Second root canal - don't know what to do

[Anxious in the chair]

Hello, sorry for the long post...I just feel a bit overwhelmed and upset.

After many issues with a problematic back molar (sensitivity to cold, intermittent random pain, now a deep aching that is controlled by one 400mg ibuprofen every 12 hours or so) I have been advised I need a root canal. This would be my second one - I had one due to a tiny crack that couldn't be seen by x-ray and which ended up being diagnosed after I got a boil on my gum. No pain though which was a blessing but I can't say the same for this tooth.

I was really nervous for my first root canal and I did a lot of research - I chose an endodontist with a microscope to do the procedure and then got a crown done at another dentist.

I've moved since then and when my tooth began acting up and the cusp of this molar broke off I went to a dentist who fixed it in a rush. The filling was rough, it felt like there was a gap in it and my floss kept breaking and I was still in pain. When I asked if there was a problem with it he forced floss into it and then said the pain 'happens sometimes after a filling' and he didn't know what else to do.

I eventually found another dentist who I really like. He's kind and patient. He told me that the filling is close to the nerve and that I probably need a root canal, but if I preferred he could make the contacts of the filling better and see if that decreased the sensitivity. I decided to do this but sadly it's been four weeks since that procedure and the sensitivity and the aching is still there.

If I wasn't nervous I would go ahead and get a root canal with this dentist but I have so many worries - mainly he doesn't use a microscope to do root canals and he isn't an endodonist, he is a general dentist (who has done root canals before). I really don't want to go through multiple re-treatments if this root canal treatment fails and I read that with a microscope it's a bit less likely. And that it is better to go with an endodontist. But at the same time, this dentist is so nice and I feel like he's careful and kind and puts me at ease. I know though that if something goes wrong I will beat myself up for not going to a 'specialist'.

Is this a totally stupid way of thinking? Has my research led me down the wrong path?

I wish I didn't have to get it done at all and even though it is silly, I am angry and really so upset that it is happening a second time. I've been told that my dental hygiene is great and that this seems to be a case of teeth cracking which makes me think I am clenching (there is no sign of grinding). I don't know what to do about that either.

 

[Gordon]

I just had a root canal redone. I have an excellent general dentist (Hi Mike!) but both of us agreed that a specialist Endo was a better option, even for a fairly simple upper central incisor.
So I went to a specialist with a microscope.

Your new general dentist may well have an endodontist he refers regularly to, ask him. I can assure you he won't be offended in any way.

 

[Anxious in the chair]

Thanks Gordon. After reading your message I ended up asking my general dentist to suggest an endodontist who uses a microscope - he said he would ask around as it isn't common where I live, but he would try to recommend someone. I found another possibility - an endodontist with great reviews. She used loupes but no microscope - do you think this would be enough?

Last time I had a root canal due to a cracked tooth (that couldn't be seen on an x-ray) there were three canals - two were dead and the other one was calcified. The microscope showed that the crack hadn't extended too far and that the prognosis for root canal treatment would be good. Neither of the other dentists I've seen have mentioned a crack on the tooth I now need a root canal (even after the cusp of the molar broke off) but I am so worried it will be this. And that it will be missed even with loupes. Maybe I am being stupid, I don't know. I just don't want to end up with an extraction.

I am worried that this will end up happening to all my teeth and I don't know why. All the dentists say the same thing - no sign of cavities, excellent dental hygiene and yet here I am at the point of getting a second root canal. I also have small chips/breaks in two other bottom molars. I asked about whether it could be bruxism, but there are no signs of grinding. Does unconsciously clenching teeth cause cracks and would a night guard help with this? I asked my general dentist and he said he doesn't think my pain is caused by clenching because TMJ is usually bilateral and not unilateral. I want to know how to stop this from happening to the rest of my teeth but I don't even know if a general dentist can diagnose TMJ. Do you know if a night mouth guard would help or could it make the problem worse?

It sounds stupid but I feel like I've failed in taking care of my teeth somehow. My parents had a lot of dental work done and paid a lot and I always swore that I would not be in that situation.

Thanks for your help in advance.

 

[Gordon]

I found another possibility - an endodontist with great reviews. She used loupes but no microscope - do you think this would be enough?

