Hi Bryanna and all,

first of all, very good message board with lots of interesting info, good job! I planned to post here about my unexplained jaw pain problems, but I have a fresh problem.

I've been having sporadic pain in gum between teeth 26 and 27 (upper left molars) for half a year now, every 3 weeks or so for 2-3 days. But this week, this just won't go away and seems to come not from what my dentist says it's a periodontal pocket but from the gum above tooth 26. My dentist performed the root canal on that tooth about 10 months ago, did an x-ray later to check the filling and said it's ok. This week he gave me antibiotics and did a panoramic x-ray, blamed the periodontal pocket for the pain and referred me to a paradontist. But the pain is getting worse as of yesterday and no over the counter analgetic helps one bit. The gland in my jaw on that side is a bit painful today. I had the x-ray done - see it attached.

Question: Am I correct in assuming this is a failed root canal with infection present again and that I'm in need of apicoectomy??? It's now late friday, can I wait till Monday or is it better to run to emergency dental care (I will do so promptly if my body temperature rises above normal...)?

Thanks
Peter

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Hi Peter,

Thanks for the kind words! I am doing my best to help here

Thanks for posting the xray. You have what is referred to as a perio/endo situation with a large blatant infection regarding tooth #14. This is a picture of your upper left first molar tooth #14. Teeth #26 and 27 are your lower right lateral and canine.

The infection may have invaded the sinus as well. I cannot tell for certain but it does appear that you have pathology in the sinus. I also cannot be sure if the root of this tooth is actually in the sinus or not as the xray is only 2 dimensional. It also looks like you a cavity on the tooth behind it in tooth #15 in the distal portion... possibly the mesial of this tooth as well.

Irrelevant of what your dentist may tell you.... this is not a failed root canal. The truth of the matter is... once a tooth has become infected and/or had a root canal procedure or an apicoectomy, the tooth remains infected. There is no access to the miles of microscopic canals (called dentin tubules or accessory canals). These canals harbor necrotic nerve tissue and there is no changing that. Generally root canaled teeth will not display symptoms until the infection is severe.

Regarding an apicoectomy.... first of all apicos never solve the problem as they are nothing more than a surgical root canal procedure that destroys the bone at the apex of a tooth. It does nothing to "cure" the infection inside of the tooth. In your case an apico would be extremely invasive as the sinus is going to be involved. This could set you up for a chronic sinus infection or worse.

The only way to rid yourself of the infection is to remove the tooth and have the socket and sinus surgically debrided of necrotic bone and tissue. You also have the tooth in front, #13, root canaled. Whether or not you would consider removing both of them at the same time is up to you.

You said your gland on that side was tender... indicative that your immune system is burdened by this infection. You may be able to wait until monday but you may not. The pressure from the infection is building up in the bone and sinus that's why the pain meds are not able to lessen the pain. The first thing to do is decide whether or not you are going to remove this tooth as that will determine who you contact for help. If you are, then contact an oral surgeon tomorrow.

Bryanna

Hi Bryanna,

thanks for the thorough, albeit scary explanation. It certainly might explain "full nose" issues I've been having for the last year (I was given a corticosteroid spray for suspected allergic rhinitis but didn't help much). I'm aware you're very much against the use of root canal therapy and I'm following your answers here with great interest, as my number of root canals increased from 2 to 6 in past year and in that time I got all sorts of yet unexplained problems.

Also the cavities you mention on #15 - one dentist alterted my of the one between 14 and 15, while my personal dentist saw no cavity there (ok at least on the panoramic x-ray a week ago, hasn't seen this one yet). No-one mentioned the one on the other side of 15, but I did mention I've been feeling discomfort there when touching the area with my tongue.

I am feeling a better today (gland not tender anymore and a bit less pain) and will try to wait till Monday. Will certainly report how it plays out (I assume they will want to try apico first as the doctrine round here is to try to "save the tooth" if possible - the healthcare insurance pays for that while I don't think it pays for the implants)...

