Pain Under a Crown: When General Dentistry Steps In

Dental crowns, when well made and well seated, should feel like a natural extension of your tooth. They shield fragile structure, restore a confident bite, and disappear into the smile. So when a crowned tooth aches, throb by throb, it feels like a betrayal. Patients arrive clutching a jaw or avoiding ice water, certain something is very wrong but unsure what happens next. This is the moment where calm, methodical general dentistry earns its keep, not with theatrics, but with disciplined evaluation and refined technique.

A crown is a protective shell, not a cure-all. It replaces the outer enamel and, depending on how much tooth was lost, it changes how forces travel down the root. Pain under a crown signals one of a handful of issues: inflamed pulp trapped beneath strong porcelain or zirconia, a cracked root that protests every bite, a high spot in the bite that hammers a single tooth thousands of times a day, or a quiet gum infection brewing at the margin. Sometimes the culprit is humble, a bit of cement lodged under the gum, irritating like a grain of sand in your shoe.

In practice, the history starts the detective work. Pain to cold that lingers for more than 30 seconds hints at pulp inflammation. Sharp pain on release after Dentistry biting suggests a crack. Tenderness to chewing alone may point to occlusion, an uneven bite. Spontaneous night pain and sensitivity to heat raise flags for deeper nerve involvement. Pain that started thirty-six hours after a new crown seated often relates to a bite high by a fraction of a millimeter. Pain three years later? That deserves a search for recurrent decay, microleakage, or a hairline fracture.

A thorough workup has a cadence. First, conversation and observation. Many patients gesture accurately to the problem, but crowned teeth can play tricks, referring pain to neighbors. I ask about onset, triggers, and what soothes it. Over-the-counter analgesics helping suggests inflammation; nothing helping suggests something more serious.

From there, teeth get tested. Percussion with a gloved finger or the back of a mirror reveals ligament tenderness; bite sticks pinpoint cracked cusp issues. Thermal testing with cold spray isolates a tooth’s nerve response. A tooth that reacts to cold and then quiets within a second or two is often healthy. Pain that lingers a minute or more is a red flag for reversible or irreversible pulpitis, depending on duration and intensity. Lack of cold response in a previously responsive tooth, especially when paired with tenderness, may signal a dying or dead nerve.

Radiographs remain fundamental. A periapical film catches the apex and can show widened ligament space, shadowing from infection, or the outline of recurrent decay sneaking under a margin. Bitewings, the unsung heroes of general dentistry, show the proximal contacts where recurrent caries often hides beneath crowns. Cone beam CT has its place for persistent cases with root fractures or hidden canals, but it is not the first step for routine pain under a crown.

Lastly, the bite. Occlusal marks with articulating paper are indispensable, but they tell only part of the story. You want to see how marks look in light closure and in function. A crown that carries the only heavy mark in a quadrant underlines the problem. I often verify with shimstock, a thin metallic foil that should pull through evenly, and I ask patients to move through lateral and protrusive movements. Premature contact in excursions creates microtrauma that can feel like a bruised tooth by evening.

Pulpitis under a crown. If the tooth was heavily restored before crowning, its nerve may already be compromised. Preparation heats the tooth, even with water spray. Drying agents can irritate. Most nerves recover quietly. Some do not. Early, reversible symptoms often respond to adjusting the bite, desensitizing agents, and time. When pain lingers and wakes a patient at night, the nerve has crossed a line. Root canal therapy preserves the crown if access can be made cleanly and the margins are sound. This is where dentistry becomes choreography: precise access through porcelain or zirconia, minimal collateral damage, and the right adhesive protocol to re-seal the entry afterward.

High occlusion. A crown that is just a hair tall can feel fine in the chair but punish the tooth later. An athlete who clenches during workouts will reveal that high spot within days. Relief can be immediate with focused adjustment. The trick is restraint. Remove only what is necessary, recheck in multiple positions, and then polish porcelain meticulously to avoid creating a rough surface that attracts plaque. The luxury approach is precision, not heavy-handed grinding.

Cracks. A cracked tooth beneath a crown tests a clinician’s pragmatism. If the crack is confined to a cusp and detected early, a well-bonded onlay or full crown can quiet it. Under an existing crown, diagnosis leans on symptoms: sharp pain on release after bite, cold sensitivity that is focal, pain to chewing on a single cusp. A crown can mask the classic visual cues. If symptoms persist after bite adjustment and occlusal therapy, or if percussion becomes sharply localized, we suspect a root fracture. Vertical root fractures often hide on radiographs, only revealing themselves as a narrow, isolated periodontal pocket or a halo-like lesion at the root tip months later. The hardest part is deciding when to stop conservative measures. Extraction may be the honest path if the crack extends below bone.

