I was having pain on the lower left side of my mouth where there were three teeth #18, #19 and #20 with large silver fillings in them that are 50 years old. A dentist looked and said there are two cracks on #19, I can cut out one of the cracks and replace the filling and the other is a craze line. She said there was decay under the filling that was deep that she removed. That night I felt the edges of my tooth and I felt a crack diagonally across the lingual groove where the craze line was that I could stick my fingernail into. I went back to the original dentist and she said its not a crack its a natural depression in your tooth. I then went to an emergency clinic of a dental school and showed them and they told me, yes there is a crack in your tooth there, we can’t fix other people’s work, we can only take out and replace the entire filling. I went back to the other dentist and requested she bond the crack shut. She did so, but she didn’t fill the area entirely and there is still a tiny almost microscopic crack there but I can feel it with my fingernail. I went to an endodontist who took a CBCT scan and did all the testing, biting, ice, tapping, and told me she doesn’t see any bonding there on #19, it’s a natural depression in my tooth. She said tooth #18 has a crack in it and an enlarged periodontal ligament and to put a crown on it, #19 is having referred pain and has nothing wrong with it. Both teeth are alive and no infection or inflammation. I went to another general dentist to have the crown placed and he said he’s not sure if #18 has a crack in it, he only sees a shadow, he wants me to get another endodontist opinion. The second endodontist did not take a CBCT scan or review the one I had. He only took regular xrays. He told me there’s no crack on #18. He said he thinks #19 needs root canal based on prior history and pain mostly in that tooth and he thinks the nerve is dying. He saw the bonded area and the little crack but when I asked him about whether it could be fixed with more bonding, he said it's not on the root. (I never said it was and what kind of answer is that?) But both teeth test alive with ice. When he did the percussion and biting on both teeth, I did not react right away. I got severe pain about an hour later which lasted for ten hours. I feel it mostly in #19 but it hurts if I press on #18 or #20 too. I have now been in pain for at least six weeks since the filling was first replaced and I was having mild intermittent pain even before that in that area. Today the pain is diminished but it is still there intermittently. I don’t know who to believe or what to do now.
(I personally believe that there is a microcrack in the bonded area on #19 and that #18 has decay under the filling. #18 might also have a crack as well. I do not want to do unnecessary root canals).
Detailed Analysis
Tooth #19:
History: Large silver filling (50 years old), decay under the filling removed, crack identified initially.
Crack/Bonding:
First dentist partially bonded a crack; however, a "tiny crack" remains, which you can feel.
The endodontist stated it's a natural depression and not bonded entirely, but also mentioned no evidence of infection or inflammation.
Pain: Intermittent pain and sensitivity, with some referred pain to adjacent teeth. The pain worsened significantly after testing.
Current Status: Nerve is alive (confirmed by ice testing), and no obvious signs of infection or inflammation.
Tooth #18:
History: Large silver filling, potential crack (disagreement among dentists), enlarged periodontal ligament seen on imaging.
Conflicting Opinions:
One dentist suggested a crack with a need for a crown.
Another dentist only saw a shadow and doubted the presence of a crack.
The second endodontist ruled out a crack but did not review the CBCT scan.
Pain: Mild tenderness when pressed; intermittent pain likely referred from #19.
Tooth #20:
Mild pain noted when pressed but no specific diagnosis mentioned. Pain is likely referred from #18 or #19.
Key Observations and Considerations
Conflicting Diagnoses:
Multiple opinions make it difficult to pinpoint the primary source of pain. Microcracks, natural depressions, or secondary decay could all be contributing.
Referred Pain:
The involvement of adjacent teeth (18, 20) suggests either referred pain from #19 or shared stress across the area.
Enlarged Periodontal Ligament:
On #18, this could indicate chronic trauma (e.g., from grinding/clenching or stress on the tooth from the filling or crack).
Recommendations
Step 1: Address Diagnostic Discrepancies
Get a CBCT Scan Reviewed Again:
A CBCT provides detailed imaging for cracks, decay, and periodontal ligament health. Ensure a skilled endodontist or radiologist reviews the scan thoroughly.
Focus on #18 and #19 for cracks, root fractures, and decay under fillings.
Transillumination Testing:
This is the gold standard for identifying microcracks. It can help confirm whether there are structural cracks in #18 or #19.
Confirm Periodontal Status:
A periodontist can evaluate the enlarged ligament around #18 and assess the gum and bone health in the area.
Step 2: Symptom Management
Monitor for Progression:
Since both teeth are testing alive and there’s no evidence of infection, avoid rushing into a root canal.
Pain that diminishes over time could indicate recovery from trauma or minor inflammation.
Occlusal Adjustment:
Ask your dentist to check for high spots on the fillings or crowns. Even minor bite imbalances can exacerbate pain in teeth with cracks or large restorations.
Step 3: Treatment Options
Tooth #19:
If the microcrack remains visible or palpable, consider:
Re-bonding: Properly sealing the crack may prevent further stress and bacteria from entering.
Crown: If re-bonding does not resolve symptoms, placing a crown can redistribute forces and protect the tooth structure.
Avoid root canal treatment unless clear signs of nerve death or infection emerge.
Tooth #18:
If decay under the filling is confirmed, replace the filling. Consider a crown if structural integrity is compromised or a crack is confirmed.
If no decay or crack is found, monitor for changes in symptoms and evaluate for occlusal issues.
Timeline
Immediate: Revisit the CBCT scan and consider transillumination for both teeth.
Next 2–4 Weeks: Re-bond or crown tooth #19 if symptoms persist or worsen.
Next 4–6 Weeks: Treat decay in #18 (if present) and crown the tooth if necessary.
Ongoing: Monitor pain and nerve vitality. Avoid invasive treatments unless symptoms worsen or diagnostics confirm the need.
Risk Analysis
Overtreatment: Avoid unnecessary root canals or aggressive treatments unless evidence supports them.
Undertreatment: Leaving cracks or decay untreated can lead to worsening pain, infection, or tooth loss.
Long-Term Prognosis: Proper bonding and crowns can extend the life of compromised teeth. However, large fillings and cracks always carry some risk of progression.
