Observation: Referred-Pain Extravaganza after Root Canal Treatment

Joined
Dec 26, 2023
Messages
80
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...
 
Last edited:
Joined
Dec 26, 2023
Messages
80
Here some snippets I extracted from the literature:

Carbamazepine

Diagnostic challenges of nonodontogenic toothache

Case


Tooth #45 responded within normal limits when tested with cold and electronic pulp tester.
...
The presenting complaint was diagnosed as trigeminal neuralgia, and carbamazepine was recommended as the treatment of choice. 200 mg of carbamazepine, taken twice daily, was prescribed. The patient's symptoms resolved within 2 weeks.
—————————

Clinical features of atypical odontalgia; three cases and literature reviews

Although carbamazepine had been prescribed at the otorhinolaryngology clinic, it was not effective. Gabapentin and pregabalin had been pre- scribed by the psychiatric department of the university hospital but they were also not effective.
—————————

Treatment of chronic pain in dentistry using anticonvulsants

The carbamazepine is used since the 60s, but their prolonged use can alter liver function.
...
The most common drugs used to treat this kind of chronic pain are anticonvulsants such as phenytoin, carbamazepine, gabapentin, topiramate and benzodiazepines like diazepam and clonazepam, which in addition to anxiolysis' activity, can also exercise anticonvulsant fuction3-4.
...
Phenytoin and carbamazepine inhibit the function of sodium channels, whereas gabapentin inhibits the function of calcium channels4.
...
In most cases the drug of first choice is Carbamazepine, being effective when prescribed in the dose of 300 milligrams, 3-4 times a day. Medications for the treatment of trigeminal neuralgia are effective in approximately 80% of cases.
...
According to Mendes et al.7, carbamazepine has been used since the 1960s and demonstrated efficacy in approximately 60% to 80% of cases. However, its prolonged use triggers complications, including tremors, drowsiness, dizziness, diarrhea, epigastralgia and changes of liver function. It is indicated during the course of the drug therapy, periodic laboratory tests and serum levels of carbamazepine, due to the possibility of development of agranulocytosis and changes in liver function.
—————————

Diagnostic Challenges of Neuropathic Tooth Pain

The oral surgeon prescribed carbamazepine, 200 mg 3 times daily. The patient’s symptoms resolved within 2 weeks. Against the surgeon’s advice, the patient discontinued the medication after 5 weeks believing that the problem was solved. Fortunately, the pain did not recur.
—————————

Trigeminal Neuralgia or Toothache

Carbamazepine, commonly used in trigeminal neuralgia, may help for toothache as well, which adds even more confusion. Practicing neurology for years, I have seen removed teeth in trigeminal neuralgia, as well toothache treated as trigeminal neuralgia.
—————————

https://paindata.org/documents/drugs-carbamazepine.pdf

Although carbamazepine is not licensed for the treatment of general chronic pain, it has been shown to be helpful in the management of certain types of pain, such as facial pain caused by Trigeminal Neuralgia. You are on this medicine to treat your pain.
...
Carbamazepine works by changing the way that nerves send messages to your brain. If the messages are reduced, then the pain will be reduced.

How long will it take to work?

It may take 2 - 4 weeks before you feel any pain relief. It may take longer (up to 2 months) to get to the right dose for you and to allow the medicine to build up in your body. Carbamazepine does not work for everyone. If you do not feel any improvement in your pain after 6 – 8 weeks, do not suddenly stop taking the tablets but speak to your doctor, community pharmacist or nurse.
...
In trials, most medicines for long-term pain provide on average a 30% reduction in pain. Some pains do not seem to respond to any painkilling medicines. Medicines work best if you combine them with other ways of managing symptoms such as regular activity and exercise and doing things that are satisfying or enjoyable, such as work, study and social activities. Setting goals to help improve your life is an important way to see if these medicines are helping.

When should I take it?

You should take carbamazepine two or three times a day, morning, afternoon and night. It is important to take your carbamazepine
...
regularly, as prescribed for it to work properly. It is not a medication that you should use on an ‘as required’ basis. You usually start carbamazepine at a low dose and increase it slowly to find the best dose for you. You and your doctor, nurse or community pharmacist will decide between you how quickly you increase your medicine. Normally you need a minimum dose of 100mg twice a day to get any benefit and the dose may need to be increased to 200mg three times a day.