Better than nothing, if that's the choice

Neither of the other dentists I've seen have mentioned a crack on the tooth I now need a root canal (even after the cusp of the molar broke off) but I am so worried it will be this. And that it will be missed even with loupes. Maybe I am being stupid, I don't know. I just don't want to end up with an extraction.

Some cracks are almost impossible to see, even with microscopes, there's nothing you can do about it if it is cracked, but not ever tooth needing RCT has a crack.

Do you have a lot of amalgam fillings? Longer term, teeth seem to crack around them, it's one of the reasons we're moving away from amalgam as a filling material now.

 

[Anxious in the chair]

Hi Gordon, thanks for your response. My general dentist has recommended a dentist with a microscope and uses it for RCT. It's triple the price of the endodontist that uses only loupes. Last time I had a root canal I paid more for the microscope because I had a crack that couldn't be seen.

If you were having treatment would you always choose the endodontist with the microscope over an endodontist with loupes? Does it always guarantee a better outcome and treatment?

I don't have any amalgam fillings. I got my first fillings (white composite) on my wisdom tooth and the molar in front (the one that now needs a root canal) last November. I have a root canal on the other side that has a crown on it. I can't remember what kind of crown I had but it might be zirconia or porcelain fused to metal. All my cracked/chipped teeth are on the bottom jaw.

The root canalled tooth was the first dental issue I had but the dentists noticed cracks and breaks in other teeth (on the bottom jaw) when they examined me.

I am healthy but I do have polycystic ovarian syndrome - I don't know if hormones contribute to tooth problems or cracks at all?

Thank you so much for your advice.

 

[Anxious in the chair]

Sorry I have a follow up question - the reason I need a root canal is that the filling on my back molar is close to the nerve and so it's really senstitive, the sensitivity lingers and I have a dull ache (that sometimes wakes me up at night). There isn't an abscess or infection. I just wondered - what is the outcome if you leave this? Does the nerve eventually die and your tooth becomes necrotic? Does it basically never get better? I am in pain and have been taking ibuprofen (which I don't want to keep doing long term) but I wanted to understand what exactly is happening. Thank you.

 

[Anxious in the chair]

I just looked into the two dentists and I am even more confused...the one I found who is an endodontist and uses only loupes - she has specialised in endodontics and all her qualifications and certificates relate to this field. The other dentist who my general dentist recommended and uses a microscope for RCT focuses mostly on aesthetic and cosmetic dentistry, digital restorations and veneers "as well as root canal treatment". I don't know whether this matters at all - I just don't know how to assess what's best for my situation.

 

[Gordon]

If you were having treatment would you always choose the endodontist with the microscope over an endodontist with loupes? Does it always guarantee a better outcome and treatment?

Yes, everything else being equal, so a very good operator using loupes will be better than a cack handed idiot with a microscope (like me, I'm crap at endo!).

I am healthy but I do have polycystic ovarian syndrome - I don't know if hormones contribute to tooth problems or cracks at all?

No.

I just wondered - what is the outcome if you leave this? Does the nerve eventually die and your tooth becomes necrotic?

Hard to say without seeing you. If it's cold sensitive then it might get better, hot sensitive then likely no, it won't.
Are you sure you're not clenching/grinding in your sleep? That would explain the cracks and possibly the pain from this tooth too...

 

[Anxious in the chair]

Hi Gordon, thanks for your answers, that's really helpful. I am seeing two dentists tomorrow, one at 9.00am and one at 5.30pm and then I will make the decision on who to go with. I think I will go with the person I feel most confident about but also who makes me feel comfortable. I've got a list of questions for them too!

Yes, everything else being equal, so a very good operator using loupes will be better than a cack handed idiot with a microscope (like me, I'm crap at endo!).

No.

Hard to say without seeing you. If it's cold sensitive then it might get better, hot sensitive then likely no, it won't.
Are you sure you're not clenching/grinding in your sleep? That would explain the cracks and possibly the pain from this tooth too...

