Need help (#31 or #30 / root canal vs extraction vs neuralgia)

[Somuchpain]

I've seen a number of dentists, endodontists and periodontists over the past month, and people haven't been able to diagnose what I should do. So I'd be interested in hearing what the dentists in this forum think of the situation. I'll provide background below, and I've included CT scans and X rays I received in this dropbox folder: https://www.dropbox.com/sh/6tmnap4wxuw3aqz/AADCaflVW6OWPLexwdCSsBJaa?dl=0

The pain began on Feb 23, when I began feeling occasional stabbing pain, like electric jolts, in my right and lower cheek and around my lower gum area and teeth. They would occur every few minutes and when I moved my jaw, for instance when eating or talking, and so I went to see my dentist on Feb 25. Since the pain hadn't localized to a specific tooth and X-Rays didn't show any specific issues, the dentist suspected neuralgia and sent me to an oral surgeon who I saw on Feb 26. The oral surgeon didn't believe that neuralgia was the issue and recommended that I see an endodontist. The pain intensified over that weekend and localized to my back lower gum area, with more pain on #30 than #31, but pain in the general area. At the time, I had already received a root canal on #30 about 5 years ago and had a 15-year old filling at #31. I saw 3 endodontists on March 1, and explained the pain to them and they took X Rays and CT scans, as well as tapped the tooth, did the bite-and-release, the cold test and other tests, and concluded that it wasn't clear whether either teeth needed endodontic treatment.

One endodontist suspected that #31 was the tooth giving me problems but said it was inconclusive. I began taking antibiotics -- Augmentin -- on March 1, and the endodontists felt waiting to see how the antibiotics helped and how the pain developed was advisable. As the week progressed, the pain isolated more to #30, and to a lesser degree #31, and intensified. I emailed two of the endodontists on March 5 and told them that the pain seemed to be coming from #30 and since that had a root canal, they emailed back for me to see a periodontist or oral surgeon to have the tooth extracted. I saw a periodontist for a consultation on March 8 and he also advised an extraction of #30. I saw one of my prior endodontists also on March 8, and he believed it was too early to extract #30 and advised that he suspected I was feeling referred pain from #31, and he advised that I get my crown replaced on #30 (since that was needed anyways) and the dentist could see if there were any fractures or other issues with #30 when he replaced the crown, since he (nor any of the professionals) could not see any fractures with #30. I replaced the crown on March 11, and the dentist saw no fractures or issues with #30. The pain was steadily getting worse and worsened over the weekend. The pain was pulsing; when I touched my front teeth together or pressed my lip, I'd feel pain around #30/#31, and when I moved my jaw, I'd feel pain in #30/#31. On March 15, I called the endodontist who suspected #31 and decided to go forward with the root canal on #31, and he did the root canal in two phases, first cleaning out the tooth and disinfecting on March 17 and then performing the root canal on March 22. Upon opening up the tooth, he saw that the nerves were dead and there was debris, and thus the tooth did indeed need a root canal. On March 18, the pain intensified and my jaw began to swell, and the endodontist recommended antibiotics (Augmentin) which I began taking. Over the weekend, from March 19-22, the pain became very intense, with throbbing, pulsing pain on #31. By the time I arrived to the endodontist's office on March 22 for the root canal, I couldn't close my mouth and the pain was very intense, with sharp, stabbing pains in #31 every 45 seconds - indeed, following the first phase of the root canal the pain had shifted from #30 to #31.

After the root canal, for a day, the pain in my teeth were gone, though the trauma to my jaw and the gums behind #31 caused pain in my jaw area, and regular spasms to my jaw. That has since dissipated. However, the tooth pain has returned, with a focus on #30. The area around #31 remains sensitive, and given the very extreme pain on March 19-22, my cheek, lower jaw, and gums behind #31 continue to have spasms and suffer pain, but that has lessened since the root canal was performed. Now, it's more pain around #30 that is continuing to grow. I feel occasional throbbing on #30; there remains tenderness around my inner cheek, gums, back gums connecting to the back of my mouth behind #31, as well as small spasms to that back gum area behind #31 when i open and close my mouth, although this could be lingering effects from the extreme pain of March 19-22; there is a lingering dull pain in #30; there is pain on #30 when I touch my two front right teeth together. I'm also constantly feeling a sharp, very painful electric jolt in the middle of my cheek, that's what kept me up at certain times at night and it's returned today after I spoke for a minute in the afternoon. I still can't eat or talk without incurring substantial pain.