Most common side effects

Dizziness
Tiredness
Drowsiness
Unsteady on feet
Difficulty controlling movements
Nausea and vomiting
Skin reaction (Hives)
Changes in liver function

Not so common side effects

Fluid retention
Weight gain
Blurred vision
Dry mouth
Headache
Easy bruising
Low sodium levels
...
Generally side effects are worse after starting carbamazepine or increasing the dose. It is important to persist in taking carbamazepine as these side effects are usually mild and will wear off after several days.
...
Drowsiness is usually temporary. If you feel drowsy, you should not drive or operate machinery.
...
Drowsiness may occur as you increase your dose. If you feel especially drowsy in the morning it may help to take the night time dose earlier in the evening.
...
The risk of drowsiness may be increased if you are taking other medicines for pain such as other anticonvulsant medications, antidepressants or morphine like medicines.

Can I drink alcohol?
Alcohol and carbamazepine together cause sleepiness and poor concentration. You should avoid alcohol completely when you first start taking carbamazepine or when you increase your dose. You should also avoid alcohol if you are going to drive or operate machinery.
...
Once you are on a stable dose, you should be able to drink modest amounts of alcohol, but only if the drowsiness has stopped.
...
You must take care with alcohol if you are also prescribed other medications that can cause sleepiness and poor concentration.
 

Vote:
Joined
Dec 26, 2023
Messages
80
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 would very carefully say the Carbamazepine takes some of the pain away. At least it takes the sting out. I also take Ibuprofen so it is very difficult to determine which of the drugs does exactly what.

But none of these drugs is a miracle cure...I am still in pain, although at a tolerable level.

One thing I can say for sure: the Carbamazepine has made me sleepy from day 1. I hope this side effect will settle soon.
 

Vote:
Joined
Feb 5, 2024
Messages
14
I would very carefully say the Carbamazepine takes some of the pain away. At least it takes the sting out. I also take Ibuprofen so it is very difficult to determine which of the drugs does exactly what.

But none of these drugs is a miracle cure...I am still in pain, although at a tolerable level.

One thing I can say for sure: the Carbamazepine has made me sleepy from day 1. I hope this side effect will settle soon.
Let's see. It takes time to build up. Is your pain 24/7 or on/off? Any trigger points by touching your gum, tooth,chewing?

I had the same with Amitryptiline. Sleepy/drowsiness was too much for me. Didn't affect the pain too so i am looking for new medication.
 

Vote:
Joined
Dec 26, 2023
Messages
80
No trigger points and no shrill, flashing pain either. The diagnosis "trigeminal neuralgia" came out of my family doctor's hip, when she heard of my associated headache.

But I also had headache previously when I had a periapical lesion on another tooth. She may have gotten it right for the wrong reasons.

No periapical lesion as of an X-ray taken a week ago (which does not mean it won't develop over time).

24/7? Almost. Difficult to say as I have a "pain roundabout" in my mouth, the pain referring all over the place. But I'm never pain free. Pain subsides somewhat in the evening, as the blood pressure goes down in its natural daily cycle (see appended figure).

But what's remarkable is that the buccal/outer side of the gingiva is somewhat sensitive to the Oral B electric toothbrush, and that this "burning" sensation is lingering for at least 30 mins thereafter (that's how it started before the continuous pain). Also, biting causes some sensation, but only for the first few bites.

When I step firmly on the ground, the shock is also felt in the tooth.

No hot or cold sensation with meals or drinks.

This is an interesting article:
https://cda-adc.ca/jcda/vol-70/issue-8/542.pdf

They cured the problem with 600 mg daily Carbamazepine over two weeks, but didn't know in the end whether it was trigeminal neuralgia or atypical odontalgia.


daily.jpg
 

Vote:
Joined
Feb 5, 2024
Messages
14
Does the pain sleep or wake you up at night? Your pain cycle again points to neuralgia
No trigger points and no shrill, flashing pain either. The diagnosis "trigeminal neuralgia" came out of my family doctor's hip, when she heard of my associated headache.

But I also had headache previously when I had a periapical lesion on another tooth. She may have gotten it right for the wrong reasons.

No periapical lesion as of an X-ray taken a week ago (which does not mean it won't develop over time).

24/7? Almost. Difficult to say as I have a "pain roundabout" in my mouth, the pain referring all over the place. But I'm never pain free. Pain subsides somewhat in the evening, as the blood pressure goes down in its natural daily cycle (see appended figure).

