Root canals

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WiseOne
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Root canals

Post by WiseOne » Wed Sep 06, 2017 4:54 pm

Root canals may be a great invention, but I wouldn't wish what I've gone through in the past couple of months on my worst enemy. Has anyone here had similar experiences with root canals?

Some fun facts I've learned that hopefully might prevent some of you from suffering through a saga like this:

- If you have a cracked tooth, wait until you're absolutely forced to do something about it before you go down the rabbit hole of restorative dentistry. I have an upcoming extended overseas trip and I jumped the gun a bit thinking I should get this resolved before I leave. Boy was that a mistake.

- If you're told you need a crown, be very sure you don't need a root canal first. In retrospective, it was ridiculously obvious that the reason I was having pain in the cracked tooth is that it was getting infected. Closing up the cracks with a crown created the perfect conditions for an anaerobic infection to take off. This bought me an emergency session with an endodontist at 8pm two days before a major deadline and a few days before a scheduled plane flight. And after being popped off and replaced several times, the temporary crown is not exactly the original shape.

- If you're referred to an endodontist who likes to do root canals in multiple visits, you probably should ask for someone who does them in one visit. A recent meta-review in the British Medical Journal demonstrated that single-visit root canals, even on molars, were no more likely to fail than multiple-visit procedures. I sure wish I knew that in advance. In my anecdotal experience of one multiple-visit procedure, each successive instrumentation on already-traumatized tissues got exponentially more painful with longer recovery times and more meds/pain control measures needed. It's been a week since the last one and I'm finally feeling like it's just starting to get tolerable.

- I thought the multiple visits were to make sure the infection is cleared, but in fact root canals don't ever actually accomplish that. It's a combination of removing the bulk of infected tissue, antibiotics, and your own immune system that does that. So...what the h**l, why the multiple visits??

All I can say is that ibuprofen (800mg every 8 hours...don't waste your time with 600mg dosing) is nice, but Vicodin or T#3 would have been nicer to have over the holiday weekend...wish I'd thought to ask for that then, and maybe even right from the start. Next time, definitely. I have another cracked tooth biding its time and waiting for the perfect moment to pounce, I'm sure.
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Re: Root canals

Post by Mountaineer » Wed Sep 06, 2017 5:52 pm

I'll offer a few comments as a lovely recipient of multiple root canals, the first being about 55 years ago when the packing material was gutta percha (look that one up :) ) with multiple repacks before the final. I still have that tooth.

Completely agree on the do it in one step method.

I have had two diagonal vertically cracked teeth, both ultimately had to be pulled and a bridge installed .... big $$$$$$$$$.

Wife had a couple root canals years after a crown was installed. The endodontist was able to drill through the crown and do the root canal; saved the tooth and the crown.

Agree on the pain comments!!!!!!!!!!!!!!!!
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Re: Root canals

Post by boglerdude » Wed Sep 06, 2017 11:00 pm

How should one select a dentist? Yelp?

I have medicaid, but would they provide lower quality care (ie do you get what you pay for?)
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Re: Root canals

Post by Mountaineer » Thu Sep 07, 2017 6:41 am

MangoMan wrote:
Mountaineer wrote:I'll offer a few comments as a lovely recipient of multiple root canals, the first being about 55 years ago when the packing material was gutta percha (look that one up :) Gutta percha is still the material of choice for filling root canals.

with multiple repacks before the final. Not sure what you mean by that.
I still have that tooth. As would be expected. The success rate of conventional endodontics is over 95%.

Completely agree on the do it in one step method.

I have had two diagonal vertically cracked teeth, both ultimately had to be pulled and a bridge installed .... big $$$$$$$$$. These days, we would probably do an implant. Also not inexpensive.

Wife had a couple root canals years after a crown was installed. The endodontist was able to drill through the crown and do the root canal; saved the tooth and the crown. Standard protocol and typical outcome for this scenario.