I'm trying to ascertain the appropriate next step, especially since the pain is getting worse and I'm concerned going into the weekend, and would welcome any thoughts you guys have.

 

[MattKW]

The RCTs look fine on the single and zipped X-rays. Sorry, but I'm not going to download and install viewing software for the CBCT images.
However, your pain does not seem to correlate with your current dental state as seen on those Xrays. Also, I can't even be sure that #31 was actually in need of an RCT as I only have the info that you relay. I would really need to see the endodontist's detailed notes to see why he came to that decision, and what he found when he opened up the tooth. There are too many vague signs and symptoms in your narration that limit what I can suggest for you. I would not extract either tooth unless a very clear and substantiated diagnosis was made.

 

[Somuchpain]

The RCTs look fine on the single and zipped X-rays. Sorry, but I'm not going to download and install viewing software for the CBCT images.
However, your pain does not seem to correlate with your current dental state as seen on those Xrays. Also, I can't even be sure that #31 was actually in need of an RCT as I only have the info that you relay. I would really need to see the endodontist's detailed notes to see why he came to that decision, and what he found when he opened up the tooth. There are too many vague signs and symptoms in your narration that limit what I can suggest for you. I would not extract either tooth unless a very clear and substantiated diagnosis was made.

So what should I do, given that I’m still feeling significant pain, which also seems to morph day by day. Right now, it’s an occasional pulsing to the area around #30/#31, and a strained, stabbing sensation around my jaw when I try to move my jaw. Is there some sort of medication I can take to calm down the inflammation to the ligaments / nerves? What’s causing the stabbing? I can’t really talk or eat without incurring pain so should I just rest and do nothing, to see how the pain evolves? I’m just trying to figure out what I should be doing given that the evidence to extract either tooth remains inconclusive. Btw, the CBCT scans don’t seem to show any problems either, based on the conclusions of the 3 endodontists and 1 periodontist that viewed them.

 

[honestdoc]

Did you have any history of trauma, stress, grinding/clenching your teeth and or viral infection? With all the inconclusive findings, it may be referred pain from undetected source. I'm suspecting TMJ and or possible Facial/Trigeminal Nerve branch. It's really hard to give you our opinions as we basically play Dr. House and provide differential diagnoses. Consider TMJ and neurology evaluation.

 

[Somuchpain]

Did you have any history of trauma, stress, grinding/clenching your teeth and or viral infection? With all the inconclusive findings, it may be referred pain from undetected source. I'm suspecting TMJ and or possible Facial/Trigeminal Nerve branch. It's really hard to give you our opinions as we basically play Dr. House and provide differential diagnoses. Consider TMJ and neurology evaluation.

I don't have a history of trauma or stress, and if I grind my teeth at night, I'm not aware of it but certainly may do so. It definitely feels like there's an issue with the trigeminal nerve branch (pain is triggered when I tough my lip or my front chin or when I bite my two front teeth together). But I suspect that that pain to the trigeminal nerve branch has been caused by a dental issue inflaming it.

 

[Somuchpain]

I have an update I'd like to share, and would be interested in any thoughts you guys may have: It is now 14 days since the root canal, and the pain remains and most recently over the past few days has not shown much signs of abating. It’s remained relatively constant the past few days. It was getting a little incrementally better for a few days, and then for the past few days, it’s gotten a little incrementally worse, with these day-to-day changes being relatively small. From the day of the root canal on March 22 to around March 31, the pain improved, to a large degree as my jaw healed, but since then the pain has somewhat flatlined and in certain ways has gotten a bit worse. In terms of how it’s worsened, as an example, I get brief ripples of pain as described above now sometimes when I walk whereas I wasn’t experiencing that 5-6 days ago.

I’ll describe the current pain. For the most part, it’s activated when I move my jaw, whether through talking, eating, or moving my tongue around. When these actions result in a ripple of pain, I basically feel a successive set of stabbing pains (maybe 4-7) in the gum / root area of 30 / 31, or somewhere along the gums of my lower jaw. The ripple of pain stabs makes me contort my mouth and, weirdly enough, lick my bottom lip – somehow, that action subconsciously seems to control the pain. This has been a feature of the pain since the original Feb 23 pain.

