Pain and nobody knows what it is. I'm worn out

[sudzs]

I had a filling done 20 months ago in an incisor. After that I kept going back to the dentist with symptoms of pain, slight numbness in lip, I was headachy, even triggered a few migraines when I am not a headache person at all and don't generally get migraines. But the dentist said it's all fine. So then the nerve died, I had root canal treatment done by the same dentist but following that all the symptoms were still there easing every so often but then returning fully again. So next a referral to an endodontist. He x-rayed the tooth and said "there's decay there under the filling, go back to your dentist and get them to put in a proper filling, that should sort out your symptoms"

So I did that and things improved for a while but then got bad again so back to the endo and he said the RCT "wasn't perfect" and I had a periapical granuloma so he re-did the root canal. Well following a massive inflammatory response the next day, it really was quite distressing, it settled down over the following months. Then the last 3 or 4 months everything was fine so I thought at last, the tooth is fixed. I hadn't been using my water flosser on it as it seemed to trigger flare ups before. Then 4 weeks ago I used it again and the pain all started up again, a few weeks of nigging and then building up to a really bad flare up for 1 day when I couldn't get enough ibuprofen into me. But then the following day it was a lot better and is just easing away again now slowly but surely.

I went to my new general dentist today just to see if there was anything to be seen on an x-ray. It all looked fine he said, gums. palate fine, granuloma looked healed.

I'm just so worn out from it all. Every dentist appointment is so stressful, I'm shaking in the waiting room, even the most recent one where I knew I wasn't even having anything done except an x-ray. I'm so nervous that I don't think I express myself properly so I feel I mustn't be giving them the right information. Or I sound like I'm talking rubbish or exaggerating my symptoms. I'm extra nervous with the endodontist as he is arrogant and doesn't listen to my concerns and dismisses me when I say it feels like an inflammatory problem. He insists it must be a nerve problem. I asked him if it was neurological would ibuprofen help it. He said no and I said well it does help, as does cold being applied to the palate so to me that says it's probably inflammatory. He didn't like that and insisted it was neurological pain or atypical facial pain and I should consider taking Amitriptyline.

I also have a small patch of psoriasis on my scalp which started some time after the initial filling. It gets worse when the tooth is worse and eases when the tooth is improving. Apparently this is so unusual that when I told the dentist today he looked at me as if I was nuts. But I've never has psoriasis before and this only cropped up after all the trouble with the tooth started. When the tooth eases off so does the psoriasis so to my mind they are surely linked in some way.

It's so frustrating and upsetting I am in tears now as nobody seems to know what it is and I'm going to be stuck with this awful dull pain and pressure in my palate coming and going all the time and no way to treat it. Well apart from "medication for atypical facial pain" which I'm not keen on. The symptoms come and go, they start with a niggle, get worse over days and weeks, peak and then improve quickly enough. Wouldn't that be atypical for atypical facial pain ???

My only hope is that it might just be a bit of residual inflammation and that it will resolve over time. But there's nothing on the x-ray.

I've told this tooth saga here before so apologies for repeating it all in a very long post. I'm really just wondering what could still be causing these symptoms. Is there any other way of finding out beyond x-rays and looking at the gum which all appeared fine today. Would an MRI be useful?? Is there another type of specialist I should be seeing? Any advice greatly appreciated.

Just to add and I would hope this isn't an issue but I live in a relatively small town and all the dentists would know each other. And the original dentist who left decay in the tooth would be a referring dentist to the endo and also my new dentist's practice.

Thanks for reading, i know it's a lot.

 

[sudzs]

Just adding this x-ray of the second RCT. Is that a bit of a gap between the plug at the apex and the rest of the root filling? Might that be a problem? Or is that normal enough?

 

[Gordon]

Sorry but that appears to be a perfectly adequate root filling. Atypical facial pain is a possibility but not really in my area to diagnose it.

