Hello Bryanna,

Perhaps you would be so kind to comment on this (I have posted before but have had no success in getting a reply).

I had a periodontist extract #19 in June 2015. #19 was badly compromised (apicoectomy in 1991, May 2015 fistulous tract.) Equimatrix bone graft with optimatrix barrier membrane placed over BG and undel F/L mucogingival flaps.

Eventful recovery with sutures falling out 3-4 days post-op, and loss of some BG material. Ultimately, the site healed over a period of 5 weeks but with numerous complaints about deep seated, gripping pain (not acute) in the LL area, as if a stake had been placed in the area.

Checked for bone regeneration with an OMFS (periodontist retired) in Novermber. The extraction site was well healed with a broad alveolar ridge. A Noble implant with a healing abutment was placed in #19, slighlty more mesial than septal area. Site healed nicely but after 3 weeks, the deep seated, gripping ache that builds up during the day and subsides at night, started again. OMFS checked the site 2 and 4 weeks post-op. There is no pathology, edema, exudate, etc. Referred to a TMJ specialist who thinks it's peripheral neuralgia and suggests anti-convulsants.

I am at a loss, speculating on the following:

#18 (RTC in 2008) is failing..but no tenderness, or pain on biting...fractured root, 3rd root not seen on saggital x-ray view...?

#20 vital tooth, but with a crown, with some biologic width violation..and a ledge on DL side...?

IAN or lingual nerve injury duing the blocks? (left side of tounge is affected, a bit sensitive but not numb, etc...hard to tell if this is referred pain from around 18-19 area..?

I have excluded other causes (ENT related, acoustic neromas, etc.).

Any hints, ideas on how to pin this down would be much appeciated. Antinflammatories are a hit and miss on this. Would a cone beam CT reveal any issues, residual infection, etc?

Best regards and thanks in advance --jr

Hi JR,

Nice description of your dental case. May I ask, what is your background that provides you with that much knowledge..??

Based on your description, it appears that the oral surgery and dental implant that you had done regarding tooth #19 was text book and nothing unusual stands out to me about that. It is also not unusual for someone who has had a dental history of root canal therapy in one or more adjacent teeth (extracted or still present) to eventually be <possibly> misdiagnosed with PN or other neurological disorder and prescribed medications to help subside the symptoms. Therefore, I think it's wise to take into consideration the health status of not just the aftermath of the extracted tooth #19 but with the adjacent #18 root canaled tooth and #20 tooth with the widened PDL.

The root canal procedure and the apicoectomy procedure irrelevant of how many times they are done or how well they are done cannot cure the infection inside of the tooth as there is no access to the many hundreds of infected microscopic canals inside the tooth called dentinal tubules. The harboring of bacteria in these canals will indefinitely produce metabolic toxins. I will attach a diagram for you to visually see why those infected canals are one of the main reasons root canaled teeth remain infected.

Another reason the tooth remains so sick is because after the root canal or apicoectomy there is no longer any blood flow into the tooth and into the tiny canals preventing the influx and buildup of bacteria.

The pathology that is present in root canaled teeth and then later on in the surrounding tissue and bone is not always clinically visible. It is often not picked up on 2 dimensional radio graphs or 2D scans either. What is more useful is a 3D cone beam computed tomography xray image.

I am going to recommend that you read the book entitled "The Toxic Tooth... How a root canal could be making you sick, written by Dr Kulacz and Dr Levy. This book will offer you a plethora of information that will bring light to what (unrealistically) appears to be a rare dental problem associated with root canaled teeth. Just a blip from the book in Chapter Five it reads... <Root canal treated teeth are hotbeds of pathogens and toxins. DNA evidence shows these dental pathogens commonly travel to and embed in various bodily tissues.>>

The book can offer you so much more than I can here. I hope you will consider reading it before you mask your symptoms with medication and before having any further dental work done.

Bryanna

Hello Bryanna,

Thanks so very much for taking the time to respond. I work at the cross-section of engineering and medicine, thus there is a degree of understanding of dental issues...:-).

I appreciate the book reference. I very much agree that going the gabapentin route would be an overkill (I really have no desire to take systemic drugs to alter my pain perception at the CNS level), yet this is quite a problem that is beginning to impact my quality of life.

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?
- take a closer look at #18 and #20 (would biological width violation produce the symptoms I had described?)
- is lingual nerve injury/damage a possibility?

Clearly, I am quite realistic about the difficulty of this situation, but I am also reluctant to do unnecessary dental work.

Again, I very much appreciate your holistic view of things.

Best regards --JR

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.......

Attached Thumbnails

 

Hi Bryanna,

Thanks again for your thoughtful ideas. And yes, a picture is worth a thousand words..thanks for posting it. Now the trick is to find a dentist who will coordinate the care in a comprehensive way. Indeed, I would like to eliminate all possible causes before folks embark on the "atypical odontalgia"...

