[nukuspot]

Hi Bryanna,

It's Nukuspot from a month ago! Hi! First let me start with the good news. The issue you were helping me through with the extraction pain from my root canal molar #19 is getting so much better. It is 7 weeks since extraction and I noticed around 4 weeks the pain was getting better. At 6 weeks the pain was mild and I was sure it would just get better and better over time. I followed all your instructions except I never had to see a periodontist for that weird tissue growth in the socket, as my general dentist looked at it again on my request and said it was normal and it would flatten over time (which at week 7 it is now starting to do.) So yay for a happy update!

Now the new issue. I have another root filled tooth. This one is my upper left canine, #11. The story behind this one is this. When I was very young (age 8/9) I was diagnosed with severely impacted adult canine teeth. They were horizontal I was told, and would never have come in by themselves. So at the young age of 9, I got braces and what I consider to be aggressive oral surgery in which I was put under general anesthesia, the gum cut back, and brackets put on the canine teeth with wires coming down out of the gums attached to the braces. Over the next few years they were tightened and it pulled the teeth down. I remember it being very painful. I had the braces/wires for 3 years. The canines were eventually pulled into place, the left one was always more difficult than the right.

Fast forward many, many years and in 2007 I saw a dentist who said he saw a "dark shadow" around the apex of the left canine during xray. The tooth never had any decay or fillings. He sent me to an endodontist who did vitality testing and said he would like to RCT it, though it was still alive. I elected to not RCT and went home. Many years passed with no issue. All of a sudden in 2011 it abscessed horribly. It was my only abscess I ever had and it was insanely painful. I was in so much pain that I rushed back to that same endodontist who declared it "chronic apical periodontitis" and attempted a same day RCT. However while he was doing the RCT he said the canal was extremely calcified and he could not access the apex. So while I was still in the chair he said he had to go in from the other direction and I had an apicoectomy. He did the whole thing that day, the attempted root canal, the apico, and the permanent filling. I went home and other than swelling, never had an issue with that tooth again for 4 years. Since learning about the issues behind RCTs I planned to get it extracted eventually, but was following a plan that my naturopath had created which was to get the RCT molar out first, wait 6 months for healing, get a zirconia implant, wait 6 months for osseointegration and get a ceramic crown, then get my 2 amalgams replaced (as soon as I was done breastfeeding) and THEN focus on #11. I liked that plan because being that it is a front tooth, I wanted to make sure that I was going to be able to tolerate an implant, and having the molar to have had that implant experience with was crucial. I do not want to get a bridge for my front teeth as they are all virgin teeth, as well as I have short roots on the lateral teeth from those early childhood braces, and it could not be an abutement for a bridge. Being that I am 35, I did not want to live my life with a removable front tooth, so that left implant as the only reasonable option for #11. I wanted to make sure it was all going to be OK. So I was not jumping to get it out right now....

Then a week ago I started to have a gentle throbbing feeling from "somewhere" in my upper front left teeth. I panicked because I just had finished that 11 month ordeal of pain relating to my lower root canal molar. I first went back to the original endodontist who did the apicoetomy in 2011 because they offer free lifetime followups on the teeth they treat. He did 3 xrays because he had a hard time getting the apex of the tooth in the photo, which is frustrating. Finally he got one where he could see it. He said it looked fine, bone had filled in well, no sign of failure, etc. He thought it could be a gum pain issue. Soon after, the throbbing turned into pain which moved throughout my upper left teeth from about the premolars to my left front tooth. Then I started to feel the most scary symptom yet--A feeling of pins and needles/numbness/like a crawling feeling under my skin right under my left nostril down to my upper lip. Like the prodromal tingling you get before a cold sore appears! But it was constant. I went to my integrative MD very concerned. She said it could be a sinus issue or a tooth issue, or both. She looked in my nose and could see congestion. I did not feel congested but when she pushed on my face the left side around my cheekbone really hurt. I had post nasal drip as well. She said that the diagnostic test would be a facial/sinus CT but she knew I would be adverse to it because of the high amount of radiation. With all the xrays I have had over this last year, I can't risk that.

