Expert: Joel S. Teig, DMD, Diplomate ABOMS, retired - 12/26/2009

Question
QUESTION: I have many dental issues.  I have many missing lower teeth and deterioration of the lower jaw bone, along with nerve issues of the lower branch of the trigeminal nerve.  I currently take a low dose of gabapentin.  This is just brief background info.
I recently changed dentists to someone who has more high tech capabilities, have had a 3D CT of my jaw, and digital xrays of my teeth.  He found my front 2 teeth in need of crowns, b/c they were mostly composites and decaying underneath and asked me if no one had ever told me that one of them needs a root canal.  It was so badly gone that you could see the circle above the tooth of the granulation into the jaw tissue.  I had been complaining about this tooth for a year to no avail.  Now I've had the root canal treatment done, it's been 6 weeks, and I'm still experiencing pain...sometimes worse than others.  Both these teeth have been crowned, but only the rct tooth is causing me pain, at times almost excruciating, to the point I have been using on occasion my lidocaine patches on the upper front tooth area at night in order to sleep.  I have been back several times and he has re xrayed the tooth and it is a "good" rct he says, but that it will take months for the tissues to heal itself, it took a long time to get that way.  I guess I'm wondering how long something like this could go on, and if antibiotics would help the jaw tissue heal.  I'm taking tylenol and ibuprofen, I'm using ora gel, etc. but there are some days, sometimes stretches of days that are really hard.
Is pain for this granulation a possibilty?  Even if it is a rare possibility...I seem to be one of those dental patients that has always fallen into the only 5% chance of this happening type of thing.  Just looking for input, b/c after 2 years of dealing with all these other nerve issues that I have to live with, this new "wrinkle" is about to put me over the edge, it becomes very difficult to deal with pain all the time.
Thank you for your input.

ANSWER: Liz - The area you describe at the end of the tooth that had the root canal, may have been a cystic lesion or it could have been a stagnent infection.  Either of those conditions can get stimulated from root canal treatment and produce the symptoms you are now having.  The usual treatment, when symptoms like yours occurs, is not to just let the infection fester.  The infection at the end of the root needs to be removed.  A simple minor surgical procedure, called an apicoectomy, needs to be done.  The cystic lesion is removed and the end of the tooth's root is sealed to prevent a recurrence.  The type of doctor who does this is a board certified oral and maxillofacial surgeon.  Your dentist's suggestion to just wait is wrong.  You can ask your dentist for a referral to a surgeon or you can find one in the yellow pages and get an evaluation.  It sounds like that simple surgical procedure will correct your problem.

Don't put this off.  The problem is festering and needs to be treated before the problem explodes.  I wish you well and hope you get this taken care of before it causes a problem.

---------- FOLLOW-UP ----------

QUESTION: THank you for the quick response...as you can imagine, after so many different dentists and specialist, I'm quite confused as to what/who to believe......
When you say, it needs to be treated b/f the problem "explodes"...could you tell me what you mean?
What can happen if I take his advice and give it 6 months for the toxins to work out and the tissue to heal......what might be the result according to what you are saying?

ANSWER: Liz - The episodes of excruciating pain vs pain all the time means that the increase in pain happens as the problem attempts to expand.  Look it is up to you.  The problem could get worse in six months and cause bone damage, but it just may stay the same.  It may go through periods of decreased pain, but the increased pain episodes is not good.  You may just have a festering infection that stays local, but if it finds an area of bone that is less dense, it can greatly expand.  I am a doctor who likes to prevent a problem before it happens.

---------- FOLLOW-UP ----------

QUESTION: Thank you once again.
I went in to see him again on Christmas Eve, and he took another xray, and said and showed me that there is some healing, the spot is smaller, and bone regeneration.......he still thinks that therefore, it is the periodontal ligament that is inflamed from the granulation tissue, et., and that will take time to heal as well.  Is there nothing that can be done to speed that up?
We mentioned the apicoectomy, and he said that he would do that as a last result, but that b/c he sees healing it is not necessary.  He also won't adjust the bite, since I have the nerve condition on the bottom that he doesn't want to disturb, and there is no more he can shave off the crown.....so apparently I have to wait and hope the pain lessens and goes away eventually.  I'm not sure if doing that apicoectomy would make the ligament no longer hurt, which would then lessen the pain or not.  I'm just so confused.  Thanks again for your input and expertise.

Answer
Liz - I fully understand your confidence in your dentist.  Of course, without examining you or seeing your xrays I cannot be totally sure, but the symptoms that you still have, six weeks after the root canal treatment, is usually a key sign in performing an apicoectomy.  That is still my recommendation.  I just don't understand why you have to continue to have pain.  Well, I guess it's up to you.  I wish you well and hope you heal soon and no longer have pain.