Best regards --jr

Hi JR,

You are very welcome! I'm glad you found the diagram helpful.

You will have a difficult time finding a conventional minded dentist who is open to the systemic risks of root canaled teeth. There are some out there. But because they don't specifically market themselves that way... as that is a big no no if you want to stay in the good graces of your peers and the ADA, they are hard to locate.

You could look for a Biological dentist as they do market themselves differently and their goal is to provide whole body dentistry. These sites may help..

https://iabdm.org/
https://iaomt.org/

Please keep us posted....
Bryanna

Hello Brianna,

The saga continues...I had a 3D CBCT done (a limited FOV, #18 and #19 area as I wanted to limit the exposure) and had it read by a board certified oral radiologist (independent from the owner of the scanner). The fellow has read thousands of scans.

Interesting findings that I have discussed with my OS. 1. A foreign body visibile on the coronal slice, adjacent to the implant screw on the buccal side 2/3 down towards the apex (indeed, a piece of amalgam was visible on the post extraction x-ray back in June 2015 -- it was apparently strongly embedded in the bone; a leftover from the apico in 1991..When I had brought this up with the original periodontist he was not concerned...)

Some luncency around the apex of the screw that the radiologist suspects to be peri-implantitis. Unclear if there some lesion in the RT canalled #19 (perhaps I moved during the scan as the image is not very clear on sagittal or coronal views).

I have had a good, long discussion with my OS who is really an experienced guy and whom I trust. Clinically he sees no problems at all with the implant and has no clinical reason to remove it. He routinelly overdrill a bit so that he does not compress the bone and has a bit of a wiggle room. Thus, the shadow in his opinion, around the apex.

So where do we go from here...? (Of course the OS could remove the implant but what guarantee do we have that the pain will subside?). Should we focus on the #18 and perhaps take it out...? A serious conversation with an endodontist? Thanks again for your thoughts! JR



[QUOTE=Bryanna;1207626]Hi JR,

You are very welcome! I'm glad you found the diagram helpful.

You will have a difficult time finding a conventional minded dentist who is open to the systemic risks of root canaled teeth. There are some out there. But because they don't specifically market themselves that way... as that is a big no no if you want to stay in the good graces of your peers and the ADA, they are hard to locate.

You could look for a Biological dentist as they do market themselves differently and their goal is to provide whole body dentistry. These sites may help..



Please keep us posted....
Bryanna

Hello Brianna, sorry to start a new thread. I have posted a quick update under that heading (to our previous several exchanges). I'd be grateful for your thoughts. Thanks JR

Hi JR,

I will re post some of your thread and answer in bold type.

<<The saga continues...I had a 3D CBCT done (a limited FOV, #18 and #19 area as I wanted to limit the exposure) and had it read by a board certified oral radiologist (independent from the owner of the scanner). The fellow has read thousands of scans.>>

WAS TOOTH #20 CAPTURED IN THAT SCAN? IF NOT, WHY NOT? YOU WERE HAVING SYMPTOMS WITH THAT TOOTH IF I RECALL CORRECTLY. ALSO TOOTH #18 IS ROOT CANALED CORRECT?

FYI ... IF THE ORAL RADIOLOGIST IS OF THE OLD SCHOOL THOUGHT THAT ROOT CANALED TEETH ARE A BENIGN MATTER THEN HE IS NOT LOOKING AT THE WHOLE PICTURE. IF THAT IS THE CASE, THEN UNLESS THERE WAS A LARGE BLARING BONE INFECTION, HE WOULD SEE NO CONCERN WITH RC #18.

<<Interesting findings that I have discussed with my OS. 1. A foreign body visibile on the coronal slice, adjacent to the implant screw on the buccal side 2/3 down towards the apex (indeed, a piece of amalgam was visible on the post extraction x-ray back in June 2015 -- it was apparently strongly embedded in the bone; a leftover from the apico in 1991..When I had brought this up with the original periodontist he was not concerned...)>>

DID THE OS CONFIRM THAT THE MERCURY WAS STRONGLY EMBEDDED IN THE BONE? DID HE GIVE YOU A REASON FOR NOT REMOVING IT WHEN THE PRIORR TO PLACING THE IMPLANT?

THE MERCURY IS A TWO FOLD PROBLEM. NUMBER ONE IT IS A TOXIC METAL THAT GIVES OFF A GALVANIC RESPONSE WHEN IN CLOSE PROXIMITY TO ANOTHER OR A DISSIMILAR METAL. KEEP IN MIND THAT THERE ARE BUNDLES OF NERVES IN THIS VERY SAME AREA THAT COULD BE GETTING ZAPPED BETWEEN THE 2 METALS. I'LL BET NO ONE HAS ADDRESSED THAT ISSUE WITH YOU.... ? THE OTHER PROBLEM IS THAT THE MERCURY IS CONTAMINATED WITH BACTERIA FROM THE INFECTION THAT WAS PROLIFERATING FROM TOOTH #19 IN SPITE OF THE ROOT CANAL AND THE APICOECTOMY. SO IT IS NOT A BENIGN PIECE OF NOTHING.

