Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

August 24, 2018

Steroids for root canal pain – not always the best answer


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Dr. Hall,
I had a root canal and crown done in March 2018, weeks after the procedure I started to have pain. I went back to my dentist who x-rayed the tooth and found no cracks, etc. They referred me to an endodontist in June 2018 and she put me on a course of antibiotics. Two weeks later I saw her again. The pain had for the most part disappeared and she said it would continue to feel better over time. We left for vacation in July and all was well. Then a couple of days ago I woke up with severe toothache. I saw my endodontist the next day she put me on a course of steroids. I’m still in excruciating pain. Throbbing, pulsing pain.
Please help!
Regards Sandra from Ukiah, California

Sandra,
Steroids are becoming popular as a treatment for root canal pain. While they’re effective in some situations, there seems to be a certain amount of misuse because of a lack of understanding of the pharmacology combined with a deficiency in diagnostic skills. In your case, steroids are clearly the wrong treatment.

Plus there are a couple of other things I disagree with about your treatment. But let’s start with the steroids.

A steroid is an anti-inflammatory drug, and a very effective anti-inflammatory. It calms down the body’s response to inflammation. But one thing to understand about the body’s response to inflammation is that there is purpose to it. Part of that response is bringing white blood cells to the area to fight infection. In other words, steroids also act to block the body’s response to infection. This makes it really important for the dentist to know what is going on before prescribing. Is there infection, or just simply irritation?

Immediately after a root canal treatment there is ordinarily some irritation of the tissue around the end of the root caused by pushing some of the infected material inside the tooth through the end of the tooth, maybe pushing some of the disinfecting solution and filling materials through the end of the tooth, and possibly from the root canal files actually poking through the end of the tooth during the instrumentation of the tooth. This irritation can cause a vicious cycle of post-operative pain because the inflammation causes swelling of the tissues around the end of the tooth, pushing the tooth up, causing traumatic occlusion, which exacerbates the inflammation, pushing the tooth further up and increasing the pain. Steroids can be an excellent therapy for this situation, though there is some risk because some of the problem is the infected material pushed out of the end of the tooth. For this reason, steroids given to patients post-operatively are often combined with a short course of antibiotics.

But when a tooth flares up weeks after, as happened in your case, that is probably going to be solely because of infection. It is much too delayed to be connected in any way to irritation from the actual treatment. That’s why the endodontist prescribed antibiotics in June, which worked. The success of the antibiotic therapy confirms that the problem was infection.

But it’s at this point where I begin to disagree with your endodontist. The fact that you had an infection flaring up in the tooth weeks after the completion of the root canal treatment indicates that there was some problem with the root canal treatment. The root canal systems inside some teeth can be complex and it can be easy to miss parts of the system that don’t get fully cleaned out and sealed. So I have a hard time figuring out why your endodontist, who has to know this, would tell you after a delayed post-operative infection in a root canal tooth, that everything is going to be fine now. In most cases, that tooth is going to flare up again with another infection—it’s just a matter of time.

And sure enough, several weeks after that, your tooth did flare up. And here is another part of what she did that is puzzling to me. How can it be not clear that this is an infection and not simple inflammation? In my opinion, steroids are absolutely the wrong treatment here. You need another course of antibiotics and, at a minimum, the root canal treatment needs to be re-done because it has clearly failed.

This brings me to another part of your treatment that I disagree with, and that is placing a crown on this tooth before being sure that the root canal treatment was successful. The crown makes re-treatment more difficult, since now a hole needs to be drilled in the crown to get access to the roots and visibility is impaired.

My recommendation? Find another endodontist who is willing to tell you the full story of what is happening to your tooth and address a real solution. The first dentist missed part of the root canal system (or some similar mishap in the procedure) and the treatment has failed. This isn’t to condemn your dentist—as I said, some of these teeth have complex canal systems and in some cases it can be nearly impossible to clean them out and seal them completely. Anyway, your options now are:
1. Root canal re-treatment,
2. Root canal surgery, or
3. Extraction of the tooth.

Good luck,
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 21, 2018

Water relieves the pain in my tooth


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Dr. Hall,
It’s been ten years since I got my two fillings. One fell out but doesn’t hurt. The other one is still in but is causing severe pain. It doesn’t bother any to bite on it, but it hurts most of the time. The only thing that relieves the pain is water and only for a few seconds. Any advice?
– Brandon from Oregon

Brandon,
I wish I had better news for you, Brandon, but your tooth, the one with the filling, is showing classic signs of a dying pulp and you’re going to need a root canal treatment on it. I’d get the other filling replaced before it’s too late.

