Gingivial Trauma during the Crown Preparation

[HAITA2]

On April 2nd, my dentist removed the old metal filling from #2 and #3 (Upper Right Molars), and an inexperienced assitant did the "Cord Packing."  The incompetence was obvious right from the start: he dropped the sharp instruments on my lip and cheek, causing bleeding.  (He kept wiping off the blood and putting the vaseline so many times on my lips so that the dentist would not find out.)  The force he used to insert the cord was about 4 times as strong as usual.  (I have many crowns and know how it feel when the assistant is packing.)  He was cutting and scratching my gums so badly that I could feel that he was cutting/stabbin my gumline.  It took 2 hours for him to finish cord packing.  The cord was left between the teeth and gum for maximum of 2 hours.  Eversince this initial Crown preparation, I have been having throbing pain that required me to take 48 x 200mg IBUPROPHEN or equal strenght of Tylenol per day.  The dentist replaced the temporary crown twice, since the temp-crowns that his assistants made was too poor.  The endodontist that the dentist referred to did not think that I have pulpitis, pointed out that there was a slight gap between temporary crowns and the gumlines, and that there was a water pocket under #3.  And the endodontist recommended to cement the permanent crown as soon as possible, assuming that this prolonged pain was from the trauma in the gum.  So the permanent crown was cemented last Thursay.  On that night, I took the painkiller hydrocodon/acetaminophen.  But that one tablet was the last straw.  I threw up from midnight to 5AM and was brought up to the ER due to unstoppable nausea.  Yesterday, I had a nervous break-down; so I had to get another painkiller, anti-depressant, and sleeping pill.  I already saw two other dentists for 2nd and 3rd opinion; however, the conclusion is that there is nothing wrong that can be detected on X-ray.  And I was told to wait 2 or 3 weeks.  If the pain does not go away, in 2-3 weeks, I will visit an endodontist and get the root canals done.  I had NO pain on these two teeth to start with.  I believe that the trauma of poor cord packing done by unexperienced assistant caused "Necrosis" in the gum and cells under teeth, which caused the pulpitis.  I would like the professionals list the potential consequences of prolonged (as bad as 1 hour per tooth) stabbing of the tissue between gum and tooth by unuaual amount of force, plus leaving the cords in the teeth (until the impression is made) for maximum of 2 hours.  I read in some website made by dental students that leaving the cords in the teeth for 30 minutes will cause gum receding in 6 month and it will void the whole purpose of cord-packing. I also read that many patients hesitate to go back to the dentist after temporary crowns are affixed, since the inflammation/pain of the gum is so strong that they are not ready for the parmanent crown cementing.  I believe that my first endodontist who recommended cementation of permanet crown was an "IDIOT!"  So I will find the endodontist that is outside of HMO/DMO.  I will switch to the decent dentist outside of HMO/DMO.  However, this kind of thing will happen to any dentists/patients, if one was unlucky. (Although no assistant should drop the sharp insturments on patients' face!!!)  Would you please comment on the Gingivial Trauma during the Crown Preparation?  Do you think that it is theoretically possible that physical stress caused during the preparation of the crown, including cord packing, would cause the necrosis (death of cells) which leads to development of pulpitis?  I have been suffering since April 2nd, today is 24th; so I am in pain for 22 days.  How long does it take for pulpitis to be reversed?  Do you think that my pulpitis to be reversed is slim?  Any input is greatly appreciated!  God Bless!

[scottma]

Inflammation of periodontal tissue, which includes periodontal legement, alveolar bone, is termed periodontitis. Periodontitis is rarely caused by physical traume, if it were caused by physical trauma, periodontal tissue generally heals up uneventfully.   Other than cavities and periodontitis, the most common culprit of thermal sensitivity is occlusal interference, particularly in the situation that a new restoration is introduced. If the periodontal tissue is healthy, gum pain is frequently caused by occlusal interference. Specifically. gum pain is generated while you close the jaw or chewing. Periodontally induced gum pain is generally spontaneous, although biting may aggravate the pain. Not to my know of sympathy pain in dental literaure. However, there is a condition known as sympathetically maitained pain, which does'nt appear to be consistent with your presentation. Bear in mind that tooth pain is not always dental origin. Other than dental origin, there are three possible causes that may cause tooth pain' 1. occlusal interference, which is the most common one and easily missed by clinician.2. myofascial trigger point pathology, which can refer pain to tooth. 3. dysfunction of central nervous system. which is rare. Seeing a periodontist to rule out periodontal pathology is advised. Since endodontic treatment is initiated, follow the course of treatment to completion is advised. If periodontal and endodontic treatment are completed, seeing a competent prosthodontist , who is experienced in occlusal equilibration is advised.

[HAITA2]

Do you or anybody know the name/term for inflammation of periodontal ligament (membrane) due to physical injury?  

I got the root canal treatment on May 1 st.  
The sensitivity for cold (water) was eliminated at once.
The pain was slightly reduced.

However, I still have severe pain as if I were hit multiple times and bruised, close to the gumline of #3.  

The gum is swolen a little and feel the heat.
It feels like that there is a blood clot under the gum.
It is difficult to tell if it is only gum that is painful or tooth that is painful.
It seems like both of the gum and teeth are painful.

I have "sympathy pain" on lower right molars, too.

I started to wonder that root canal was not necessary, and that perhaps I have been suffering the inflammation of periodonatl ligament due to the physical trauma.

Any information, advices, opinions are greatly appreciated.

[HAITA2]

Thank you, scottma, for your professional feedback.
I am going to see the endodontist again, and try to get the referrel to the periodentist, also.  It has been 28 days that I am suffering from the pain.
There is nobody who can identify the cause of this pain and solution to this pain.
So far 4 dentists think that my teeth were traumatized physically druing the crown preparation procedure and developed irreversible pulpitis.
I was wondering if the dentist could crack my teeth, which should be almost impossible to detect. Anyway, wish me luck.  And God Bless You!

[scottma]

Crown prepararion is not always associated with gingival trauma. Depending where the crown margin placed. If crown margin is supragingival, gingiva would not be traumatized by crown prep procedure. If crown margin is subgingival, minimal trauma of gingiva is inevitable .Cord pac king may cause minute recession of gum.However, gingival necrosis is unlikely to happen.If necrosis does happen, blackish and sloughing of gingiva tissue would appear.Pulpitis is highly unlikely to happen after gum recession.It appears that you may have gum recession and the exposed root surface is sensitive to cold stimulus,which may be managed by desensitizing agent. Another possibility of sensitivity to cold stimulus may be associated with occlusal interference of new restoration.With regard to gum status, seeing a periodontist is advised.