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.

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.

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

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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 12, 2016

Root canal re-treatment isn’t working


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Dr. Hall,
I had a root canal re-treatment on my front tooth 3 weeks ago, by an endodontist specialist. I had the tooth checked just over a week ago and although I was still having pain around the tooth, he said that there was no swelling and it would all settle down. However, it is still very sore and sometimes the gum throbs, particularly if I am active, which surely tells me there is inflammation still. I am unable to take ibuprofen or aspirin and take paracetamol when needed.

I had gum swelling around the tooth before the root canal re-treatment, which was treated by erythromycin and this was finished about a week before the treatment was completed.

My question is what should I do next? It does not seem to be settling and I am worried if the bone around the tooth is infected and if it could spread. Should I wait more time to see if settles or see if the dentist will prescribe more antibiotics?
– Diane from Ashfield, UK

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Diane,

It doesn’t look good for your front tooth. Your instincts are correct – after three weeks it should be feeling better. Am I correct in assuming there is no improvement in the tooth? Residual tenderness in a tooth after any root canal work isn’t that unusual, but there should at least be some gradual improvement which you should be able to notice after three weeks.

I would not do any more antibiotics. Antibiotics won’t get at the source of the infection in a tooth – they only assist your body in fighting off the infection. Yes, the tooth would feel better for a while but then when you quit taking the antibiotics, since you haven’t eliminated the source, the pain will come back and now you will have an antibiotic-resistant infection.

There is no significant risk of the infection spreading at this point. You aren’t having an increase in pain, from what you are saying, and there isn’t any serious swelling.

Something is still wrong with the tooth that wasn’t fixed with the root canal re-treatment. Re-treatments don’t always work and it appears that yours isn’t. After initial root canal failure, which you experienced, the chances for success for re-treatment are somewhere in the range of 50-80%, depending on the nature of the problem that led to the failure.

The way antibiotics were used in your case seems strange to me. You said you had erythromycin before the treatment, and this was finished a week before doing the re-treatment. That would just give the infection a chance to come back before starting the re-treatment. If antibiotics were needed, I would have started them, done the re-treatment after they had taken effect, and then continued the antibiotics for a couple of days afterward. I just mention that because it’s strange – that’s not why your tooth isn’t getting any better.

Your options at this point are limited. You could have root canal surgery, but I’m skeptical about the chances for success of that treatment in your case, since, based on what you’re telling me, your endodontist isn’t inspiring me with a lot of confidence. You could maybe try that if you get outside your UK National Health Service. Your other option would be to have the tooth extracted and then replaced with whatever options they give you in the UK.

Dr. Hall

Question and answer go here.

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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.

July 20, 2016

The use of steroids to treat root canal pain


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Dr. Hall,
I had a root canal in May in a front tooth and serious pain following it, I was treated with antibiotics and steroids. This did not help so the dentist redid the root canal. I felt OK for 2-3 days then the pain came back. I feel a lot of pressure on this front tooth and the gum is inflamed and the root area is tender.
– Patty from Kansas

Patty,
There are some experts in root canal treatment who recently have been advocating treating postoperative root canal pain with steroids, but I disagree with that. Yes, if there is simple inflammation, steroids are an effective treatment. But the problem is that you have some dentists who don’t understand pharmacology well enough or aren’t good enough at diagnosis, and you have the treatment being misapplied, as I believe it was in your case.

Steroids block inflammation. That’s why some of these dental school professors recommend it for post-operative pain. There is irritation of the tissue around the end of the root of the tooth because the instruments used to clean out the teeth irritated it. When that happens, that tissue tends to swell, raising the tooth and causing traumatic occlusion, which only irritates that tissue more. It’s a nasty vicious cycle and Decadron, a steroid, is an effective treatment.

But the problem is that steroids also block the body’s response to infection. So when you have a post-operative infection, as you apparently did, steroids do more harm than good. And then the dentists feel that, to cover the possibility that there is infection involved, they need to prescribe antibiotics. This leads to an overuse of antibiotics and contributes to the serious public health problem of cultivating antibiotic-resistant bacteria in the population.

What I did for post-operative root canal pain in my practice, that was very effective, was that I would give a strong dose of ibuprofen at the beginning of the root canal appointment, so that it was fully absorbed by the time I was done with the appointment. This would help head off that inflammatory response. (Ibuprofen is a non-steroidal anti-inflammatory drug.) Then I would reduce the occlusion of the root canal tooth so that it didn’t touch the opposing tooth when the patient clenched together. Since the tooth would later need a crown anyway, it wouldn’t hurt to reduce it a little. That pretty much took care of any post-operative pain.

So what do you do now? 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 in your case appears to be a failed root canal. In your case, this would be the second failure on this tooth. It seems that the infection here has never completely gone away, and thus the tenderness around the root comes from that persistent infection. If this wasn’t done by a root canal specialist, I would ask for referral to a specialist. The specialist may feel that he or she could solve the problem by re-doing the treatment one more time. Or, root canal surgery is fairly simple on an upper front tooth, if that’s what tooth we’re talking about. That may be required. Or you could end up losing the 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.

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.

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