Dentistry/root canal

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QUESTION: Hi, I will try to be very precise !!, i had a root canal done on my bottom right pre-molar now 7 weeks ago, stil it does not feel right...i have contacted my dentist and endo regarding this and they are like give it more time, ...but its neva been good since 2 weeks after treatment,..anyways, Firstly i work in the chillers here,(meat processing..) it's generally quite cold, i can feel the tooth achy in general, then when after 2 hours i leave and go to smoko, ..into a warm environment, it becomes significantly more achy, and in fact a vague throbbing sensation, Definitely sore to tap, and to bite on with hard food...like biscuits for instance, even now at home it is sore to tap on, but i have to tap quite firmly, yet at times like at work...it becomes really sensitive to tap on...

  Secondly now im getting a bad taste in my mouth which i fear its from infection within the tooth..?,  the dentist seems to think it  will settle and the pain may just be from the pdl...(but i have serious doubts, from past experiences, and the fact there is a achy throb at times, which doesn't add up to me..)

  It seems Dentist and endo want to hold out until like it gets really bad or obvious i don't know, but im off  away for holidays in 3 weeks and i want this solved, not just going nowhere so to speak,...what i wonder is if the tooth is fractured ?, as times in the past iv felt like something move within the tooth, then like settle back into place, i know there is the possibilty of a root that has been missed ....would that explain the vague throbbing..? if this tooth is fractured across the root, is there no hope not even for a endo to fix it..?

  i didn't want to pull the tooth as it would be obvious but if that is my only course of action,...well then it is

  Point of note ....i currently have 2 root canals besides this tooth in my mouth , and neither took more than 2 weeks to settle,..plus iv NEVER   had an achy throb with any of them like this tooth...which is weird..not to mention annoying
 Thanks for your help any advice would be very helpful, to get this solved cause iv felt like the last 5 weeks, there has been no improvement...
  Cheers Shane

ANSWER: Hi Shane and thanks for your question.

Firstly let me express my sympathy with your situation and I somewhat agree that the length of time you have endured pain is pretty taxing.  You seem to have a good understanding of what you have been through and of the process of root canal treatment, which I feel is always an asset to any dental clinician, because an educated patient can save a clinician considerable time getting down to the root cause of the problem - excuse the pun.

If I was you, I would get a referral to see an endodontist, a root canal specialist, who has more advanced techniques at their disposal to analyse your situation in greater depth and decide on the right course of treatment.  It would be somewhat unprofessional of me to assume that I know what the correct course of treatment for you should be, without having the privilege of clinical assessment or without evaluating your x-rays or clinical notes of the treatment.  Having said that, There are some facts which I can discuss with you regarding your situation.

1. A tooth which has undergone root canal treatment (ie where the nerve has been removed) should be asymptomatic following the treatment as the nerve has been removed (or should have been).  There are always deviations from the normal in any person and it wouldn't be unusual for any tooth to have additional canals with additional nerves or even the splitting of a canal into smaller lateral nerve tributaries which are inherently difficult to identify and seal - sometimes even impossible due to to access and vision limitations.  The fact that you still have pain, makes me think that either the root canal treatment is incomplete, where there could still be some viable nerve left at the apex or tip of the root, or the possibility of an additional canal - although this would be highly unlikely with a lower premolar, which usually has only 1 canal.

2.  There is always a possibility that the pain could be coming from another tooth, considering that oral pain can mask itself and present in another location in the mouth.  This fact often makes the location and specific diagnosis of dental pain somewhat complicated and a reason why a thorough intra-oral exam and full x-rays is always indicated before designing any treatment plan.

3.  It is true what you say regarding tooth/root fractured and this must be investigated fully to exclude this possibility, because as you rightly say, a tooth which is fractured or where the root is fractured, has generally got a very poor prognosis and can be a long standing source of intra-oral pain - and somewhat unnecessarily, if an extraction would have solved the problem from the start.  But fractures, especially those involving the root, are notoriously difficult to diagnose and this is usually dome by gradual elimination of all other possibilities. Here again, I feel that an endodontist would be a in a better clinical position to give you a better guarantee on this unfortunate event, especially as the fracture is clearly not obvious in your case (if this is the problem).

I hope this helps and wish you a speedy resolution of this matter - and hope that your upcoming holiday is nothing more than enjoyable, free of all pain and worry.  Take care.

Kind regards
Dr Craig Peck

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

QUESTION: Hi Craig, Thank you for your fast response !

