Tooth Pain: Causes and Diagnosis of Lower Left Molar Discomfort

Q: Tooth Pain: Causes and Diagnosis of Lower Left Molar Discomfort

Hello： 1. <br>Because teeth have a three-dimensional structure and the orientation of microscopic cracks can vary greatly, both periapical and panoramic radiographs are flat images, so I cannot guarantee that there are no cracks. <br>2. <br>In most cases, it should be possible, b

Pain in the occlusion of the lower left molar?

Dear Dr.
Lin,
About a year ago, I experienced a dull pain in the area of my lower left molars (the pain point is near the first or second molar, and I do not have wisdom teeth as they have been extracted).
At that time, I visited a dental clinic where X-rays of the lower left molars were taken.
The dentist interpreted the images and examined the surface of the teeth, finding no signs of cavities.
It was suggested that the dull pain might be due to gingival inflammation or other factors.

In recent months, the dull pain in my lower left molars has changed to a sharp pain when biting during meals, although it does not occur every time.
It seems to happen when eating harder foods or biting at certain angles.
Therefore, during a recent routine dental cleaning, I mentioned this issue to the dentist.
The dentist examined the surface of my teeth and reviewed the X-rays taken a year ago, explaining that since cavities have been ruled out, my biting pain could be due to three possibilities: 1.
a hidden crack in the tooth, 2.
inflammation of the periodontal ligament, or 3.
sensitive teeth.
I am particularly concerned about the possibility of a hidden crack in my teeth.

I would like to ask Dr.
Lin the following questions:
1.
Why can't standard dental X-rays directly determine if there is a hidden crack in the tooth?
2.
Can CBCT (Cone Beam Computed Tomography) accurately assess whether there is a hidden crack in the tooth? Additionally, is this examination covered by health insurance or does it require out-of-pocket payment?
3.
Both my first and second lower molars have extensive silver fillings, and since there are no visible cracks on the teeth or in the X-rays, the dentist mentioned that to confirm the presence of a hidden crack, all the silver fillings may need to be removed.
I would like to ask Dr.
Lin if removing a large area of silver fillings would potentially harm the remaining healthy tooth structure.

4.
Since it is uncertain whether the biting pain in my lower left molars is indeed caused by a hidden crack, the dentist advised me to observe the situation without any immediate treatment.
I would like to know if this could lead to a delay in treatment (for example, if the tooth were to crack), or if it is acceptable to wait until problems arise (such as increased pain or visible cracks) before addressing the issue.

I am truly unsure how to proceed; I am worried about delaying treatment but also concerned about unnecessarily sacrificing healthy teeth.
I appreciate Dr.
Lin's guidance on these matters.
Thank you.

Axiang, 30~39 year old female. Ask Date: 2022/02/08

Dr. Lin Jiayong reply Dentistry

Hello: 1.
Because teeth have a three-dimensional structure and the orientation of microscopic cracks can vary greatly, both periapical and panoramic radiographs are flat images, so I cannot guarantee that there are no cracks.
2.
In most cases, it should be possible, but it will likely be out-of-pocket (as the primary purpose of CBCT is actually for dental implants).
3.
Yes, so if you do not have any plans or budget for more extensive restorative treatments (such as crowns or full dentures) or even root canal therapy, it is advisable not to remove the old fillings (especially silver amalgam) just yet.
4.
I recommend regular monitoring without excessive anxiety.
Teeth are consumable by nature, and the natural process involves wear and tear; undergoing too many procedures often leads to results that differ from expectations.
Sincerely, Lin Chia-Yung, Department of Dentistry, Taichung Hospital, Ministry of Health and Welfare.

Reply Date: 2022/02/08

More Info

Tooth pain, especially in the lower left molar area, can be a complex issue with various underlying causes. Based on your description, it seems that you have already consulted with a dentist who has ruled out cavities through X-rays and visual examination. However, you are still experiencing discomfort, which has evolved from a dull ache to sharp pain during chewing, particularly with harder foods. This situation raises several important considerations regarding potential causes and diagnostic approaches.

1. Why X-rays May Not Show Cracks: Traditional dental X-rays are excellent for identifying cavities, bone loss, and some structural issues, but they may not effectively reveal hairline fractures or cracks in teeth. These cracks can be very subtle and may not alter the density of the tooth structure enough to be visible on standard X-rays. This is why your dentist suggested that hidden cracks could be a possibility.

2. CBCT for Detecting Cracks: Cone Beam Computed Tomography (CBCT) is a more advanced imaging technique that provides a three-dimensional view of the dental structures. It can be more effective than traditional X-rays in identifying hidden fractures, as it allows for a detailed examination of the tooth's internal structure. However, whether CBCT is covered by insurance can vary by provider and specific policy, so it is advisable to check with your insurance company regarding coverage for this type of imaging.

3. Impact of Removing Silver Fillings: The concern about removing large silver fillings (amalgam) to check for cracks is valid. While it may be necessary to inspect the tooth thoroughly, this procedure can indeed compromise the remaining tooth structure. Each time a tooth is drilled or filled, there is a risk of weakening it further. Dentists often weigh the benefits of investigating a potential issue against the risks of further damaging the tooth. If the fillings are large and the tooth is structurally sound, your dentist may recommend monitoring the situation rather than immediate removal of the fillings.

4. Delay in Treatment Concerns: The decision to observe rather than intervene immediately can be a common approach in dentistry, especially if the symptoms are not severe. However, it is essential to maintain open communication with your dentist. If you notice any changes, such as increased pain, sensitivity, or visible cracks, you should return for further evaluation. Delaying treatment can sometimes lead to more significant issues, such as a cracked tooth that may require more invasive procedures like root canals or extractions if left untreated.

In summary, the discomfort you are experiencing could be due to several factors, including hidden cracks, inflammation of the periodontal ligament, or tooth sensitivity. While monitoring the situation is a reasonable approach, it is crucial to stay vigilant for any changes in your symptoms. If the pain worsens or becomes more frequent, you should seek further evaluation. Additionally, discussing the possibility of CBCT imaging with your dentist could provide more clarity on the condition of your lower left molar. Remember, maintaining good oral hygiene and regular dental check-ups is vital in preventing further complications.

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