Pain is also activated when I press my front right lip, or front right chin, or touch my two right front teeth together. I’ll feel a jolt in my lip, or a streaking pain across the right side of my face along the bottom gums, or I’ll feel the jolt of pain in my lip and in the gum / root area of 30 / 31.

I feel the pain in the gums / roots area of molars 30 and 31, a little more towards 31. If I reach inside my mouth and touch the inner top of my gums behind molar 31, it’s highly sensitive and sends a ripple of pain. If I press down on my teeth with my finger, at varying times, I’ll feel pain in different teeth. On occasion, it may be my first 3 teeth, and the pain is felt in that tooth’s gum / root area. On other occasions, it’ll be when I press down on 30 and 31. But there’s always a time if I press on one of the teeth, there’s some sort of pain.

The pain will vary in intensity at different points in time. The pain is a little more active after I wake up and do my first set of talking or eating breakfast, and will moderate a bit over the course of the day, and then end up being pretty active by end of the night until I stop moving my jaw and go to sleep. For the most part, if I’m not moving my jaw and just holding still, there’s not much pain. It’s more activated when I do some of the above-described actions involving moving my jaw.

There does seem to be a point in the gum / root areas of 30/31 where the pain tends to be the central point. This also seems to be the same area that was suffering far more significant pain prior to the root canal, especially in the excruciating days of pain in between my first phase of the root canal (the pulpectomy) on Weds March 17, and the actual root canal on Monday March 22.

I went to see an oral surgeon on March 25 after my root canal, when the pain was more severe, and when the pain was really focused on my inflamed back lower jaw following the excruciating pain of March 17-21 prior to the root canal. At that point on March 25, a few days after the root canal, I could not talk at all. The oral surgeon advised pain killers, Methylprednisolone 4 mg and waiting to see if the pain continues to decline. He mentioned that if the pain continued to decline, I could skip the Methylprednisolone, and so I never took it. I haven’t really been taking pain killers either, since the issue is less that I’m dying of pain, versus I just want to recover so I can talk, exercise and live a normal functioning life again.

The pain did continue to decline but has flatlined and has stayed constant, with small variances of improving or worsening, since about March 31. As of now, I continue to not talk or exercise (running, jumping and heavy breathing activate the pain).

 

[honestdoc]

You may have TMJ dysfunction. If you are in the US, have your medical doctor refer you to a TMJ specialist that your medical insurance may cover (it is very expensive without insurance help). If that doesn't resolve it, consider neurology evaluation.

 

[Somuchpain]

You may have TMJ dysfunction. If you are in the US, have your medical doctor refer you to a TMJ specialist that your medical insurance may cover (it is very expensive without insurance help). If that doesn't resolve it, consider neurology evaluation.

I definitely seem to -- so much of the lingering pain is centered around the TMJ right now. When I google TMJ, google says: "Temporomandibular joint (TMJ) syndrome is a disorder of the jaw muscles and nerves caused by injury or inflammation to the temporomandibular joint." Yep, that sounds about right -- the tremendous toothache (that I think I agree with my endodontist was brought about by tooth decay in #31, since the root canal seemed to dramatically cut down the pain in the tooth) has caused "injury or inflammation" to my trigeminal nerve and my temporomandibular joint, and both those are what seem to account for 80% of the pain now, although there still is pains in the gum and tooth around 30/31, but they seem to be lessening very little each day. What's nutty about this pain is the healing is so slow, and every few days seems to worsen, then gets a touch better, then evolves to some new form of pain -- I feel like I've felt so many different types of pains on the right side of my face over the past 6 weeks. Every few days when I draft a description of my pain, it's different than before, but still debilitating enough that I can't talk. Today, for instance, the pain is focused right at the TMJ, right at the point where my lower jaw and upper jaw meet, and it's just ongoing spasms and pain ripples focused in that area. It's almost as if once the spasms start, the muscles just get used to spasming regularly, and so it takes days for the spasms to calm down. A good night's sleep and complete rest to the muscles helps -- they get a chance to calm down and spasm a bit less the next day. I guess my concern is that there's a microfracture in one of the teeth that's triggering the ongoing pain, but it may be just that the healing process for TMJ and trigeminal nerve inflammation/injury is just real slow. I guess I'm just continuing to wait it out. You're right though, I should probably book an appointment with a TMJ specialist because by the time the appointment arrives, I'll have either gotten worse or I can just cancel it then. Thank you very much for the comments.