Expert: Frederick R. Liewehr DDS, MS, FICD - 7/21/2005

Question
Hello,
I had a root canal treatment on a tooth that was throbbing, but not excruciating pain.  My dentist said a lot of blood came out and most of the nerve was dead already.  After the first day, I was doing fine.  I went in the next day to have it finished.  When my dentist started packing the tooth, i felt a pressure extend into my face.  It is now the second day after and the tooth is still painful when i bite down on it.  I am also having a feeling of pressure above the tooth (2nd molar in front of wisdom tooth) on the side of my nose and over my eye.  Is this normal?  My dentist says it should go away in a couple of days, but I am nervous something more serious is wrong.  No one in my family who has had a root canal treatment has any pain like this.  My mother stated she had a reaction to the cement used, but my dentist does not seem to think this could be causing it.  When I look at pictures of NICO, the pain associated with it is in the same spot as my pain,  COuld this be NICO?  I am on Vicodin and Penicillin.  The Vicodin seems to relieve the pain in the gum around the tooth(which I assume is from the novacaine), but does nothing for the pressure.  I should also mention I clench my teeth when I am sleeping, but I wore my nightguard last night and it did not relieve the pressure.  The pressure is also not always constant but an on and off thing.  I also notice it more prevalent and constant in the evening.
Thanks for your help.

Answer
Hi Keith,
    The problem with this Internet forum is that there is not a whole lot that I can do for someone like yourself who really needs to see me in person for a complete exam but to give some general advice.
    When we treat teeth, a lot of what we do depends upon the condition of the pulp, the "nerve" inside your tooth. Essentially, the treatment of a vital pulp varies significantly from that of a necrotic, or "dead", one. Judging from the throbbing pain you had and the blood that came out of the tooth (we say the pulp was "hyperemic", your pulp was not dead but what we call "irreversibly inflamed". This means that due to some insult, which is usually caries, a "cavity", the pulp has become inflamed. It tries to swell, as does any part of your body that becomes inflamed (if you bang your head and get a knot on top of it you know what I mean). Problem is that it can't swell because it is imprisoned inside your hard toothl. So, when it tries, it causes pressure inside the tooth that presses on the nerves in the tooth and gives you a toothache. No bacteria or infection is involved, as it would be if the pulp were necrotic. Therefore, antibiotics like penicillin are unnecessary and inappropriate.
    Since the pain is caused by pressure, it is logical that when we make a hole into the tooth to remove the pulp, that there would be no more pressure and the pain should stop. Plus, when the pulp tissue is removed, the nerves go with it, so you should feel well afterward.
    Without seeing your radiographs, I can't comment on your treatment, but the pain you describe is usually attributable to one of two things. Either the pulp was not entirely removed from the tooth, and some vital (and very sore!) pulp remains, mashed underneath the filling your dentist put into the space in the roots were the pulp used to be, or else material is extended outside the tooth that is causing inflammation in the periodontal ligament, the fibers that hold your tooth in, and the bone surrounding your tooth.
    If the problem is the first case, it may resolve spontaneously if the remaining tissue necroses, but it may not. If the problem is the second csse, sometimes that resolves if the extruded material is absorbed by your body, but this depends on how much was extruded and where it went.
    As for NICO, this theory is promoted by a small group of devotees who seem to find it where nobody else does. It is highly controversial. An otherwise reputable oral pathologist by the name of Buquot has written a number of articles on it, but they are essentially a collection of unrelated case reports that have no controls and do not by any means constitute a scientific study. They have been heavily criticized for exactly that reason. So, I think that while this entitiy may possibly exist, it is by no means prevalent and it is so poorly defined that diagnosis is impossible. Besides all that, your history and symptom picture do not at all coincide with those we would think of in association with NICO.
    So, bottom line is that you can wait a few days, or however long you can tolerate it, to see if you get some improvement. If not, your dentist needs to diagnose and treat your problem. If he doesn't know the answer, he should refer you to an endodontist who does.
    Good luck; I hope you get some relief soon.

Dr. Liewehr