Help :(
 

Hi all, I got my first RCT done 10 years ago on the lower jaw left premolar and although it got infected shortly afterwards, it settled down eventually and I got it crowned. My dentist initiated my second RCT on the upper left molar number 26 this November (2015) and since then the nightmare has started! My dentist cleaned out the infection and killed the root in the first sitting, prescribed painkillers and told me to come back after a week. A few days later, I felt extreme pain in the tooth and could not sleep for 3 days! I went back to my dentist and she said it was because of a reaction to the disinfectant used to clean the canals. She prescribed augmentin antibiotic along with pain killers and told me to come back after a week. The pain reduced a bit, but it was still bothering me so I went back to her and she realized that one of the canals had not been cleaned out properly. She then recleaned the canals and the pain went away. However, the sensitivity remained. A week later, she filled the canals with gutta percha and sealed the tooth with a temporary filling. She wanted me to come back after a week for the post and core filling, but I told her that I wanted the tooth to settle down and for all the sensitivity to go away and then continue. It's been almost 2 weeks since then. The tooth sensitivity has increased and even the molar next to it is quite sensitive. Also, the tooth on which this RCT tooth is biting on in my lower jaw has become sensitive also! They are reacting to touch both with my tongue and finger! What could the problem be?

Hi JamesSmith,

I am going to re post some of your post and reply in bold type. Makes it easier to follow.

<< I got my first RCT done 10 years ago on the lower jaw left premolar and although it got infected shortly afterwards, it settled down eventually and I got it crowned.>>

There are several reasons why root canal therapy cannot cure an infected tooth but the easiest reason to understand is because it is not possible to remove all of the nerve tissue and sterilize the tooth. Your symptoms may have calmed down with this upper tooth, but the tooth itself is not healthy. Crowning the rc tooth does not alter the bacterial status of the tooth. It is more like putting a hard blanket over it to help prevent the fragile tooth from cracking when chewing on it.

<<My dentist initiated my second RCT on the upper left molar number 26 this November (2015) and since then the nightmare has started! My dentist cleaned out the infection and killed the root in the first sitting, prescribed painkillers and told me to come back after a week.>>

Again, the nerve tissue cannot be removed entirely. Some teeth will act up right away, while others won't. Also, the dentist did not kill the root of the tooth. The root system is still intact in the jaw bone. She scraped out visible nerve tissue from inside the root system. The tooth may still have partial vitality because not all of the nerves can be removed. Sometimes the remaining nerves flare up and cause pain, other times they become necrotic and may or may not show symptoms of infection until sometime later.

<< A few days later, I felt extreme pain in the tooth and could not sleep for 3 days! I went back to my dentist and she said it was because of a reaction to the disinfectant used to clean the canals. >>

A reaction to the disinfectant?? Did she perforate the tooth with the disinfectant? If she did, then bacteria and inflammation can build up around that perforation. You should find out if she did that because that problem can lead to complications involving the nerve bundles that reside in the bone surrounding that tooth.

<<She prescribed augmentin antibiotic along with pain killers and told me to come back after a week. The pain reduced a bit, but it was still bothering me so I went back to her and she realized that one of the canals had not been cleaned out properly. She then recleaned the canals and the pain went away. However, the sensitivity remained.>>

It is possible that she missed a visible canal and/or perforated the tooth. The number of visible canals (one to four depending on the tooth) are significantly less than the many hundreds of non accessible microscopic canals.

<< A week later, she filled the canals with gutta percha and sealed the tooth with a temporary filling. She wanted me to come back after a week for the post and core filling, but I told her that I wanted the tooth to settle down and for all the sensitivity to go away and then continue. It's been almost 2 weeks since then. The tooth sensitivity has increased and even the molar next to it is quite sensitive.>>

This indicates vitality in the tooth as well as inflammation in the accessory canals. Also, the tooth is intricately connected to a live periodontal ligament which becomes inflamed from the infected tooth. The inflamed ligament can literally push the tooth down from the original position causing the tooth to hit the lower tooth too hard. An inflamed ligament can cause pain, sensitivity, soreness, etc.

