Second root canal - don't know what to do

[Anxious in the chair]

Hi @Gordon thanks for your message. The pain basically got much much worse and was barely controlled with painkillers. The pain would wake me up at around 5.00am and gradually get worse throughout the day. Ibuprofen on its own had no effect so I started taking a combination of paracetamol and ibuprofen four times a day. The pain was like flashes - it would start and then reach a huge crescendo before subsiding for a couple of minutes and then coming back again. Even after taking both painkillers they didn't seem to work for about 2 hours and I couldn't eat or sleep properly. I only got relief from massaging my mouth area but as soon as I stopped the pain would come back.

I tried a hot compression as you suggested - I think the ice was making the muscles too tight and that was causing more pain. I've been sleeping sitting up as lying down is much worse.

Yesterday I took my painkillers, tried swishing with salt water a few times and before bed I applied some clove oil to the area to see if I could numb the pain so I could try and sleep.

This morning I woke up with no pain. The tooth that I think is the problem feels tender when I press on it. The jaw also feels a bit achey (more tired than tight) but not the dull ache or the flashing pain I have had for 5 days. None of my teeth feel sensitive.

This makes me think that the nerves inside the tooth have died and that's why I am not feeling any pain now. The only reason I think this is because the last time I got RTC was because I had searing pain for one night in a tooth and then the next day there was nothing. I thought it was all fine and then I got a boil on my gum underneath the tooth.

I have a few questions if you don't mind?

Does it make sense to think the tooth has died? Is there any other possible explanation why the extreme pain has suddenly disappeared? Would swishing it with salt water have possibly helped to improve it?

Do you always have to treat a dead tooth nerve with a root canal? I am guessing if I leave it, something will probably happen to it like an infection but I want to check that this is what I should do. The endodontist with the loupes is available next week and I am thinking I will get the procedure done with her but I am scared.

Is there a chance that there is an infection spreading to the other teeth? I am so paranoid that I am going to need RCT in other teeth now because this problem tooth has been a problem for a while. The endodontist took an x-ray on Friday and said she couldn't see an infection but I don't know if it always shows up on an X-ray.

I think the dentist who did the sensitivity treatment must have irritated the nerves in my problem tooth during the treatment (that I think were already irritated) even more and that's why it flared up so badly. I guess this was inevitable...he probably just sped up the process.

Thanks so much. I have been filled with anxiety and fear (as well as pain) over the last few days and it has really helped me to be able to talk to you.

 

[Gordon]

Does it make sense to think the tooth has died? Is there any other possible explanation why the extreme pain has suddenly disappeared? Would swishing it with salt water have possibly helped to improve it?

Yes, it's pretty likely I'm afraid. I doubt if salt water would make any difference.

Do you always have to treat a dead tooth nerve with a root canal?

Yes. Or an extraction. Otherwise you're just gambling on when it will flare up big time. Much better to deal with it on your own terms than on Christmas Day for example. The dead pulp is a big hamburger meal for any passing bacteria, once they get in there and get established, the body can't attack them (because there's no blood supply into the tooth anymore) and then they spill out into the space between the tooth and socket, which is how an abscess starts.

Is there a chance that there is an infection spreading to the other teeth?

Nope. Not a chance.

The endodontist took an x-ray on Friday and said she couldn't see an infection but I don't know if it always shows up on an X-ray.

It won't show up until after the pulp dies as above, if your symptoms were the pulp dying off then nothing to see on x-ray.

I think the dentist who did the sensitivity treatment must have irritated the nerves in my problem tooth during the treatment (that I think were already irritated) even more and that's why it flared up so badly.

Possibly. It's impossible to know for sure.

 

[Anxious in the chair]

Thanks for all your replies @Gordon that's really helpful. My appointment with the endodontist is next Tuesday, it can't come quick enough.

When I went for my previous appointment with her, she said that it was a straightforward root canal as the tooth was still vital. However, now that the tooth has died is the process more complicated? Will I need to have antibiotics or does anything need to be placed inside the tooth before the root canal treatment is completed (in my previous procedure I think I had an antibiotic placed inside and a temporary filling in one stage before the treatment was completed in another stage).

She told me she could do the procedure all in one appointment but I don't know if it will be different now because my condition has changed.

Also now that the tooth has died does that negatively effect the chances of a successful root canal treatment?