Agree on the pain comments!!!!!!!!!!!!!!!! Anecdotal, and not typical. Nobody bothers talking about the painless root canal they had. Like in the MSM, sensationalism sells. Does anyone think WiseOne would have bothered to start a thread on her root canal if it had been uneventful? I doubt it. She's way too busy with her upcoming trip O0
Pugchief,

Followup re. the 55 years ago root canal: I was kicked in the mouth while playing sandlot football, no big deal I thought as that had happened before with no consequence (kids will be kids ;) ). About three days later my lip swelled considerably and the pain began. My parents took me to the doctor who said I needed to see our dentist who diagnosed the condition. He drilled to open the canal of the tooth - incisor with one canal - and removed all the pulpy material to the tooth root tip. Due to the infection, he said he had to pack and repack the canal multiple times (probably 3 or 4 over a period of a week or two) with some kind of medication before he did the final. It all turned out well.

Re. the vertially cracked tooth - the dentist did offer me the option of an implant as well as the bridge. I asked him what he would personally do if he were in my place. He said the bridge because my lower jaw bone in the front where the tooth was not very thick. I went with his advice as I've been going to him for 20 years or so and trust him. Prior to the bridge my dentist sent me to an oral surgeon to remove the cracked tooth as he was afraid it would break off in the bone; fortunately the oral surgeon was able to remove the tooth without having to cut it out. That situation has also turned out very successfully. Thanks be to God for competent dentists.

I thought your overall response to Maddy and me was great. Thanks for the information.
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Re: Root canals

Post by WiseOne » Thu Sep 07, 2017 7:17 am

Pugchief, thanks for the detailed info.

Yes I quite understand some procedures may be more complicated than others, and mine probably was. However, this was never discussed with me. When I went digging into the literature, I read that about 20% of patients report severe pain (> 7/10) in the 1 week post-procedure, and the incidence is probably double that for molars. The pain-free numbers tossed around are apparently based on return visits, and thus probably grossly underestimates the incidence. There is also no data on pain associated with procedures involving more than 2 visits.

I would have understood 2 procedures given the emergency situation. However, it wasn't 2, it was 3 procedures, and the pain was worst after the last one. Add in the initial crown prep and that's 4 procedures total. No wonder! Of note, it's percussion, vibration, and general movement (induced by talking or walking up or down stairs) that are the worst triggers. So I am guessing it's the ligaments under the tooth that are inflamed.

I did hit on something worth trying, based on reading: a steroid pulse. Going to ask about this today. Again, I wish the endo had thought of this - and yes, offering a few T#3s over the holiday weekend would have been appreciated. I told him about the pain after the 2nd procedure so he should have known it would be worse after the 3rd one. I'd also told him over the weekend that the Motrin/Tylenol combination was not effective. It is now, thankfully. But almost worse than the pain was the worry that it signified a treatment failure. I would have liked to discuss this also, but the gradual improvement is reassuring, plus what I've managed to read about "flare-ups" being common and not necessarily signifying treatment failure.

What I am faulting the endo community for is false advertising. Some root canals are pain free but many are not, and it does patients a disservice to pretend otherwise. I feel like my situation was dismissed because dentists are trying to minimize fear of procedures by promoting an overly rosy narrative. It would have been much better to know in advance that this could happen, and have a plan for dealing with it. And by the way, as a busy academic with a LOT going on over the summer, having two months of sharply reduced productivity is not a trivial matter.
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Re: Root canals

Post by Mountaineer » Thu Sep 07, 2017 7:45 am

WiseOne wrote:Pugchief, thanks for the detailed info.

Yes I quite understand some procedures may be more complicated than others, and mine probably was. However, this was never discussed with me. When I went digging into the literature, I read that about 20% of patients report severe pain (> 7/10) in the 1 week post-procedure, and the incidence is probably double that for molars. The pain-free numbers tossed around are apparently based on return visits, and thus probably grossly underestimates the incidence. There is also no data on pain associated with procedures involving more than 2 visits.

I would have understood 2 procedures given the emergency situation. However, it wasn't 2, it was 3 procedures, and the pain was worst after the last one. Add in the initial crown prep and that's 4 procedures total. No wonder! Of note, it's percussion, vibration, and general movement (induced by talking or walking up or down stairs) that are the worst triggers. So I am guessing it's the ligaments under the tooth that are inflamed.

I did hit on something worth trying, based on reading: a steroid pulse. Going to ask about this today. Again, I wish the endo had thought of this - and yes, offering a few T#3s over the holiday weekend would have been appreciated. I told him about the pain after the 2nd procedure so he should have known it would be worse after the 3rd one. I'd also told him over the weekend that the Motrin/Tylenol combination was not effective. It is now, thankfully. But almost worse than the pain was the worry that it signified a treatment failure. I would have liked to discuss this also, but the gradual improvement is reassuring, plus what I've managed to read about "flare-ups" being common and not necessarily signifying treatment failure.

