3D X-ray to help diagnose problem root canal tooth?

Hoot_Owl

Hi, I’ve posted a few weeks ago about resurgence of toothache from what I suspect is from a previously root canal treated upper first molar.

Apologies for the long post but I’m trying to include as much detail as possible to get some answers.

So about a year ago I had an infection in my upper first molar tooth, which I had root canal treated from an Endodontist. Though expensive (£700) it seemed to be successful and I had no issues for the next 12 months. However 3 weeks ago out of the blue I started having a dull pain/ache coming from the area near the RCT molar, this pain can vary throughout the day, sometimes it’s very painful and at nighttime it tends to settle down a little. I went to my NHS dentist and they did a standard 2d X-ray and they said all looked fine, no infection, the root canal tooth looked good (3 good root fillings all the way down to the base of the roots). Then dentist said it could be sinusitis  (which I disagreed with since I had no symptoms) and gave me a course of amoxicillin and sent me on my way.

A few days after that I went for a second opinion to another NHS dentist at a different practice and again they gave me another X-ray and again said the they could not see any infection with that that or any other surrounding teeth and the RCT tooth looked well done. But said they could remove the tooth if I wanted which I refused, not wanting to remove teeth with no certainty it is the source of the problem.

Days after that I went back to my Endodontist and they also X-rayed the tooth (which I’m a little concerned I’m going to get radiation poisoning at this point) and repeated what the other dentists said, the X-ray doesn’t show a problem. But he said my gums looked a bit red around the tooth and said to wait and see if the amoxicillin helps calm things down (which was the last day on a 7 day course). 

A week after that (this week) still suffering with tooth pain I went back to my Endodontist and he said my gums still look a little red around the edges and said I needed a deep cleaning. He went ahead used ultrasonic scaler around the tooth and also drilled down the composite filling slightly to make sure the tooth wasn’t riding high and causing pressure when I bite down. He also prescribed me another course of different antibiotics (which I’m hesitant about taking since the first course did nothing), he was pretty sure that would solve the tooth ache. 

3 days later (and a total of 3 weeks suffering) the toothache is still no better!  

I’m now thinking there may be a  possibility I have a hidden tooth infection in the root canal treated Molar that standard 2D X-rays aren’t picking up on (especially any hidden infection around the jaw bone). The only way to diagnose the issue is to get myself a 3D X-ray (CBCT scan) which is vastly more detailed but is expensive (£200, which I’m hesitant about wasting any more money on this tooth). It requires me to search for 3D X-ray providers, but so far the nearest location requires me to travel 20 miles to the nearest city. Then if any infection is spotted I will at least feel assured I’m making the right choice about getting the extraction. But then again I’m also concerned having a cone beam X-ray along with 3 other dental X-rays in one month is too much, all that radiation can’t be good for me.

The cheaper and far more convenient option is to simply have the RCT molar extracted by an NHS dentist and pray it solves this incessant pain I’ve been dealing with for weeks now! But I run the small risk of having the molar extracted and it turns out it wasn’t the source of the pain, but I am fairly certain that is what is causing the pain. 

I believe Toothsmith mentioned from my previous thread about teeth clenching possibility having said I was given a night guard by another dentist last year (no other dentist mentioned it) , but I really couldn’t use the night/mouth guard as I was up into 4am trying to fall asleep which I failed to do until I removed the damn thing! Lol, but I really don’t think I even have been grinding my teeth because I have no other symptoms, it’s only one tooth that is causing the pain. 

Any help/opinions from Dentists on this board would be highly appreciated! Thank you.

Toothsmith

First of all don't worry too much about the X-Rays you've had for this one thing. You are exposed to x-rays all day every day on a low grade (sunshine, electrical equipment, bananas and Brazil nuts are all among sources of electromagnetic radiation)

if you imagine that down on the ground, the x-rays from the sun are filtered out by all the atmosphere the light goes through, then you will understand that whilst up in an aeroplane, you are being exposed to more x-rays than when on the ground. A small dental x-ray is the equivalent of a couple of hours in an aeroplane. The cone-beam scan is a bit higher, but none are as big as something like a barium meal - which is equivalent to a couple of decades in an aeroplane!

It's still true that they can cause changes in the body, so you should only have exposures when necessary. If 3 different dentists have taken x-rays and said it's ok, I would say chances are, it's ok. As they are positioned by hand, each one would have a slightly different angle, so if something was wrong, it would probably have shown up on at least one of them. I can't guarantee that, but it's hard to justify more radiation at this time.

Going back to the bite guard, did you try wearing it during the evening before bed? Just because you're having problems tolerate a bite guard doesn't mean your problem isn't tooth grinding related. In fact, I sometimes find that tolerance problems are higher amongst those that really need the things!

If wearing it just the evening doesn't overcome the tolerance issue, then try wearing it for more time during the day. It doesn't have to be a continuous run all the way to bedtime. Just have it around, and any time you can pop it in your mouth for a while, then take it. The more you wear it, the more natural it will become, so the easier you will get to sleep with it in. 

