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.

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.

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 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

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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 1, 2016

Lingering infection after an extraction

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Dr. Hall,

I had a root canal performed more than a year a half ago. At that time, the endodontist performing the procedure said there were C-shaped roots and she ‘hoped’ it worked. I was given the standard antibiotic regimen, which I followed. I was told to follow up with my regular dentist. About six weeks later I had a routine cleaning and mentioned to the hygienist I still had the same pain (referred to the tooth in front of the root canal treated tooth). The dentist was not in the office that day, she said she would have him call me after he looked at the x-ray. I never heard back from the dentist, so I assumed all was well. In December 2015, I saw my dentist for a routine cleaning. I reported I still felt the root canal was less than successful. The problem tooth was x-rayed again and showed signs of infection. I was told there was a problem and I should call the endodontist for re-evaluation. Due to holiday scheduling difficulties, the endodontist’s office prescribed Penicillin tablets and scheduled an appointment for later in in the month. I ended up having the tooth pulled on January 8, 2016 by an oral-maxillofacial surgeon. Since then I have had improvement of a myriad of symptoms: sinus symptoms and pain, facial pain, headache, ear pain. At this writing, I continue to have pain in my jaw directly under where the tooth was extracted. While the tooth socket has healed well and many symptoms have improved, I am concerned there may be simmering infection in the jaw bone. Is this possible? How best do I proceed? My faith in my regular dentist has, understandably, been shaken. The dentist who pulled the tooth did not schedule a follow-up appointment. Your opinion would be most appreciated. Thank you.

– Kellie from Missouri

Kellie,
It’s too bad you weren’t able to connect with the endodontist. A failed root canal isn’t the end of the world and most of these teeth can still be saved with re-treatment or root canal surgery. But extraction is often necessary anyway, and that’s where you are.

It’s quite rare to have a lingering infection in the bone after the extraction of a tooth. The open socket left after the extraction leaves a clear path for drainage and your body, in that case, has no trouble getting rid of the infection. Where you can occasionally get a post operative infection is in the case of a surgical extraction, particularly if the tooth is fully impacted, and the tissue is sutured closed over the extraction site. And from your description of your symptoms, it sounds like your jaw healed normally.

If There Is a Post-Operative Infection

Nevertheless, there are some cases where a stubborn infection can linger and it can require a strong dose of post-operative antibiotics to be completely rid of the infection. I would go back to the oral surgeon for an evaluation.

If that is the case, I would not go back to the penicillin, since you apparently took that over an extended period already. In the rare possibility that you have a lingering infection, that infection is probably penicillin-resistant. I would go to a strong antibiotic like clindamycin in a situation like that.
– 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.

May 2, 2012

Strange toothaches – what’s the answer?

Filed under: Pain in teeth — Tags: , , — mesasmiles @ 5:40 pm

I have several tooth aches that have already had root canals. My Dentist put me on prednisone and tylenol 3 for 6 days and the pain went away. Now that the medicine is all gone, the pain is back. He says I should see a neurologist because there is a nerve that goes to the side of my head that is telling the tooth that it is not dead. The neurologist is supposed to give me medicine which may help. Can you explain it to me a little bit better. I have good days and bad days with several teeth hurting on one side of my face. I have 4 teeth in question and they all have good root canal done. My dentist says they are all in very good condition and he doesn’t want to bother the root canals. Any advice sure would help me.

Thank you
Rose from Michigan

Rose,
I don’t know that I can explain what is wrong with your teeth. I’m not following the explanation of what you are saying your dentist told you. He apparently is trying to translate a clinical diagnosis into something you would understand, but as you relay to me that “translation”, I am not able to get anything better than a vague understanding of what is going on with your mouth.

But I can tell you this much. It does sound to me like your dentist knows what he is talking about. There are nerve disorders that can mimic toothaches. And if prednisone and Tylenol was able to get your pain to go away, it sounds like he is on the right track. And if your dentist were trying to take advantage of you or cover up for his own ignorance, he has a ready excuse for any number of treatments in an attempt to solve your pain. So I respect that he has advised against any further treatment of these teeth.

My advice would be to go to the neurologist.
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 12, 2012

I would be asking some serious questions of this dentist, about this root canal and crown

Back in Dec I had a root canal done by an endodontist on tooth 14 that already had a crown. After this procedure I felt fine, no pain or hot/cold sensitivity and went to my dentist and he stated I had to have a new crown. He removed the old crown and gave me a temp for two weeks. I immediately started having sensitivity to hot/cold. After the permanent crown was put on this continued and has for the last month. Any ideas on whats going on here? Thank you.
Jerry from Ohio

Jerry,
I don’t want my comments to be taken as a substitute for an examination by an in-person dentist who can test your tooth and look at x-rays, but I can be helpful and tell you what your problem sounds like.

What you are experiencing is consistent with a missed canal in the tooth. If this is what is happening, the endodontist, in doing the root canal treatment on your molar, thought he or she had treated the entire root canal system but missed a part. If the root canal had been done completely, there would be no sensation whatsoever in this tooth to heat or cold.

Tooth #14 is a maxillary first molar. This tooth has a frequent anomaly in the root canal structure. Usually, there is only one canal per root of a tooth. But in the maxillary first molar, there can be a second canal in the mesiobuccal root. This canal can be hard to find, and studies show that it is the most frequently missed of any canal in root canal treatment. So I would have the endodontist re-check this tooth, test it, and see if this is what is happening.

With a crown already on the tooth, it is only a little more challenging to go back into the tooth and work on the root canal treatment. An opening will need to be made in the crown, and then that opening will need to be sealed over later with a durable filling material. For most crowns, this won’t have an effect on the structural integrity of the crown.

