat, just so I appear cool. This multi-rooted situation means that the clinical symptoms might be slightly more clouded. You might get some symptoms from the front half of the tooth and other symptoms from the back half. What this means is that the infected root (back half) is relieved by "cold" while the other two roots (front half) are aggravated by the "cold." So this confuses the diagnosis. At this point, the other two roots will definitely become abscessed fairly soon and the entire tooth will need root canal therapy. It is not possible to do root canal therapy on part of the tooth. Infected is infected. One more thing. There are many non-vital teeth with absolutely no observable abscess. The pulp has "mummified" which is my personal description for it based upon some guessing. This means that the non-vital nerve tissue has obturated (stopped up) the apical foramen (hole in end of tooth) so that no bacteria can enter. This is just a quirk of nature, as far as I can tell. If the endodontist does root canal therapy, he replicates this procedure, of course by opening through the top of the tooth, instrumenting and cleaning the canals, and then obturating with gutta percha, which is a rubbery substance manufactured (that is hand rolled - the original meaning of the word, "manu-factured") in India. * * * * Some important root canal treatment information My first bit of advice about root canal therapy is to avoid it if at all possible. I do not mean to imply that you should not get root canal therapy for a tooth which clearly needs it - I am suggesting that you do not have root canal treatment for a tooth that does not need it. How do you know if you need it? 1. Symptoms - the tooth feels raised up and out of its socket. You cannot bite your other teeth together because this one is way too high. 2. Percussion - if you or the dentist strikes the tooth "sharply" with the handle of a mirror or with a dinner fork or chopstick and it hurts a lot. 3. Pain - You have a dull aching pain which is relieved by applying cold or ice to the tooth. We frequently see the emergency patient come in with the 32 oz. Taco Bell cup filled with ice walking in to the office. It is snowing outside. This is a tip-off that the dude has an abscess. I can make this diagnosis at 30 feet away. Literally! I look out the operatory window and I already know what to do. 4. An observable radiolucency (dark area) in the shape of a ball around a root. This is no mystery. This is an abscess. However, this must be differentiated from an artifact (or error) on the x-ray. 5. Swelling from around the root tip (3/4 inch below the margin of the gum) of the tooth. This is a sure sign of infection. The location is key. It is opposite the end of the root. 6. A fistula (opening in the gum) which may be oozing white pus. Not surprizingly, once this happens the tooth stops hurting. Why not just go ahead and have the root canal even if it does not need it? 1. Root canal therapy seems to "dry out" the tooth and make it more brittle, although the experts and current research disagree with me on this. They are most likely right, however instrumentation of the root, as in root canal therapy definitely weakens the tooth. I've just seen too many root canal teeth split way down the root, while I rarely see this kind of trauma with a vital tooth. We dentists frequently see a broken cusp on a vital tooth. This is not what I am talking about. With root canal teeth, the tooth sometimes splits right down, way down. 2. The mechanical access to the canals undermines the cusps and increases the possibility of splitting the tooth right down the middle. Yikes! 3. It will most likely require a crown. 4. It will most likely require a post. 5. It may even require an ext . . . . (I won't say it!) 6. Some teeth do not respond well to this therapy necessitating additional surgical procedures. An example is the upper lateral incisors which are particularly hard to obturate as they contain accessory canals. "What if I need a crown? Shouldn't I go ahead and get the root canal anyway?" No way. Many teeth have crowns and have not undergone root canal therapy. Sometimes root canal therapy is necessitated by the trauma of the crown preparation, so there are no guarantees at all. A friend of mine (a self-described big producer) always does root canal therapy before a crown. Gee whiz! I wondered what made him a big producer. He also does a crown if the tooth has anything but the teensiest filling. Should I let my regular dentist do it, or should I see a specialist? In this case, I agree with Pankey who says, "The dentist has no right other than to prescribe the best treatment available for the patient." I am assuming that the specialist is board-certified in his specialty (endodontics) and the general dentist is not board- certified in that specialty (he only took a 3-day course). Therefore, I go with the specialist. He, most likely has much more experience with root canals than the general dentist who is doing lots of other stuff too. Some patients like to get everything done in the same