If this doesn't work, then take it to your dentist, let them know you've been recommended it before but are having problems using it. There are several types of bite guard, and a different one might prove better for you. It might simply be that this one isn't fitting right and needs a bit of adjustment. 

I'm not saying this is a tooth grinding problem either. It's just it sounds like a possibility, and just because you can't get to sleep in this bite guard (yet) doesn't mean that it isn't.

Finally, sticking to one dentist can often be a better way to sort out tooth problems when a direct cause isn't obvious. There can often be several things that have to be looked at as a possibility, and different treatments tried, and given some time to see if they get to the bottom of it. By swapping about, one dentist won't know what a different one has tried, and so you may find one trying something another one has already tried. It can often be a bit of a detective job to pin down a particular problem, but the very last thing any dentist would want to do, or you as a patient would want, would be to have a tooth out that wasn't responsible for the pain. 

elsien

Why are you hesitant about taking the second course of antibiotics? If one type doesn’t work then a second course of a different type isn’t unusual and has to be worth a try as a short term measure, surely? 

Hoot_Owl

Hi Toothsmith, thanks again for your help, much appreciated.

It is interesting about the different levels of radiation put into context, I shall not worry too much from now on, but the same time try not to have any more unnecessary X-rays. The only reason I mentioned the possibility of getting a 3D X-ray is because I came across an article online through google titled “infected root canals and what to do about them - integrative dentistry, San Diego” (sorry I can’t post a link) and it showed a perfectly fine root canal tooth on a standard 2D X-ray with no signs of infection, however once a 3D X-ray was used they spotted rather large infected granulated tissue going up into the sinus cavity! I’m concerned any possible infection may not be obvious using the 2D X-rays? My Endodonist show me my previous X-ray before I had the root canal (when it was infected and I was in extreme pain) and I couldn’t  believe how subtle and small the dark shadow was on the base of the root looked on the X-ray! So I wonder any smaller infection may be virtually invisible to further X-rays? 

Regarding the mouth guard I found it highly uncomfortable, I have mildly crooked lower teeth and I found the customised mouth guard felt like it was putting horrible pressure on the teeth, it felt like I was wearing braces! Also the depth of the mouth guard went all the way down to the base of my lower jaw and felt like it was cutting into the skin, Finally once I was wearing the guard I felt like I had no room for my tongue which had to rest above the guard. 

I actually messed up the mouth guard trying to make it more comfortable (which I know you shouldn’t do but I wasn’t going to wear the guard as is anyway) I trimmed away a lot of the excess material at the bottom (it now ends just past my gum line which now doesn’t feel as secure and worry will pop out during sleep) and to get rid of the awful pressure on my teeth I submerged the guard into hot water (another no no) and reshaped the guard around my gums and teeth which helped quite a lot, but still find the thing uncomfortable and claustrophobic for my tongue. I tried your suggestion of wearing the mouthguard a few hours before bedtime to get accustomed to wearing it but I still couldn’t sleep..

As an experiment I should simply pull an all nighter (ie try to sleep with the mouth guard) and not get any sleep to see if my toothache improves the next day, but it is hard and frustrating not getting any sleep all night, but at least I shall know if any clenching is responsible for this toothache or not.

I may go back to my NHS dentist and ask for another guard/or different design to be made to see if it makes any difference. But I have my reservations, why would nightly jaw clenching cause pain now? And only in one tooth that subsequently had been infected and root canal treated only 12 months prior? Like I said I have had no other symptoms and never have (no TMJ/jaw pain/clicking etc), it’s just that tooth. Too much of a coincidence I think.

Thanks again.

Hoot_Owl

elsien said:

Why are you hesitant about taking the second course of antibiotics? If one type doesn’t work then a second course of a different type isn’t unusual and has to be worth a try as a short term measure, surely? 

Fortunately the toothache is tolerable, nothing like the agonising pain the first time the tooth was infected (rolling around the floor with tears in my eyes). This is a low level 2-4 out of 10 pain, uncomfortable and annoying but not debilitating like the first time around. If the tooth is reinfected, the lower pain in comparison may be due to the Root canal tooth no longer having a nerve/pulp, more like pain in the surrounding area. Trust me when I say if I was in agonising pain I would be straight onto any antibiotics they give me! Lol. 

I’m just sick of antibiotics to be honest! I felt terrible during my weeks course of amoxicillin, I actually developed a mild non allergic full body rash from head to toe! But I still finished the course because I was concerned about developing any resistance to the antibiotics in the future, but I’m so glad to finally be off them.