So I went back to my general holistc dentist. I brought the xray from the endodontist and told him what my MD said. Without even looking at me he said he was worried it was #11 because, like you, he did not trust RCT teeth. I explained to him that unlike when I extracted #19, because this was a visible front tooth, I did not want to just guess it was the cause and extract it to see. Personally and professionally, I cannot be missing a visible tooth, so I only wanted to go ahead with extraction at this point if he was sure the issue was from the tooth. He did a tapping exam on all my upper left teeth. They all felt fine. He ran his finger over all the upper teeth at the gumline. They all felt fine. He looked at the xray (which I will attach here) and said he also did not see anything on it.) I asked him if he could take another 3D scan as it would show all the teeth plus the sinuses. He agreed. We did the scan. It looked identical to the 3D scan I had before my extraction in January. He showed me that #11 has a small black circle above it, but it had not grown since January, and was not visible on any 2d Xray. He said that most dentists would call it a scar from the apicoectomy, though he "didn't like scars". However without any change in the size, he could not say it was anything else that would warrant extraction of that tooth. He did what he called a "diagnostic" ozone injection above #11. He said that ozone would kill anything it came into contact with and be antiimflammatory though it would not be permanent. Most likely a few days of relief, but if it got better than it would be diagnostic the pain was coming from that area. It did get confusing because he said that injection might also affect the sinuses too. I saw no change for the first 24 hours but day 2 I saw about a 50% improvement in the numbness and about a 30% improvement in the pain. Like he said, it was short lived. It is now day 3 and it is all back.

I guess I am not sure what to do with this info. I find it so inconceivable that my two root filled teeth would coincidentally fail one after the other, when they aren't even in the same quadrant. But it looks like either that or sinus issues are the best diagnoses I have.

Do you have any advice? I am very very afraid to disfigure myself by pulling a front tooth if it might not be the problem. If it had visible issues on the scans, I would rush to do it. But I am just so concerned that I would do it and it wouldn't solve anything, I would go through more pain, still have this pain, and then have to go through 2 implants in different quadrants of my mouth right after each other. With the zirconia implants you have to wear an Essix plastic appliance on all your teeth to protect the implant as the bone heals since it is one piece for 6 months until it is ready for the permanent crown, not like the titanium ones. If I have to wear a top and bottom Essix at the same time it will greatly affect my speech. I really wanted to avoid having to do that.

I know this is long. You have been such a great support and help in the past. Is there anything you can add or recommend? What do you think I should do from here?

[nukuspot]

If I can figure out how to upload screenshots from the CBCT scan I will. There is a great panoramic photo which shows all my teeth, but I cannot figure out how to save an image from the disk to my computer.

[nukuspot]

Oh, one last thing. When I went back to the endodontist I asked if they could tell me exactly what materials were used in the 2011 procedure. I was worried I had an amalgam root filling. They said their office is amalgam free and this is what they wrote for me (I said my dentist wanted the notes about what they used):

"#11 RCT attempted, unable to negotiate the canal due to calcification, filled with obtura. Buccal perforation repaired with MTA. Apicoectomy #11 with IRM retro-fill."

Is obtura a type of gutta percha? When I google it I find a endodontic machine called Obtura which seems to melt gutta percha, so I assume so.

[nukuspot]

I have been playing with the CD of my 3D scan for an hour and I admit defeat. I don't think they will let one copy and paste an image from it. So I resorted to a screenshot of my computer with my phone. It's not pretty but maybe it is useful for you anyway? It's the best I can get unfortunately. At least you can see that little black spot (scar?) above #11. I loaded my January CBCT scan and that dot is the same in that one too. It actually looks a little smaller in this recent picture, but that could be an angle thing.

[Bryanna]

Nukospot,

Unfortunately this xray is crappy and not taken at a good diagnostic angle. So I won't even speculate on it.