  Just would like to add a few follow up points

  I have seen an endodontist and my dentist has talked to him...i think the fact i have seen him a couple of times for a consult in the last couple of years, ..with how could i say...  pain, that at times is non specific, yet is localized to the lower right of my mouth (around canine pre-molar area) ..last time i saw him was like 3 weeks after root canal, when i was getting a knawing dull ache(but i could not say conclusively it was the newly done root canal, was more presumption)....(which continued the whole drive down to Karamea here, when i was hiking) ...any ways i did get some antibiotics, and they helped in short term, but were no solution..  I got back to work and it was after that i noticed, i had developed this strange  (throb)  in a supposedly dead tooth so to speak, especially relevant at work, while at home it was a dull ache that continued...after this i contacted dentist again, recently to say this is not right  so to speak, ...in between this...  i saw a local dentist to fix a chipped piece of a top tooth..and to get a like 2nd opinion on my other ache (bottom), he thought the root-canal may be high, (as happens..) so he drilled it done a little , now the next day after like very slight amount taken off that tooth , it was very sensative to biting and tapping..(like a nerve had been stirred up,..but there is none..?)...


     Sorry for the long passage

    After that the following night..the chip he fixed broke off again while eating..grrr,   so i went back and i also mentioned at the time, how his drilling had stirred up my other tooth previously....he took a look at x-rays said root-canal looked fine, but there was a tiny hole in the tooth left of the canine on the bottom, (very tiny) shd not be causing a ache he thought but i got it fixed...now once again...  the drilling on that tooth 2 to the left of my pre-molar stirred it up again...to more a throb..sore to tap..etc (which lasted maybe three days before it settled back to a dull ache..)..all in all  , this has been going on too long for my liking, ..my past experiences with teeth, in this situation,  has not been good, i wish time would help in this situation but i have doubts

    You are quite right in the respect a fracture is clearly not evident, but i have had this before, and then the tooth extracted and he's showed me the crack right across the root

    in your opinion would i be more likely looking at a cracked root, or an extra canal ?..i guess there is possibility of another tooth, but when i can specifically tap on this tooth and NOT ..others around it ... and pain comes from the tap, it concludes it is this tooth..? as the drilling i mentioned also lead  the ache back to that tooth not others when they were  worked on....

  a quick point my chip on my top tooth is broken off again..within a week...should this be happening..?

Cheers  Shane.....and sorry for my long winded explanation, but i wanted to cover everything

 Im hoping for a great  holiday an island getaway  even :)

Answer
Hi Shane and thanks for your follow up and don't stress about your lengthy explanations - the more info the better I can assess your specific situation.

I must just stress that ethically, I cannot consider myself as arrogant as to assume I know exactly what is causing your discomfort, when my learned and experienced colleagues who have had the privilege of examining and treating you, are struggling to do so.  All I can do is try and point you in the right direction and give you some more food for thought to discuss with your clinician in the hope of solving your problem as quickly as possible.

Firstly the issue of your chipped upper tooth... No, any restorative or bonding material used to repair lost tooth structure, is suppose to have a certain life-time in the mouth under normal function.  This time varies from dentist to dentist and between patients given the vast biological differences between all of us and the nature, position and extent of the damage on the tooth. Very often, especially when the damage is small, most dentists try to be as conservative as possible so as not to cause more unnecessary loss of tooth structure and attempt a simple bonding procedure.  Sometimes, when the surface area that one is bonding to is not sufficient to maintain an adequate bond strength with the tooth, the material will dislodge - especially during function, or if the patient suffers from clenching or grinding habits, or if the material added caused a discrepancy in your normal occlusion or altered your bite pattern even in the slightest.  Sometimes the conservative approach has limitations, because it prevents clinicians from making proper allowances for the fact that teeth - and enamel in particular - are extremely hard and functional structures and any material used to replace small amounts of tooth material, must bond to the tooth with the largest surface bonding area possible.  The choice of material is also vitally important because all materials have different properties and most are indicated for specific uses. This means that sometimes, even to repair what seems like a small chip, might well need a degree of drilling to prepare the tooth adequately for maximum bonding of the material.  The amount of the material used is also important, because a certain bulk of restorative material is needed to ensure that it has the capability to withstand the forces placed on it and on the tooth itself during function. The extent of this preparation is really up to the clinician and one is usually lead by the extent of the damage or chip itself - trying at all times to be as conservative as possible.

Back to your pain... In my opinion, even if an active infection was present at the time of your original canal treatment, any pain symptoms should have abated after 7 weeks post-treatment. It wouldn't be unusual for there to be a slight tenderness in the area, which may have been caused by bruising of the PDL as a result of extrusion of the tooth whilst the infection was present. This may also be responsible for the percussion or tap reaction the tooth has post-treatment, but since the x-rays and other intra-oral findings contradict any signs of pathology/infection relating to the root canal treated tooth, this fact is less likely to be the cause. Unless, of course, the tooth is periodontically compromised -ie. has signs and symptoms of periodontal disease, in which case a root canal treatment will be of little use - unless there is a perio-endo or an endo-perio lesion associated, which would have been diagnosed on x-ray at your original consultation and identified by your endodontist.