Regarding the teeth numbering - looks like you're using the "Universal numbering system" that is used in the USA, while I'm using the "FDI World Dental Federation notation" used in Europe (as I'm from Europe) Interesting to know, wasn't aware there were multiple nomenclature systems.

Thanks
Peter

Hi Peter,

Yes, different tooth numbering for different areas of the world. Why?? Who knows.

Okay, so it is imperative to tell the oral surgeon about your chronic long standing sinus issues as I am betting they are related to this tooth... if not the root canaled one next to it as well. Some dentists will not admit the correlation between the sinuses and the teeth. While others laugh at the idea of not connecting the two as they are so intricately related. Medically there is no question about the connection.

Interesting that you mention how your health has changed since you have had some teeth root canaled. That is not uncommon for people to report to their dentist. It is however often neglected by their dentist.... again some make the physical connection while others don't.

I understand that the doctrine is to "save the tooth" .... however, dentists are aware that term does not indicate "cure" the problem. It simply means to "retain" the problem. That is what needs to be conveyed to the patient. Your tooth will remain infected and so will the sinus. The major health concern with an upper tooth that is infected after it has spread to the sinus is that it can also spread to the brain. I know that is scary to think about, but it can and does happen. Again, dentists should convey this fact to their patients.

You also need to be aware that the apico will permanently injure the bone and set up for additional infection in both the bone and the sinus. The bone that is compromised during the apico is not replaceable.

I inform people of the facts that they are often not told by their dentist because after 35 yrs in dentistry I know just how detrimental it can be for the patient to not be properly informed.

I wish you all the best. In spite of what the "typical protocol" is as far as the insurance is concerned..... please think about being your own advocate and be mindful of what I have shared with you so that you can make a wise choice that you feel is in your best interest.

Bryanna

Bryanna,

thanks for the additional info. Dentist certainly tend to think only about teeth and nothing else, at least the ones I went to... I have much better experience with oral surgeons, which are also MD-s.

BTW what is your opinion regarding implants? I've done a bit research and even found a lot of info about all sorts of possible complications on web sites of oral surgeons that offer the service. So that solution is also not optimal. So what is it, to remove the tooth and have a hole there? Ok in my case maybe the #13 would be string enough to carry a bridge along with #15...

And one more question regarding root canals. I understand why they are not good - not being able to clean the the bacteria inside microscopic canals and just trap it in there. But would you say there are bad and less bad root canals? Over here, the dentist usually tries to perform the treatment, but sometimes (in my case actually quite often) the canals are unpassable and in that case, an endodontist performs the procedure using a microscope. In fact, 4 out of my 6 root canals were performed by the endodontist. The one possibly causing trouble right now was not.

Peter

There are definitely some complications with implants, but a good oral or periodontist can avoid those complications. For example, one complication on bottom molars is they can hit a nerve and cause permanent numbness. So, when I had to get implants there last month, I asked my dentist how he would avoid that. He showed me in dental how he would avoid it-showed me the X-ray (it's a weird x ray they use-it shows the jaw in 3D, explained how he computer program helped determine what length the implant should be, and then showed me how there is an attachment on the drill that prevents him from going too far.

I'm not a fan of bridges because they compromise other teeth.

Root canals always leave an infection-I'm sure there are varying levels, but they're still a bomb waiting for a flair up again. I've had quite a few root canals (Bryanna don't read this next part, you'll cry). I've had 21 or so root canals on 15 teeth. All done with microscopes by specialists. I've had 6 teeth extracted, 5 of which were second root canals. Then 6th tooth I refused to get a root canal redone, and just had it extracted. All 6 of the teeth broke or became infected with the infection literally coming on overnight. I was fine when I went I sleep, and woke up with a horrible throbbing pain that Vicodin barely touched.

Hi Peter,

First let me clarify that all oral surgeons are not MD's.... at least not in the US. To obtain both degrees they have to attend medical and dental school as separate entities. Perhaps it is different where you live?

