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.

September 9, 2017

Swelling after a tooth extraction


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Dr. Hall
The tooth right beside my lower left wisdom tooth was extracted last Wednesday. There was swelling already on my jaw before the extraction. After extraction, the dentist prescribed amoxicillin for the infection. After 3 days, the swelling has worsened and pain killers are no longer helpful. The swelling below my jaw hardened and is larger than half of a golf ball.
– Jem from the Philippines

Jem,
It sounds like your infection is getting worse, even with the antibiotics. You need to report this to your dentist and he or she should switch antibiotics. I don’t think your dentist has done anything wrong here—amoxicillin is a good first choice for an infection from a tooth. But there are many infections that won’t respond to amoxicillin, sometimes because the bacterial strain has developed amoxicillin resistance.

These infections in the jaw can become quite serious, so I wouldn’t mess around with this but work with your dentist to find an antibiotic that will get this infection under control.
– 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.

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.

September 21, 2016

Follow-up on Lyndi’s sinus perforation after extraction


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About three weeks ago I published a post about a patient named Lyndi who had a large sinus perforation after her extractions. She responded telling me about her subsequent experiences, and I gave her some additional advice. Here is a copy of the follow-up correspondence with her.

Hi again Dr. Hall,
I thought I would send an update. I waited the full 2 weeks and saw the oral surgeon for the follow-up this week. In the meantime, I developed yet another bad sinus infection. I had my family doctor call me in antibiotics because I was really scared this infection would spread. I am still having a ton of drainage, but only from the left side, where the perforation occurred. It still pours out my left nostril when I gargle and I have had that same drainage in my denture. The oral surgeon poked around with a q-tip, which was very painful, and said the hole is sealed. He also had me plug my nose and blow (I didn’t blow hardly at all for fear I’d make it worse). I questioned him due to the above symptoms and he basically crossed his arms and said “look I told you the hole is healed and you don’t need surgery. You should be happy.” I explained that news sounds great, but I’m confused and that was the end of my appointment. I’m so lost, still quite sick (4 weeks straight now) and really don’t know where to turn.

I don’t want to make trouble but I am extremely frustrated. I’m out of sick pay, so I’ve lost some pay and also had to work even though I’m sick. I am emotionally and physically exhausted. I still can’t eat well, can’t chew at all for the pain is intense and not worth it. I’ve lost at least 15 lbs and I’m small to begin with. I deal with this horrid smell/taste all day every day and I know it is the infection. I explained all this to the original dentist. Again, any advice would be much appreciated. I am a social worker and advocate for people every day, but for some reason I’m having trouble being heard in this situation.
Lyndi C.

Lyndi,
I’m just going on what you were able to tell me, but the feeling I got from what the oral surgeon told you as opposed to what the ENT doctor told you was that the ENT doctor was the one you should trust. I don’t like it when doctors talk to you the way you are saying this oral surgeon was talking to you. Lecturing you that you should be happy? You’re not happy, and he should care enough to listen to why. There are two ingredients to quality medical and dental care–competence and caring. One without the other isn’t quality care.

Why don’t you just stick with the ENT doctor? It doesn’t sound to me like this oral surgeon cares whether you are sick or not or how much work you are missing. And the oral surgeon could well be buddies with the dentist. He probably gets referrals from her, so part of what is going on may be that the oral surgeon is trying to downplay the seriousness of your complications to protect the dentist.
Dr. Hall

Second follow-up, a couple of weeks later

Dr Hall,
You have been so kind to answer my questions and I appreciate it a great deal. I do still have a small hole that does not want to heal for some reason. I’m under the care of yet another ENT who appears to be taking me seriously. I wanted to update you as I finally received my medical records from the original dentist. My “informed consent” does not have a date, nor my signature. As a matter of fact, on the signature line it states, “reviewed with patient, not signed due to sedation.” Apparently they said they went over this with me the morning of my procedure, while I was under the influence of benzos, as I had been prescribed and told to take both pills 1 hour prior to my appointment. The dentist is refusing to pay my medical bills, saying they forgave my balance with their office in order to free up my money so I could pay the medical bills. I am completely aghast. I have called an attorney but still waiting for a call back. Any comments or advice is appreciated.
Thank you for your time.
Lyndi C.