This is a frequent error and I’m confident it has happened to most endodontists, and isn’t necessarily an indication of incompetence or sloppiness. However, I would expect there to be no extra charge to fix this.

And did you mention the sensitivity to the dentist that put the crown on? I’m surprised that he didn’t catch this. When the new crown was seated, it should have been obvious that there was some vitality in this tooth, if it was sensitive to hot and cold. There should not have been any novocain administered for seating a crown on a tooth that had a root canal treatment. So I have two questions for this dentist. The first is why, because of the root canal treatment, you needed a new crown. Was the root canal treatment being used as an excuse for doing an extra procedure? Just having a hole drilled in the crown for the root canal treatment isn’t reason for re-doing the crown – there needs to be something else wrong. And the second question is why he didn’t pick up on the problem with your tooth sensitivity. I would be asking some real questions here.

And realize that in saying what I’m saying, I’m assuming that I have accurate information, and that the source of the sensitivity is this root canal tooth and not really some other tooth and it feels like the root canal tooth. Clinical testing would answer that question.

Dr. Hall

Links: read more about root canal failure.
Read more about pain after a root canal.

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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.

June 3, 2011

Can a tooth infection spread to a salivary gland?

Filed under: Infected teeth,Root canals — Tags: , , — mesasmiles @ 6:23 pm

Dr. Hall,
Is it possible for root canal packing to “leak” and infect a salivary gland? My daughter has had two unilateral salivary gland infections within 6 months. Hospital CT showed nothing and dental x-rays showed nothing. We have no other ideas on what could cause these recurrent infections. (She’s had two root canals with crowns done on her lower jaw above the infected gland.) Thank you!
– Jeff from Chicago

Jeff,
I guess it would be possible for infection from a tooth to spread to a salivary gland, but the tooth would have to be infected first. And a tooth with a root canal treatment would not be infected if it has healed properly. And if it hasn’t healed properly, it would show on the x-ray.

So the answer, in your case, would be no. Given what you say that the dental x-ray shows nothing, then, no, there is no root canal failure, and no infection of the tooth, so nothing that could spread to the salivary gland.
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.

November 29, 2010

Root canal tooth was fine for a couple years and now is hurting. Why?

Filed under: Root canals — Tags: , — mesasmiles @ 8:56 am

I had root canal work done some time ago on a tooth that has started hurting again. I have had no problem until now. The pain is pretty bad. I hope I don’t lose the tooth. What is the trestment for this? Your feedback is appreciated.

Thank You,
– Gail from Kansas City

Gail,
Maybe one out of every ten teeth that has a root canal treatment experiences what is called root canal failure, where the tooth doesn’t completely heal and it flares up again some later time. This is probably what has happened in your case. Root canal treatments can be tricky because it is impossible to see deep down inside a tooth, and it can be difficult to clean out all the infection in some curved, branching roots. If anything is missed, the tooth will later flare up.

The treatment for root canal failure is to either re-treat the tooth, or to do root canal surgery. This usually will need to be done by a root canal specialist, because most general dentists don’t get into this type of specialized root canal work. The object of the additional treatment is to find the source of the infection that was missed the first time and remove it or seal it off. Root canal specialists, called endodontists, sometimes say that the chances of a re-treatment or surgery working is about 50-50, but in my experience the chances are much better than that.

It is also possible that the tooth has cracked. This could also cause later problems. If that happens, the chances of being able to save the tooth are pretty slim.

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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 28, 2010

A Case of Root Canal Failure

Filed under: Root canals — Tags: , — mesasmiles @ 10:23 am

Dr. Hall,
I had a root canal on the last upper right molar approximately 1 year ago. I have had no problems since then until last week. The previous week I had a cold & took a z-pac antibotic. No sinus infection that I know of. Then my tooth gradually began to hurt with pressure (no problem with hot or cold) and got progressively worse over a weekend. The dentist thought I had an irritated socket and removed some of tooth surface to correct the bite. 3 days later I am still in pain & taking large doses of ibuprofen and acetaminophen. Today he checked my gums and found a pocket on one side of this tooth of 5mm. My checkup of 6 months ago was recorded at 3mm. He treated me today for periodontal diease thinking this could be the source of my pain and he eliminated the bite altogether on this tooth. The tooth is not loose and shows no problem on the xrays. I was hoping to save this tooth, but I having serious doubts now after the periodontal procedure. I have been in a lot of pain now for a whole week and more today after the procedure. At this point I just want this tooth out of my mouth. How common is it to have periodontal issues on a crowned tooth with root canal? The readings on my other teeth are 1mm & 2mm. I feel like this is most likely not the problem and I most likely have a cracked root. Thank you for any comments.
– Sharon from Texas

Dear Sharon,
I’m not sure why your dentist is puzzling over this and trying all these theories. From the very first symptoms, when the tooth started to hurt to pressure one year after having a root canal treatment, it seems to me like a straightforward case of root canal failure. Everything else you’re saying only reinforces this. I can’t confirm that, of course, without an exam, but the history of this tooth fits that, and that would be the first thing to check. I’d ask your dentist to refer you to a root canal specialist, because they specialize in dealing with root canal failure.

And, while a 5 mm pocket isn’t perfect health, that shouldn’t be causing any pain. That sounds strange to me that your dentist would treat you for gum disease thinking that this was related to your pain. Maybe there’s something I don’t know about your case that makes him think that.

I see on the map that you aren’t that far from Dallas. You should be able to find a good root canal specialist (endodontist) there to help fix this tooth.

Links: Click here to ask Dr. Hall a question.

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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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