What I am faulting the endo community for is false advertising. Some root canals are pain free but many are not, and it does patients a disservice to pretend otherwise. I feel like my situation was dismissed because dentists are trying to minimize fear of procedures by promoting an overly rosy narrative. It would have been much better to know in advance that this could happen, and have a plan for dealing with it. And by the way, as a busy academic with a LOT going on over the summer, having two months of sharply reduced productivity is not a trivial matter.

I REALLY agree that knowing up front what the likely pain will be is really helpful. Not to divert too far from this root canal thread, but I sure would have appreciated knowing that 8 1/2 days of excruciating pain was somewhat typical (enough to make me lay on the bed and scream a couple of different times when everyone was out of the house but me) after a hemorrhoid operation.
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Re: Root canals

Post by WiseOne » Thu Sep 07, 2017 8:02 am

1. Nope. Of course, legalese like this is nice but doesn't get you off the hook, you know. Nobody ever reads these things, or digests them in one sitting. Of course I knew that ~5% of RCT's fail...and that's part of the problem, when you're in a lot of pain that you are told is not supposed to happen, and you're worried that means the RCT has failed. It doesn't. It would actually have been reassuring to know that pain like this is expected.

2. Nice euphemism. No discussion of that either.

3. No drainage/pus seen with visit #2 - I was told that specifically. I had been on antibiotics and these were stopped, also. Even as an MD it's hard to question someone at the time, but believe me I've been questioning why the 3rd visit as well, since.

4. Thanks for the info about bite being elevated due to ligament swelling!! That makes sense!!!!! The cap was adjusted at the emergency visit on Monday, which seemed to help slightly. Also, I cut way down on chewing on my own...made a big pot of soup over the weekend.

And shame on endos for not considering the Medrol pack option. We do it all the time for things like carpal tunnel flareups. This is no different.
Last edited by sophie on Thu Sep 07, 2017 8:18 am, edited 1 time in total.
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Re: Root canals

Post by farjean2 » Thu Sep 07, 2017 9:14 am

The story of my last root canal is also the story of how I finally lost nearly all faith in modern medicine.

I was feeling weak and tired and having frequent bouts of diarrhea and then when a lump appeared under my jaw I finally got worried and went to a doctor. She did a test and found blood in my rectum so she referred me to a Gastroenterogist and also an ENT doctor. The gastro doctor ordered a colonoscopy and the ENT sent me for an MRI. In the meantime he told me it was just some kind of deposit that would eventually resolve itself if I sucked on lemon drops but he would call me with the results of the MRI. My primary care doctor got the MRI result first and she had her assistant call me to make sure I called the ENT doctor as soon as possible. It was Friday afternoon and I couldn't reach him so I was worried all weekend about what it might be. I couldn't reach him the whole next week and in fact I was never able to reach him. I finally got an assistant to tell me the result and it was "unremarkable". So I have an "unremarkable" lump under my jaw and I'm sucking on lemon drops and arranging a colonoscopy for blood in my rectum but decided maybe I'd better start googling myself to see if I could figure something out. I know doctors hate it when you do that but sometimes it can be a matter of life and death.

So guess what one cause of "blood in the rectum" was? A dental abscess. Hmmm - lump under my jaw and blood in my rectum maybe this is it even though I had no dental pain. So I made an appointment with a dentist and sure enough, I had an infected tooth. It took her about 1 second to make the diagnosis because it was so obvious you could see the pus sack around it in a mirror. So I had a root canal and in six months the lump was gone. In the meantime the gastro doctor sent me a nasty letter firing me as a patient because I didn't have the colonoscopy despite his recommendation. I had one a few years later and it was "unremarkable".
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Re: Root canals

Post by jhogue » Thu Sep 07, 2017 10:42 am

WiseOne and Pugchief,

What a wonderfully informative exchange!

WiseOne, I am so sorry to hear of your horrible experience with your recent root canal. If it is any consolation, I read and re-read your post several times. Given my family history and age, I am expecting more of those in the next decade.

Pugchief, you said:

“Nobody bothers talking about the painless root canal they had.”