My response:

Lyndi,
From what you have told me, you have a very valid complaint, and I have some words of advice for you.
First, I would tell the dentist that you are contacting an attorney and let them know that they could make this a lot easier on themselves if they just pay your medical bills, if that’s all you’re asking. When you mention that an attorney is going to get involved, that should trigger a call by your dentist to her malpractice insurance carrier, and they would likely advise her to settle this before it gets out of hand and may reimburse her for any expenses involved in settling it.
You didn’t give them consent, so they are on pretty shaky ground. It seems reasonable to assume that you were too sedated at the time to sign your name, so clearly you were too sedated to give consent. But you have more grounds than just that, as, from what you have told me, they fell short of the standard of care in several important respects.
I may not be getting all this right, but I’ll make a list of what is in my head of their mistakes, as I remember your case and refresh my memory by scanning your emails.

Mistakes made by this dentist:

1. Not getting informed consent from you (consent under sedation isn’t consent).
2. Poor extraction technique resulting in bone fragments being left at the surgical site, a large sinus perforation, and infection (and, I suspect, material being pushed up into the sinus).
3. Not telling you on the spot that there was a sinus perforation.
4. Not beginning treatment of the sinus perforation until the day after.
5. Starting off with the wrong antibiotic.
6. Not changing the antibiotic in a timely manner.

They should compensate you for all the post-operative care expenses you incurred, not to mention the time you missed from work, in my opinion. And, if your case got into court, I think you would be entitled to significant pain and suffering damages and possibly a punitive award.
You also have remedies beyond just going to an attorney, and you might want to let them know you are aware of those. You could complain to the state dental board, and you could complain to the dental insurance company. The dentist would not want either of those to happen.

You could let the attorney know that you have shared details of this with me and that I said I believe you have a strong case. A requirement of any successful malpractice case is the opinion of another professional that the care was substandard. But hopefully the dentist will be reasonable and you won’t need to take that step.

The oral surgeon is very possibly a buddy of the dentist, which could be why you didn’t get very good care there and had to go to the ENT physician.

Dr. Hall

Question and answer go here.

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.

December 20, 2013

Taking antibiotics for an infected tooth

Filed under: Infected teeth — Tags: , , , — mesasmiles @ 12:53 pm

Dr. Hall,
My tooth became infected about 11 days ago. I saw the dentist Friday. I have been taking Keflex 500 mg three times a day, and since Friday, also Flagyl 250 mg three times a day. The swelling was almost gone, but 2 days ago, it swelled up again. My gums are red and swollen, and painful sometimes. Initially, the swelling was all of the way up to my eye and down to my chin. There has also been a yellow spot there, and I can taste the bacteria in my mouth. Now what?
– Susan from Indiana

Susan,
I”m hoping that you are either not understanding what your dentist is doing or you aren’t communicating it to me clearly enough, because if I’m getting an accurate picture of what is going on here, your dentist doesn’t understand tooth infections.

Antibiotics are not a proper treatment for a tooth infection – they are only an aid to treatment. The reason is that when a tooth becomes infected, the living tissue inside it dies. Therefore, there can be no circulation inside your tooth and there is no way for any antibiotics or other defenses to get into the tooth to eradicate the infection. The dead tissue has to be removed by one of two methods. The tooth can be opened up, the tooth cleaned out, and then sealed so bacteria can’t get back in. This is called a root canal treatment. The other option is to remove the entire tooth which, of course, also removes the dead, infected tissue.

There are cases where, if a tooth is infected and you are swollen, that you would start by taking antibiotics and then commence treatment after the infection is under control somewhat. If the tooth is an upper tooth and the plan is to extract it, the infection will interfere with the ability to get the tooth numb, so it would have to be controlled first, and then the tooth extracted. But in most cases, the best emergency treatment is to begin getting rid of the source of the infection. If the tooth is opened up, often that will provide drainage for the infection through the tooth. In some cases, the act of opening the tooth will provide immediate relief from pain, also. Your infection sounds pretty serious, and why nothing was done clinically is troubling, so I’m hoping I don’t have the full story. The yellow spot is probably a point of drainage of the infection, which would give you that taste in your mouth.