Bryanna

Originally Posted by nukuspot

Hi Bryanna,

It's Nukuspot from a month ago! Hi! First let me start with the good news. The issue you were helping me through with the extraction pain from my root canal molar #19 is getting so much better. It is 7 weeks since extraction and I noticed around 4 weeks the pain was getting better. At 6 weeks the pain was mild and I was sure it would just get better and better over time. I followed all your instructions except I never had to see a periodontist for that weird tissue growth in the socket, as my general dentist looked at it again on my request and said it was normal and it would flatten over time (which at week 7 it is now starting to do.) So yay for a happy update!

Now the new issue. I have another root filled tooth. This one is my upper left canine, #11. The story behind this one is this. When I was very young (age 8/9) I was diagnosed with severely impacted adult canine teeth. They were horizontal I was told, and would never have come in by themselves. So at the young age of 9, I got braces and what I consider to be aggressive oral surgery in which I was put under general anesthesia, the gum cut back, and brackets put on the canine teeth with wires coming down out of the gums attached to the braces. Over the next few years they were tightened and it pulled the teeth down. I remember it being very painful. I had the braces/wires for 3 years. The canines were eventually pulled into place, the left one was always more difficult than the right.

Fast forward many, many years and in 2007 I saw a dentist who said he saw a "dark shadow" around the apex of the left canine during xray. The tooth never had any decay or fillings. He sent me to an endodontist who did vitality testing and said he would like to RCT it, though it was still alive. I elected to not RCT and went home. Many years passed with no issue. All of a sudden in 2011 it abscessed horribly. It was my only abscess I ever had and it was insanely painful. I was in so much pain that I rushed back to that same endodontist who declared it "chronic apical periodontitis" and attempted a same day RCT. However while he was doing the RCT he said the canal was extremely calcified and he could not access the apex. So while I was still in the chair he said he had to go in from the other direction and I had an apicoectomy. He did the whole thing that day, the attempted root canal, the apico, and the permanent filling. I went home and other than swelling, never had an issue with that tooth again for 4 years. Since learning about the issues behind RCTs I planned to get it extracted eventually, but was following a plan that my naturopath had created which was to get the RCT molar out first, wait 6 months for healing, get a zirconia implant, wait 6 months for osseointegration and get a ceramic crown, then get my 2 amalgams replaced (as soon as I was done breastfeeding) and THEN focus on #11. I liked that plan because being that it is a front tooth, I wanted to make sure that I was going to be able to tolerate an implant, and having the molar to have had that implant experience with was crucial. I do not want to get a bridge for my front teeth as they are all virgin teeth, as well as I have short roots on the lateral teeth from those early childhood braces, and it could not be an abutement for a bridge. Being that I am 35, I did not want to live my life with a removable front tooth, so that left implant as the only reasonable option for #11. I wanted to make sure it was all going to be OK. So I was not jumping to get it out right now....

Then a week ago I started to have a gentle throbbing feeling from "somewhere" in my upper front left teeth. I panicked because I just had finished that 11 month ordeal of pain relating to my lower root canal molar. I first went back to the original endodontist who did the apicoetomy in 2011 because they offer free lifetime followups on the teeth they treat. He did 3 xrays because he had a hard time getting the apex of the tooth in the photo, which is frustrating. Finally he got one where he could see it. He said it looked fine, bone had filled in well, no sign of failure, etc. He thought it could be a gum pain issue. Soon after, the throbbing turned into pain which moved throughout my upper left teeth from about the premolars to my left front tooth. Then I started to feel the most scary symptom yet--A feeling of pins and needles/numbness/like a crawling feeling under my skin right under my left nostril down to my upper lip. Like the prodromal tingling you get before a cold sore appears! But it was constant. I went to my integrative MD very concerned. She said it could be a sinus issue or a tooth issue, or both. She looked in my nose and could see congestion. I did not feel congested but when she pushed on my face the left side around my cheekbone really hurt. I had post nasal drip as well. She said that the diagnostic test would be a facial/sinus CT but she knew I would be adverse to it because of the high amount of radiation. With all the xrays I have had over this last year, I can't risk that.

