Help please on which tooth is causing the pain!

[Toothquest]

Hi kind Endodontist people!

This is my first post here, so I do hope someone can help me. I've had pain around the UR 2 tooth since May 2018 and I'm desperate for help! I do appreciate that these things can be difficult to diagnose. Now I'm in daily pain and have a gap in my front teeth, both of which are really awful, so I would be very grateful for any help you can give me.

Background:

- I'm aged 62 - no fluoride toothpaste when I was young, so a fair bit of restoration in my mouth, but I follow rigorous cleaning regime and regularly visit dentist / hygienist - last visit I was congratulated on absence of plaque

- UR2 had some pain in 2017 and was diagnosed as having a calcifying root; pain went away, but came back worse this year, so endodontist did root canal on May 16th 2018

- RCT did not stop pain, so eventually UR2 was extracted on July 31st 2018 with a view to having a Maryland bridge

- Pain receded a bit and bridge was fitted on August 14th 2018, attached to UR3

- Bridge seemed to be making the pain worse, particularly as the jointing material made the UR3 the only point of contact between the upper and lower teeth (dentist told me there was no alternative and that the bridge had to be like that)

- Pain worsened, so after a month the bridge was removed on Sept 18th 2018

- I'm still getting intermittent pain nearly everyday - I get about 1-2 days a week when the pain is hardly noticeable when taking painkillers, then 2 days with bad spells of pain: 9-10 /10 (dentist asked me to keep a pain diary) - and some days with just a mild to medium ache; when the pain is bad my right cheek swells and goes red

- I've been taking 400mg ibuprofen + 1000mg paracetamol 3 times a day and my doctor prescribed amitriptyline at dentist’s suggestion to help me sleep - I'm desperate to stop taking the pain killers as I've now been on them since May

- I would like to have an implant, particularly as going around with a gap in my front teeth is awful for me, but this can't be done until the pain has been sorted

- I've seen 2 endodontists so far - initially I was told that the pain could be just reaction to all the dental work, but it is still going on; the one I saw last week said that there might be a small fragment of bone or root left in the UR2 socket / possibly some infection there and recommended apicoectomy of UR2 root area

- Today when I was chewing some warm food on the right side the pain came on very badly and appeared to be mainly further back than the UR2. The pain receded after a couple of hours. I called the endodontist and spoke to their nurse and she said she would get back to me by the end of today, but I’ve had no reply.

- I’ve posted 2 x-rays showing UR2 – 5 (UR4 has old RCT, previously not given any issues)

My questions:

- Looking at the x-rays, which tooth or teeth do you think are causing the pain?

- Do you think a problem with the UR2 socket area would cause a problem like the severe pain when eating warm food?

I would be extremely grateful if anyone could tell me if they can see anything in the x-rays at all or if they can help with any other suggestions.

Many thanks

 

[MattKW]

1. Marylands bridges shouldn't be used if they interfere with the bite. They're a nice idea but have limited usefulness. This means I really only get the chance if there's very little overbite.
2. There's a radiolucency (darkish) area that I've marked with white arrows. I assume this is what the endodontist wants to go in and attack with an apicocectomy (he means curettage). I think that's very unlikely cause of your pain, and a curettage will certainly cause nerve disturbance. The dark area looks like healing bone, and I'd want to see pus or swelling to suggest going in there.
3. In the angled x-ray of the UR4, there appears to be a possible 3rd canal (yellow arrows) with the suggestion of paste going into that canal. That's a possibility to be rechecked by the endodontist. Maybe a 3D X-ray would help.

Good luck.

 

[Toothquest]

Hi Matt
Many thanks for your reply. In relation to the UR4, please could you tell me what is the vertical line appearing on that tooth, which appears to lead to some radiolucency above?
Many thanks! Toothquest

 

[honestdoc]

I agree with Dr. MattKW. I believe UR4 (tooth #5) has a 3rd root. It is hard to pick up on x-rays because it is only 2-dimensional. If Upper first premolar (bicuspid) has 3 roots, it has 2 roots on the cheek side (buccal) and 1 on the palate side. Vertical lines are difficult to interpret and I believe it indicates a 3rd root. Do you have pain when you bend forward, walk up & downstairs? I like to rule out sinus pain.

 

[Toothquest]

Hi Honestdoc + MattKW
Thanks for your replies. I don't get pain walking upstairs / bending down and my doctor says they can't see a sinus issue (no blocked nose or mucus etc).
I've marked the vertical line in the x-ray showing the UR4 with apparently some radiolucency above with red arrows in the attached x-ray - please could you let me know if you have any thoughts on what it is?
Also, endo said he's recommending going into UR2 socket via an incision in the bottom where the extraction was made to remove tiny fragment of root / bone that he can just about see on CT scan, not apicoectomy (I misunderstood).
Many thanks! Toothquest

 

[Toothquest]

Hi All
I managed to open up the file with the CT scan taken earlier on September 25 2018 -

please have a look and let me know if this tells you more.
Many thanks! Toothquest

 

[MattKW]

• Vertical line is apparently outline of extra root.
• The radiolucency is too unclear - looks like normal bone. Not every radiolucency is pathological.
• The CT scan requires the full volume of images in order to manipulate in 3D. That single view is not enough.

 

[Toothquest]

Hi MattKW
Sorry I wasn't able to manipulate the CT scan - but I have a question on what you said about "curettage" and nerve damage - please could you let me know - is curettage the same as going into the socket via the bottom of the gum (i.e. where the tooth was extracted) and going into the socket to find the ankylosed root / bone fragment?
Many thanks! Toothquest

 

[MattKW]

Curettage is really a cleaning out. In cases like your where the wound has healed up, I assume it would be going through the gum directly where the tip of the root used to be. But I'd expect to have some draining abscess or swelling to justify that treatment.
Going in and curetting upsets the nerve fibres (like a spiderweb) in these situations. It's not a bad thing - patients just say it feels "different" afterwards.
Yes, a full CT volume is many Mb - I usually get them from the radiologist on a DVD.

 

[Toothquest]

Thanks Matt - when I asked the endo he said he wasn't proposing apical surgery and rather than going in via the palate gum, he would go in via the healed wound through which the tooth was extracted - interested to know your thoughts on this mode of entry?
Many thanks again! Toothquest

 

[MattKW]

I suppose you can if there's not much bone reformed. Usually easier and much more direct to go in from the buccal gum.

 

[Toothquest]

Thanks once again Matt - do you think that going in from the extraction incision site might cause less potential nerve damage?

 

[MattKW]

Don't worry about the nerve damage. It's not a major thing and i simply tell patients about the altered feeling, and they're OK. It won't make any difference whichever way it's approached.

 

[Toothquest]

Many thanks, Matt - really appreciate your help - good karma will come your way!