If the dentist prescribes antibiotics, he or she should explain clearly what the action plan is, and the treatment should be scheduled promptly. If you simply take the antibiotics without getting rid of the source of the infection, you will be cultivating antibiotic-resistant bacteria and complicating later treatment. So I’m hoping your dentist made this clear to you and scheduled your follow-up. If not, I would find a new dentist who is more competent and caring.

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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.

May 4, 2013

If the antibiotics don’t work, my dentist says he wants to pull the tooth.

Dr. Hall,
I have been trying to find information about calcification/mineralization of a tooth. (I was told by my dentist that, on x-ray, he does not see any remaining canal in one of my molars. It is one that already has a crown. After a round with antibiotics, if I still have discomfort in the tooth he says it may need to be pulled. Without a tooth canal present, he said he cannot do a root canal. I would rather keep all my teeth. Is there an on-line site with information about this subject so that I can read and be educated?) Thank you.
– Mikala from Wisconsin

Mikala,
I’m not comfortable with what you say your dentist is telling you.

First of all, this idea that if you’re not comfortable after the round of antibiotics you need to have this tooth pulled. Antibiotics alone in treating a toothache doesn’t solve anything. Sometimes antibiotics are used as a diagnostic tool – if the antibiotics solves the tooth pain, then we know your pain is caused by a tooth infection. That would be an indication that the tooth needs a root canal treatment or an extraction. But once you stop taking the antibiotics, if the pain has indeed gone away, it will return sooner or later, because you haven’t addressed the source of the infection.

But if the antibiotics don’t solve your tooth pain, then that would be an indication that the pain is NOT caused by a tooth infection, and the dentist should be looking for some other explanation for the pain. It could be from nerve irritation or who knows what. In that situation, he doesn’t have a diagnosis, so proceeding with treatment would NOT be the next step. It’s like he has this backwards.

And I have a problem with the notion that because the dentist can’t see a canal in the tooth, it doesn’t have one. Especially in an upper molar tooth where there is a lot of bone around it, it can make the root canal hard to see.

If you want to try to save this, I would get a second opinion. Look up endodontists in your area. Those are root canal specialists. Or just tell your dentist that you want a referral to an endodontist. If it were me, I would look up an endodontist on my own for fear that the dentist would send me to a buddy who would simply parrot what the dentist has said.

And to explain calcification, here’s what happens. As we get older, the canals in our teeth tend to shrink. This is a natural process that can be aggravated if there is irritation in the tooth, the tooth builds up more dentin on the inside of the pulp chamber and the canals of the tooth, making them narrower and possibly harder to find. It can make root canal treatment more difficult and sometimes, in extreme cases, can block the canal. But root canal specialists should have special tools to navigate through these calcified canals.

Good luck. If you want to save this tooth, go for it.

– 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 9, 2012

Several ways for a dentist to screw up a root canal treatment

My husband fell on 11/29/11, while coaching my son’s basketball team. He suffered concussion, chin laceration with sutures and his front two teeth fractured. He was treated same day in dentist and ER. Dentist did not want to do any treatment for 2 weeks. In 2 weeks, tooth #8 (right front tooth) started to discolor without pain-she felt only dried blood and no treatment at that time.He was fitted for temp crowns and placed within 3 weeks.

Two months later, he had severe pain and an emergency root canal began with amoxicillin for 5 days. There was slight relief of pain for 24 hrs and then severe pain up to his nose with a cold sensation. Root canal finished one week later without pain relief.

Two weeks after that, the dentist root canaled tooth #9 (left front tooth) because she didn’t understand why there was still pain. Novocaine in place, still no relief and pain never by tooth #9?  Probable unneeded root canal.