<< Also, the tooth on which this RCT tooth is biting on in my lower jaw has become sensitive also! They are reacting to touch both with my tongue and finger! What could the problem be?>>

This may be due to the inflamed ligament as I stated above. Both the rc tooth and the one it is biting against will become sore as both of their ligaments become inflamed.

An xray should help determine if there was a perforation of the tooth during the rc procedure... it can also help determine an inflamed perio ligament... and also infection if it is large enough to be seen on the 2 dimensional xray.

Bryanna

Thanks Bryanna. I made an appointment with my dentist for next week. Assuming it's an inflamed perio ligament, how can it be treated? Also, assuming the tooth got perforated, how can it be treated?

JamesSmith,

All root canaled teeth are chronically infected for the reasons I offered you in my first replhy. So irrelevant of what is done to that rc tooth, it will remain infected.

Pertaining to root canaled teeth, the ligament becomes inflamed when bacteria overwhelms the area. Other than extraction and removal of the ligament, there is no way to alter this once it has happened. If the tooth were perforated during the rc procedure, the bacterial contamination to the jaw bone from the perforation is not repairable. The only cure is to extract the tooth and remove all of the diseased tissue, ligament and infected bone.

I am sorry to deliver this news to you. If you are curious about learning up to date information about this topic ... buy the book The Toxic Tooth by Dr Robert Kulacz.

Bryanna

Thanks for replying Bryanna. I called up my dentist and spoke about the inflamed perio ligament as well as tooth perforation. She said neither is applicable in my case and after doing the post and core and crown the sensitivity should go away. She also said the sensitivity is due to the disinfectants reacting with my bone. When I specifically told her that I'm not going to continue further with the treatment until I get relief, she advised me to take augmentin (antibiotic), 2 tablets a day for 3 days. I told her the fact that she is telling me to take antibiotics clearly implies that she knows that there is an infection! She said that that's not the case and it will help calm my tooth! Obviously what she is saying does not make sense! It seems like she knows that there is a problem but she just wants to do the post and core and crown and take my money!! I'm thinking of consulting another dentist. Even If i'm getting the tooth removed, could you advise me what to do to get some relief in the mean time? Also, the tooth below the RCT seems to be bothering me quite a bit. Some days back I had flossed and a piece of the string got stuck between that tooth and another molar. It was quite uncomfortable and when I finally managed to pull it out, the tooth hurt a bit. Now, its a bit sensitive. I'm not sure if it's the flossing or the RCT tooth that is troubling this tooth. Any advise would be appreciated. Thanks :)

JamesSmith,

The disinfectants used during the rc procedure should not have entered the jaw bone during the procedure unless the tooth was already perforated (possibly fractured) and/or she perforated the tooth.

A post put into a root canaled tooth actually further weakens the integrity of the tooth, pre disposes it to fracture and contributes to additional inflammation. It's like driving a nail into a splinter of wood and then using that piece of wood as a hammer. The nail is the post.. the wood is the tooth... and the hammer is the chewing forces between the upper and lower teeth. Dentists who put posts in rc teeth do so because:

1) There is an inadequate amount of tooth structure to put a crown on the tooth so they use the post as a replacement for the missing area of tooth.
2) Some dentists think all rc teeth should have posts just because the tooth is fragile and the post will give it some support. See my #1 comment.
3) Some do so for the $$.

A crown is put on a weakened or fragile tooth more or less to act as a hard shell for chewing. Crowns are also put on for esthetics or when the tooth is unable to be restored properly with a filling material. Crowns do not strengthen the tooth, they just kind of hold it together for chewing purposes.

I think the reason your dentist prescribed antibiotics may be because she is concerned about the contamination that possibly occurred during the rc procedure (which has not clearly been established and if it did occur, antibiotics would not make any long term positive difference) .... or she is suspicious of infection .... or she knows there's a lot of inflammation in the tooth and ligament and she's hoping (???) that the antibiotic calms it down just long enough to do the post and crown.

Most conventional dentists are going to side with your dentist because this is basically how they practice too. You could consult with an oral surgeon (although he would most likely be of similar thinking) about the present status of the surrounding bone of this tooth...a periapical xray and possibly a panoramic xray might be helpful. But they are only 2 Dimensional so there could be something happening that is not able to be picked up on them.