I am going to re post your questions and answer in bold type. Makes it easier to follow

<<<BTW what is your opinion regarding implants? I've done a bit research and even found a lot of info about all sorts of possible complications on web sites of oral surgeons that offer the service. So that solution is also not optimal.>>>

MY OPINION ON DENTAL IMPLANTS IS SIMPLY THIS. IMPLANTS ARE A VIABLE, HEALTHY OPTION FOR "CERTAIN INDIVIDUALS" PROVIDING THE SURGEON DOES AN EXCELLENT PLACEMENT AND THE RESTORATIVE DENTIST DOES AN EXCELLENT PLACEMENT OF THE CROWN PORTION.
A GOOD CANDIDATE WOULD BE SOMEONE WHO IS HEALTHY... NO MAJOR AUTOIMMUNE DISORDERS ... NO PERIODONTAL DISEASE.... NO INFECTED TEETH IN THEIR MOUTH..... NON SMOKER.
IN ANY INDIVIDUAL IT IS ALWAYS RISKY TO PLACE AN IMPLANT IN AN AREA THAT HAD A ROOT CANALED TOOTH AND/OR IN AN AREA NEXT TO A ROOT CANALED TOOTH. SIMPLY BECAUSE THE CHRONIC INFECTION FROM THE TOOTH CAUSES A NECROSIS TO OCCUR IN THE JAW BONE WHICH MAY OR MAY NOT BE ABLE TO BE REMOVED WHICH WOULD MEAN THAT THE HEALTH OF THAT BONE WOULD REMAIN COMPROMISED.
DENTAL IMPLANTS ARE ARTIFICIAL "SCREWS" THAT GET DRILLED INTO THE JAW BONE AND THE SURROUNDING BONE INTEGRATES WITH THE IMPLANT TO HOLD IT IN PLACE. IN ORDER TO BE SUCCESSFUL AND WITHOUT COMPLICATION IDEALLY THE BONE NEEDS TO BE HEALTHY AND THE PATIENT NEEDS TO BE HEALTHY.

<<<So what is it, to remove the tooth and have a hole there? Ok in my case maybe the #13 would be string enough to carry a bridge along with #15...>>>

IT IS NOT IDEAL TO LEAVE THIS SPACE AS THE TOOTH BEHIND IT WILL DRIFT FORWARD IN AN UNNATURAL PATTERN WHICH COULD RESULT IN PERIO POCKETING. IT COULD ALSO CAUSE THE BITE TO BECOME MISALIGNED.
IN YOUR CASE IT WOULD BE RISKY TO ANCHOR AN BRIDGE ON TO TOOTH #13 AS IT TOO IS ROOT CANALED WHICH MEANS IT IS IN A COMPROMISED STATE AND CHRONICALLY UNHEALTHY. WHEN THIS TOOTH DECIDES TO ACT UP AND NEEDS TO BE EXTRACTED, IF IT WERE THE ANCHOR TO A BRIDGE, THEN THE ENTIRE BRIDGE WOULD NEED TO BE REMOVED AND REMADE LONGER TO ACCOMMODATE THIS NEW MISSING TOOTH. IT IS NEVER RECOMMENDED TO USE A ROOT CANALED TOOTH AS AN ANCHOR FOR A BRIDGE AND ALL DENTISTS ARE AWARE OF THIS. HOWEVER, MANY WOULD DO THE BRIDGE ANYWAY.

<<<And one more question regarding root canals. I understand why they are not good - not being able to clean the the bacteria inside microscopic canals and just trap it in there. But would you say there are bad and less bad root canals? >>>>