Here’s what’s going on. There has been some decay get into the tooth, probably getting under the filling. That decay has grown until it has infected the pulp. As the infected pulp tissue dies, it can go into a state where it is called a gangrenous pulp. In that state, it gives off gasses that increase the pressure inside the tooth and cause a toothache. When you cool the tooth with water, it causes the gas to shrink somewhat and eases the pain.

This is a classic situation. When a patient reports that cold water or ice water is the only thing that relieves their toothache, you can be 100% guaranteed that they’re suffering from a gangrenous pulp in a tooth that has almost died. Relief can be obtained by simply creating an opening into the tooth to relieve the pressure, but then it needs to be followed up with a root canal treatment to fully remove all of the infected tissue inside the tooth and seal it against further problems.

It’s a similar situation when a tooth is sensitive to heat—it’s a nearly dead tooth.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 7, 2018

Can a root canal treatment be re-done a second time?


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Dr. Hall,
I have a tooth with a root canal that has been redone once, nine years ago. the tooth is bothering me again. Can the root canal be redone more than once?
– Jodie from Ohio

Jodie,
A root canal treatment can be re-done twice, three times, whatever, but that’s not the question. The question is whether or not that makes sense as a treatment.

Root canal treatment is one of the less predictable treatments in dentistry. It is accepted that even when the dentist has done everything right, there could be a failure rate of 5-15%, maybe more if the dentist is less skilled at this procedure. Let me explain the reason for this.

The living tissue inside your tooth is the pulp. There is a pulp chamber up in the crown of the tooth and a pulp canal that conducts the blood supply and the nerve to this pulp chamber. When the pulp becomes infected, the chamber and the canal have to be cleaned out and sealed against any bacteria re-entering the tooth. The problem is that the pulp canal can have branches and twists and turns inside the tooth that can, in some situations, make it difficult or even impossible to full clean out and seal. For example, in a molar, the standard number is three canals—one for each of the three roots. But often there is a small, difficult-to-find fourth canal. Furthermore, sometimes some of the canals can split off into branches at right angles. The dentist has tiny, highly flexible files that he or she inserts into the tooth and cleans out the infected tissue. There is no way this file can be manipulated to enter a side branch that comes off at a right angle.

Now these anomalies occur in a small minority of teeth, so the large majority of root canal treatments are successful. If a root canal treatment fails, re-treatment can remedy the situation, but only in somewhere around 50 to 75% of the cases. But if that re-treatment was done by a dentist skilled in root canal treatment and didn’t work, there’s a pretty slim chance that it will work if tried again.

There is another option, and that is root canal surgery. The dentist, most likely a root canal specialist, will make an opening in the bone and cut off the root tip of the infected tooth, and probably do a small filling at the end of the tooth to help ensure that it is sealed. This is called an apicoectomy and retrofill. If a root canal re-treatment has failed, this is usually the next best option and will be successful again in somewhere around 50 to 75% of the cases. Furthermore, some roots of some teeth are not surgically accessible or are in locations that would make surgery very risky, such as near the nerve that goes to the lower jaw and lip.

Another option is extraction. This isn’t the first choice, for sure, but some teeth are simply not savable.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

February 14, 2018

Days of pain after a root canal treatment


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Dear Dr Hall,

I found your page on post root canal pain the be very reassuring, thank you.

I was hoping that you might be able to advise on my particular case.

I had quite a traumatic root canal (my first ever) done over 3 sessions in October 17. It remained painful so I didn’t get it crowned as I wanted to wait . The discomfort persisted and I was referred to an endodontist who after reviewing X-rays suggested that a canal might have been missed. Based on that I decided to have it redone.

During the procedure no missing canals were found. I could feel discomfort close to the bone where it felt raw and exposed, the root canal was completed and I was advised I would be in discomfort for a few days.

I am now on day 4 of immense discomfort and I intend to ring up for some advice tomorrow. I feel worried that things haven’t worked and I’ll have to have the tooth removed.

How long should it take to calm down do you think before I jump to conclusions and assume something nasty is happening in there? This has been a worry for 5 months now, I just don’t know what to do and I don’t want anybody else fiddling with my tooth anymore.

