Which is the Culprit: Natural Tooth or Implant?

Get a CTscan

need a ct scan. you would be shocked at what it will pickup that an x-ray doesn’t show!!

have a dentist make the diagnosis and treatment plan

Cause of pain is likely endodontically related to the natural tooth #15 (International and Canadian tooth numbering system for you Americans to be aware of) which displays underfilled endodontic obturation however a hairline crack at #15 is another possibility. An Endodontic consultation for #15 is indicated as I very much doubt the implant is implicated.

It needs CT for proper diagnosis

The implant fixture seems okay. Seems like there are 3 things wrong here. First the premolar root canal filling is incomplete, needs to get re-done. Secondly, you probably still clench your teeth a lot at night and thirdly the occlusion on this side could need more balancing. The ligaments of the premolar in front and the molar at the back of the implant appear separated probably due to the clenching exacerbated by the interfering occlusion. The crack in the premolar in front needs to be ruled out as well. Here’s what I suggest: Get the premolar crown removed and get the root canal re done. Keep that tooth crown free out of occlusion a few days. If this solves the problem then get another crown fit on it. If it doesn’t get the premolar removed and replaced by an immediate implant. Make sure the occlusion isn’t getting locked while you clench. Get a predictive night guard that allows free movement.

I see what looks like a very well distinct radiolucency on the apex of the mesial root of the posterior molar. Have that tooth tested for vitality. as someone previously said takr a CT scan to evaluate. My guess is a vertical fracture of that most posterior molar. The premolar has a poorly filled root canal. But radiographically I do not see any pathology. And the implant looks fine. Wear your night guard regularly as clenching is probably the culprit here.

Second molar needs root canal It seems it has a periapical lesion on mesial root, get a consult with Endodontist ( root canal specialist) or a dentist for evaluation!

For starters, do not touch that premolar unless if it’s fractured. Periodontal ligament looks fine. The root canal seems fine as well and will probably remain fine for a very long time. Your sinus runs low into the roots of your teeth, which will refer pain over the whole quadrant. The pain could also be from the molar. If we follow the periodontal ligament, we really don’t see it on the apex of the mesial root; which makes me suspect your pain may originate from this area and referred throughout the sinus. You have a pretty big filling on that tooth and it’s usually the culprit. I would take a cone scan to take a closer look at the apices if your roots for any infection or fractures. From radiograph provided, we don’t see much to make a definitive diagnosis. I would also keep a careful watch of your bite. Your bite may have changed after crown placement and is challenged by your chewing. I hope this helps and your pain subsides. Cases like this are a little tricky and would need full evaluation and cone scan. In my office, this may take several visits to pinpoint exactly where pain is coming from. Would hate to have you undergo unnecessary dental work if all it may take is a bite adjustment and time for healing. Thanks for posting.

Quick question, when your dentist cemented the crowns, where you anesthetize? The crown over the implant looks like it may be impinging on the tissue from radiograph provided. Does the tissue hurt when you floss between the crowns?

With your history of pain after procedures, perhaps it’s not the tooth but referred pain from your TMJ. You mention you don’t grind because your mouth is slightly open....mouth breathing is associated with TMJ dysfunction which can radiate pain in the mouth mimicking tooth pain. Get a CT scan and have your dentist look at the teeth and also your jaw.

Ask your Dentist to reduce the proximal surfaces of the implant crown.The crown seems to be very tight fit and may be pressing the adjacent teeth Even though RC filling not proper tooth seems no periapical lesion

Looks like there is an area of pathology midway up the premolar on the distal aspect of the root. A CBCT scan will likely show a chronic area of infection. Likely an extraction is needed and there will be an area of granulation tissue that will need to be cleaned out carefully to avoid perforation of the sinus floor. Re-treatment may lead to years of more pain/ cost and there’s a risk of ledging/ perforation the roots.