Thanks again for all your help.

 

[Gordon]

However, now that the tooth has died is the process more complicated? Will I need to have antibiotics or does anything need to be placed inside the tooth before the root canal treatment is completed (in my previous procedure I think I had an antibiotic placed inside and a temporary filling in one stage before the treatment was completed in another stage).

Not really, no. Nothing in the tooth or systemic antibiotics required. Very rarely if the endo can't get the tooth dried, i.e. there's pus still seeping out the canals, they will need to use a 2 visit technique and put in some antiseptic paste between visits, but that's unusual these days.

It doesn't affect the likely success rate at all.

 

[Anxious in the chair]

Hi @Gordon thank you - that makes me feel much better about having the procedure done. I really want it to be successful. Fingers crossed it will be.

I've noticed that the affected tooth feels a bit high in my mouth, like it is sort of raised. There is also a bit of an ache in that area. When I take an ibuprofen it settles down. Do you think it feels high because an infection has set in already?

Thanks for your help.

 

[Gordon]

I've noticed that the affected tooth feels a bit high in my mouth, like it is sort of raised. There is also a bit of an ache in that area.

Yes, pretty normal.
There will be some inflammatory cells gathering at the apex of the tooth as your immune system will be aware that something is going on so there will be some pressure in the area and possibly the tooth will actually be pushed a little bit out of the socket.

The Immune System is a remarkable thing, it's fascinating what it does and is capable of. But I digress...

 

[Anxious in the chair]

Thank you @Gordon , it's great to know my symptoms are normal.

I had my root canal treatment today. The endodontist was so kind and wonderful - she kept checking to see whether I was in any pain and told me I could lift my left hand to tell her to stop if necessary. It was far less painful procedure than the sensitivity treatment . In fact after the two injections I felt nothing at all.

The endodontist told me at the end of the treatment that she was able to clean out and treat three canals and that one was calcified but she was able to clean it and reach the apex.

She said that my tooth was cracked and the crack extended slightly below the periodontal line. She said because 1/3 of my root canalled tooth is now composite filling and 2/3 has a crack, she would recommend getting a crown in order to preserve the tooth. She said with a composite filling the tooth would be okay for a few years but there is a likelihood it would eventually fail. She also said something about how she had to cut a bit more into the gum because of the crack but I am a bit confused about what she meant.

Do you think getting a crown sounds sensible? I am happy to get one especially as the tooth is cracked. I am a bit worried about what the endodontist said about the crack being slightly below the periodontal line - last time I had RCT the endodontist said she wouldn't perform a root canal on a tooth that was cracked below the gumline (she recommended extraction in these cases instead) so I am wondering why my current endodonist was happy to go ahead with it.

I am scared that I'll pay for the root canal treatment and a crown and because of the crack it will all fail anyway.

Thanks for your help.

 

[Anxious in the chair]

@Gordon I spoke to the endodontist again today and she said that the crack is at gum level. She said that when she does the crown she will extend it 1mm below the gum which will make it stronger. She said this is why she has recommended a crown instead of an onlay. I feel a bit better now.

 

[Gordon]

It sounds fine to me, a mm below the surface isn't a problem if you keep on top of cleaning the area.

Glad you got it done now.

 

[Anxious in the chair]

Hi @Gordon thanks so much. I am glad I got it done as well. I am a bit nervous about the crown now - I decided to get one because the tooth is cracked and also because of where the endodontist said the crack was but at the same time the idea of destroying most of my tooth to put a crown on top is now a bit upsetting. However, I don't know about having just a filling there if it's likely the tooth will crack eventually (because it's already cracked) and then need a crown anyway. I'd feel a bit more confident just having a filling on my tooth if the root canal was needed due to decay and not a crack for example.

I guess I am asking - is a crown generally the best choice is 2/3 of a tooth is cracked and the crack is at gum level?

Thanks for your help.

 

[Gordon]

I guess I am asking - is a crown generally the best choice is 2/3 of a tooth is cracked and the crack is at gum level?

Yes, or an onlay to preserve as much tooth structure as possible.

 

[Anxious in the chair]

@Gordon the endodontist recommended a crown over an onlay in my case because the crack is at gum level and that she will extend it 1mm below the gum line to make it stronger. Does this all make sense? I am scared of making the 'wrong' choice. I was initially veering towards getting an onlay, but because of what she has recommended due to the nature of the crack in my tooth it sounds like a crown is better...