Your advice would be greatly appreciated.

Regards,
Michelle from the UK

Michelle,
The key in evaluating your tooth and whether or not the root canal treatment is successful or not isn’t how long you are in discomfort, but the direction the discomfort is going. Is it getting better, albeit slowly? If so, I’d be optimistic.

The fact that your endodontist predicted that this would hurt for a few days adds to my optimism here. If the treatment weren’t working, you could be having some increased swelling. I take it that isn’t happening in your case.

The root canal failure at the hands of your general dentist apparently wasn’t the result of a missed canal, but may have been an inadequate seal at the end of the root.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

January 24, 2018

The filling in my root canal tooth came out

Filed under: Root canals — Tags: , , , , — mesasmiles @ 6:10 pm

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Dr. Hall,
So it might sound a little crazy, but I had a root canal done a few years ago. Since then I haven’t been to the dentist, and can’t currently go due to financial problems and no health insurance. Since it’s been so long the cap or synthetic tooth, has fallen out and is now revealing a metal rod. The rod seems to be moving back and forth. What would be my best option? Can I remove the metal rod myself? Should I just leave it till it falls off or till I can get to a dentist?
Heather from Pennsylvania

Heather,
You really need to go to a dentist for a simple replacement of the temporary filling material. And knowing that your finances are strained, you may be able to talk some compassionate dentist into doing this very cheaply or even for nothing at all. Goodness, a dental assistant could do this for you—just get some Cavit and plug it into the hole. Otherwise, you’re going to lose this tooth. Cavit is a simple temporary filling material that comes out of the tube as a paste but when placed in a moist environment like your mouth it hardens. Since it requires no mixing or tray of tools, it can be placed in a few seconds.

When a tooth has a root canal treatment, the root canal filling material then needs to be protected against the oral fluids. Otherwise, saliva will seep down and loosen that root canal filling, which allows the tooth to become re-infected. This causes failure of the root canal treatment. The tooth would then need a new root canal filling in order to save it. So the dentist will put in a temporary filling and then plan when to finish the treatment of the tooth, probably protecting it with a crown.

When I was in practice, knowing that some patients could get into your situation and not come back for the crown, I would fill the tooth with a bonded core material, often using a metal post. If they didn’t get back right away, this would hold up for several years. Maybe something like that has been done in your situation. If the metal post is still present, hopefully there is still time to save the root canal treatment, but the hole needs to be sealed.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 28, 2017

I want to avoid getting a crown on my front tooth, after a root canal


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Hello Dr. Hall,
Back in May 21st I had my front upper tooth knocked out. It was put back in, bonded and set back into place. I had a root canal done on it as well. I’m noting that the color is slightly off (more yellow) than the rest of my teeth. My dentist said that I would probably have to get a crown after my last visit, but looking online I see that a crown for a front tooth may not be a good idea. How can I preserve the whiteness of this tooth without needing a crown? Thank you for your time.
– Joseph from Staten Island, NY

Joseph,
You’re right. A crown on a front tooth, while it strengthens it against chipping, actually weakens the tooth against lateral stresses. So if you have a heavy bite at all, it is at greater risk of breaking off.

After a root canal treatment, a tooth tends to discolor. But that discoloration can be greatly lessened by cleaning out the inside of the crown from any root canal filling materials such as gutta percha or cement. If it is starting to discolor already (four months after treatment), the dentist has left some of those materials inside the visible part of the tooth.

Here’s what I would do.

Go to one of our recommended cosmetic dentists in Manhattan, Queens, or New Jersey, and have them clean out the inside of the crown. Since the tooth has begun to discolor already, it would be a good idea to have them do internal bleaching. Then you could have them fit the tooth with a fiberglass post inside and seal the opening, and you should be good for several years before it starts to discolor.

Then, when it discolors, I would just have them do a single porcelain veneer to correct that. This would require a fair amount of expertise in appearance-related dentistry to match the color of the adjacent tooth, but I’m confident that any dentist we list would be able to get that to look great for you.

Oh, one other thing. Since this is a replanted front tooth, you want to have it x-rayed again to make sure you don’t have any external resorption. It’s possible that your body could be eating away at the root. That happens sometimes with these replanted teeth. Be sure to find that out before you invest much money into this tooth.

