At a total loss 2 root canals and still in pain 2 yrs

[Acheygirl]

I am at such a loss and not sure what to do.

Mid 2019 I developed a tooth ache in my premolar #12. I had a root canal by an endodontist. The pain continued so he retreated the tooth twice. He also did a cone beam scan all looked good with some curved roots but he or his radiologist did not see that to be an issue. No cracks visible inside the canal or on scans. Crown was adjusted many times but still almost 2 years later sometimes the tooth feels off alignment and hits the bottom strange like it's moved and out of bite. Not only does it feel out of bite or "fat" at times but touching it with my tongue the tooth feels strange mildly painful and like it's not anchored in there good?

My pain continued and we moved to the neighboring tooth and did a root canal. That tooth was partly dead. We felt that would fix it but the pain continued.

After numerous visits to the dentist and endo with no clear answers I visited an orofacial pain dentist who did a set of cone beam scans and also found no issues and diagnosed atypical odontalgia and ordered an MRI. With Covid and some uncertainty I did not get the MRI yet. My dental pain had started to improve but the beginning of this year something new happened. When I eat hot foods and it hits #12 I get an intense pain jolt in it. I can drink cold no issues. I have always had discomfort biting on this and the neighboring tooth after the root canals but dentists could not explain why. I accepted this would be a new normal but the pain with hot is not only incredibly painful but alarming how bad it hurts.

I have developed severe dental anxiety from all of this. With your years of experience in the field does this sound like trigeminal type pain? Would a cracked root canal tooth do this if it had a hairline fracture? Recent dental x-ray was normal. My dental ache is constant and the extreme pain is only with hot foods touching that tooth. I can eat hot foods on the other side no issue. The pain is only in the teeth/tooth and does not spread in my cheek etc. I feel the pain at the very tip of the tooth root area or that's how it feels. I am embarrassed and ashamed to further bother my dentist or endo as I think I have exhausted any further options they can offer and I know they are frustrated which makes me feel even more hopeless of the problem. My biggest fear is extracting teeth or doing more root canals that would only make it worse if neuralgia. Thanks for listening.

 

[Gordon]

Pain on hot is almost always a sign for periapical infection. It doesn't sound like a crack but they're sneaky wee beggars and can give all sorts of weird symptoms.

Sometimes even fantastic looking root canals can "fail".

It's complicated... basically, with the very best technique and materials there is no way to TOTALLY clean out and seal up every single root canal. There are occasionally a number of tiny little "accessory" canals that radiate out from the canal at the apex, think of a river delta and you'll get the idea. We can't sterilise all of them and seal them up, so we do the best we can. There is then a sort of balancing act between the bacteria and the body's own defences. By cleaning out most of the canals we can tip things in favour of the body, the more we clean out the more we help. Sometimes if the patient's own defences are a bit lowered, just by being physically a bit out of sorts, then the balance tips a bit more towards the bacteria. We can't really see all these accessory canals on x-rays, the resolution isn't fine enough.

There's no need to be embarrassed or ashamed, it's not your fault and your dentists know that sometimes these things can happen. If it's as clearly associated with that single tooth, then it's not likely to be neuralgia or whatever, so the tooth needs further investigation.

 

[Acheygirl]

Thank you Dr. Gordon. As always your insight is invaluable. I can't thank you enough for taking the time to answer my questions, and all of ours for that matter.

As a dentist would you start feeling frustrated with your patient if they kept coming back? I've gone back and fourth between the Endo and the Dentist, both very nice folks. But I feel as if they just don't know what the heck to do with me. And the receptionists already know my story when I call. And it hurts me as I don't even like to visit the doctor and I feel like an imposition to these wonderful docs who are wanting the best for me.

So Dr. Gordon, it seems that #12 is the culprit but there are times #13 feels slightly weird. It has always focused on #12 and #13. But always more #12. There were periods where I would wake up and bite down and my teeth were hitting hard on 12. Like a sensation where a seed gets stuck and you know something is causing your bite to be off yet no seeds of course. And there are moments of a strange off sensation if I tap on it. I've resigned myself that this was something I was conjuring up in my own mind but when the heat caused this severe jolt of pain I decided I was not crazy - something is wrong.

What would the next step be? My last cone beam scan was May of last year and it looked fantastic. That was roughly 6 months after the initial root canal. I got a hot cup of water and dipped a q-tip and touched it on 12 and 13... nothing! I can't recreate the pain but when it does hurt the shooting pain undeniably is right above 12.

 

[Gordon]

I'd be frustrated with myself not the patient if they kept coming back, it's not like people choose to get dentistry done (up to a point!).
First thing I would probably try given your description is to really carefully check the occlusion (bite) on the tooth, if that's a bit off it can give all sorts of weird symptoms. Patients can be quite creative the way they manoeuvre their teeth sometimes when eating, so it's worth spending time going into all the different excursions...
If that's definitely OK then it might be worth opening up the tooth and checking for a crack with some dye and magnification.
After that you're looking at either re-treating the canals again or apicectomy at a pinch.

 

[Acheygirl]

Thank you Dr. Gordon - you are such a great man to take the time to respond. I really and truly appreciate that.