A Strange Tooth Issue

[Ronsch]

History:

About three months ago I got a new crown on the lower right, front molar. I went for the first diving of the season on May 17 and had no problems. Over the next week and half I started getting irregular instances of a strong ache near that crown. Being only a few days before a week-long trip to Bonaire and fearing an abscess, I got to my dentist. He couldn't find anything wrong, no sensitivity to pressure whatsoever on that crown or the gum anywhere near it and nothing on an x-ray. I got some amoxicillin and Tylenol-3 anyway as I could just see it getting worse after I got to Bonaire.

The Diving:

It seemed to be better as I got to the start of diving in Bonaire but then the real problem started. Each time I would get down to about 30', I would get an excruciating pain from that crown that made me want to take the regulator out of my mouth. Even holding it in my mouth instead of biting down didn't help. Funny thing is once I got down to 70 - 80' it would go away completely and I could change depth at will both up and down without any further pain. This went on for four days and finally on the last day of diving it was replaced by only a general ache from biting down. There also seems to be a small knot just on top of the lower jaw bone underneath that crown now that is a little sensitive to being pushed but no longer any pain at all from the crown. I should say that all the diving was done with Sudafed and there were no clearing issues.
Any ideas?

 

[Walter]

Tooth squeeze?

 

[DocVikingo]

This certainly sounds like barodontalgia of some type.

I am alerting our diving dental maven, Laurence Stein, DDS, of your post.

Best regards.

DocVikingo

 

[Laurence Stein DDS]

Dear Ronsch.

Let's first state the obvious...it sounds like a barodontalgia. The next most obvious item is that the most obvious tooth to be problematic is the most recently treated tooth.

It is very common for a barodontalgia to be most pronounced in the first atmosphere after leaving the surface. Most reports of barodontalgia is at about 2 ATA--either on descent or ascent.

A couple of things to note is that sinus barotrauma is actually the most likely cause of dental pain on diving. Additionally, an undiagnosed upper tooth could also be a culprit or contributory.

Now back to the recently treated tooth. Molar teeth...especially 1st molar teeth are now know to have extra nerve canals. About 30% may have extra canals. There may be 3, 4 or even 5 canals within the tooth while the dentist is looking for the usual three canals.

For this reason, I am routinely referring molar root canals to specialists--especially those who have fiber-optic video to look down the canals and operating microscopes. Yes, it makes the procedure more expensive but I would rather treat that tooth once.

Another normal variation of a nerve canal is the occurance of lateral or accessory canals. These are fine canals that branch off main canals at almost right angles. They are exceeding hard to clean out. Most of the time we try to dissolve material within them and then compress the filling material until it squirts out these lateral canals.

The are probably two other causes for a barodontalgia. First, there is another offending tooth causing problems. Simplistically, you could take the attitude that the "wrong tooth was treated". This is probably not true. The dentist takes care to carefully identify the offending tooth. It is possible to have more than one offender...the most likely cause is treated.

Another problematic tooth is one with an undetected fracture within it. Often it has an old silver filling in it. As silver get older, it corrodes and expands within the tooth...ultimately causing a fracture within the tooth. Frequently, such a tooth is sensitive to biting pressure, cold, possibly sweets and you may notice a "rebound" sensitivity when releasing pressure on that tooth. It is a sharp, sudden sensitivity that is momentary.

I would go back to the treating dentist and check the ajacent teeth for problems, old fillings, fractures, sensitivity. Finally, you might be forced to re-open the completed crown and look for an additional canal. It is most likely right next to the mesio-buccal canal opening and thus called the MBII canal. It may not extend to the root end. Anothe place to look is for a second canal or division of the canal of the distal canal.

Finding these bugger are really tough. Also, don't forget that despite this tooth hurting you there is a remote chance that another tooth is the problem.

If your dentist is not an endodontic specialist, you may delicately want to ask if a consult with a specialist would be of value. Your dentist most likely tried his best and sometimes "spit" happens.

Let me know how it goes.

Regards,


Laurence Stein DDS


:doctor:
Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)

 

[Ronsch]

Thanks for your reply Dr. Stein.

I take it from the way that your answer is worded that there is an assumption that a root canal was done with the crown and I think I've heard from others that that is a common way to do it. That is not the case. I have several crowns, many from the "old silver filling deterioration" that you describe including the one in question but my regular dentist , who does the crowns but not root canals, has never referred me to the endodontist for a silmultaneous root canal. I did subsequently have to have a root canal on one of the crowned teeth but that's all. There are no silver fillings left on the lower right. The tooth with the new crown does indeed have many nerve connections as it took almost an entire inventory of novocaine to numb it during the initial shaving down for the crown. I am torn between going back to the dentist immediately or waiting to see what happens the next time I go diving, which hasn't been scheduled yet.

 

[Laurence Stein DDS]

For some reason, I just assumed that your crowned tooth already had a root canal.

It is not necessary nor is it appropriate for a tooth that needs a crown to do a prophylactic root canal.

That being said, probably one in ten teeth needing caps go on to require caps FOLLOWING the cap procedure...either immediately or years later.

Something in your last post stood out...the amount of anesthetic you required to get the job done. There are lots of reasons that a tooth is hard to numb but the one that stands out in my mind is a tooth that fails to numb eventhough the patient has all the signs of profound anesthsia.

The most likely cause is that the local pH (acidity) of the affected tooth goes down (becomes more acid. This occurs when a tooth is infected--even if subclinical or symptom free.

I would definitely have this tooth revaluated for vitality. 5 will get you 10 that the nerve in this tooth is dead or dying. There could well be a fracture within the tooth that allowed bacterial into the nerver and started killing it.

FYI there are other reasons for the failure of anesthesia. Multiple nerves supplying the same tooth. A sinus infection of an upper tooth, an extra long root, a fractured tooth. Stress (I've seen patients have to fight traffice for an hour and their tooth won't get numb till they get home. In many of these cases, a systemic change in the bodies chemistry is the causitive change.

After two or three tries my suspicion level goes up. Often, during the prep of the tooth, the tooth material smells funny--dead tooth.

Finally, any dentist can cap a dead or dying tooth and be unaware of it. It does not mean something was purposefully done wrong.

I would also recommend that even though root canals can be done in one visit, on problemic teeth, save yourself some aggrevation. Use multiple visits (this is my own rule of thumb). I've done one visit root canals. The teeth most likely to be a problem are ones with pus or necrotic, dead material inside. So, now unless there is a dying, bleeding canal with no pus, two or more visits are used. Not all dentists will agree with this but the fewer 2:00 AM calls I get the beetterr I feel.

I think you're gonna need a root canal

sorry,

Laurence Stein DDS:doctor:

Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)

 

[Ronsch]

Thanks again. I'll post again when I get a resolution.

 

[Ronsch]

Well, I finally got some more dives in. No discomfort whatsoever. In fact I even forgot about it until after the dive because I was so focused on my new camera.

 

[Laurence Stein DDS]

You were FOCUSED on your new camera. Right.

Glad everything worked out OK.

Laurence Stein, DDS

 

[Ronsch]

And that wasn't even an intentional pun! You can see one of the pictures in the Underwater Photgraphy section.