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Dentistry/Pain-Apicoectomy-Fractures?

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Pre Surgery X-ray
Pre Surgery X-ray  
QUESTION: Hi Dr.;

In February 2013, i started feeling burning/throbbing in 16 year old root canals/post/crowns #7 & 8 (pre surgery xray attached). The pain came and went constantly throughout the day and went up into my right nostril area. Old x-rays revealed dark shadow/infections were at the root tips for many years but I had no pain and they were left alone. Last December I had both teeth apico'ed, mta retro-filled, and bonegrafts placed by an endodontist; he said the teeth had no fractures during the surgery. The area was immediately numb for a while, then slowly OK but a bit sensitive, but now, 9 months later, the exact old pain has returned (burning/throbbing from the teeth up into my nostril area). There is slight sensitivity to the two teeth, but nothing major. The doctor still sees no signs of fracture. He took new xrays and pointed to the area above 7 and 8 and said the bone is filling in great with no signs of infection and that the teeth look and feel solid. He then proceed to poke around and feel the area above teeth with his finger but he could not feel anything out of the ordinary or produce pain. What do you think is happening here? Do you see any signs/symptoms of fracture in my pre-surgery xray?  Any ideas? I really do not want to go through extractions/implants for front teeth, as i can't think of having to work with a flipper and also worrying how the implants will eventually look in an aesthetic area :(

ANSWER: Thank you for this great question Anthony. Firstly I do not see any signs of fracture in this film and by  the way thanks a lot for attaching it, it is quite helpful to me.  Secondly I do not see the signs of a retrofill on either tooth. I see an apparent apic on 8 but not on 7.  The root canals look very good and look like they are filled properly and with the proper material. I don't see much on 8 but on 7 I see a definite radiolucency (abscess). Have you been put on any antibiotics? It looks to me like there is recurrent abscess on 7 which probably is causing your pain but I cannot say why it is there. ON occasion there are accessory canals in a tooth and they are small enough they don't show on an x-ray and it's possible one of these is the cause of your problem.  The crowns and posts look good too.  If this was taken before the apico was done then it's hard for me to evaluate what's there at this point. This is what I see on the x-ray you have provided.  On 8 the root tip is blunted which indicates infection and of course it is evident on 7. I think that reevaluation by the endodontist is in order. I think there is a recurrent problem which is probably infection again and only the endodontist can really do a good evaluation for you.  Thanks again and if I can be of any further assistance, please write again.


Dr. Karmen

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

QUESTION: Hi Dr. Karmen,

Thanks again for replying so quickly. Further information: I was put on antibiotics AFTER I had the endodontic surgery this past January (after 7 & 8 had apicos, mta, and bonegrafts). Although numb, I was feeling a lot of throbbing from both teeth after the surgery so the endodontist prescribed clindamycin--i don't think it did much but wreak havoc on my stomach. It has been about 7 months since the surgery and I just went back to my endodontist for evaluation/x-rays and he thinks the bone is filling in great and there is no signs of infection. He's perplexed as to why I have any pain right now. He said both teeth feel rigid with no obvious signs of fracture (he didn't see any fractures during the surgery either).  So I'm honestly not sure what to do about this burning/throbbing pain that is continuing from the area of both teeth and up through my nose.  I appreciate your input.

Answer
You are most welcome Anthony and thank you for contacting me again.  I agree this is a difficult thing to diagnose. With all you've been through I have been giving thought as to what the problem might be. If there is no infection and if there is no crack then the pain must be coming from other source.  I know that at times the periodontal ligament (the thing that holds your tooth to bone) can be inflamed or can be stretched and cause pain but it usually isn't a burning type of pain.  What you are describing is almost more like a neuralgia and the best advice I could give at this point is to see a neurologist for evaluation.  I am with you on not wanting to remove these teeth and implant because I'm not convinced that they are the source of your problem. You might try a course of doxycycline or amoxicillin to see if it helps as both are less stomach irritants but it sounds like you have a different problem. I am not convinced it's infection.


Dr. Karmen

Dentistry

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Thomas Karmen

Expertise

All general dentistry questions, especially those related to fixed prosthetics. Endodontics, Periodontics, and implants, minor oral surgery I can't answer much about othodontics nor advanced treatment of carcinoma nor deep tissue surgery nor osseous surgery such as jaw reduction or advancement.

Experience

DDS In general practice and consulting with having done some lecturing for local dental societies.

Organizations
ADA and Florida Dental Association and Iowa Dental association

Education/Credentials
DDS degree

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