The bottom line here is this.... ALL root canaled teeth are unhealthy. Your symptoms are not uncommon and therefore are often regarded as "normal" meaning "typical". The lower tooth may be biting too hard against the upper one causing the ligament around the lower tooth to be inflamed. Taking these two teeth out of occlusion, meaning drilling away minute amounts of either tooth so they hit against each other more gently does not alter the health status of the upper rc tooth. It would however reduce the inflammation in the ligament of the lower tooth. BTW.... what is the health of that lower tooth? Is it decayed, filled or crowned?

Bryanna

Hey Bryanna, thanks for replying. I consulted another dentist. He told me that one of the canals had not been sealed fully with the gutta percha and there was some space left. He advised me to go back to my dentist and tell her to refill it. He also mentioned that he could see a minor infection and cleaning would be required before refilling it. He also said that it would not trouble me much now but in the future it would start paining and I would have to redo it then. He offered to redo it if I wanted but said that it would be a re-root canal and I would have to pay even more than a regular root canal! My dentist was previously working under a senior dentist (he now does implants only) and had an assistant to position the xray machine while she adjusted the device in my mouth. Now she has started her own practice and does not have an assistant so she has to re take xrays multiple times before getting them right! I'm very concerned about getting so much radiation! Even if I show her this dentist's xrays, and she refills it, I don't know how many more xrays she will take just to see if it's been filled properly! What would you advise?

JameSmith,

In the scheme of things it is irrelevant if she missed a canal. Re treating the tooth, filling that canal, will not change the status of the infection inside of the dentin tubules. I will post a diagram of the anatomy of a tooth so you can see for yourself just how many dentin tubules are inside of every tooth. In the diagram each brown line represents a tiny canal. These tiny canals are not accessible and will therefore harbor infected nerve tissue irrelevant of how many times or how well the rc procedure is done.

I cannot advise you of what to do. I can only offer you the information that is evidently not being given to you by your dentist to help you become better informed. Only you can decide what you feel is in your best interest.

Thanks Bryanna. About my lower tooth, it has an old filling. I should have shown it to the new dentist I consulted but with all the talk about the root canal tooth, I forgot. The sensitivity keeps on coming and going. The weird thing is, If i'm feeling sensitivity in the root canal tooth, then it goes away from the lower tooth and vice versa! Assuming I decide to remove the root canal tooth, that comes with it's own set of problems like ensuring the infection is thoroughly cleaned and the ligament removed etc. I'm going to take a few days and think about all this. Also, I'm attaching pics of the root canal tooth that the new dentist took.

JamesSmith,

Thanks for posting the xrays.

The recently root canaled tooth is #14 (using the Universal numbering system), your upper left first molar. The xray is of mediocre quality, but here is what I see:

1) The dentist instrumented and placed gutta percha in all 3 visible canals in the 3 large roots.

2) The distal root, the short one furthest to the right, is NOT filled to the apex (end) with gutta percha. There is also an infection around the root tip. Possibilities: this area of infection may have been present prior to the rc OR she may have perforated this root during the procedure. In which case the disinfectant and/or bacteria was pushed into the bone beyond the tooth. Although it is not healthy and it can become progressive... it is typical to see infections around the roots of rc teeth.

3) The palatal root, this is the longest root in the middle, appears to be filled past the apex. Meaning the root tip was perforated during the procedure and although there is currently no obvious mass of infection (like at the distal root) the same perforation issues concerning the disinfectant and bacteria are possible. Also the gutta percha that was pushed into the bone is a chronic irritant. Again, it is not a healthy scenario but a typical occurrence.

4) The center of the tooth where the pulpal chamber was is now a large open void. Although this is unfavorable, it is commonly seen in rc teeth. This void substantially weakens the integrity of this area of the root system. Putting a post in this tooth could result in a fractured root and/or a perforation of a root. This area will be prone to decay irrelevant of how well a crown were to fit over it.

Regarding the lower tooth.... you could be getting referred pain.... the ligament could be inflamed and at times it's less inflamed than others .... or there is something else going on with this tooth that you are unaware of. It would have been good to take an xray of that tooth.