So I went back to my general holistc dentist. I brought the xray from the endodontist and told him what my MD said. Without even looking at me he said he was worried it was #11 because, like you, he did not trust RCT teeth. I explained to him that unlike when I extracted #19, because this was a visible front tooth, I did not want to just guess it was the cause and extract it to see. Personally and professionally, I cannot be missing a visible tooth, so I only wanted to go ahead with extraction at this point if he was sure the issue was from the tooth. He did a tapping exam on all my upper left teeth. They all felt fine. He ran his finger over all the upper teeth at the gumline. They all felt fine. He looked at the xray (which I will attach here) and said he also did not see anything on it.) I asked him if he could take another 3D scan as it would show all the teeth plus the sinuses. He agreed. We did the scan. It looked identical to the 3D scan I had before my extraction in January. He showed me that #11 has a small black circle above it, but it had not grown since January, and was not visible on any 2d Xray. He said that most dentists would call it a scar from the apicoectomy, though he "didn't like scars". However without any change in the size, he could not say it was anything else that would warrant extraction of that tooth. He did what he called a "diagnostic" ozone injection above #11. He said that ozone would kill anything it came into contact with and be antiimflammatory though it would not be permanent. Most likely a few days of relief, but if it got better than it would be diagnostic the pain was coming from that area. It did get confusing because he said that injection might also affect the sinuses too. I saw no change for the first 24 hours but day 2 I saw about a 50% improvement in the numbness and about a 30% improvement in the pain. Like he said, it was short lived. It is now day 3 and it is all back.

I guess I am not sure what to do with this info. I find it so inconceivable that my two root filled teeth would coincidentally fail one after the other, when they aren't even in the same quadrant. But it looks like either that or sinus issues are the best diagnoses I have.

Do you have any advice? I am very very afraid to disfigure myself by pulling a front tooth if it might not be the problem. If it had visible issues on the scans, I would rush to do it. But I am just so concerned that I would do it and it wouldn't solve anything, I would go through more pain, still have this pain, and then have to go through 2 implants in different quadrants of my mouth right after each other. With the zirconia implants you have to wear an Essix plastic appliance on all your teeth to protect the implant as the bone heals since it is one piece for 6 months until it is ready for the permanent crown, not like the titanium ones. If I have to wear a top and bottom Essix at the same time it will greatly affect my speech. I really wanted to avoid having to do that.

I know this is long. You have been such a great support and help in the past. Is there anything you can add or recommend? What do you think I should do from here?

[Bryanna]

Nukospot,

Okay I will re post your thread and reply in bold.

<<"#11 RCT attempted, unable to negotiate the canal due to calcification, filled with obtura. Buccal perforation repaired with MTA. Apicoectomy #11 with IRM retro-fill.">>

CALCIFICATION MEANS THERE WAS NO OPENING IN THE CANAL. SO WHAT DID HE FILL WITH GUTTA PERCHA?? BUCCAL PERFORATION MEANS HE PUSHED AN INSTRUMENT THROUGH THE FRONT WALL OF THE ROOT OF YOUR TOOTH TRYING TO OPEN UP THE CALCIFIED CANAL. SO THIS MEANS THAT BACTERIA WAS ALSO PUSHED THROUGH THAT OPENING. MTA IS MINERAL TRIOXIDE AGGREGATE WHICH IS BASICALLY STERILIZED PORTLAND CEMENT AND IT IS USED TO COVER A LIVE NERVE OR A PERFORATION OF A ROOT IN AN ATTEMPT TO HEAL THE TOOTH. IN SOME CASES MTA WORKS PRETTY GOOD BUT IT IS NEVER REALLY A CURE. IRM STANDS FOR INTERMEDIATE RESTORATIVE MATERIAL AND IT IS A ZINC OXIDE EUGENOL CEMENT. IT IS USED AS A TEMPORARY FILLING MATERIAL OR USED TO PLUG UP A SURGICAL OPENING IN THE BONE AFTER AN APICO. OBTURA IS A HEATED GUTTA PERCHA GUN USED TO MELT THE GUTTA PERCHA MATERIAL INSIDE OF THE LARGE CANALS.