And just a comment about your dentist. It looks like he or she did a nice job of saving your tooth—did all the right things, and is probably an excellent dentist. But these demanding aesthetic problems are over the head of the vast majority of general dentists.

I hope this is helpful.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 16, 2017

I have a titanium allergy and think I have a titanium post in my tooth


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Dr. Hall,
I have recently been diagnosed with a titanium allergy. I have two crowns on my left side, upper and lower. I have various odd symptoms that have been addressed with my dentist. They have been checked out and I’ve been told everything “looks” fine. The dull ache surrounding my upper remains. I’m wondering if I have a titanium post and if this is possibly contributing to this dull ache and possibly other unexplained ailments throughout my body. Where do I go from here?
– Jennifer from Kentucky

Jennifer,
Titanium allergy used to be considered very rare, but with the increasing use of dental and orthopedic implants, which almost always use titanium, there are increasing reports of titanium allergy. The MELISA Medica Foundation, which conducts the MELISA test for metal sensitivities, estimates that as many as 4% of the population could be allergic to titanium. However, this test has been criticized as generating false positives, and my guess would be that titanium allergy is less prevalent than that.

Titanium is a very biocompatible metal, apparently due to its high corrosion resistance. Given this corrosion resistance, I would not think that the presence of titanium in a post inside of a tooth would affect tissues outside of the tooth, but I guess that would be possible. If you want to investigate that, I would just go to the dentist that put the post in your tooth and ask if it is titanium. Your dentist should have a record of the type of post that was inserted. I will add that there should only be a post in your tooth if the tooth has had a root canal treatment.

Metal posts are often used in root canal teeth to help retain the buildup that is placed in the tooth and the buildup in turn helps retain the crown on the tooth. For many years, stainless steel posts were the standard. Stainless steel contains nickel, and it is estimated that 10 to 20% of people are allergic to nickel. It was assumed that this wasn’t an issue, because the post was sealed inside the tooth and not in contact with living tissue. Then, about 30 years ago, it was discovered that corrosion products from the stainless steel could leach through the teeth and many dentists, including me, switched to using titanium posts.

Could your dull ache be from a metal sensitivity? I would say that it could. I would wonder if there is any metal in the crowns you have—that is something worth checking also. There could also be a problem with the occlusion of the crowns. In any of these scenarios, everything would “look fine,” but that doesn’t mean that everything actually is fine.
– Dr. Hall

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Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 27, 2017

This is too much sensitivity – you need a root canal


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Dear Dr. Hall:
On June 26, my dentist prepared my cracked tooth number 30 (lower right first molar) for a crown. I had several problems with the temporary crown including very sore gum and pain with biting and cold sensitivity. However, since the pain was not lingering, my dentist placed my permanent crown on July 12. But it didn’t subside and in fact, it got worse. After one week, I visited him again and he took X-ray and did cold test and pressure test. He also knocked at my tooth which was not painful. My tooth was very sensitive to cold but it went away in less than 30 seconds. Also, I didn’t feel pain with pressure test although I felt pain when I bit on hard things. So my dentist said I had to wait and I had high chances to get better. He said sensitivity to pressure is normal even for 30 to 90 days. Now 10 days has passed and from my permanent crown placement, but I don’t see any improvement. Also, today I discovered my tooth is sensitive to hot food too although it doesn’t linger for a long time after the hot food is removed. I think once I realized this sensitivity with that temporary crown but didn’t care about it.
Are these reversible pulpitis symptoms? Does that heat sensitivity show my tooth nerve is dying? How long do you think I must wait before I see an endodontist?
Thanks a lot.
– Bita from Iowa