It is cold sensitive but also seems hot sensitive. Also my jaw aches - like a dull throbbing. I can sleep through the night but I usually wake up with a jaw ache. It eases if I massage it and press on certain points and also use an ice pack, but eventually I need to take a painkiller. The pain goes up into my ear. For a while I had crackling and popping in my ear but that is gone now and the pain is worse. The pain is only on one side.

I don't think I am grinding but I could be clenching - I haven't been diagnosed. Would an endodontist be able to tell if I am doing this? Can they check to see if I have a TMJ/TMD disorder? Does clenching alone usually cause cracks? Sorry I know that's a lot of questions!

What I am paranoid about is that I will get RCT on this tooth but my jaw ache won't go away and then I have treated a tooth for nothing.

Is there anything I can do or ask to make sure the endodontist checks that the source of pain is definitely of endodontic origin?

Thanks so much!

 

[Anxious in the chair]

The other thing I've noticed is that the pain in my jaw eases slightly when I am chewing. But it starts again after I have finished. I don't know if this is significant - it just seems a bit strange.

 

[Anxious in the chair]

Hi Gordon, I've seen the first dentist today who works with the loupes. She was really friendly and allowed me to go through my list of 19 questions. She said that because I don't have an infection, I could actually have the root canal procedure done in one day and not staggered over a few weeks (my previous experience involved a root canal and temporary filling plus antibiotics with a permanent filling weeks later). I didn't know it could be done in one appointment. Is this normal?

She said that she does 6 or 7 root canal appointments a day. It seems to be her bread and butter. She was very confident but understood that I was nervous. She also checked my jaw for tightness and clenching and said that she didn't feel anything abnormal. She has great reviews and talked me through all the equipment she uses including the rubber dam, the loupes and the different types of files. I asked her about success rates and she said that a good root canal can last 10, 20 years or more.

She was ready to do the procedure in my first appointment but said that she was happy for me to think about it. I could either come back in a few weeks (as I am going on a trip which complicates matters) or I could book in for tomorrow. I've scheduled an appointment for tomorrow with her so I have it in case.

I have the appointment with the dentist who has a microscope this afternoon. I will see what he says and then make a decision.

I am still really nervous that somehow I will make the "wrong" decision. I just want a good outcome for my tooth.

She said that if I don't clench or grind then a composite filling over the root canalled tooth would be enough. I got a crown on my other root canalled tooth because it was a cracked tooth. What would you recommend? Is a filling enough or is it always better to get an onlay or crown after RCT whatever the condition of the tooth?

Thanks again for your help.

 

[Gordon]

I didn't know it could be done in one appointment. Is this normal?

Yes, it's routine now. Seems to cause less issues than the previous multi-stage process.

What would you recommend? Is a filling enough or is it always better to get an onlay or crown after RCT whatever the condition of the tooth?

A filling is fine if the tooth isn't too badly broken down. Composites are bonded into the tooth so provide some reinforcement. It really depends on the condition of the tooth, mostly they're pretty badly broken down to need endo in the first place, so a crown is required, but my second premolar has been RCT'ed for about 40 years now and is doing just fine with only a filling.

 

[Anxious in the chair]

Yes, it's routine now. Seems to cause less issues than the previous multi-stage process.


A filling is fine if the tooth isn't too badly broken down. Composites are bonded into the tooth so provide some reinforcement. It really depends on the condition of the tooth, mostly they're pretty badly broken down to need endo in the first place, so a crown is required, but my second premolar has been RCT'ed for about 40 years now and is doing just fine with only a filling.

Thanks for your reply Gordon. Wow, that's amazing that it has lasted 40 years. Mine is a molar right at the back near the wisdom tooth. Do you think the placement of the tooth that is treated makes a difference? Is there a difference in the biting force?

I went to see the second dentist this afternoon. He asked me lots and lots of questions and did lots of checks including a cold test. He then said to me that he believes my issue isn't a filling close to the nerve but sensitivity due to exposed dental tubulars because of gum recession. I asked him why he thought this and he said because the cold test shows that several teeth are affected not just the one I said is causing the problem. I told him that my tooth is hot AND cold sensitive and he said hypersensitivity can cause this problem. The first dentist I saw who first fixed my tooth after the molar cusp broke off also said this when the sensitivity and aching didn't settle, and gave me a fluoride treatment but it didn't help.