office. They like "one-stop shopping." I do too when I am at Wal-Mart. With dentistry, I do not mind a bit of driving. You should not either. If you like "one-stop shopping," get the root canal at Wal-Mart too. Try the paint department first. They do excellent root canal work. I am distorting what Pankey really means, but you get the general idea. I do not mind kicking Pankey a bit. I'm just saying, all things being equal, get the best treatment possible. If you are on welfare, have no car, and can only get the root canal at the clinic, then . . . take your chances. Right now, you have no choice. In the future, listen to my colleagues. Enroll in a computer school, get your CNA, get an $80,000 job and then get the 'thang done right. By then you can afford the implant anyway. What else can I do to insure some degree of success? 1. Make sure that the dentist grinds the top of the tooth down "big time" so that there is no possibility of cracking the tooth right down the middle while waiting for your crown. If you eat bagels, add 2 millimeters to this information for a little extra clearance. If you eat Dunkin' Donuts bagels then be sure to add 3 millimeters. Its a pretty common occurrance. I mean "cracking," not eating Dunkin' Donuts bagels. 2. An alternative to this is a copper band reinforcement or a temporary crown. A copper band is like a giant orthodontic band which is cemented around the entire circumference of the tooth to keep it from cracking. It works great, but it sure looks wierd! 3. Ask the dentist to be sure to refer you to an endodontist who uses a conservative operative approach. This means, "limited access" and preserves more tooth structure. This is good. It is harder to do, but the tooth could last lots longer. Now you are going to have to cooperate and be a good patient! I see so many root canal teeth and I look at the x-ray. I say, "Where's the tooth?" I can't see much left! 4. Be sure to tell the dentist that, rubber dam or not, you will need to rest your jaw every 10 minutes (for 15-20 seconds at a time), to wiggle your jaw laterally, left and right a few times, to avoid the type of TMJ affront that Woody Allen experienced in the movie, "Manhattan." In that movie, Woody experienced the same TMJ stress, although Diane Keaton was completely unsympathetic. But it can make a difference. So be sure to look out for "numero uno." I mean with the rubber dam stuff. Cheers, Joel Joel M. Eichen, D.D.S. PS- Half the battle is understanding the words! ========================================================= wrote: I propose that the term 'cracked tooth syndrome' be replaced or supplemented with 'cusp flexure syndrome'. Many times, I find the classic patient who exhibits sharp pain on biting and release does not have any visible or stainable fracture lines. One or more cusps may be weakened to the point of flexure that stimulates the pulp. Conversely, patients who exhibit visible crack lines may be symptomless. Another thought: I often wonder how many patients get root canal treatment for these symptoms. I've had these symptoms for several years in two lower first molars, including sensitivity to heat (often taught as diagnostic for irreversible pulpitis), and I'm just now getting the second onlay made. I didn't rush because I knew the teeth were decay free, and I was reluctant to have crowns made. The symptoms are gone in the completed tooth, and the other one has somewhat stronger symptoms, probably because the temporary material doesn't provide as much support to the cusps as the amalgam did. (If these teeth had been asymptomatic, I would have left them alone) I know I have healthy pulps, if only because of the duration of symptoms without change. The symptoms are significant enough that I believe some patients might describe them very dramatically, leading to root canal treatment. However, in applying an 'onlay first, then wait and see' approach where I'm not sure the pulp is irreversibly inflamed, it's important to involve the patient in the train of logic. I explain that we have little to lose by placing the onlay and monitoring the symptoms and radiographic appearance. At the first sign of pain, I can treat with a root canal. If that worries them, I say, the root canal can be started right away. Most of the time, I'm right, and the tooth settles down just fine. ```````````````````` What is the proper treatment when the sharp pains you describe persist or begin *after* a tooth is crowned? I have a crowned tooth which hurts when I lightly bite, say, a popcorn kernel over a particular cusp. Is a root canal best, or a recrowning, or just living with it? I'm hesitant to get a root canal, since I'm told it weakens the tooth, and that can't possibly help the fracture problem. This is an important question to me, because my current treatment plan calls for crowning all my teeth to protect them from fracture. (I'm a pretty serious nighttime bruxer and have lost several teeth already due to fracture.) But if crowning doesn't offer much protection, seems like I ought to just pull them all and get dentures. - Tom