Development of Periapical Lesion

Joined
Dec 26, 2023
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How long does it take maximally for a radiolucency indicating a periapical lesion to develop from pulpitis?

My dentist mentioned 2-3 months, literature says 2-10 months.

See: Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Development of periapical lesions. Swed Dent J 1993;17:85-93.

Reason for asking: tooth 41 became symptomatic in March and peaked in intensity in early May. Two CBCT scans in early May and late July showed no periapical abnormalities and pulp was normal. The paradox is that tooth 41 was/is sensitive to my own horizontal percussion which points to the opposite.

The endodontist interpreted the condition in tooth 21 related to trauma from bruxism and advised monitoring.

The pain in tooth 41 disappeared over the summer and returned a bit weaker in the fall. It is not constant but only present when I move around (and sometimes not even then). In the summer, I was on daily 800 mg Carbamazepine for another condition. If Carbamazepine caused that temporary relief, it must have taken 70 days to become effective....and then ineffective again as the pain returned while I still was on this med.

The condition is not so much an ache but more like a pushing (like in the early stage of a pulpitis) and has not changed in intensity since its reappearance (it is not your classic sharp alpha fibre pain).

I wonder whether, 8 months after tooth 41 became symptomatic, this could still be a developing endodontic condition or whether this is a neuropathic pain.

This issue followed the extraction of first molar tooth 46 last December and endodontic treatment of tooth 21 in February.

To add another complicating factor: after obturation in June, the periapical abscess around tooth 21 has never healed and is still constantly painful. This tooth may have to be extracted.

BUT: the pains in teeth 21 and 41 flip all the time...either one OR the other is symptomatic, but never both simultaneously.

A neurologist thinks at least tooth 41 constitutes a neuropathic condition and prescribed low-dose amitriptyline.

Complicated? Yep! Oh, I forgot that tooth 36 became symptomatic in March and failed an endo ice pulp test in April (pain lingered for a few minutes). When re-examined in July, pulp was normal again but the crown was observed to be cracked and extraction was recommended as long-term prognosis was poor. Tooth 36 was extracted in September.

So much for diagnosing "irreversible pulpitis." Endo ice is not reliable.

BUT, with all the gaps and sensitivies, the occlusion is obviously affected negatively and that poor tooth 41 may have to work harder than before, which could explain its condition.
 
Last edited:
Joined
Sep 6, 2024
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You reported that tooth 41 became symptomatic in March, with peak intensity in early May. This suggests an acute phase of discomfort or pain associated with this tooth. The fact that two Cone Beam Computed Tomography (CBCT) scans in early May and late July showed no periapical abnormalities indicates that there were no visible signs of infection or significant structural issues at those times.
You mentioned taking Carbamazepine daily at a dosage of 800 mg for another condition during the summer. this medication provided temporary relief from any underlying nerve-related discomfort associated with tooth 41. It seems likely that tooth 41 may be experiencing non-specific dental pain possibly related to bruxism or other mechanical factors rather than a straightforward pulpal or periapical pathology since imaging has not shown abnormalities.

It is possible that tooth 41 could still be developing an endodontic condition given its prolonged symptomatic nature since becoming symptomatic eight months ago.
Concurrently, the persistent issues with tooth 21 suggest unresolved endodontic pathology which could also contribute to referred sensations in adjacent areas.
The alternating symptomatology raises suspicion for neuropathic involvement but should be confirmed through appropriate diagnostic measures.
The case involves complex interactions between dental pathology (tooth 36), potential neuropathic conditions (tooth 41), and occlusal dynamics following extraction procedures. Proper management requires careful consideration of both local dental issues and broader neurological implications.
 

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Joined
Feb 5, 2024
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@Brause I started finding relief at 35mg of nortryptiline. I was told that you should reach 30-40 mg and if there is no effect there it is not the right medication.

For your info, and this will not make it easier: after my dentist wrecked my teeth, I tested positive at two endo's on the ice test (meaning all 3 painful teeth where vital). No percussion or pressure pakn The pain got worse and one endo decided to RC. It was fully necrotic. Two weeks after we opened the next one - 1 canal necrotic. No one has an idea why I didn't get a leasion and why I tested false positive.
This was roughly 7 months after my dentist destroyed my teeth.

The pain still remained after the treatment. It took a solid 1.5 year for one tooth to settle, and the other tooth almost 2 years. And the final one was actually neuropathic and notrtyptiline helped greatly.

So lessons learned:

- leasions don't always develop
- you could have a mix of neuropatic and dental pain
- endo ice and percussion tests are not always accurate
- it can take up to 24 months for teeth to settle after a RC

Literature doesn't help. Every situation is unique in its own way.
 

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MattKW

Verified Dentist
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Mar 18, 2018
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Endo ice is very good, but must be compared to similar teeth known to be alive, and I also pretend to use endo ice to test for true reactions.
 

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