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September 2006 – Thermal Symptoms Occlusally Realated
This 46 Year old female presented with symptoms of elevated thermal sensitivity and mobility in her maxillary left second molar. The referral was concerned that the tooth had a possible exposure during amalgam placement or possible M-D crack.
Clinical examination of the tooth revealed higher than normal levels of mobility and heavy faceting on the occlusal surface. Pulp tests showed elevated responses to cold and normal responses to heat. Percussion was positive and palpation negative.
Periapical radiography showed #27 had a conical root system with widened PDL spaces.
Bite wing radiography showed an amalgam that was fairly deep but the deeper portion (on the BW) was actually the palatal portion of an occlusal/palatal amalgam. The amalgam was fairly conservative, so this was unlikely to be the source of the problem.
Closer examination of the bite wing showed that the mandibular second molar was high above the occlusal plane. The occlusion in this area was “locked in” and resulting in the heavy faceting. This was placing severe torquing pressure on the maxillary molar and causing the mobility and symptoms.
The problem was not therefore NOT endodontically based and was actually caused by the occlusion. Because mobility of the tooth, this problem could not be easily addressed by merely “shaving the tooth down”.
The patient was referred back to the referral with my findings. Attempts to modify the occlusal relationship between these second molars with occlusal adjustments was considered but eventually the high levels of mobility, pocketing and conical roots resulted in the decision to extract the tooth rather than to continue to have further bone loss and risk eventual loss of the maxillary first molar. Mention was also made of the caries under the endodontically treated maxillary cuspid crown.
Mobility of a tooth in combination with elevated thermal responses and thickened PDL spaces generally indicates a periodontal rather than endodontic source for the problem. Other factors such as the depth of restoration and possible fracture should be considered but a periodontal source related to occlusion and/or bruxism can often be the source of confusion. Endodontically treating this case would only result in devitalization of the tooth and in no way assist in treatment of the problem. If there is no obvious endodontic etiology, this diagnosis should be considered.
Fig. 1 PA shows widened PDL space in #27