An Oral Medicine specialist would be the best person to see if you can find one. Most big dental schools have an Oral Med. department.

 

[sudzs]

Thank you @Gordon, I really appreciate your reply. And that's great that everything looks ok

I have ruled out this atypical facial pain purely on the basis that all over the internet it says that ibuprofen doesn't really help with it and when I take Ibuprofen it does ease the pain considerably when it's at its worst and completely when it's is not quite bad as that. Also ibuprofen isn't great for neuropathic pain either.

Do you think a CT scan of the tooth would be of benefit? My general dentist did mention that x-rays are 2D images and can only show so much.

If that comes back negative I might consider an oral medicine specialist.

Many thanks again.

 

[Gordon]

Certainly worth thinking about, like he says, it's a 3d structure you're investigating. Even taking a few conventional films from a variety of different angles may be helpful.

 

[sudzs]

Thank you so much again @Gordon Discomfort easing again now so maybe that was the very last bit of healing of the granuloma. I'll live in hope! But next flare up I'll look into a CT scan.

 

[sudzs]

Just an update. I had the CBCT with the endo I'm not very comfortable with but it's the only place near me to have it done. Also on the day it was done the tooth was not giving any problems. He had a look at the images, just took a few minutes for that but he said there is no pathology there, it's all fine.

I'm struggling to accept that there is nothing wrong with the tooth. I really do not think it's "atypical facial pain" as the endo keeps telling me. I can feel something in the root when I have pain and discomfort. Also pressure and sometimes heat in the palate where the root is The problems all started 24 hours after a filling. I can mostly manage the pain with Ibuprofen but I don't like thinking there is something wrong in there and am thinking of extraction now but my general dentist says they wouldn't do it as the tooth looks sound.

So just a quick question, is it still possible that there could be something wrong with the tooth that would not necessarily show up on the CT? I don't know what degree of resolution he used. If there was a tiny fracture or something else undetectable in the root could it cause the symptoms? Sorry, that's 2 questions!


Just editing to say I also have a small patch of psoriasis on my scalp, again something very unusual for me, never had it before. This flares up at the same time as the tooth/palate pain flares up. It calms down when the tooth is not bothering me although never goes away fully. I don't think I mentioned it before in case it just complicated things but could this be happening because of inflammatory processes going on with the tooth root? I've read that there is a link between gum disease and psoriasis.

 

[Gordon]

A small root fracture is always a possibility but it's a single rooted tooth, fractures in those are fairly unusual, given that the single root is a fair bit thicker and stronger than a multi-rooted tooth like a molar. I'd want somebody to take a really good look at the occlusion (bite) in that area, the flare ups are maybe related to stress/clenching/grinding complex.

As would be the psoriasis, I suffer from that too and it's definitely stress linked.

I've not read about a link with gum disease, can you remember where you read it?

 

[sudzs]

Thanks @Gordon. I used to clench my teeth at night but that was 20 years ago. I don't do it now, not that I'm aware of anyway. When I did do it I always knew when I'd wake up that I'd been clenching. But maybe it's possible I'm doing it again. Although I'd hardly have suddenly started doing it again the night after the filling. And thankfully my mental health is great and I don't have a lot of stress in my life at the moment either so don't think that could be causing the psoriasis. It's all very odd, often I will notice the psoriasis starting to itch several hours before the tooth trouble starts again.

And I came across some studies that found a like between gum disease and psoriasis but of course there are other studies that found no association between the two! A lot of them conclude with "further studies are required..."

The endodontist advised I go to this guy https://drdermotcanavan.ie/about/
He specialises in orofacial pain management but I think more neuropathic pain and I really don't think that's my problem. I wonder if I might be better off going to this oral medicine specialist?? https://www.marlboroughclinicbelfast.com/team/maria-tumelty/


Thank you so much again Gordon for all your advice about this tooth of mine over the last 20 months. I really appreciate it.

 

[Gordon]

Although I'd hardly have suddenly started doing it again the night after the filling.