I told the dentist today that the tooth ache has sometimes woken me up at night. I said that when I take an ibuprofen it usually sees me through the night but I have jaw ache in the morning. And also when I got sick, coughing repeatedly really made my tooth hurt and it felt extremely sensitive.

He checked my jaw and manipulated it and asked me to open it slowly. He also pressed inside the jaw with his finger (something that I have done before after watching a video and that gave pain release). He said that although my jaw is a little unbalanced it doesn't seem like it's that that is causing the issue. I said that I was favouring the right side of my jaw to eat after I kept getting sharp pains when chewing before the molar cusp broke off. I asked him whether it could be a cracked tooth - he asked me if I can chew on my new filling. I said I can and that chewing actually brings some pain relief. He also did a bite test and a percussion test and nothing caused pain.

He did a pulp vitality test on the affected teeth and the ones on the opposing side. He said everything is vital.

The dentist recommended treating the hypersensitive areas with novamin powder paste and then waiting two weeks to see the outcome and whether the sensitivity will subside. I asked if the dull aching would subside as well and he seems to think so, though I don't understand this.

He said if this doesn't work, he could put a filling on the exposed areas of the tooth (is this like bonding? I wasn't sure of this) to provide increased protection against sensitivity and see how that goes. He said a root canal would be the final step if that doesn't work.

I decided to opt for the novamin powder treatment because I would like to not have a root canal if it isn't necessary. The worrying thing for me was that the treatment was unbelievably painful. The dentist applied a numbing gel to the gum followed by a shallow injection but when he started the process I couldn't take the pain of the sensitivity and the throbbing afterwards. On a scale of 1 to 10 it was around 9. I asked him to stop and he had to do quite a few more more numbing injections before we could continue.

He applied three coats of the paste. After the treatment I was in such terrible pain (sharp, severe pain) I had to take 600mg of ibuprofen and it bought only little relief. I managed to get home and applied ice pack after ice pack and then took another 200mg of ibuprofen. It's dissipated somewhat now and I feel very bruised and my face is aching but I am so frightened that the pain will come back. It doesn't feel normal that this kind of treatment would result in such an increase in pain. This is the worst it has been through the entire tooth saga.

Is it possible that once this pain dissipates it could be gone for good? Have I somehow made things worse by having this treatment? I am so worried now. My teeth on my top and bottom jaw on the left hand side are all aching now. I've never experienced dental pain like this in my life. I have had a root canal and a filling before and they didn't hurt like this. This was totally different. And I didn't expect this to happen at all.

Thanks in advance for your help.

 

[Gordon]

Wow, that's amazing that it has lasted 40 years. Mine is a molar right at the back near the wisdom tooth. Do you think the placement of the tooth that is treated makes a difference? Is there a difference in the biting force?

Not really. Once they're done they're done 95% of the time. Regarding bite forces, that's a big topic...
https://www.ncbi.nlm.nih.gov/pmc/ar...ned by the mechanical lever system of the jaw. Have fun!

He did a pulp vitality test on the affected teeth and the ones on the opposing side. He said everything is vital.

With an electronic pulp tester? Anything else is unreliable at best.

I've never come across a case where treating sensitive dentine produced the extreme results you mention, but let's be open minded and see how you feel tomorrow? I've also not used Novamin so I can't say if that's why you're having this issue. Maybe Lincoln has used it?

Pretty sure you haven't made anything worse.

 

[Anxious in the chair]

Not really. Once they're done they're done 95% of the time. Regarding bite forces, that's a big topic...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2853825/#:~:text=Bite force varies in different regions of the oral cavity.&text=The more posteriorly the transducer,the greater the bite force.&text=It has been explained by the mechanical lever system of the jaw. Have fun!


With an electronic pulp tester? Anything else is unreliable at best.

I've never come across a case where treating sensitive dentine produced the extreme results you mention, but let's be open minded and see how you feel tomorrow? I've also not used Novamin so I can't say if that's why you're having this issue. Maybe Lincoln has used it?

Pretty sure you haven't made anything worse.

Thanks Gordon.

