Hi JR,
Interesting. I was betting on some type of engineering background
I forgot to attach the diagram of the dentinal tubules. So I will do that with this reply. If you haven't already seen it, I think you would appreciate the visual.
The current problems that you are experiencing may be in part due to the recent dental work that you've had done. But irrelevant of past clinical symptoms, the problem stems from a long standing bacterial infection with root canaled teeth #19, #18 and now possibly #20 is getting in on the act as well. It is very common for someone to have multiple root canaled teeth in one quadrant as the infection migrates from one tooth to the next. Of course you would understand the process of bacterial migration and how easily an infection can spread. But are you aware of how easily it happens with teeth and how it can develop into a neurological problem?
I recommended that book to you because it will explain how the pathogenic bacteria and the small molecule exotoxins readily travel out of root canaled teeth. Eradicating these toxins completely in spite of removing the rc tooth can be difficult. It depends on the individual circumstances, the health of the patient and the skill of the oral surgeon.
I will re post your questions and reply in bold type as it's easier to follow.
<<The key questions still remain, thus would the following be a reasonable course of action?
- you appear to confirm my desire to do the CBCT?
YES, THE 3D CONE BEAM COMPUTED TOMOGRAPHY IS ABLE TO PICK UP AT LEAST 20% MORE THAN 2 DIMENSIONAL XRAYS. IN MY OPINION, THIS SCAN SHOULD HAVE BEEN DONE PRIOR TO THE EXTRACTION OF #19 TO GIVE A BROADER AND DEEPER VIEW OF NOT JUST THAT TOOTH BUT THAT QUADRANT. WHEN THE PATIENT PRESENTS WITH OLD OR TROUBLED ROOT CANALED TEETH AND/OR MULTIPLE ROOT CANALED TEETH IN A QUADRANT, TAKING A 3D SCAN PRE OPERATIVELY CAN DRASTICALLY CHANGE THE TREATMENT PLAN.
- take a closer look at #18 and #20 (would biological width violation produce the symptoms I had described?)
THE SYMPTOMS THAT OCCUR FROM A NON BACTERIAL WIDENING OF THE BIOLOGICAL WIDTH WOULD BE SORENESS AND TEMPERATURE SENSITIVITY. THE VIOLATION CAN OCCUR FOR SEVERAL REASONS. SUCH AS... MALOCCLUSION .... BRUXISM HABIT ... ILL FITTING DENTAL RESTORATIONS.... OR A BUILD UP OF PLAQUE FROM POOR ORAL HYGIENE. HOWEVER, IT IS OFTEN ASSOCIATED WITH A DRAINING INFECTION FROM ROOT CANALED OR OTHER INFECTED TEETH. TOOTH #18 IS ALREADY HARBORING THE BACTERIA THAT I'VE WRITTEN ABOUT SO IT COULD BE DRAINING. TOOTH #20 MAY BE INFECTED AS WELL.
- is lingual nerve injury/damage a possibility?
IT IS A POSSIBILITY ESPECIALLY WHEN A BADLY INFECTED OR ROOT CANALED TOOTH IS EXTRACTED. NERVE ISSUES COULD DEVELOP IF ANY OF PIECES OF THE TOOTH WERE NOT REMOVED BUT RATHER PUSHED DOWN INTO THE BONE. ALSO WHAT MOST PEOPLE ARE UNAWARE OF IS THAT THE INSTRUMENTATION OF THE LARGE CANALS DURING A ROOT CANAL PROCEDURE CAN EASILY PERFORATE THE TOOTH AND CAUSE NERVE INJURY. ANOTHER FACTOR COULD BE INFLAMMATION AND POSSIBLE MIGRATING BACTERIA ALONG THE LINGUAL NERVE FROM THE INFECTION OF THE ROOT CANALED TEETH.
<<Clearly, I am quite realistic about the difficulty of this situation, but I am also reluctant to do unnecessary dental work.>>
I'M SURE YOU ARE ON BOTH COUNTS. AGAIN, I STRESS THE IMPORTANCE OF KNOWING THE FULL EXTENT OF THE RISKS ASSOCIATED WITH RETAINING ROOT CANALED TEETH.
<<Again, I very much appreciate your holistic view of things.>>
I AM VERY HOLISTIC MINDED BUT MY VIEWS ON ROOT CANALED TEETH GO WAY BEYOND THAT. THE RISKS OF A SYSTEMIC INFECTION CAUSED BY THE MIGRATION OF INFECTIOUS BACTERIA FROM ROOT CANALED TEETH IS THE SAME AS IT WOULD BE IF YOU HAD A BONE INFECTION ELSEWHERE IN YOUR BODY.
I'll attach that diagram of the dentinal tubules.......