If the filling was slightly too high, and if you were already clenching that would exacerbate the problem from the tooth.

I think I'd go with the Oral Medicine specialist all other things being equal. I have a feeling I might know that particular lady actually.

 

[sudzs]

Thanks again Gordon. The original dentist actually reduced the filling during one of my return visits soon after it was done. But there is still contact there if I slide the bottom jaw forward.

And that's gas you know that specialist! I was leaning that way myself so glad you are too.

But today I heard from the clinic where I had the CBCT scan last week. They want me to pop in for 5 minutes to have a chat with their guy there who does implants and has "a special interest in CT scans" as it says on the website. They said he wants to make sure nothing was missed. I'm afraid to hope he might have actually spotted something on the scan. Going in at the end of the week so will report back!

 

[Gordon]

That's interesting, let me know how you get on.

 

[sudzs]

Well I went in today @Gordon and was told there is no pathology on the scan. The dentist examined my face pressing hard to see if there were any differences in one side to the other. There wasn't. He checked my bite which was fine. So that's that.

I did ask for a copy of the referral letter that was sent to the neuralgia specialist and when I read it I was surprised to see that the endo is still insisting I have trigeminal neuralgia when I have no real symptoms of that, But I was really shocked to see that he had given a quite different history of our consultations. When I went to him the second time after the original decay below the filling was removed by the original dentist, he x-rayed the tooth and showed me where there was a periapical granuloma and said that he'd redo the RCT and that he'd "open it up now". In his referral he says "she was very keen to try specialist root canal re-treatment". I'm actually stunned. I don't understand it. Has he a bad memory? Why would he lie?? And there are other inconsistencies in it too but the main one is that I requested another RCT. As if I would!

I'm aware that this all sounds very bizarre but this is what has happened. I don't know what to do next.

 

[Gordon]

It's a mystery. I honestly have no idea what's going on with the records.
Lying on a patient's notes is a big deal and could get you into major issues with the GDC, so it's very unlikely that they're deliberately not telling the truth.

Go see the Oral Medicine specialist and take it from there?

 

[sudzs]

Thank you so much for the reply @Gordon. I can't go to that oral medicine specialist as she is in the same clinic as the endo. He works some days here and some days there. After seeing the referral letter, unfortunately I would have no faith in any other specialist associated with him in any way. No reflection on that doctor, it's just the way that letter has left me feeling. I might look for someone south of the border.

In addition I requested the CBCT images and they put them on a memory stick but only the axial images. So I have to go back in today to request the others. I'm also requesting all reports he would have sent to my general dentist to see if they are more accurate than that referral letter.

I apologise for taking up so much time and space here but could I please ask for your opinion on some CBCT images when I get them? It will only be if I think they don't look right. Please tell me if I'm going beyond acceptable levels of asking for advice. This website is a wonderful resource and I wouldn't want to seem to be taking advantage.

 

[Gordon]

I can take a look for you, but I'm not an expert on CBCT imaging at all. One of the other younger dentists will hopefully be able to chip in though.

 

[sudzs]

Oh thank you @Gordon. I've had a look myself a the images but only the axial ones were on the memory stick so I had to go back in to the clinic to get the others loaded. I won't have them until next week.

A million thanks again !!!

 

[sudzs]

OK, well after a lot of getting familiar with the software I finally managed to caprture the attached. In the image showing the axial plane, could that be something to the right of the root filling? I know the filling materials can cause distortions but could this be a fracture??? If I can find any more I'll stick them up!

 

[Gordon]

I know the filling materials can cause distortions but could this be a fracture?

Might be, but it might equally just be an artefact. Sorry.

 

[sudzs]

Thanks Gordon, it's probably not a fracture considering I was told there was no pathology by the dentist who did the scan. I suppose looking at all the images together it would be easier to decide which it it. I don't think you would want me to post up hundreds of pics!!!