Recurrent decay. Margins do most of the heavy lifting. If cement fails or hygiene lapses, acids sneak under the edge. Gumline decay under a crown is soft, often sweetly musty when explored, and radiographically demure. Patients notice dull ache, food trapping, or a darker line at the gum. Conservative repair at the margin can buy time, but if decay undermines a large area, recrowning is more predictable. For subgingival margins, crown lengthening by a periodontist creates a clean, accessible border. A precise general dentist knows when to bring in that support rather than forcing a hero crown on a short tooth.

Cement and tissue irritation. Fresh cement debris left in the sulcus can spark angry gums within twenty-four hours. The solution is simple but exacting: anesthetize if needed, gently retract the tissue, remove all remnants, flush, and soothe with chlorhexidine for a few days. I have seen thirty minutes of meticulous cleanup spare a patient weeks of discomfort.

Sinus or nerve referrals. Upper molars love to share symptoms with the maxillary sinus. A seasonal flare can masquerade as dental pain, especially if both molars are crowned and relatively quiet on testing. Tenderness when bending over, feeling clogged, and widespread pressure suggest sinus. Lower molar pain that jumps to the ear or jaw joint can be muscular. The general dentist’s role includes ruling out dental pathology before sending a patient off for decongestants or a TMJ consult.

Luxury in dentistry is not marble floors. It is a crown that seats with a buttery glide and clicks into place, a light occlusion that needs a whisper of refinement, and a postoperative course so boring the patient forgets they had work done. When pain intrudes, the elevated response is disciplined and personal.

An example. A client in her early fifties, fastidious oral hygiene, two all-ceramic crowns on upper premolars placed abroad six months earlier. She arrived with zinging cold sensitivity in the right second premolar and chewing tenderness that ruined crostini night. Radiographs were clean, the bitewing showed shadowing at the distal margin but not obvious decay. Cold testing lingered around 20 seconds with mild ache. Articulating paper showed a bold mark in lateral excursion. We gently lowered that contact and polished. She left comfortable, but I was not satisfied with the distal margin’s look, so we scheduled a follow-up. A week later, her cold sensitivity had improved by half. The gum at the distal margin still reddened after flossing. We retracted and found a small ridge of old cement, removed it, then applied a varnish desensitizer at the margin. Two weeks after that, symptoms had resolved. No endodontics, no recrown, just careful attention to two small problems colliding.

For a crowned tooth with persistent temperature pain that lingers or spontaneous throbbing, especially if biting feels swollen or percussion hurts, root canal therapy can be curative. Patients often ask if the crown must come off. In many cases, no. We create a precise access through the occlusal surface, maintain the integrity of the margins, and later seal the entry with a bonded composite or a porcelain inlay. Zirconia and lithium disilicate are workable with specialized burs and irrigation, and they reward patience. The success hinges on straight-line access without widening the entry hole unnecessarily. If caries is present at a margin or if the crown is poorly fitting, replacing the crown after endodontics is more sensible.

The procedure timeline matters. An acutely inflamed nerve may not numb easily, so a two-visit approach, with medication between, makes the experience kinder. For an infected, necrotic tooth, irrigation protocols and the choice of calcium hydroxide medicament turn the tide. I prefer to pack a crowned tooth with a protective temporary that tolerates the patient’s normal function without crumbling, then schedule a short, definitive bonding appointment once the canal work is complete. That final restoration should be as seamless as the crown around it.

Bruxism and clenching sit behind more crown pain than many suspect. Crowns can be ideal, yet nightly force twists them into problems. Microtrauma inflames the ligament, the tooth feels high in the morning, and coffee on one side becomes a hazard. If I see facets, abfractions at the gumline, or hypertrophic muscles, I bring the conversation to protection.

A well-made night guard, carefully adjusted, is a small investment that protects thousands in Dentistry. Precision here matters. A guard should distribute force evenly and make disclusion smooth, not create new interferences. If a patient travels often, a duplicate can save a weekend. If they hate bulky acrylic, a lower-profile option may keep it in use. The luxurious solution is the one they actually wear.

Every material brings trade-offs. Full gold crowns, still unmatched in kindness to opposing teeth and ease of adjustment, rarely cause postoperative bite soreness once polished. Lithium disilicate shines for esthetics and reliable strength in the premolar region, but it asks for precise cementation technique. Monolithic zirconia is tough, a workhorse for grinders, yet its hardness requires an exact polish after adjustment to prevent roughness that irritates soft tissue and wears opposing enamel.

