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Irreversible Pulpitis of TMJ?

User Level:
Patient
Posted by: Lily85  (5 years ago)
I had many fillings done (7) in a period of 4 weeks. This was right after a root cleaning and wisdom tooth removal. My mouth was going through a lot basically. One of the fillings (first molar, top right) started throbbing about three weeks after the filling which was very deep. This was also the tooth that went through three bite adjustments and frustrated my dentist. I think she shaved it a bit too much as when I clench my teeth don’t seem to meet like before.

Anyway, the throbbing (started 2 days after final bite adjustment) was mild with a dull ache that would last a couple of minutes and reduce intermittently. I am not sensitive to cold or hot and touching, pressing the tooth etc does not hurt. Even chewing is ok, but the throbbing was there off an on. I was also getting radiating pain in nearby teeth, even the lower jaw. Slowly the pain in the jaw started, then there was shooting pain in the ear, just below the neck and in the jaw joint. It was similar to the TMJ pain I experience every time I go through dental treatments, only worse. I went back to the dentist (the one who treated me was on a vacation so another one saw me). She banged the tooth a couple of times with the mirror, touched it with ice and took xrays. Nothing conclusive came out of it. She said filling was fine, tooth was fine and it might be that the pain is coming from the premolar next to it as when she hit that spot between the teeth, I felt a bit painful. But there was no decay or cavity so she gave me a painkiller for three days and told me that everything looks fine. The pain in the ear, jaw and neck was apparently due to the wisdom tooth surgery trauma (horizontally impacted) that happened some 6 weeks back (??)
After three days of painkillers, the tooth feels a tad better. I have not taken any pills today and it hasn’t deteriorated, but I fear it may not last. The throbbing has reduced but it still happens once in a while (unstimulated). The pain in the jaw and ear and continues, but has reduced. The pain still radiates to the nearby teeth intermittently. I am wondering now if the tooth has got better or the nerve has simply died and I am looking at developing an abscess. Or if the entire episode was a flare up of the TMJ as the application of moist heat on the jaw does give me relief. Last thing, I had worked out pretty hard just before the pain episode, so I don’t know if its connected. My dentist is not in town for another week and I don’t want things to take a turn for the worse. I will be grateful if you can give me some advice.

PS: The subject title is Irreversible Pulpitis or TMJ? Pardon the typo, the forum settings do not allow editing of the subject :(
User Level:
Dentist
I had many fillings done (7) in a period of 4 weeks. This was right after a root cleaning and wisdom tooth removal. My mouth was going through a lot basically. One of the fillings (first molar, top right) started throbbing about three weeks after the filling which was very deep. This was also the tooth that went through three bite adjustments and frustrated my dentist. I think she shaved it a bit too much as when I clench my teeth don’t seem to meet like before.

Anyway, the throbbing (started 2 days after final bite adjustment) was mild with a dull ache that would last a couple of minutes and reduce intermittently. I am not sensitive to cold or hot and touching, pressing the tooth etc does not hurt. Even chewing is ok, but the throbbing was there off an on. I was also getting radiating pain in nearby teeth, even the lower jaw. Slowly the pain in the jaw started, then there was shooting pain in the ear, just below the neck and in the jaw joint. It was similar to the TMJ pain I experience every time I go through dental treatments, only worse. I went back to the dentist (the one who treated me was on a vacation so another one saw me). She banged the tooth a couple of times with the mirror, touched it with ice and took xrays. Nothing conclusive came out of it. She said filling was fine, tooth was fine and it might be that the pain is coming from the premolar next to it as when she hit that spot between the teeth, I felt a bit painful. But there was no decay or cavity so she gave me a painkiller for three days and told me that everything looks fine. The pain in the ear, jaw and neck was apparently due to the wisdom tooth surgery trauma (horizontally impacted) that happened some 6 weeks back (??)
After three days of painkillers, the tooth feels a tad better. I have not taken any pills today and it hasn’t deteriorated, but I fear it may not last. The throbbing has reduced but it still happens once in a while (unstimulated). The pain in the jaw and ear and continues, but has reduced. The pain still radiates to the nearby teeth intermittently. I am wondering now if the tooth has got better or the nerve has simply died and I am looking at developing an abscess. Or if the entire episode was a flare up of the TMJ as the application of moist heat on the jaw does give me relief. Last thing, I had worked out pretty hard just before the pain episode, so I don’t know if its connected. My dentist is not in town for another week and I don’t want things to take a turn for the worse. I will be grateful if you can give me some advice.

PS: The subject title is Irreversible Pulpitis or TMJ? Pardon the typo, the forum settings do not allow editing of the subject :(


Diagnosis in a case like this where much treatment has been done over a short time is very, very difficult. Sometimes it can only be solved by trial and error treatment.

One possibility in the inflamed nerve has died, and is going through a "quiet time" before it abscesses. Testing is not always accurate in these cases. Often such pulps give spontaneous pain that comes and goes.

Another possibility is TMJ flareup. This can be tested by giving muscle relaxants. If the pain gets better, it was muscle spasm.

Another possibility is post-op pain from the extractions.Although after 6 weeks, it seems unlikely that pain would start again, even from impactions.