Currently I’m trying to recover my poor gut microbiome which has been senselessly obliterated by the amoxicillin. I have been reading the essential role gut bacteria play to your health, including your immune system, digestion and well-being etc. I’ve read it may take 6 months up to a year to recover the  trillions of diverse bacteria that live in the gut, that have been killed off by broad spectrum antibiotics  (up to 90%). There is some research findings that show even though the majority of this gut microbiome recover in time, many beneficial species of friendly bacteria are permanently lost for good! I was amazed to read 90% of all serotonin created by the body and used in the brain (feel good hormone amongst other roles) and up to 50% of dopamine ( brain neurotransmitter key to motivation) is actual produced by the microbiome in the gut! Once they have been eradicated by antibiotics that’s potentially 90% less serotonin and 50% less dopamine for the brain, no wonder I felt so depressed and listless while taking them! I appreciate antibiotics are useful and a life saving necessity when required, but taking them needlessly is something I want to avoid from now on personally.

kayeb

This might not help too much, but, I’ve got an old root canalled tooth that flared up this week (it was only x-rated last month during a check up & looked fine).  Sensitive to heat & sweet things.  I thought “that’s it” & booked into the dentist for this coming week.  In the meantime I stayed off it (chewing wise), & touch wood, it seems to have settled. My dentist says that teeth can flare up then settle.  I hope your tooth settles too.  

Toothsmith

I really think you're over-using Google. 

The Alexander Pope quote is really apt here.
"A little learning is a dangerous thing. Drink deep or taste not the Pierian Spring; There shallow draughts intoxicate the brain, and drinking largely sobers us again"

Like your fear of illness from the x-rays was calmed when put in a bit of context, the problems a single week of amoxicillin can cause really don't add up to what you've concluded from Google.

On the other hand, your rather specific diagnosis of a 'mild non-allergic rash' from head to toe and 'feeling terrible' would be something I'd be a little more concerned to investigate, and certainly wouldn't put it down to serotonin and dopamine level fluctuations caused by destruction of gut bacteria. That does sound to me more like an allergic reaction. But obviously, I can't see you. But I would mention it to your dentist (although you might have done, if he gave you a different type of antibiotic this time) 

Tooth/jaw problems can come in many and varied forms. One thing about jaw problems though is that they are linked to stress. So something that has not caused you a problem before could be doing now as at the moment everyone is more stressed due to this bug that's going around! I'm seeing a big increase in tooth grinding symptoms and people breaking cusps off teeth! 

I'm not saying it is or it isn't - again, I can't see you. But to me it looks like it's something worth investigating. The fact antibiotics made little difference is an extra bit of evidence that it's not infection based. 

You probably have mucked up your bite guard by taking so much off. Learn from it, and don't try DIY adjustments again. Get another one made, (if your dentist agrees one might be necessary) and if you find it uncomfortable after wearing it for a while, go back to the dentist to let them adjust it. Often just very little adjustments make the difference. If patients do it themselves, they always over-estimate how 'wrong' it is and whack off way to much, and often with completely inappropriate tools.

 My advice would be to choose the dentist you want to help you sort this out, stick with them, and let them investigate it properly and work through the processes they need to to come to the correct diagnosis, and leave Google alone for a while whilst this process works through. 

Hoot_Owl

I’ve just re read my previous post, apologies for sounding like such a condescending arrogant  twit, I don’t really know what I’m talking about to be honest and you’re right- I do spend too much time reading useless nonsense on the internet! Lol.

Thanks for all your advice which I will take on board. I will persevere with the mouth guard (it’s 1am and I’m currently using it lol) and ask my dentist for a new one. If that doesn’t solve the problem I will keep exploring ideas with my dentist.

Thanks again and Merry Christmas to you! 

Toothsmith

No probs Hoot 

In all honesty, from what you say you've done to it, I'm not sure your bite guard would be much use now. I would ask your dentist what his opinion on you trying a new one would be, and get one made. Taking in your old one to let him see it and as an aid to you describing what you found uncomfortable with it would be useful. 

It is one thing for medics ( and dentists) to make use of Google - I turn to it pretty often. But we look at it with different eyes to 'civilians'. We have a lot of training and experiences which aid us in both knowing what we are looking for, and filtering out the dangerous stuff you find there.

Just prior to lockdown, the brake disc on my pedal bike wore out. Bike shop couldn't fit it in to do it ( and bike shops had to close right at the start) I looked on you tube, and found a video on how to change them. I'm the son of a mechanic, and have always been pretty handy at fixing stuff, so I got the part online, and I fixed it. 

When I fell off my bike a few years ago and smashed my shoulder, I did not Google one thing about shoulder injuries, complications, ( and I had a few) or how long the replacement I had put in is likely to last! Despite being 'medical' and likely to understand some of it, I just didn't want to know. I asked my consultant questions, trusted his answers, and let him get on with it.

It took 18 months and 4 operations, ( including 2 replacements) to get right! I was on a broad spectrum antibiotic at a huge dose for 3 months between replacement one coming out, and replacement 2 going in. I didn't Google anything! (At the same time, I was getting divorced! I didn't Google anything about that either! )

So yes, Google can be useful for some things, but many times it can be a rabbit hole you can disappear down and end up way more dispirited or confused than you otherwise would be. It needs great care.