Cement choice matters. Resin cements bond strongly and seal well, decreasing sensitivity in many cases, but they are unforgiving if extra oozes into the sulcus. Glass ionomer cements release fluoride and are kinder to the gum line, useful when margins sit close to tissue. A general dentist weighs saliva control, margin position, and the patient’s caries risk when choosing. The quiet headache from trapped resin cement around a subgingival margin is entirely avoidable with careful isolation and thorough cleanup.

Remaking a crown is not failure. It is a professional promise kept: if the fit, function, or margins are wrong, start again. I advise a remake when:

Sometimes the root cause is the preparation itself. If there is not enough occlusal clearance, a lab compensates with thin porcelain that chips or a bulky contour that interferes. If margins are uneven or in a damp field, microleakage invites sensitivity. A new impression or scan with absolute moisture control, refined soft tissue management, and a clear bite record solves what endless chairside tweaks cannot.

Comfort after a crown is a partnership. Early days matter, both after initial placement and after adjustments. I give patients a simple roadmap that respects their time and improves outcomes.

This is one of only two lists in this article. The rest is lived detail. Patients who follow that guidance sail past the tender window. Those who rush back into almonds and ice water might need another visit. It is human nature, and gentle coaching helps.

A few scenarios deserve mention because they challenge even seasoned clinicians:

That is our second and final list. Everything else belongs in careful sentences, not bullet points.

General Dentistry is the art of integrating diagnosis, materials, occlusion, and patient rhythms into a coherent plan. When a crowned tooth hurts, the general dentist is the conductor, not just the first violin. We triage, we treat, and we decide when to bring in a specialist. Endodontists, periodontists, and oral surgeons are essential colleagues, and knowing when to refer is part of the luxury standard. A seamless handoff, complete records, and a shared plan avoid redundant discomfort and extra cost.

I think of a client who bounced between offices for six months with a crowned lower molar that throbbed randomly. Her radiographs were unremarkable, bite marks unconvincing, and every dentist glazed the crown with adjustments. She arrived carrying a bag of night guards. Cold testing was negative. A CBCT revealed a lurking second distal canal, untreated beneath a crown that otherwise fit like a glove. We accessed through the zirconia, located and treated the canal, then bonded a porcelain inlay to close the window. She wrote later that she had her mornings back. That outcome required no gimmicks, just proper steps in the right order.

People who choose higher-end Dentistry want more than a fix. They want to understand what happened and what will keep it from returning. Cost discussions should be as clear as radiographs. We explain the range: minimal adjustment and desensitizer might be a short visit, while root canal plus restoration carries a larger envelope. We detail how we preserve the existing crown when possible, with photographs and intraoral scans that make the plan visual. Comfort is not afterthought but design choice: topical before injection, warmed anesthetic, unrushed anesthesia onset, and a quiet operatory where instruments are organized and predictable.

A well-done crown begins its life set up for a quiet future. That means impeccable margins, a bite balanced in light closure and excursions, and surfaces polished to resist plaque. It also means personalized maintenance. For someone with a history of sensitivity, a prescription fluoride toothpaste and periodic varnish applications reduce flare-ups. For someone with bruxism, a guard from day one. For someone whose gumline creeps, a schedule that includes meticulous professional cleanings and gentle home technique with soft brushes and interdental aids.

Little habits matter. Swishing with cold water after red wine can trigger a zing in a freshly crowned tooth, not because the crown is wrong, but because acids and temperature dance on an irritable nerve. A few days of caution and a reminder to rinse with lukewarm water shifts the experience from jarring to uneventful. Precision instructions feel luxurious because they respect the individual, not the average.

The most memorable care blends clinical mastery with hospitality. Your dentist remembers that your right jaw stiffens when reclined flat and adjusts the chair. They protect lipstick from the rubber dam edges, offer a warm towel for the cheek after a long appointment, and send a text that evening to check on comfort. These small details do not change the science, but they change the experience. Pain under a crown is an unwelcome guest; hospitality escorts it out quietly.

A crown is a promise: strength, beauty, and function in balance. When pain intrudes, the response from a skilled Dentist delivers more than relief. It restores confidence in the mouth and in the process. Good care does not rush to drill or delay in denial. It listens, tests, adjusts, and, when necessary, treats decisively with the least invasive path that will truly solve the problem.

General Dentistry earns its reputation here, in the unglamorous grind of getting it right. The tools are simple, the judgment is not. If your crowned tooth hurts, do not settle for guesswork. Seek a clinician who measures twice, polishes once, and explains the plan as if your time and comfort were the most important things in the room, because they are.