On the upper arch it is possible to numb up individual teeth. A good test is to pop into the office when you are in pain, and have the dentist numb above individual teeth, starting with the most likely culprit. When he numbs over one tooth's root and the pain goes away, you know that tooth is the problem. If it is TMJ, the pain will not go away when the teeth are numbed.
Posted 5 years ago
User Level:
Patient
Posted by: Lily85  (5 years ago)
Hello Doctor,

I wanted to let you know the update on my case as you were kind enough to give such a detailed reply. So as I had mentioned my upper teeth were hurting and no one could tell why. I met a oral and maxillofacial surgeon who detected a severe TMJ trauma (probably from so much work done so quickly) and gave me muscle relaxants and put me through physiotherapy regime. Ten days later, the pain in the jaw and ear had reduced considerably and I could actually point at where the pain was originating. It was between my first upper molar and premolar next to it. The throbbing was also coming from there and probably radiating all the way to the front tooth. Even when I flossed, it felt tender.

So, I went back to the dentist who checked again and took xrays. Nothing again. She told me that the filled tooth is alive, no pulpitis. The pain came and went and I remained in agony until yesterday when I went to another dentist for a second opinion. Within minutes, she took out a piece of food that was stuck inside the gum between the molar and the premolar. The relief was immediate and I couldn't thank her enough to heal me of the pain that had made my life miserable for almost a month.

SO now, I feel much better, although the space between the said teeth is still painful but no throbbing and the pain is tolerable. I just wanted to share my experience with everyone as all should know that seeking 2nd, 3rd, 4th opinion is not unnecessary. I met two dentists and one oral surgeon who missed something so obvious. Just one question to you doctor, how much time do you think this pain will take to heal properly? How did food get lodged like that between the teeth (escaped the floss for weeks) and what precautions can I take to avoid this horrible ordeal again?

Thanks a lot!
User Level:
Dentist
Hello Doctor,

I wanted to let you know the update on my case as you were kind enough to give such a detailed reply. So as I had mentioned my upper teeth were hurting and no one could tell why. I met a oral and maxillofacial surgeon who detected a severe TMJ trauma (probably from so much work done so quickly) and gave me muscle relaxants and put me through physiotherapy regime. Ten days later, the pain in the jaw and ear had reduced considerably and I could actually point at where the pain was originating. It was between my first upper molar and premolar next to it. The throbbing was also coming from there and probably radiating all the way to the front tooth. Even when I flossed, it felt tender.

So, I went back to the dentist who checked again and took xrays. Nothing again. She told me that the filled tooth is alive, no pulpitis. The pain came and went and I remained in agony until yesterday when I went to another dentist for a second opinion. Within minutes, she took out a piece of food that was stuck inside the gum between the molar and the premolar. The relief was immediate and I couldn't thank her enough to heal me of the pain that had made my life miserable for almost a month.

SO now, I feel much better, although the space between the said teeth is still painful but no throbbing and the pain is tolerable. I just wanted to share my experience with everyone as all should know that seeking 2nd, 3rd, 4th opinion is not unnecessary. I met two dentists and one oral surgeon who missed something so obvious. Just one question to you doctor, how much time do you think this pain will take to heal properly? How did food get lodged like that between the teeth (escaped the floss for weeks) and what precautions can I take to avoid this horrible ordeal again?

Thanks a lot!


So you actually had TWO SEPARATE PATHOLOGIES causing pain. You cannot imagine how difficult such a case is to diagnose. I have been in that situation many times. To compound matters, patients often have preconceived ideas about what is wrong, and try to steer my diagnosis their way.

Inflamed gums would seem fairly easy to diagnose. I have had it happen between loose contacts on my own teeth, so I know to look for it. It can be quite painful.

As far as prevention, you should make sure that there is a good contact between these teeth. Good contacts prevent food impaction. Yet another of the problems with white resin fillings between back teeth is that it is often hard to achieve good contacts with them, compared to amalgam. If virgin back teeth lack contacts, food will often impact. If the spaces cannot be closed orthodontically, sometimes I am forced to do fillings on virgin teeth just to achieve contact and prevent food impaction like you experienced.
Posted 5 years ago
User Level:
Patient
Posted by: Lily85  (5 years ago)
Thank you for the advice doctor. I will discuss the possibility of closing the gap with my dentist to avoid future problems.
User Level:
Patient
Posted by: Lily85  (5 years ago)
Hello Doctor,

I discussed the possibility of closing gaps with the dentist, but she refused saying the gap needs to be there for the saliva to remove the food, else it will lead to gum disease as the food will remain trapped. There is some gum recession on both sides of the second upper premolar, but she said it wasn't so significant that it should be closed. I must also add that I have no fillings on the surface of the tooth, only inside the grooves. The outer part is the natural tooth itself.

The pain I was feeling returns sometimes, but I feel it more and more in the first premolar and the canine which are far from the site where the food had impacted. The first premolar aches if I even touch it with my tongue. I met a periodontist also, but he said there was no sign of gum disease or and its probably referred pain from the second premolar (which is not painful at all now). When I floss though, the space between second premolar and first molar (from where the food was removed) still feels tender like a wound.

I want to know how come the first premolar and canine hurts more that the second one? The premolars and canines are completely cavity free and xray shows nothing as well. I am currently doing warm salt water rinses 4-5 times a day and using a gum astringent, but am frustrated with the constant pain in first premolar and canine. I will be grateful for any suggestion from your side. Thanks
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