Bryanna

[Bryanna]

nukuspot,

Thanks for posting the panoramic xray.

I am going to assume that since the large canal of #11 was calcified that the endodontist was able to drill out the interior of the tooth from the apico opening down into the tooth. Because it is full of gutta percha and he could not get that in the tooth from the opening in the biting surface of that tooth because the canal was closed. Yes, I can see the black area above the apex of the tooth above the area where he placed the IRM retro grade filling. That black area could be a cyst or a void in the bone. A panoramic xray does not offer enough dimensions or slices for anyone to diagnose that area.

I can see how the roots of your upper anterior teeth are fore shortened or blunted from orthodontia. That occurs when teeth are moved too quickly and too forcefully. You could also have had some blunting of those roots prior to ortho which may be a hereditary thing.

The problem is that this tooth has been through such trauma between force ably being pulled from the bone to an upright position, then an attempted root canal with a buccal perforation, then traumatic surgery done to the jaw bone above the tooth. Frequently the bone surrounding a tooth that has been through all of this is more fragile than say a healthy non root canaled tooth. So a dental implant in this area may be a bit tricky and no one can really know the extent of the condition of the jaw bone until the tooth is removed. I know.... that is not what you want to hear. :/

I would recommend that you discuss this tooth is great detail with your dentist and get a time line down as to when you want to undertake this extraction and exploration of bone. You may be awhile, a few months, without a tooth there as that may be the best option for complete healing. If this area is not healthy enough to receive a dental implant, then you will be dealing with other issues.

I wish this were easier to explain and I really wish I didn't have to give you this news. Teeth are such a pain in the........ ss!

Bryanna

[nukuspot]

Thank you so much for your reply. I have been reading and retreading your response and I have just a few followup questions. Firstly, are there any specific questions you can advise me to ask the dentist who would be doing the extraction and implant other than "am I a candidate for an implant in this area if I extract #11?"

The scan was not just a pano, it was a Galileos 3D CBCT scan. I just took a picture of my desktop when it was on the pano setting, but would there be any other view I could show you that would be helpful? I just took the pano one because I knew what I was looking at since I cant really read scans.

Finally I am wondering what to do about temporary replacement of the tooth if I do extract. Having a gap is not an option. I would be devistated. When I called today to make the consult appoint with the dentist who extracted my other RCT 7 weeks ago I asked what they do, after the extraction, if I would leave with a gap. The front desk person said they take impressions before the extraction and I can get a temporary tooth to wear until implant. My fear is because the tooth next to it, the lateral, has such short roots, can it be damaged by 6 months of wearing a temporary tooth? I imagine it would hold on to the teeth on either side, right? I've never seen one in real life, just photos. She didn't know and said I have to ask the dentist. Do you know if this is a valid concern? I don't ever want to have to lose another tooth or choose between a RCT or extraction.

Is there anything else that could be causing these symptoms that might not be related to the apico tooth? I saw an ENT who looked at the CBCT scan and said my sinuses look fine. And so it can only be tooth or nerve related he thinks. He asked me if I could live with it, if so maybe I should do nothing until I know exactly what I'm dealing with.

What would you do in my situation? Can you put yourself in my place and advise further? I'm so afraid of making a bad decision and having life long consequences.

[Bryanna]

nukuspot,

To clarify.... the xray that I felt was not very diagnostic was the single film. The scan was okay.

I know you want to have some concrete reassurance about whether or not removing #11 is warranted. I cannot advise you one way or the other. I can just inform you of what this tooth has been through, based on your information, and how fragile this tooth is from all that it has had done to it. The abscess it had in 2011 clearly indicates that the tooth had been in trouble for awhile as that type of infection does not occur over night. In your case it was already brewing in 2007 when the blackened apical area was seen on the xray. You are fortunate that the sinus does not appear to be involved but that does not mean it won't be if the bacteria progresses into the sinus cavity. On one hand you were fortunate that the tooth was asymptomatic for 4 years but at the same time the lack of symptoms gives the illusion that the tooth was okay until now. Do you know what I mean?