But what's remarkable is that the buccal/outer side of the gingiva is somewhat sensitive to the Oral B electric toothbrush, and that this "burning" sensation is lingering for at least 30 mins thereafter (that's how it started before the continuous pain). Also, biting causes some sensation, but only for the first few bites.

When I step firmly on the ground, the shock is also felt in the tooth.

No hot or cold sensation with meals or drinks.

This is an interesting article:
https://cda-adc.ca/jcda/vol-70/issue-8/542.pdf

They cured the problem with 600 mg daily Carbamazepine over two weeks, but didn't know in the end whether it was trigeminal neuralgia or atypical odontalgia.


View attachment 6619
You can see in that article that Carbamazepine is used because he has shocking pains. In the second part it was stated that TCA's and Capsaicin are used for Atypical Odontalgia. When I saw your graph, that seems to be a atypical odontalgia pattern. Atypical Odontalgia/TN2 often sleeps at night, and gets active slowly upon awakening.

I might give Carbamazepine I try too.

Unfortunately there is no empirical evidence here. I'm stuck the same way you are. My orofacial pain specialists urge me not to do an extraction without evidence, as this can create additional trauma to the damaged nerves.

So try to rule out TN2 first. One option to see if it is localized nerve pain vs centralized nerve pain is to have local anesthesia.

If they pain does not fully go away you know that there is a central component involved.

If the pain does go away fully you are still not use it is neuropatic or not. It can be either perapical (local) nerves or a odogentic problem.

When we did a anesthetic on a tooth which for now sure have ATN the pain did not diminish fully. On my other two problematic teeth, where I suspect a failed root canal to be the cause, I did try anesthesia yet.


Give either Carbamazepine/Amitryptiline and or a mix of topical Orajel/Capsaicin a chance. If they fail I'd say it's odongentic.
 

Vote:
Joined
Dec 26, 2023
Messages
80
The graph also worked for irreversible pulpitis with an apical lesion in my case.

I could also sleep with that previous condition and now.

But what is weird is that it is getting stimulated by simply stepping on the ground.

In my current case, I have to wait it out and see whether X-rays/CBCT scan will show an apical lesion in the future for a differential diagnosis. I still fear it is pulpitis.

As to extraction, you may have gotten some good advice...here what I pulled out of the literature:

Treatments that are irreversible and potentially harmful to the underlying dentoalveolar structures must be avoided when the diagnosis is uncertain.

————————

The atypical odontalgia is a nonodontogenic form of toothache that is difficult to diagnose; therefore, it leads to a number of invasive dental procedures which normally worsen the pain condition.

————————

AO often results in repeated, and possibly unnecessary, dental treatment such as extractions, root canal therapy and apicectomies in the pursuit of pain relief. A patient presenting with such pain and giving a history of multiple extractions possibly preceded by root canal therapies should raise suspicions of AO. Diagnosis and management as early as possible is vital to avoid unnecessary invasive treatments.
 
Last edited:

Vote:
Joined
Mar 28, 2024
Messages
14
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.
It sounds like you are experiencing referred pain from tooth 21, causing confusion in the diagnosis. Comprehensive examination is needed to determine the actual source of the pain and decide on a proper course of action.
 

Vote:
Joined
Dec 26, 2023
Messages
80
Does the pain sleep or wake you up at night? Your pain cycle again points to neuralgia

You can see in that article that Carbamazepine is used because he has shocking pains. In the second part it was stated that TCA's and Capsaicin are used for Atypical Odontalgia. When I saw your graph, that seems to be a atypical odontalgia pattern. Atypical Odontalgia/TN2 often sleeps at night, and gets active slowly upon awakening.

I might give Carbamazepine I try too.

Unfortunately there is no empirical evidence here. I'm stuck the same way you are. My orofacial pain specialists urge me not to do an extraction without evidence, as this can create additional trauma to the damaged nerves.

So try to rule out TN2 first. One option to see if it is localized nerve pain vs centralized nerve pain is to have local anesthesia.

If they pain does not fully go away you know that there is a central component involved.

If the pain does go away fully you are still not use it is neuropatic or not. It can be either perapical (local) nerves or a odogentic problem.

When we did a anesthetic on a tooth which for now sure have ATN the pain did not diminish fully. On my other two problematic teeth, where I suspect a failed root canal to be the cause, I did try anesthesia yet.


Give either Carbamazepine/Amitryptiline and or a mix of topical Orajel/Capsaicin a chance. If they fail I'd say it's odongentic.
Does your pain get relieved by Ibuprofen?
 