Extracting this tooth would leave an open space that ideally should be filled with a replacement. If not, then the molars behind it will drift towards the open space. How far or how oddly they will drift, no one can tell you that. Sometimes the drifting of a first upper molar is not very bothersome especially when it has 2 healthy adjacent teeth.

I know again.... I'm delivering unpleasant news to you. Please consider all of the information as only you can decide as to what you feel is in your best interest for the long term.

Bryanna

Thanks for replying Bryanna. I can clearly see that the palatal root is filled past the apex after you mentioned it. I'm surprised that the second dentist I consulted did not even bring it up! He was only concerned with the distal root not been filled to the apex. You mentioned that although both these things are unhealthy, they are a typical occurrence...So in your opinion, would most dentists consider this root canal a success or failure? Also, regarding the infection around the root tip of the distal root, I'm aware that the tubules would always be infected, but is there something that can be done (like taking antibiotics for example) to get rid of the visible infection in the xray?
My tooth is reacting to hot liquids at times. Also, it's still sensitive to touch. A few days back, the gums from my wisdom tooth to this tooth got quite red and painful but seem to be getting better now. Could all this be because of the infection at the root tip? The second dentist I consulted tapped my tooth 3 times with a metal instrument but I did not feel any pain or sensitivity.

JamesSmith,

<< I can clearly see that the palatal root is filled past the apex after you mentioned it. I'm surprised that the second dentist I consulted did not even bring it up! He was only concerned with the distal root not been filled to the apex.>>

TWO REASONS WHY HE DIDN'T MENTION IT:

1) ALTHOUGH A PERFORATED ROOT TIP IS A HUGE CAUSE FOR CONCERN, IT IS A TYPICAL "OOPS" FREQUENTLY SEEN AND NOT JUDGED UNTIL THE AREA SHOWS SIGNS OF INFECTION.

2) HE IS CAUTIOUS AS TO WHAT HE INFORMS YOU ABOUT REGARDING ANOTHER DENTISTS WORK.

THE SHORT FILL IN THE DISTAL ROOT IS SOMETHING HE CAN "COMMENT" ON AS THIS COULD BE THE RESULT OF A CALCIFICATION IN THAT PORTION OF THE ROOT. MEANING THAT PORTION OF THE CANAL MAY BE CONGENITALLY CLOSED OFF NOT ALLOWING INSTRUMENTATION TO GET IN. I DOUBT THAT'S WHAT THE CASE WITH THIS TOOTH, BUT IT IS POSSIBLE.

<< You mentioned that although both these things are unhealthy, they are a typical occurrence...So in your opinion, would most dentists consider this root canal a success or failure?>>

IT'S A TYPICAL, MEANING FREQUENT, BUT GENERALLY ACCEPTED OUTCOME BECAUSE THE ONLY ALTERNATIVE IS TO EXTRACT THE TOOTH. THAT MEANS DUE TO THE ANATOMY OF OUR TEETH AND THE NECESSITY FOR ALL BODY PARTS TO REMAIN VITAL, THE RC PROCEDURE IS A FAILED PROCEDURE TO BEGIN WITH AND IT IS IRRELEVANT OF HOW WELL IT IS DONE, THE TOOTH WILL REMAIN INFLAMED AND DISEASED.

<<Also, regarding the infection around the root tip of the distal root, I'm aware that the tubules would always be infected, but is there something that can be done (like taking antibiotics for example) to get rid of the visible infection in the xray?>>

THE INFECTION SEEN ON THE XRAY AT THE APEX OF THE TOOTH IS THE PROLIFERATION OF INFECTIOUS BACTERIA THAT IS SPREADING FROM THE INSIDE OF THE TOOTH. IT IS ACTUALLY LARGER AND DEEPER THAN DEPICTED ON THE 2 DIMENSIONAL FILM.

AN APICOECTOMY SURGERY, THIS IS A SURGICAL ROOT CANAL, IS SOMETIMES DONE TO REMOVE THE AREA AT THE APEX. BUT THE PROBLEM WILL ONLY RETURN BECAUSE THE TOOTH IS STILL INFECTED. ANTIBIOTICS CANNOT CURE THIS APICAL INFECTION BECAUSE THE TOOTH IS A BREEDING GROUND OF VARIOUS AEROBIC AND ANAEROBIC BACTERIAL MICROBES THAT ARE NOT KILLED OFF BY AN ANTIBIOTIC.