SO GLAD YOU HAVE UNDERSTOOD MY EXPLANATION ABOUT THE TRAPPED BACTERIA! )
ARE THERE BAD AND LESS BAD ROOT CANALED TEETH?? NOT REALLY BECAUSE THEY ARE ALL UNHEALTHY. DEPENDING ON THE PERSONS OVERALL HEALTH SOME RC TEETH MAY POSE A MORE SERIOUS THREAT TO THE PATIENTS HEALTH THAN OTHERS. SOME ARE OBVIOUSLY MORE INFECTED THEN OTHERS FOR VARIOUS REASONS BUT THAT IS NOT A GOOD GAUGE TO DETERMINE HOW DETRIMENTAL THEY CAN BE. SOME HAVE MORE OBVIOUS SYMPTOMS THAN OTHERS AND AT DIFFERENT STAGES OF THE INFECTION. I HAVE SEEN HUGE ABSCESSES FROM RC TEETH THAT LITERALLY SPREAD THE ENTIRE LENGTH OF THE QUADRANT REQUIRING THE PATIENT TO HAVE NOT JUST THE ROOT CANALED TOOTH REMOVED BUT ALL OF THE TEETH IN THAT QUADRANT ALONG WITH A GOOD PORTION OF THE JAW BONE.... AND SOME OF THESE PATIENTS HAD ONLY MINOR FLEETING SYMPTOMS AND THEIR INFECTION WAS UNEXPECTEDLY PICKED UP ON A RADIOGRAPH DURING A ROUTINE EXAM.

<<<Over here, the dentist usually tries to perform the treatment, but sometimes (in my case actually quite often) the canals are unpassable and in that case, an endodontist performs the procedure using a microscope. In fact, 4 out of my 6 root canals were performed by the endodontist. The one possibly causing trouble right now was not.>>>

GENERAL DENTISTS WILL TELL A PATIENT THAT THE ENDODONTIST HAS SOME MAGIC MICROSCOPE AND PERHAPS POWERS TO MAKE A TOOTH HEALTHY AGAIN. THE FACT IS THAT THE MICROSCOPE CAN ONLY PICK UP THE BACTERIA THAT IS LEFT BEHIND IN THE VISIBLE CANALS. THERE IS NO VISIBLE ACCESS TO THE CURVY, NARROW MICROSCOPIC CANALS. SO THOSE CANALS WILL ALWAYS CONTAIN NECROTIC NERVE TISSUE.
THE DIFFERENCE BETWEEN THE ENDODONTIST AND THE GENERAL DENTIST IS ADDITONAL EDUCATION TO TEACH HOW TO UTILIZE VARIOUS EXPENSIVE INSTRUMENTS TO GET INTO LARGE CANALS THAT MAY BE SOMEWHAT CALCIFIED OR IRREGULAR IN ANATOMY. ANOTHER DIFFERENCE IS THE ENDO DENTIST DOES IT FOR A LIVING SO HE USUALLY DOES THE PROCEDURE QUICKER. THE LAST DIFFERENCE IS THE ENDO DENTIST CHARGES MORE FOR THE PROCEDURE..... BECAUSE HE'S A "SPECIALIST". :/
THE END RESULT IS BASICALLY THE SAME SIMPLY BECAUSE OF THOSE DOG GONE MICROSCOPIC CANALS! AND HUGELY BECAUSE ALL TEETH REQUIRE NUTRITION FROM THE BLOOD VESSELS TO BE HEALTHY... THE RC PROCEDURE SEVERS THE BLOOD VESSEL AT THE APEX OF THE TOOTH RENDERING THE TOOTH NON VITAL. ANYPLACE IN OR ON THE BODY WHERE THERE IS NO LONGER CIRCULATION OF BLOOD WILL END UP VERY SICK.

I really do not like giving people this crappy news. I just wish you were told these things prior to having the teeth root canaled because your replacement options at that time would not have been compromising as they are now.

The replacement options for you would be dependent on which teeth you have removed and if you considered have the other rc teeth removed as well. If you wanted the least invasive replacements then you may be a candidate for removable partial dentures which would replace teeth on both side of an arch at one time. You may be able to have bridged made to replace teeth depending on what teeth would be missing and what teeth would be the anchors.

Bryanna

socasusie: 21 RCs on 15 teeth?? Good grief. I think I'll invest into intradental toothbrush, water flossed and replace old amalgam fillings with ceramic inlays as soon as $$$ permits it and while I'm still young (I'm 35).

Bryanna:
Yup, I don't know about other people, but I certainly received very little info from all the dentists I've had so far, about anything at all. I usually do my own research online, but only when the need arises, and the need usually needs to stem from chronic, not acute health problem (those we forget quickly and rightly so). One year ago my knowledge about teeth was about 1% of what is it now. I've actually started reading "Clinical Endodontics: A Textbook"...