Thanks!

 

[Gordon]

Yes, it makes perfect sense. The idea is to try to hold the tooth together, the crack is at a pretty weak area to begin with. The new bonding materials mean that the crown will significantly strengthen the tooth.

 

[Anxious in the chair]

Hi @Gordon, your reply made me feel much better before my crown appointment.

I went to get my crown fitted yesterday - the endodontist made sure that it fit properly and I asked for a few adjustments to the colour (just putting a bit of staining on so it looked more like my other teeth). The endodontist asked me to look at it in the mirror before it was cemented. The lights in the dental office were very bright and under those lights everything looked fine - it looked a similar enough shade to my other teeth.

However, when I came home I looked in the mirror (under home bathroom light) and the crown looks much whiter compared to my other teeth. I am a bit upset because now it's cemented I don't think there is anything I can do. I didn't realise colour matching was a complicated process - in my previous crown the dentist matched the shade and showed me and I felt like it was really similar to my tooth colour. The teeth around the crown I just got done now look white-grey in comparison.

I thought that it might look different in natural light so I had another look this morning and it still looks very white to me. My other crown looks more reflective and natural for some reason, but I know that that is also a full zirconium crown so it's made of the same materials. I've had that crown for 6 years - I don't think it has changed colour and I feel like I would have noticed if it was a dramatically different colour when it was fitted.

I started looking it up and didn't realise 'metamerism' was a thing I needed to even worry about in dentistry...I just thought the crown would look the same whatever light it was in.

I know that no one apart from a dentist will probably see it as it's a molar far back in the mouth but I still feel very down about it. Does it look so different because the teeth around it are darker in colour? Is it possible to stain a zirconium crown after it has been cemented? If not, is the only way to change the colour to have a new crown put in (which will mean paying again?).

I really don't want to get in the chair again and have something else done, I just wanted this to be over. But at the same time, I wanted the crown to look like it was my tooth (I know a perfect perfect shade match is impossible).

I've attached some photos taken under natural light (my teeth look horrible in them) so you can see what I am talking about. I feel like sometimes it is less noticeable but sometimes it is more obvious e.g. in the photo labelled 'tooth crown 2' and 'new crown'.

Thanks for your help.

 

[Anxious in the chair]

I've taken some more pictures in the bathroom light where I think the colour of the crown looks worse and then some in natural light. In some lights it doesn't seem as obvious but in others it seems to standout . I don't know if I am being too critical...maybe I should just live with it.

 

[Gordon]

Give it a few more days, to see what you think then, it really doesn't look that far out to me, but I'm a man and therefore useless at matching colours (says my wife!).

Different light balance from different light sources do make crowns look different shades. I had a patient once who was a (quite well known) model and TV presenter and we finished up going to a photographer's studio to get the shades right for her front teeth. They didn't look so great in daylight but she wasn't so bothered about that!

 

[Anxious in the chair]

Thanks @Gordon, that made me laugh! I am going to try and get used to it and see if I can live with it. I really don't want to go back to the dentist's chair - I feel like that's all I've done recently! If I do decide to get it changed, will removing it risk damaging the tooth underneath? I don't know how a zirconia crown is removed but I read it has to be cut/drilled off?

My crown is the most noticeable in warm, household type light and a little in daylight. And in flashlight and really bright fluorescent light (like at the dentist) it looks like my other teeth. I know nobody is likely to see it because I have to open my mouth in this really weird way for the back teeth to be shown (and why I would do that in public I don't know) but I think it bothers me because I notice it.

Lastly, does zirconium gradually stain/change over time? I do floss and brush well, but I just wondered if there is any chance it will gradually change (first time in my life I am hoping for staining!).

Thanks again for your help.

 

[Gordon]

If I do decide to get it changed, will removing it risk damaging the tooth underneath? I don't know how a zirconia crown is removed but I read it has to be cut/drilled off?

Yes, I'm afraid so. Depends what it's been cemented on with but probably.

Lastly, does zirconium gradually stain/change over time? I do floss and brush well, but I just wondered if there is any chance it will gradually change (first time in my life I am hoping for staining!).

Not really, it might pick up a bit of staining but I wouldn't count on it. You could always bleach your other teeth to match... (that's not a serious suggestion btw!)