Tooth Pain: Causes, Diagnosis, and Treatment Options

Dental Inquiry Consultation

Dear Dr.
Tseng,
Over a year ago, I experienced a dull pain near my lower left first or second molar.
I visited a dental clinic where an X-ray was taken of the affected area.
The dentist examined the tooth and interpreted the X-ray, concluding that I did not have any cavities.
The dull pain might have been caused by gum inflammation or other non-cavity-related factors.
However, in recent months, the dull pain has transformed into occasional sharp pain when biting down (not every time I bite).
It seems to occur when eating harder foods or at certain angles, so during my recent routine dental cleaning, I immediately reported this issue to the dentist.
The dentist examined the tooth and conducted a bite test using cotton.
At that moment, the biting pain was not significant.
The dentist then showed me the X-ray taken over a year ago and indicated that since cavities were 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 the tooth.
I would like to ask Dr.
Tseng the following questions:
1.
Why is it that X-rays taken at a general dental clinic cannot directly determine if there is a hidden crack in the tooth?
2.
What testing methods are available to more accurately assess whether there is a hidden crack in the tooth? (I have found information about CBCT (Cone Beam Computed Tomography) but am unsure about its accuracy and cost.)
3.
My lower left first and second molars have extensive silver fillings, and the dentist mentioned that there are no visible cracks in the tooth or on the X-ray.
The dentist also stated that to confirm the presence of a hidden crack, all the silver fillings would need to be removed.
I would like to know if removing a large area of silver fillings could potentially harm the remaining healthy tooth structure.
4.
Given that it is uncertain whether my lower left molar biting pain is indeed caused by a hidden crack, the dentist advised me to observe the situation and not take any immediate action.
I would like to ask Dr.
Tseng if this approach raises concerns about delaying treatment (for example, if the tooth suddenly fractures in the future).
Is it better to wait until a problem arises (such as increased pain or visible cracks) to address it, or could this lead to a delay in necessary treatment? My concern is that while I fear delaying treatment, I also worry that the biting pain might simply be due to "periodontal ligament inflammation" or "sensitive teeth." Being overly aggressive in treatment (such as hastily removing extensive silver fillings) might unnecessarily compromise otherwise healthy teeth.
I am truly hesitant and worried.
I would greatly appreciate your insights, thank you, doctor.

Axiang, 30~39 year old female. Ask Date: 2022/02/09

Dr. Zeng Guanghui reply Dentistry

1.
X-rays cannot detect small hidden cracks unless the fracture has become significantly evident, causing the tooth to split.
2.
Unless there is a noticeable crack in the tooth or a significant defect, CBCT still has difficulty detecting hidden fractures.
3.
It is also possible that there are cracks or micro-leakage at the junction of the silver amalgam filling and the tooth, or that the silver filling itself has fractured, which can lead to tooth sensitivity.
If any of these conditions are present, it is recommended to remove the original silver filling and replace it.
4.
If the occlusal pain caused by hidden fractures persists, it may lead to gingival inflammation and spontaneous pain.
Therefore, if the pain worsens or there is spontaneous pain, immediate follow-up treatment should be sought.
Dr.
Tseng Kwang-Hui, Department of Dentistry, Nantou Hospital.

Reply Date: 2022/02/09

More Info

Tooth pain can be a complex issue, often stemming from various underlying causes. In your case, the discomfort you've been experiencing in your lower left molars could be attributed to several factors, including gum inflammation, tooth sensitivity, or even hidden cracks in the tooth structure. Let's break down your concerns and questions regarding the diagnosis and treatment options for your tooth pain.

1. Why can't standard X-rays detect hidden cracks?
Traditional dental X-rays are primarily two-dimensional images that may not capture the full extent of a tooth's internal structure. Hidden cracks, especially those that are small or located beneath existing fillings, can be challenging to visualize. These cracks may not always show up on standard X-rays because they can be oriented in a way that does not create a clear shadow on the film. This limitation is why dentists often rely on additional diagnostic tools when they suspect hidden fractures.

2. What are the best methods to detect hidden cracks?
One of the most effective ways to identify hidden cracks is through the use of Cone Beam Computed Tomography (CBCT). This imaging technique provides a three-dimensional view of the tooth and surrounding structures, allowing for a more accurate assessment of any cracks or other issues. While CBCT is more expensive than traditional X-rays, it can be invaluable in complex cases. The cost can vary depending on the dental practice, but it typically ranges from $100 to $300. Discussing this option with your dentist could provide you with more clarity on whether it’s necessary for your situation.

3. Is removing large fillings to check for cracks harmful?
Removing large fillings can indeed pose a risk to the remaining tooth structure. Each time a filling is removed, there is a chance of further damaging the tooth or exposing it to decay. If your dentist believes that the fillings are concealing potential cracks, they may recommend this step, but it should be approached cautiously. It’s essential to weigh the risks and benefits of such a procedure. If the fillings are intact and the tooth is functioning without significant pain, it may be prudent to monitor the situation rather than proceed with removal.

4. Is it wise to observe the situation without immediate treatment?
Observing the tooth without immediate intervention can be a reasonable approach, especially if the pain is intermittent and not severe. Many dental issues can stabilize or resolve on their own, particularly if they are related to inflammation or sensitivity. However, if you notice an increase in pain, changes in the tooth's appearance, or if the discomfort becomes more frequent, it would be wise to return to your dentist for further evaluation. Waiting for a more definitive symptom can sometimes lead to better treatment outcomes, as it allows the dentist to make a more informed decision based on the current state of the tooth.

In conclusion, your concerns about tooth pain are valid and reflect a thoughtful approach to your dental health. It’s essential to maintain open communication with your dentist about your symptoms and any changes you notice. If you feel uncertain about the current treatment plan, seeking a second opinion from another dental professional could provide additional insights and reassurance. Remember, proactive dental care is crucial, but it’s equally important to avoid unnecessary procedures that could compromise your tooth's integrity.

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