Vote:
Joined
Feb 5, 2024
Messages
14
Does your pain get relieved by Ibuprofen?

Sometimes I feel like tylenol helps, otherwise it doesn't. I cannot take brufen because of stomach issues.

On moment it helps I feel like I have a mixed neuralgia mixed tooth problem issue. Other movements it does not touch the pain and I'm sure my pain is neuropatic. Any progress on the carbamazepine?
 

Vote:
Joined
Dec 26, 2023
Messages
80
Sometimes I feel like tylenol helps, otherwise it doesn't. I cannot take brufen because of stomach issues.

On moment it helps I feel like I have a mixed neuralgia mixed tooth problem issue. Other movements it does not touch the pain and I'm sure my pain is neuropatic. Any progress on the carbamazepine?
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.
 

Vote:
Joined
Dec 26, 2023
Messages
80
Yes ,I agree but It's essential to get a thorough dental check-up to figure out what's really going on.
It is a diagnosis of exclusion...first, odontogenic pain has to be confirmed/excluded, through pulpal and periapical diagnoses:

1. Pulpal diagnosis:

#21 is sensitive to cold test with endo ice...which means the pulp is vital and possibly badly inflamed as the pain lingers upon removing the endo ice.

Most dentists would diagnose irreversible pulpitis ...but would this alone justify invasive and irreversible treatment (mine thinks the lingering is ambiguous and did not recommend endodontic treatment)? Therefore, what's needed for confirmation is...

2. Peripical diagnosis:

No radiolucency around the root's apex [middle tooth in X-ray], not tender to percussion/bite, no problems with biting...this points to no abscess/lesion/cyst around the root's apex.

What now? If you have irreversible pulpitis, it takes 2-10 months for a radiolucency to show up around the root's apex. If it does not show up, it points to non-odontogenic pain.

Suggestions for further testing other than waiting?

Kraus Jurgen 4762_20-Mar- 2024_0.jpg
 

Vote:
Joined
Dec 26, 2023
Messages
80
It is a diagnosis of exclusion...first, odontogenic pain has to be confirmed/excluded, through pulpal and periapical diagnoses:

1. Pulpal diagnosis:

#21 is sensitive to cold test with endo ice...which means the pulp is vital and possibly badly inflamed as the pain lingers upon removing the endo ice.

Most dentists would diagnose irreversible pulpitis ...but would this alone justify invasive and irreversible treatment (mine thinks the lingering is ambiguous and did not recommend endodontic treatment)? Therefore, what's needed for confirmation is...

2. Peripical diagnosis:

No radiolucency around the root's apex [middle tooth in X-ray], not tender to percussion/bite, no problems with biting...this points to no abscess/lesion/cyst around the root's apex.

What now? If you have irreversible pulpitis, it takes 2-10 months for a radiolucency to show up around the root's apex. If it does not show up, it points to non-odontogenic pain.

Suggestions for further testing other than waiting?

View attachment 6645
Actually, not #21 but # 36..
 

Vote:
Joined
Mar 28, 2024
Messages
14
Actually, not #21 but # 36..

Given the current findings, further testing options could include:

  1. Conducting vitality tests on adjacent teeth to rule out referred pain.
  2. Performing diagnostic nerve blocks to localize the source of pain.
  3. Considering cone-beam computed tomography (CBCT) imaging for more detailed evaluation of dental and periapical structures.
  4. Consulting with a specialist or seeking a second opinion for additional insights.
These steps can help in confirming or excluding odontogenic causes and guiding the next course of action.
 

Vote:
Joined
Dec 26, 2023
Messages
80
Given the current findings, further testing options could include:

  1. Conducting vitality tests on adjacent teeth to rule out referred pain.
  2. Performing diagnostic nerve blocks to localize the source of pain.
  3. Considering cone-beam computed tomography (CBCT) imaging for more detailed evaluation of dental and periapical structures.
  4. Consulting with a specialist or seeking a second opinion for additional insights.
These steps can help in confirming or excluding odontogenic causes and guiding the next course of action.
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?
 

Vote:

Ask a Question

Want to reply to this thread or ask your own question?

You'll need to choose a username for the site, which only take a couple of moments. After that, you can post your question and our members will help you out.

Ask a Question

Members online

No members online now.

Forum statistics

Threads
7,634
Messages
22,386
Members
11,489
Latest member
dentalnewbie21

Latest Threads

Top