Endodontic Treatment or Extraction?

[Brause]

My opinion: extraction!

The story: #36 (no restoration, no caries) has been acting up for 1 month now. First, it was sensitive to brushing, then to biting and even when pulling out the floss -- and a good week ago, it started with 24/7 pain.

No clinician has seen it yet. My family doctor prescribed a low dose of Gabapentin (100 mg 3-times daily) in support to the 1000 mg daily Ibuprofen I take.

This comes on the heal of a fracture in #46 last summer that first received RCT, which did absolutely nothing. Extracted just before Christmas.

Four days later, #21 started acting up, was endodontically treated a month ago...and it also made no difference. Zip and zero. Probably also needs to be extracted.

The symptoms on #36 point to a periapical abcess. What else could it be? And what could have caused it? Bacteria entering through a fracture. The tooth is lost. No CBCT scan needed imho.

Even if endodontic treatment was successful (which I doubt in his case), #36 bears the main chewing stress (particularly in the temporary absence of #46). A friend of mine cracked two crowns on #36 and then went for an implant.

Considering I have not had any issues with my teeth ever, incidents #21 and #36 following the extraction of #46 are suspicious. I still think some teeth on the left-hand side were/could have been damaged/traumatized by biting on a rubber mouth prop while the surgeon worked on extracting #46 on the other side...tons of vibrations. If trauma can be related to bruxism, why not to this?

 

[Painful teeth]

If there is a micro fractures,

Don't you take it will take some time for bacteria to travel trough the filled canal and past the apex seal to cause pain? The canal is filled with sealer and gutta and the apex is fully sealed and antibacterial. Personally I feel like your tooth will at least survive a couple of months, years maybe before bacteria accumulate and push through the apex. The fact that they RCT did not resolve pain makes me wonder as I said before if there is no neuropatic component to this. The fact that your GP prescribes Gababentin supports this?

Edit, this was a non treated tooth I see. I'd be cautious just extracting teeth like this. You'll need proper diagnosing and imaging. Some forms of neuralgia tend to jump around. You extract the tooth and pain appears days weeks or months later at a different tooth. It moves around. Its very typical for neuralgia patients to have extracted several teeth before diagnosis. I understand you have a fact and empirical approach for your diagnosis but this is something to seriously consider if two virgin tooth cause symptoms shortly after another

 

[Brause]

Hmmm...if the pulpitis infection has not reached the apical area yet, the imaging will show nothing.

As to the first virgin tooth: RCT revealed necrotic pulp, hence neuralgia could be excluded for this one.

The endodoonist, obviously, always wants to start with RCT and see whether it sticks. And even if it worked, it will be a can of worms forever...as #36 carries the most chewing weight.

There are always two items tested: pulp and apical area.

Apical area: if the imaging shows "rarefying osteitis", it points to microfractures. If it does not, it is inconclusive.

Pulp test:..if a cold test reveals progressed pulpitis or necrotic pulp...we can also exclude neuralgia.

Ibuprofen works to some extent...which would also point against neuralgia.

Another option is a bruised ligament...from overuse or occlusional issues.

The GP had no idea of the details. I was there on a routine check and she simply wanted to ease the pain.