<<My tooth is reacting to hot liquids at times. Also, it's still sensitive to touch.>>

HOT TEMP SENSITIVITY WITH RC TEETH GENERALLY INDICATES NERVE VITALITY. THIS MEANS THAT THE TOOTH STILL CONTAINS SOME LIVE NERVE TISSUE (COULD BE IN THE DENTIN TUBULES AND/OR THE DISTAL ROOT AND/OR REMNANTS OF NERVE TISSUE IN THE LARGE CANALS) AND IT'S BECOMING NECROTIC. THE TOUCH SENSITIVITY IS LIKELY DUE TO THE VITALITY AS I MENTIONED AS WELL AS THE INFLAMMATION INSIDE AND OUTSIDE OF THIS TOOTH. IN ADDITION TO THE INFLAMED LIGAMENT AND INFECTION IN THE JAW BONE.

<< A few days back, the gums from my wisdom tooth to this tooth got quite red and painful but seem to be getting better now. Could all this be because of the infection at the root tip? >>

EVEN THOUGH THOSE SYMPTOMS SUBSIDED, THEY ARE A SIGN OF ALL THAT I HAVE MENTIONED HERE. AS THE INFECTION FINDS A PLACE TO DRAIN, YOU MAY OR MAY NOT HAVE SYMPTOMS. IN MANY CASES SIMILAR TO YOURS, THE NEXT "SYMPTOM" MAY BE A FISTULA THAT APPEARS ON THE GUM ABOVE THE ROOT OF THE TOOTH. A FISTULA FORMS WHEN THE BACTERIA FROM THE INFECTION BORES A HOLE THROUGH THE BONE AND OUT THROUGH THE GUM TISSUE. AGAIN, THIS IS ANOTHER WAY FOR THE BODY TO RELIEVE THE PRESSURE FROM THE INFECTION.

<<The second dentist I consulted tapped my tooth 3 times with a metal instrument but I did not feel any pain or sensitivity>>

THIS DOES NOT MEAN MUCH IN THE SCHEME OF THINGS. :/

Bryanna

JamesSmith,

About 6 years ago when I was working overseas in Australia, I had another major filling/restoration done on tooth #26 (number 14 in US numbering system) because of pressure/sensitivity in that area. Didn't realize it at the time, but there was already a major infection in/above this tooth/area that had been there for a very long time. About 6 months after this filling and return to the US, I had worsening and major systemic symptoms/health issues and wasn't quite sure what was going on because I didn't have "pain" directly associated with this tooth. I went to my family doctor (repeated referrals to ENT, Neurologists, etc.), general dentist, and then to two other oral surgeons with my concerns and was just prescribed augmentin, clindamycin, amoxicillin, ciproflaxin, etc. for over a year. I was always told everything was "OK". A root canal was never done on tooth #14 but instead eventually one was done on #19, the tooth directly below it because of the "referred" and increasing nerve pain and sensitivity from the tooth above it (#14). I honestly and "mistakenly" thought all along the problem was with #19. I went to an endodontist and he stated he didn't see any active infection or apparent problems with #19, but since I wanted to get rid of this jaw/nerve pain and sensitivity, I agreed to have the root canal done on this tooth anyway. Symptoms persisted and kept getting worse until finally getting a PA x-ray on tooth #14. There was a major infection/cyst above this tooth and an old root canal tooth #13. Problems with a root canal on #13 and undiagnosed abscess on tooth #14 had caused major destruction of my upper left jawbone in this area over at least 15-20 years. So I ended up having #13, #14, and #19 extracted. There most likely was never a problem with #19 (bottom left first molar) but still lost this tooth because of a failed root canal and "referred" nerve pain. (This subsequently also happened to me on an abscessed tooth #3 on the upper right and referral to #30 below). Finally with extraction of tooth #3, #13 and #14, two debridement surgeries, and removal of a retained root tip from #13 (last debridement in upper left jaw and root tip removal by a holistic dentist), I have been recovering and many of the chronic health issues I have been dealing with for years are finally resolving.