Questions for the dentist about #11....

Be sure to discuss the surgery and the protocol to follow. Ask him about doing bone graft at the time of the extraction depending on if he feels the site is healthy enough to receive it.
Ask about a temporary replacement. What are your options? Express your concerns about using the short lateral for support... good idea or not really?
Ask about the essix retainer and can it be made to just include 4 teeth, the lateral/the pontic #11/and both pre molars or does it have to include the whole arch? Usually it is just a few teeth. They are not meant to be worn when you eat or sleep. But they are very esthetic looking replacements and simple to use. Sometimes they need to be replaced because they do wear out.

The dentist will not know for certain if the site is healthy enough for a dental implant until he removes the tooth and visually sees and feels what is present in the bone.

I know it's hard to make a decision because you felt the tooth was somewhat stable due to the lack of symptoms. An example of something similar would be.... you have a sliver of wood embedded in the palm of your hand. Initially it's uncomfortable but you remove a piece of it and it seems to settle down. All of sudden one day you wake up with an inflamed hand and it's painful. You are able to remove another piece of it and sure enough it seems to calm down again. Then one day your hand feels a bit sore, but now your fingers hurt and your arm is tender. But they look fine both visibly and radio graphically. Could the embedded splinter be causing these symptoms in your fingers and arm since it was never entirely removed from your hand? This scenario is known as a focal infection in which bacteria has traveled from one area of the body to another. This focal infection is a common occurrence with root canaled teeth unless they are extracted before the bacteria moves elsewhere.

Perhaps if you, your dentist and your naturopath work together to come up with a time line to remove it, you will be better prepared mentally and physically to deal with it.

Bryanna

Originally Posted by nukuspot

Thank you so much for your reply. I have been reading and retreading your response and I have just a few followup questions. Firstly, are there any specific questions you can advise me to ask the dentist who would be doing the extraction and implant other than "am I a candidate for an implant in this area if I extract #11?"

The scan was not just a pano, it was a Galileos 3D CBCT scan. I just took a picture of my desktop when it was on the pano setting, but would there be any other view I could show you that would be helpful? I just took the pano one because I knew what I was looking at since I cant really read scans.

Finally I am wondering what to do about temporary replacement of the tooth if I do extract. Having a gap is not an option. I would be devistated. When I called today to make the consult appoint with the dentist who extracted my other RCT 7 weeks ago I asked what they do, after the extraction, if I would leave with a gap. The front desk person said they take impressions before the extraction and I can get a temporary tooth to wear until implant. My fear is because the tooth next to it, the lateral, has such short roots, can it be damaged by 6 months of wearing a temporary tooth? I imagine it would hold on to the teeth on either side, right? I've never seen one in real life, just photos. She didn't know and said I have to ask the dentist. Do you know if this is a valid concern? I don't ever want to have to lose another tooth or choose between a RCT or extraction.

Is there anything else that could be causing these symptoms that might not be related to the apico tooth? I saw an ENT who looked at the CBCT scan and said my sinuses look fine. And so it can only be tooth or nerve related he thinks. He asked me if I could live with it, if so maybe I should do nothing until I know exactly what I'm dealing with.

What would you do in my situation? Can you put yourself in my place and advise further? I'm so afraid of making a bad decision and having life long consequences.

[nukuspot]

and...because you have been helping me with my saga about #11---here is the one the new endo took on #11. He said it looks fine but his idea was that the MTA at the root end filling could be irritating. He wanted to re-apico and replace the MTA with something called endo-cal (I think). For me, I am not that interested in that idea but I do like to know all my options. I would most likely extract over a re-apico at this point. But I am still waiting to see the dentist who would be doing an extraction and implant on #11 to consult with him to see if I am even a candidate for implant at that site. If not, my only option may be to try the re-apico, though that would be less than ideal. Anyway, that is beside the point because that is not the burning issue at the moment (what to do about #7 is...see other thread.) I thought you might want to see the new xray of #11.