Observation: Referred-Pain Extravaganza after Root Canal Treatment

[Brause]

Had a root canal started in upper incisor (tooth 21; not obturated yet) 5 weeks ago, but the periapical abscess does not heal. Either needs revision or extraction.

BUT, interesting observation: pain sometimes moves completely over to tooth 36 (started 4 days after root canal treatment), then sometimes to (former) tooth 46 (recently extracted), also sometimes to tooth 26.

Whichever tooth hurts, the other ones mentioned are simultaneously dormant.

Since tooth 21 is the actual source of the pain ("abscess"), I expect this referral business to disappear once the source of the pain (tooth 21) has been removed.

My family doc thinks [without examination] it is "trigeminal neuralgia" and my endodontist is referring me back to the dentist for a "comprehensive exam" [because he thinks there is nothing wrong with tooth 36...also without exam, but his exams are pricey].

I don't think it is "trigeminal neuralgia" because the pain is not sharp or shrill, and also does not appear in short flares. It is dull and permanent.

To be continued...

 

[smithwilfer]

No, but i really wish you to recover soon.

Thanks.

Vitality tests on adjacent teeth have been conducted: all vital.

I am going to see a periodontist mid month (for an implant) who I will ask for a second/third opinion.

I will also have to go back to my endodontist very soon to decide whether to obturate #21 (it has been 56 days since RCT). I hope the temporary filling is still holding up (the oral surgeon in my family claims they last for at least 6 months).

As probably mentioned, if it is odontogenic pain, it may be too early for imaging to be conclusive as there are no periapical changes yet.

Are you a dental clinician?

No, i saw my mother in pain with similar symptoms and you really made a wise decision. Recover soon .Good luck

 

[Brause]

Please let me know the outcome.

Carbamazepine is usually prescribed for TN1 (the shocks). TN2 the first line is low dose TCA (such as Amitryptiline). But I guess Carbamazepine or Gababentin will work too.

I have been taking Carbamazepine (2*300 mg daily) since 22 March. I'd way it took some time to work, and, initially, I was sleepy. That tiredness subsided after 5-6 days...and the drug also took some time to work properly. But now I am confident to say that it does...it makes the pain much more tolerable.

I read somewhere it could take 2-4 weeks to start relieving pain.

 

[Painful teeth]

Not sure about any progress as I don't know what really helps, the Ibuprofen or the Carbamazepine...and whether the Carbamazepine dose is right.

The worst pain I ever had was before taking the Carbamazepine...since then it has never been as excruciating...nevertheless rather bad today.

I'm starting carbamazepine today too.
I did some extensive research and TCAs are the standard (Amitryptiline the first). Second line is Gababentin/Pregabalin. Carbamazepine is rarely prescribed for atypical odontalgia, only for shock pains TN1.

 

[Painful teeth]

I have been taking Carbamazepine (2*300 mg daily) since 22 March. I'd way it took some time to work, and, initially, I was sleepy. That tiredness subsided after 5-6 days...and the drug also took some time to work properly. But now I am confident to say that it does...it makes the pain much more tolerable.

I read somewhere it could take 2-4 weeks to start relieving pain.

Just checking on you if you have anything new to report.

 

[Brause]

Upped dose to 2*400 mg of Carbamazepine since 18 April. Stopped Ibuprofen on 15 April...which, in retrospect, made no difference.

Essentially knocks pain in tooth 36 completely out, but only reduces sensation on tooth 31 to a pushing type. Tolerable but annoying.

Upping the dose came with tiredness that eased off as of today.

Will see a neurologist next week.

Still have an abscess in tooth 21, that has not healed after pulpectomy on 8 Feb...still needs to be re-treated before obturation or extracted.

Lots of headaches, even when getting out of bed in the morning. No idea, what causes that. I don't think it is a side effect of the meds (as I had it before). Would guess it comes from tooth 21.

 

[Brause]

Saw a neurologist today. He concluded that all my pains are entirely dental: no trigeminal neuralgia.

This means:

Carbamazepine works well for suppressing pain in tooth 36.
It does not work well for tooth 41.

The dental clinician cannot do a reliable cold test for tooth vitality because of the Carbamazepine.

Tooth 41 pain only came on a month ago, hence there is likely no periapical lesion to be detected by a CBCT scan or X-ray het. Pulpitis infections/inflammations only push through the root's foramen after 2-3 months.

I'll have to wait.

But I am still sitting on a non obturated tooth that has not healed after pulpectomy some 80 plus days ago...held together by a temporary filling.

It is a complete mess.

 

[Painful teeth]

Saw a neurologist today. He concluded that all my pains are entirely dental: no trigeminal neuralgia.

This means:

Carbamazepine works well for suppressing pain in tooth 36.
It does not work well for tooth 41.

The dental clinician cannot do a reliable cold test for tooth vitality because of the Carbamazepine.

Tooth 41 pain only came on a month ago, hence there is likely no periapical lesion to be detected by a CBCT scan or X-ray het. Pulpitis infections/inflammations only push through the root's foramen after 2-3 months.

I'll have to wait.