I decided to get oral surgeon second opinion, who suggested Augmentin TID for 7 days with medrol dosepak. 5 days into meds, cold sensation resolved and tooth #9 RC completed by general dentist who then removed filling from tooth#8 and my husband felt pain free for 1st time in 3 months! However, it returned at 50% within 24 hours, but cold sensation gone. I am a NP and I spoke with a pharmacist friend who said you will often see rebound pain with medrol dosepak quick tapers? He recommended a 2 week taper of prednisone with abt in place now that canal is open and can drain possibly? What would be recommended next step? My neighbor thought maybe tooth fractured at gum line? The dentist says she sees black spot on x-ray, but thinks it is nothing? My husband has been tortured for months without any pain control offered and is a teacher and is suffering. Do you think this tooth should have been root canalled immediately when it turned dark or 2 months later? Would that have saved the tooth and torture he is living? Do you think tooth could be saved? Should he need extraction, would you recommend implant next to permanent crown or bridge?
– Kathleen in New Jersey

Kathleen,

When tooth #8 (your husband’s right central incisor) started to discolor two weeks after the traumatic injury to the tooth, it clearly needed a root canal treatment. The nice thing about doing the root canal treatment at that time is that there is less chance of post-operative complications since infection would not have settled in yet – it would be just a matter of cleaning out the dead tissue, maybe leaving the tooth open for a couple of days as a precaution against flare-up, and then sealing it. I cannot for the life of me understand what your dentist thought was going on inside this tooth. Dried blood?? If there is dried blood in the tooth, isn’t it pretty clear that the tissue inside the tooth is dead?

And I don’t understand why there was a prescription for amoxicillin and for only 5 days. So if I am understanding this treatment sequence correctly, the tooth was opened and the amoxicillin started. I can’t tell from what you are saying whether the tooth was left open during this time or not. But then the amoxicillin ran out, and AFTER that, the root canal was completed – in other words sealed. Doing it this way, there would be a fairly substantial risk of flare-up. Once a root canal tooth is sealed, there is no longer any pathway for drainage for any infection that may be there. And a five-day course of amoxicillin would not be enough to completely wipe out the infection. In fact, amoxicillin would not be a first-choice antibiotic anyway for this type of tooth infection.

My recommended next step? See an endodontist (root canal specialist). An oral surgeon would not be a good choice of specialist to see here. And a pharmacist doesn’t have the correct training either. There is something to be said about getting a professional involved who has the specific training for this type of problem. I can’t tell by just e-mails what is happening here. But I can tell you I disagree with some of the treatment choices made by your general dentist, and the flare-up is not surprising to me at all. Doing a root canal on the other front tooth appears to me to have been a stab in the dark, and it also doesn’t surprise me that it didn’t help. And the prednisone would also be the wrong treatment if the infection isn’t resolved. And what is this about your dentist seeing a “black spot” on the x-ray but thinks it is nothing? That sounds almost grade school. Is there a continuous, intact lamina dura around the tooth? Is there a widened periodontal ligament space? You need an endodontist to look at this x-ray and read it, not someone who will try to take wild guesses at what is going on.

There should be no need to extract this tooth. None of what has happened is any indication that the root canal was not sealed properly. And even if there was that type of error here, there are several options for correcting that, short of extraction. You need the correct choice of antibiotic therapy – probably clindamycin at this point – which in most circumstances should get this to settle down in a couple of days. However, if there is a root fracture, that is a different story.

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 29, 2011

Will a tooth infection spread to my brain?

i went to the dentist two days ago and was told that i have a small tooth infection and i was given a proscription for antibiotics but was told to not take it until a week before i come back to have the procedure done but i dont go back to have it done until two weeks into July i asked if i would be ok until then and i was told that the infection is so small that its little to none o i will be ok until then is there a such thing as that i just want to make sure because i know that tooth infection can spread to your brain and kill you so do you think i will be ok?
– Edwina from Maryland

Edwina,
Yes, there is a such a thing as a tooth infection being so small that you don’t need to worry about it affecting your general health. Usually that’s the case.

Yes, a tooth infection can get out of hand and then you’re right, it can spread to your brain. If it’s in the lower jaw, the swelling can also spread down your throat and complicate breathing.  But before it did that it would become painful and would swell up quite a bit.
Dr. Hall

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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