Yes it was with an electronic pulp tester. He tested my upper and lower jaws on the left hand side and the lower jaw on the right hand side.

The pain woke me up in the night and I had to ice my cheek and jaw regularly. I took 400mg of ibuprofen this morning and kept icing and it took it away for about 8 hours. It's coming back now though. It feels like a shooting pain throughout the teeth that goes right into the ear. It's weird - like I can 'feel' all of my teeth. It's not as excruciating as yesterday but I feel like if I didn't take anything it could get there. At night I kept waking up because for some reason my jaws kept clacking together every time I fell asleep.

I contacted the dentist and he said that the treatment might have triggered my joint problem and he prescribed a myorelaxant to take at night before bed in addition to a painkiller. He said I can take it once a day but if I am in pain I can take it up to three times a day. He also told me to get a particular toothpaste and an MI paste to apply on the area for the next two weeks.

I am trying to be open minded. The pain level was frightening. I don't want that again. I am wondering if the number of injections I had to have in my gum to get the procedure contributed to the pain.

Thank you!

 

[Anxious in the chair]

I took the muscle relaxer last night with a painkiller before bed and I did feel more relief. I had barely noticeable pain when I went to bed but I still had to get up in the early hours of the morning to get an ice pack because my jaw was aching. I find that sleeping positions make it worse or better - on my back it is slightly better but on my side it is worse. At one point the pain went away (without a painkiller) and I was able to fall back to sleep.

I've been putting an ice pack on the side of my face since I woke up - the dull ache is back. No shooting pain yet this morning, but I have still got the dull ache that I had before. I feel like the sensitivity has decreased a little but when I put a little cold water on my wisdom tooth and the molar with the deep filling they still felt sensitive. Sigh. The dentist said to wait two weeks to monitor what happens - I am supposed to be going away next week and I am dreading having to deal with this while travelling.

 

[Anxious in the chair]

@drhirst have you ever used Novamin powder paste for tooth sensitivity before? (After Gordon mentioned you it took me a while to work out how to @ message someone on here!)

@Gordon another thing the dentist mentioned was that my sensitivity issue could be caused by breathing through my mouth when I am sleep. It's true - I woke up several times last night with my mouth open and it was dry. But could that cause sensitivity that results in a dull spontaneous ache?

Thanks!

 

[Gordon]

another thing the dentist mentioned was that my sensitivity issue could be caused by breathing through my mouth when I am sleep. It's true - I woke up several times last night with my mouth open and it was dry. But could that cause sensitivity that results in a dull spontaneous ache?

No.

It does sound like your TMJ is flaring up, have a wee read of this:

TMJ Pain, Clenching and Grinding

What can you do about TMJ pain, clenching, and grinding? We've collected tips from our readers and from dentists!

www.dentalfearcentral.org

 

[Anxious in the chair]

@Gordon thank you for the article and your response. I went to bed last night (quite late, around 1am) and took a muscle relaxant and painkiller. I woke up at 5.30am with pain. The pain is worse lying down than sitting up. Does this sound like nerve pain or TMJ to you?

I couldn't sleep, tried icing but it seemed to make things worse after a while. I then got up. There are two types of pain: one feels like stabbing with a needle - inside my ear, along my jawline and the teeth are very tender. This comes and goes. The one I woke up with this morning is a dull ache. My ear feels full/blocked.

When I chew there isn't a flash of pain on them but the ones along the affected side are tender to chew on or press on. The pain also seems to extend to my throat and when I swallow it feels a bit painful/sore which is weird.

When I finally couldn't stand it anymore I took 800mg of ibuprofen and I've now taken a muscle relaxant during the day. I am going to contact the dentist who treated me and ask what else I could do, but this is really the most out-of-control the pain has been. Prior to getting the Novamin treatment I could take a painkiller and sleep till about 8.00am.

Thanks for your help.

 

[Gordon]

Bit stuck TBH, it doesn't really sound like it's ALL TMJ that's causing this, possibly you're unlucky enough to have something going on with a tooth and the TMJ on top? I'd really need to see you to come up with anything else right now, sorry.
Sometimes heat works better than ice for TMJ symptoms, so you may want to try that?