Bita,
Thanks for the clear description of your symptoms! You told me what kind of pain, what provokes it, and gave me a clear history, which makes it much easier to figure out what is going on with your tooth.
I would call the endodontist today. There are a couple of red flags here and I’d get an expert diagnosis before this tooth gets any worse. It doesn’t look good.
I don’t want to be too critical of your dentist, because I don’t know the whole story of your tooth—just what you’ve told me. But just taking what you’ve told me, some additional caution in your case seems like it would have been wise, and I’ll explain why. It also isn’t normal for a tooth with a new crown to be sensitive to pressure for more than a few days, if the occlusion is adjusted correctly.
First, you had a cracked tooth. A crack can easily involve the pulp of a tooth and by itself can cause a tooth to become infected and the pulp to die.
On top of this, you had significant cold sensitivity after the crown preparation. This could have been due to an incompletely sealed temporary crown, or it could have been due to the extra irritation to which the tooth was subjected from the crown preparation, or a combination of the two. It would have been wise to have coated the tooth with some type of desensitizing product at this point. Maybe that was done.
Also, given those two things, it would have been prudent to have temporarily cemented the crown. This is a lower first molar, so the crown would have to be made out of some strong material that could have been cemented with a soothing type of cement in hopes that it would settle down, or, if it didn’t, to allow easy removal of the crown for root canal treatment. Permanently cementing a crown is usually an additional irritation which can push a borderline tooth over the edge to needing root canal treatment.
So your dentist permanently cemented the crown and the pain got worse. Your sensitivity is headed in the wrong direction and appears that it will end up in irreversible pulpitis, requiring root canal treatment.
And now it is getting sensitive to heat. I wouldn’t go quite so far as to say that it’s absolutely certainly suffering from irreversible pulpitis at this point, but if not, it’s awfully close. The endodontist should be able to tell you for certain. There would be subtle changes in the ligament of the tooth around the end of the root that most general dentists wouldn’t see but the endodontist should.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 26, 2017

My dentist put a screw post in my front tooth

Filed under: Root canals — Tags: , , , , — mesasmiles @ 11:58 am

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Hi Dr Hall,
I just had a front right central incisor break at the gumline after getting a root canal treatment. My dentist has used a metal screw post for the temporary crown. I have a continuous dull feeling in nasal cavity area but no pain. Is the screw a good idea for this type of problem as I cannot afford a bridge?
Many Thanks,
Frank from Pietermaritzburg, South Africa

Frank,
These screw posts generally are pretty solid as far as staying in the tooth, but they are risky. They exert a lot of stress on the root. The risk is that the root will split from the pressure. Is that happening in your case and is that why you have this dull feeling in the nasal cavity (which would be where the end of the root of this central incisor would be)? That could be, but I would wait it out.

But a front tooth that has broken off at the gumline is a tough situation. Many dentists would consider the tooth to be unrestorable. There are rotational forces on a front tooth that over time can loosen the crown and/or the post. My advice would be to go ahead with the crown, cross your fingers, and hope this post and crown last a long time. My guess would be that they would fail at some point.

If you can’t afford a bridge, the budget option for replacing a single front tooth would be a flipper partial. That may be where you end up.

In retrospect, it would have been good if your dentist had placed a simple post in your tooth after the root canal treatment, before the tooth broke off.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 8, 2017

Delayed pain after a root canal treatment


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Dr. Hall,
I think your response to Patty from Kansas about increased post-root canal pain a few days following the procedure was somewhat misleading. It’s my understanding (and several resources suggest) that it is not uncommon to experience peak inflammation/pain 48-72 following a root canal, yet you advised: ‘The tooth being fine right after the second time doing the root canal but then the pain coming back a few days later, that is a particularly bad sign. This isn’t ordinary post-operative pain but a failed root canal.’
– Nan Anne from Chicago

Nan Anne,
I didn’t write what I wrote from reading research about it, but from actual extensive clinical experience and an understanding of the physiology involved. And I’m not sure that your reading is disagreeing with me. You didn’t say who these “several resources” were, but you did say they are suggesting that peak inflammation occurs 48-72 hours following the root canal. I think that may be true, if the pain is not treated by reducing the occlusion. The tooth hurts right after the novocain wears off but then, untreated, it feels worse the second day, maybe a little worse the third day, and then starts getting better. So the pain has peaked on the third day. That sounds about right. When there is postoperative pain after a root canal treatment that comes from simple inflammation, it will hurt right away and then get worse, and then get better.

But that is different from what Patty from Kansas reported to me. She said her tooth felt fine for 2-3 days after the procedure and then started to hurt again after that. That’s a typical pattern for post-operative infection. And then, to add further weight to this being an infection, she indicated that the pain continued after that and the root area is still tender.

Prodded by your comment, I did revise the blog post to make it more clear that when I said she had a failed root canal, I was talking about her particular case, and I don’t mean to imply that whenever a root canal tooth begins hurting a few days later it is a failed root canal. This was her second time around, so the root canal had already failed once. I’m confident that her renewed pain was not just a simple inflammatory reaction to the instrumentation of her tooth.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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