If I was you, I would suggest that the material used to finally restore the tooth after the root canal treatment, be removed and the tooth dressed temporarily with a slightly softer, more malleable material which would make more allowances for any aberrations in your bite and remove any occlusion hurdles which could be causing continuing bruising of your PDL - if the tooth was crowned, this option is not possible. An endodontist has given you his option that the completed root canal is sound and the tooth is free of any diagnostic signs of infection and/or fracture - and I cannot dispute this fact with the information - or lack thereof - that I have at my disposal. If all the other teeth in that region of the mouth are clinical and radiologically free of any and all signs of pathology, then one has to consider the possibility of a tooth or root fracture.  There is one other possibility, which is that the integrity of root canal treatment, or that of the restorative seal or the apical seal at the tip of the root, has been disturbed in the interim.  This would have resulted in re-contamination of the canal itself and of the apical environment, causing a low grade, chronic-type of secondary infection in the tooth. With the contents of the canal reamed cleaned, any such infection could find drainage much easier out of the tooth without excessive signs or symptoms of active infection caused by the build up of pus at the end of the root. This would have to be discussed with the endodontist to get his feelings on the likelihood of this still causing problems for at 7 weeks post-treatment and what the value of a re-root canal treatment would be - even if the canal was reamed clean again, medicated and left for a period of 2-4 weeks to evaluate your symptoms before extraction is considered. But the choice is really up to you.  Nothing is stopping you from getting an opinion from another endodontist and I would advise this before you agree to an extraction anyway.

That's about as much as I can advise you on this matter. I wish you all the best of luck and good health further and have a super holiday.

Kind regards
Craig

PS - please don't forget to rate my responses to your questions. Much appreciated.

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Dr Craig W Peck ( B.Med.Sc., B.Ch.D., Clin. Botox, Cosmet. Derm.)

Expertise

I am a General Dental Practitioner, with special interests in Cosmetic Dentistry & facial aesthetics and Periodontology, placing a strong emphasis on the establishment and maintenance of a healthy periodontium (the support structure of the tooth) before cosmetic options are considered. I uphold all principles of prevention above interventional treatment and try as far as possible, to remain conservative in my approach. I believe in detailed, open and honest patient discussion, establishing what the patients expectations are and what the reality is of achieving this and involving the patient at every level of the treatment. I have strong principles on ethical treatment and appropriate patient management. I have chosen to treat and rehabilitate many nervous and phobic patients, who, for whatever reason, find it impossible to take part in the very important task of even a routine check-up. I will accept questions relating to general and cosmetic dentistry (in conjunction with the use of facial cosmetic procedures) and dental fears/phobias. I will be more than willing to answer any academic questions in dentistry, biology, physiology, psychology and health sciences in general. As most dentists will tell you, there is often not only one way of dealing with a dental issue - so very often, there is no precise right and wrong way of approaching the problem. All clinicians vary when it comes to treatments and what works best in their hands is often the treatment that is advised. Be understanding of this and bear in mind that nothing lasts forever! Patients are happy to accept only a one-years warrantee when buying a new car, but seem to expect that dental work is going to last them their lifetime.

Experience

I have worked for many years in the UK and RSA as a general dental practitioner - within the NHS, private practice and the government dental health services. I am certificated for the administration of Botox and Dermal Fillers for facial lines and wrinkles as I have attended further courses in minimally invasive facial cosmetic procedures. I started seeing an increasing number of patients who presented with severe to moderate dental fears, even with full-blown phobias, so I started with the slow and patient task of tackling this problem and have successfully rehabilitated many patients. The key is good, effective, concise and understandable communication, shifting control from the dentist to the patient in order to slowly, but confidently, regain their trust back in dentistry, thereby giving them the feeling of achievement and this self-empowerment which drives them to the next level of treatment.

Organizations
Academy of General Dentistry. American Dental Education Association. IAPAM (International Association for Physicians in Aesthetic Medicine). Professional Speakers, Writers and Managements Consultants in Dentistry. The British Dental Association. UK Aesthetics Group. ARC - Aesthetic Professionals. Botox. Aesthetics & Beauty. American Association for Dental Research. FDI - World Dental Federation. SOURCE1uk. World Dental Hygiene Forum. ProDentalCPD. Public Health Dentistry. Dentist Network. LinkedIn. Who's Who of South Africa.

Education/Credentials
B.Med.Sc. Degree (Medical Physiology and Medical Virology; Physiology Cum Laude; Stell 1994). B.Ch.D. Degree (Bachelor of Dental Surgery; Clinical Dentistry Cum Laude; Stell 1997). CPR and CPR-Advanced Courses (2000/2001; UK). Clinical Botox (UK, 2001). Cosmetic Dermatology (Botox and Dermal Fillers; RSA 2011).

Awards and Honors
Placed on the Dean's List at University for academic achievement (1994). Highest achievement in the subject Dental Materials. Medal from 3M and the Radiology Association of South Africa for highest achievement in the subject Dental Radiology and Imaging. Medal from The Periodontal Association of South Africa for highest achievement in the subject Periodontology. Highest achievement for Oral Medicine. Highest achievement in Oral Pathology. Received the DASA (Dental Ass. of South Africa) Gold Medal for highest achieving dental student across the 5 1/2 years of the Degree. Passed the subject, Clinical Dentistry with distinction in final year.

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