Persistent Tooth Pain: Seeking Solutions After Multiple Dental Visits

Severe toothache?

Hello Doctor: My brother has been experiencing tooth pain and has seen the dentist for three consecutive days without resolution.
Here's the situation: On Thursday afternoon, he visited the dentist due to pain in his upper left second molar, which had previously undergone root canal treatment last year due to pain.
During the Thursday visit, the dentist opened the previously treated cavity, explored it for a while, and found no issues.
He prescribed some medication for my brother to take home.
However, the next day, the pain returned, so he went back to a different dentist who identified a nerve issue and completed the necessary treatment.
On the third day, he experienced pain again and requested the dentist to extract the tooth.
The procedure took nearly three hours but was not completed because the roots of the upper left second molar and the third molar were fused together.
My brother has a history of drug resistance to anesthesia due to a previous surgery from a car accident, which made the anesthesia less effective.
During the extraction process, the second molar fractured (it was only discovered during the extraction that the roots of the second and third molars were connected).
The dentist performed suturing, but only the crown of the second molar was removed, leaving the root still connected to the third molar.
The dentist mentioned that if there is no further pain, it should be fine, but if the pain persists, he would refer my brother to a specialist in endodontics.
By the evening, he experienced pain again (this time in the fourth molar), and I called to get the contact information for the endodontist, but it was already Saturday night, and no dentists were available until Monday.

Could you please advise if there is a definitive solution? Also, why did the previous X-ray not reveal that the roots of the second and third molars were connected? If we go to a larger hospital (such as Chung Shan Medical University in Taichung), will they have better medical equipment for a more detailed examination of the nerves? Regarding the fused roots of the second and third molars, should both be extracted? If extraction is necessary, will it create a large gap, and considering the patient's drug resistance, could it be dangerous? Can a small clinic handle this, or is it safer to go to a larger hospital? I would appreciate your prompt advice and response.
Thank you.

williams, 20~29 year old female. Ask Date: 2002/09/28

Dr. Chu Boqin reply Dentistry

1.
Both private clinics and large teaching centers have dentists with valid dental licenses, and there are no restrictions on their practice.

2.
For tooth extraction, alternative medications can be used for those with drug allergies.

3.
The size of the extraction wound will heal well within a month as long as inflammation is controlled.

4.
For the upper left second and third molars, the X-ray images show the roots of both teeth.
However, the flat X-ray cannot definitively confirm if they are fused.
The angle of the X-ray can provide some insight into whether the upper left second molar may be difficult to extract, especially since it has previously undergone root canal treatment.

5.
The decision to extract the upper left second and third molars is made collaboratively between the dentist and the patient.
If you agree, the extraction can proceed; otherwise, a referral to an oral surgeon at a teaching hospital is recommended.

Reply Date: 2002/09/28

More Info

Persistent tooth pain, especially after multiple dental visits, can be incredibly frustrating and concerning. Your brother's situation, involving a previously treated tooth that has undergone root canal therapy, seems particularly complex due to the interconnected roots and his unique medical history. Here’s a comprehensive overview of potential solutions and considerations based on the information provided.

Understanding the Situation
1. Root Canal Complications: It’s not uncommon for teeth that have undergone root canal treatment to experience persistent pain. This can be due to several factors, including:
- Incomplete removal of infected tissue.

- Presence of additional canals that were not treated.

- Development of new infections or abscesses.

- Structural issues, such as cracks or fractures in the tooth.

2. Interconnected Roots: The fact that your brother's second and third molars have interconnected roots complicates the situation. This anatomical variation can make extraction more challenging and may lead to complications if not handled properly.

3. Anesthesia Resistance: Your brother's resistance to anesthesia due to previous medical conditions adds another layer of complexity. This can make dental procedures more painful and difficult, as adequate pain control is crucial for patient comfort and successful treatment.

Recommendations for Management
1. Seek a Specialist: Given the complexity of your brother's case, it would be advisable to consult an endodontist, a specialist in root canal treatments. They have advanced training and equipment that can provide a more thorough examination and treatment of the tooth's root system.

2. Advanced Imaging: If the previous X-rays did not reveal the interconnected roots, a Cone Beam Computed Tomography (CBCT) scan might be beneficial. This imaging technique provides a 3D view of the dental structures, allowing for better visualization of root canals and any potential issues that may not be visible on standard X-rays.

3. Consider Extraction: If the tooth is deemed non-restorable or if the pain persists despite treatment, extraction may be necessary. However, given the interconnected roots, it’s crucial to have a skilled oral surgeon perform the extraction to minimize complications. They can assess whether both teeth need to be extracted or if one can be saved.

4. Pain Management: Since your brother has shown resistance to standard anesthesia, discussing alternative pain management strategies with the dental team is essential. This may include sedation dentistry options, which can help alleviate anxiety and discomfort during procedures.

5. Follow-Up Care: After any procedure, whether it be further root canal treatment or extraction, close follow-up is necessary. This will help monitor for any signs of infection or complications and ensure that healing is progressing as expected.

Conclusion
In summary, your brother's persistent tooth pain after multiple dental visits requires a careful and thorough approach. Consulting with a specialist, utilizing advanced imaging techniques, and considering all treatment options—including extraction—are critical steps in resolving his dental issues. It’s important to communicate openly with the dental team about his pain management needs and any concerns regarding his medical history. Seeking treatment at a larger facility with specialized equipment may provide the comprehensive care needed for his complex situation.

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