The situation in upper left quadrant seems bad with two adjacent RC'd teeth, but it's good to get to know the options as other RC'd teech are not adjacent to each other. I recently started using a "private" dentist in addition to "public" one (the one provided as part of public healthcare) and this was the first time I learned about options other than amalgam and composite (white) fillings... the inlays, onlays etc. So now I can actually plan a solution that would include removing a RCd tooth, and change the old fillings on adjacent teeth with inlays = inlay bridge.

I guess the long term viability of RC depends on the magnitude of initial infection, quality of performed procedure and person's immune system? So all RC will "fail" eventually (I now often hear from my mother she has "focal infections" visible on panoramic x-ray according to the dentist - I'd bet many of those teeth were root-canaled...), but not necessarily in 5 or 10 years. Age + general health must be a factor too. 5/6 of my root canals were done without any symptoms other than pulpal pain that wouldn't go away after 2 days (irreversible pulpitis), i.e. no abscess or granuloma. Pain was noticable in 3 of them, and 1 was actually done without any pain whatsoever (dentist saw a cavity on x-ray, tried to fix it, discovered the pulp is already irritated and performed a RC right away - I thought what the hell, but maybe that wasn't such a bad decision after all).

Peter-I'm actually only 38. My parents neglected my teeth when I was a child, so by the time I could afford to pay for dental work myself, I was in my early 20's and needed to get tons of root canals. I have needed very little work since then-until there was an accident when I was having surgery, and they broke my root canal teeth. If I knew then what I know now, I wouldn't have gotten the root canals-but most dentists won't even admit they aren't permanent solutions, let alone that they'll never get rid of the infection.

I haven't figured out what I am going to do long term to get rid of the root canals.

Peter,

I'm gasping at socasusie's statement about all of those root canals.... OMG! I have known dental patients who have had most of their teeth root canaled.... never a healthy picture. I could cry when I hear or see stuff like that because I know what's coming down the road for that person :/

Peter, what provoked you to read that endo book? Is it written by an Endodontist? Is it about performing the actual procedure? Does it go into the pathology of root canaled teeth?

It is not a question about if or when the root canal will "fail". The procedure is flawed due to the anatomy of a tooth since there is no access to the tiny canals. In addition to that anatomical issue, all teeth require blood to be healthy. So even if there was magic to allow access to the tiny canals and clean them out, the lack of blood would still render the tooth sick. Any body part that is deprived of blood eventually becomes gangrenous and if it is not removed that bacteria will spread through the blood stream. The mouth should not be thought of as different than any other area of the body. There are some dentists who have biopsies and cultures done on extracted root canaled teeth to determine the proper antibiotic protocol for that patient. I have worked with dentists who do that and have seen the pathological reports.... most of the results have one or more of the following (this list is limited) : gangrene .... staph infection .... multiple of strains of strep.... remnants of instruments broken in the tooth ... poorly filled canals.... always necrotic nerve tissue.... formocresol/formaldehyde residue and the bone biopsied comes back with ischemia. These are the things found in root canaled teeth.

Some people have retained root canaled teeth for many, many years. Many of them report no dental symptoms. Yet their xrays show a different story. Because people tend to gauge their problem with the discomfort or the pain.... some dentists don't even inform their patients about the findings because they know the patient is not open to hearing about it. So a note of the findings will be written in the chart so that when the patient does call with pain the dr and staff are already aware of the problem. Of course I don't agree with this way of doing things I believe in informing people of the truth. But lines need to be drawn when what we say falls on deaf ears... sometimes we have to just let the chips fall where they may.

Interesting about your mom and focal infections. Here is a link to a dental site where the biological dentist eloquently explains root canals/cavitations/focal infection in words that we all can understand. I feel validated when I read sites like his ..... by the way I do not know this dentist nor do I have any association with this dentist what so ever. We just speak the same language
http://www.drerwin.com/article_06_rootCanals.html

Bryanna