THE PERIODONTISTS DIS-CONCERN TO THE MERCURY BEING PRESENT WAS ... NOT SURPRISING COMING FROM A CONVENTIONAL DENTIST. HE HAS YET TO CATCH UP WITH THE ABUNDANT INFORMATION CONFIRMING THE DANGERS OF RETAINING MERCURY IN THE MOUTH OR ANYPLACE IN THE BODY. BUT OF COURSE, HIS DIS-CONCERN LED YOU TO BELIEVE THAT ALL WAS WELL.

<<Some luncency around the apex of the screw that the radiologist suspects to be peri-implantitis. Unclear if there some lesion in the RT canalled #19 (perhaps I moved during the scan as the image is not very clear on sagittal or coronal views).>>

IT IS NOT ABNORMAL TO HAVE SOME LUCENCY AROUND THE APEX OF A DENTAL IMPLANT. THIS COULD BE DUE TO INFLAMMATION SUCH AS PERI-IMPLANTITIS, OR IT COULD BE THAT THE ORAL SURGEON INITIALLY DRILLED FURTHER INTO THE BONE THAN THE ACTUAL LENGTH OF THE DENTAL IMPLANT. SO THAT WOULD BE A VOID IN THE BONE AT THE APEX OF THE IMPLANT. IN EITHER CASE, SOMETIMES IT'S A PROBLEM AND OTHER TIMES IT'S NOT.

RC TOOTH #18 IS A PROBLEM IRRELEVANT OF WHETHER OR NOT THERE IS A BLARING LESION OR BONE INFECTION. PLEASE VIEW THE DIAGRAM OF THE ANATOMY OF A TOOTH ... ALL OF THOSE DENTIN TUBULES, OF WHICH THERE ARE MANY MANY HUNDREDS, CONTAIN INFECTED NECROTIC NERVE TISSUE. BY THE TIME THE INFECTION BECOMES PROLIFERATED ENOUGH TO SEE ON AN XRAY OR SCAN, THE BACTERIA HAS ALREADY GONE BEYOND THE TOOTH.

<<I have had a good, long discussion with my OS who is really an experienced guy and whom I trust. Clinically he sees no problems at all with the implant and has no clinical reason to remove it. He routinelly overdrill a bit so that he does not compress the bone and has a bit of a wiggle room. Thus, the shadow in his opinion, around the apex.>>

OKAY SO THEN HE DID OVER DRILL THE LENGTH OF THE IMPLANT. WHICH COULD ACCOUNT FOR THE APICAL LUCENCY. HOWEVER, THAT DOES NOT ADDRESS THE MERCURY OR THE INFECTED #18 ISSUES.

<<So where do we go from here...? (Of course the OS could remove the implant but what guarantee do we have that the pain will subside?). Should we focus on the #18 and perhaps take it out...? A serious conversation with an endodontist? Thanks again for your thoughts! >>

A DENTAL COLLEAGUE OF MINE RECENTLY EXPLAINED TO A GROUP OF PEERS HOW ENDODONTICS IS THE BREAD AND BUTTER OF DENTISTRY. I THOUGHT THAT STATEMENT SAID A MOUTHFUL!

THE ENDODONTIST IS GOING TO RECOMMEND ANOTHER ROOT CANAL OR AN APICO ON #18. WHICH WOULD PUT YOU IN THE SAME POSITION AS WITH TOOTH #19. ONLY WORSE BECAUSE YOU ARE ALREADY HAVING ISSUES ASSOCIATED WITH THE REPLACEMENT OF #19 REGARDING WHAT WAS LEFT BEHIND FROM THAT TOOTH INFECTION AS WELL AS WHAT WAS LEFT BEHIND FROM THE EXTRACTION OF THAT TOOTH.

THE REMOVAL OF #18 IS INEVITABLE. THE COMPLICATIONS FALL UPON THE FACT THAT #18 WAS STILL PRESENT WHEN #19 WAS REPLACED WITH AN IMPLANT ... THE MERCURY PLUG FROM THE APICO ON #19 IS STILL PRESENT ... AND NO ONE IS MENTIONING THE SPREAD OF BACTERIA FROM 19 TO 18 AND NOW POSSIBLY 20.

The issues you are having would be very clear to someone who appreciates the vast problems arising from the issues I have mentioned. However, it is unlikely that any of your conventional dentists are going to put all the pieces of this puzzle together. Instead they are going to treat one symptom at a time without looking at the picture in it's entirety.

By any chance have you gotten the book that I recommended to you? The author Dr Kulacz talks about all of this and explains it in terms that you would especially appreciate given your intellectual knowledge.

JR... I just sent you a reply. Very sorry for the delay ... lots going on in my life right now. I will try to get back here soon.

Bryanna