But I am still sitting on a non obturated tooth that has not healed after pulpectomy some 80 plus days ago...held together by a temporary filling.

It is a complete mess.

That's a tough cookie. My neurologist had no idea. Only knew shocking pains. Was of no help. Didn't have any patient before with neuralgia in the teeth so he didn't diagnose. Just said try anticonsulvants.

I'm 15 months after my root canals. Getting x ray at the end of this month. Hoping finally to see this leasion so I can pull the damn thing. I still think it's a tooth problem as I cannot chew after 15 months and I have pain without stimulation.

 

[Brause]

I bit the bullet and got a CBCT scan of all 4 quadrants done ($400 CAD). Currently waiting for the radiologist's report.

The periodontist needed one quadrant for his implant planning, upgrading to 4 was relatively "cheap".

In the meantime, Carbamazepine's side effects (tiredness etc.) have subsided/disappeared.

 

[Painful teeth]

I bit the bullet and got a CBCT scan of all 4 quadrants done ($400 CAD). Currently waiting for the radiologist's report.

The periodontist needed one quadrant for his implant planning, upgrading to 4 was relatively "cheap".

In the meantime, Carbamazepine's side effects (tiredness etc.) have subsided/disappeared.

Let me know the outcome. My pulpal necrosis never showed on a x ray nor CBCT. And I walked around with 2 teeth necrotic for over 6 months in pain before getting RC's. In the last 21 months (6 months of pain before RC) and 15 months aftwr, despite pain, chewing pain, 2x CBCT, never any leasion. So I don't trust the "general science" around leasions forming etc. Every person has a unique immune system.

 

[Brause]

Going back to the original problem: endodontist performed pulpectomy on tooth 21, almost 90 days ago. It has not been obturated.

This has not healed properly, hence a decision has to be made, how to proceed.

I received a phone call from the admin yesterday that the Endodonist will not "add more medicine"...she was pushing towards obturation...or extraction. The admin!!!

No chance for me to have the Dr examine the tooth - and no desire for the Dr to await the results of the CBCT scan [they know that the CBCT scan had been done and they even have access to the raw data].

The patient has to decide what to do, without technical means of performing a proper diagnosis.

That's outright unethical and negligent in my opinion.

 

[Brause]

After 4 weeks, 800 mg daily Carpamazepine does not have any/full effect anymore. Tylenol is my new friend.

Saw a neurologist: according to him, I am not suffering from trigeminal neuralgia.

 

[MattKW]

I can see significant erosion on 36 with wafer-thin enamel.
Your radiation of pain does not correlate with the treatment for 21.
When you go for full check-up, look for fractures, and consider bruxism in the possible diagnoses. I had a pt once who was in excruciating pain for 4 weeks - had been given neuropathic pain drugs, had seen 2 GP doctors, 1 dentist, and emergency dept at hosp. Was unable to work and zonked out on carbamazepine, had appt with neurologist for further tests. Had no fillings but heavy bruxer and had almost invisible hairline fracture in lower molar - extracted; problem solved.
Keep us updated.

 

[Brause]

I can see significant erosion on 36 with wafer-thin enamel.
Your radiation of pain does not correlate with the treatment for 21.
When you go for full check-up, look for fractures, and consider bruxism in the possible diagnoses. I had a pt once who was in excruciating pain for 4 weeks - had been given neuropathic pain drugs, had seen 2 GP doctors, 1 dentist, and emergency dept at hosp. Was unable to work and zonked out on carbamazepine, had appt with neurologist for further tests. Had no fillings but heavy bruxer and had almost invisible hairline fracture in lower molar - extracted; problem solved.
Keep us updated.

Same or similar issue with #46 last Q3 (with crown fracture): Pulpectomy did not provide any relief for even one day, tooth extracted 11 weeks later, before obturation. Oral surgeon mentioned teeth flattened by bruxism.

Tooth 21 became symptomatic 4 days after extraction of tooth 46, but with vigour....must have been a long-standing issue as pulp was largely necrotic and pulp testing with endo ice yielded non vitality. Widened PDL with abscess was diagnosed.

Following pulpectomy of tooth 21, tooth 36 became symptomatic another 4 days later.

A custom-made mandibular nightguard was fitted immediately before tooth 21 pulpectomy (has not healed/not been obturated 100 days later...should the clinician try MTA, look for lateral channels...or have it chucked, too...may be a fracture; radiologist writes on tooth 21: "...lateral canal or represent an early sign of a non-displaced root fracture...".

I think I am clenching while sleeping on the side.

Question mark needs to be added to image's labelling.

 

[Brause]

Tooth 36 does not come as a surprise considering the thin enamel: had to chew for 4 months on it in the absence of a functioning/extracted tooth 46. That and bruxism combined must have been too much.

Radiologist writes (2024-05-02):
"...The periodontal ligament space at the mesial root apex of tooth 36 is slightly widened. This may reflect a normal variant or an early sign of endodontic pathology. The distal root appears normal at this time. The periradicular bone associated with tooth 36 is intact and there are no specific signs of a root fracture..."