Annoying as it might seem, diagnosis from a radiograph alone is often inaccurate or not possible and thus a clinical exam is usually required. This is especially in a case like yours when there are many possibilities for the cause of pain. In reality these options need to be properly assessed and probably eliminated one by one (a “shot gun” approach is not wise). As mentioned, a 3D radiograph will be helpful. However it would not be sensible to make a quick decision – especially if extraction is required. Imagine your frustration if a tooth was extracted and does not solve the problem. Here are list of possibilities which need to be checked by a dentist or specialist (endodontist and/or oral surgeon). • 17 has a suspicious area on the mesial apex. However there is no apparent reason why this tooth would be non vital (the filling is not that extensive). Further, although there is a sign of rarefied bone, it is not definitely different compared with other bone images within the sinus. So the radiograph is not conclusive. A simple vitality and TTP test will help in the assessment. • You may be suffering from TMJD – especially after having a new crown placed. Proper occlusal assessment is required and also palpation of the appropriate musculature. • The implant looks fine but you can see a possible outline of a mesial apical lesion. I doubt this is a real lesion (probably a radio-artefact) but a 3D image will help determine this. • The 15 has previous endo treatment but it is well short of the apex. However there seems to be only calcified canal from the GP point to the apex (so this may not be significant). As has been mentioned there does not seem to be any apical pathology but given your pain, a 3D radiograph will help eliminate or implicate this tooth. A specialist opinion would be wise – particularly if an extraction is contemplated. • As well, one cannot overlook the possibility of sinusitis or other pathology (possibly neuronal). These are more remote candidates but something that needs to be checked if resolution by simple methods cannot be achieved. So hopefully you can understand why this is a complex problem to solve. Not that the solution will necessarily be complex – just that there are numerous possibilities to aetiology. This is why this forum is not usually for lay people but rather for professionals to discuss various aspects of dentistry (with the emphasis on implants). Hence the reason there have been many suggestions for you to seek out professional help. This may require you or your dentist obtaining specialist advice in order to finally help you.

Hi everyone, patient here. Thanks for all the replies. I already feared as much, that this would be a complex matter. Dentist already said the canal of the premolar seems calcified, which can make it hard to reach and clean properly. I remember it having two roots. Problems with this tooth are lingering for years, actually directly after root canal treament was started ... Previous dentist did the rtc, but forgot to make the actual, definitive root canal. After a lot of whining on my part, he checked it and said: oh, there is no filling in it yet! Duh. So after he made the root filling (not even entirely properly, it seems) I left that office. I asked the new implantologist-denists, back when the implant was placed, if the problems with the premolar induced no contra-indications for implant placement. But he saw no reason to think any of that. Crack may be possible, but dentist said that probing in that case would feel different. But can not be ruled out without a scan, as I understand. The second upper molar has been out of function for years, since the opposing second molar in the mandible was extracted years ago because it was the expexted culprit for the atipical facial pain. After the extraction, no relief of the atipical facial pain, that only subsided totally after the third molar totally erupted. Because of this, I don't bother treating the second upper molar with either a rtc nor an implant. The main reason for me to keep it was the preservation of bone. I understand that, for as far as can be determined by the x-ray (scan needed I know), the implant looks fine. When I find a new specialist, I'll also request a nightguard and possibly a referal to an orofacial specialist.

Patients thoughts: Get rid of both the 17 and 15, get the area debrided and cleaned througfully. Perhaps another sinus lift. Then, an implant for 15, either immediate of delayed. I read pro's and cons for both immediate and delayed placement (bone remodelling/resorption, sinus gets into the socket, infected sockets, and such).I think the specialist can advice me on this. Anyway, first get a scan to determine problems for both 15 and 17 and have a nightguard.

The # 16 implant seems to be doing well, with a proper fitting permanent crown. The endodontic treatment on #15 is not well done. There are two canals, and neither of them have been properly filed, shaped or sealed. There is also a hint of a radiolucencies, which indicate periapical pathology....a good reason for pain....so forget about a crown for this tooth at this time, have the endodontics redone properly.

Excellent comments below. I agree, CT scan. #13 may be poorly filled, but could be sealed without problems. Thickened periodontal ligament on mesial root #15 that seems to fade at the apex...I agree, test for vitality. How about a neuritis? However, this is an implant site, so, my thought is that this is tooth related. Screw retained crown; no need to worry about cement...bone levels look good on implant. Pt admits to clenching, is she wearing a guard? Has the occlusion been checked in both occlusal and parafuntional movements?

Maude seems to be more knowledgeable in dental/medical terminology than the average patient. Perhaps a health care or dental professional?? I agree the mesial root apex of #17 is suspicious radiographically and it could be a source of the pain. I would see a dentist or endodontist for pulp vitality testing so you know its status. Also an opinion on the incomplete root canal fill #15 is warranted.

Do a pulp vitality test on the molar.There is secondary caries on the mesial pulp horn . Whilst the molar has an MO restoration it does not harm to re-restore it after investigating for secondary caries. But make sure the dentist gets a favourable contact with the implant this time. Well if the secondary varies is pulp involved then extripate the pulp and follow up with RCT. Now to the implant itself .. I can see see a well demarcated radiolucency associated with the apex of the implant leading into the sinus . Sit right in the chair and lean your head forward. After 2 mins of you develop throbbing pain in the sinus then it could be sinus inflammation. Aetiogenesis : implant ? Then a course of anti histamine plus a nasal decongestant May be helpful