So, here is my experience with my first and, so far, only root canal five years ago:

I woke up one morning with an intense pain. The tooth was absolutely unbearable to touch. I stayed in bed and took ibuprofen, but by noon, the pain was so excruciating that if I had a pair of pliers handy, I would have yanked the tooth out myself. (no kidding)

I called my dentist, who was actually on vacation over a long weekend. He took my call on his cell phone even though someone else was technically on call in his practice. He immediately made a same day appointment for me with an endodontist. No later than three in the afternoon, I was sitting in the chair. Once the endodontist (obviously an old pro) drilled through the tooth, the pain instantly vanished. Just amazing. He put in a temporary fill (to be sure any lingering infection had subsided, I think) and I came back the next week for a post-op inspection and permanent. I did not lose the tooth and it has been fine ever since.

Of course, the causal underlying infection was painful, but I was really impressed with the response and professionalism of both the dentist and the endodontist. I had heard all the stories about painful root canals, but mine was as close to painless as I can imagine. Not only that, the swiftness of how the whole procedure was handled still amazes me and I can only wonder what kind of attendant health problems I might have had without the advances in modern dentistry.

So there you go, Pugchief. I have no idea how typical my experience is, but the dental profession certainly worked for me.
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Re: Root canals

Post by WiseOne » Thu Sep 07, 2017 6:52 pm

Thank you jhogue. That's the kind of story I heard from several other people, but it was mostly not on molars and all also single visit - yours was the first double visit I heard tell of. Pugchief is right that the majority of root canals relieve pain and don't cause it. Yes Pugchief, I know that the Steve Martin's character in Little Shop of Horrors is not representative of the profession.

I went ahead and took the starting dose for a prednisone taper this AM. I'm now nearly pain free despite the fact that the NSAIDs I took this AM wore off about 5 hours ago. At this time yesterday I was in quite a bit of pain right through the Motrin after taking 800mg at 2 or 3pm, and that was the best day since the procedure a week ago. I then sailed right through a very busy day. The percussion tenderness is gone too - yesterday if I tapped on my tooth I'd hit the ceiling. Today, nothing.

It was so effective I'll probably drop right down to a low dose tomorrow AM, or maybe not even bother taking any more. Yes, prednisone has side effects - but so does taking Motrin and Tylenol around the clock for weeks. One day of high dose prednisone instead? Sold.

Somebody seriously needs to do a clinical study on this. Hey Pugchief! Caveat by the way...don't do this unless you seriously know what you're about, and only after consulting with your PMD. And with the endodontist regarding the possibility of an infection - in my case both I and the endo were confident that wasn't happening.

I have no idea why no one has thought to use this for severe postoperative dental pain, but I guess the firewall between medicine and dentistry explains it. Prednisone tapers are commonly used in medicine, but a dentist has probably never seen it done.
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Re: Root canals

Post by Benko » Thu Sep 07, 2017 8:24 pm

WiseOne wrote:don't do this unless you seriously know what you're about, and only after consulting with your PMD. And with the endodontist regarding the possibility of an infection
Important since taking prednisone if you have an infection is a seriously bad idea.
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Re: Root canals

Post by Maddy » Thu Sep 07, 2017 9:29 pm

Prednisone for . . . ?
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Re: Root canals

Post by WiseOne » Thu Sep 07, 2017 9:36 pm

Pugchief, I'd love to hear if this idea works for your patients. I expect it would help if pain is inflammatory in origin, but won't do much for neuropathic pain. Cheap to try though. If it's going to work it should get results within a few hours.

I took prednisone 60mg, which is a high dose. Typically, the taper is 60mg x 2 days, then 40mg x 2 days, then 20mg x 2 days, then off. There is also a 6 day Medrol dose pack (methylprednisolone), easy to prescribe. I was planning to taper over 3 days: 60mg, then 40mg, then 20mg, then off. 6 days may be overkill, but it's fine to stop the taper at any point, no actual need for slow withdrawal if treating for less than 2 weeks.

The infection risk for a short pulse is minimal. But, it would be prudent to make sure you're not dealing with persistent active infection. Obviously if the patient worsens after starting prednisone you'll have a good idea that it's an infection, so warn them to call right away if this happens.

Other things to be aware of:

- insomnia: patient should take prednisone in the AM, not PM. Some people may have trouble sleeping after the first dose, regardless.
- if your patient is diabetic: prednisone increases serum glucose. When treating with prednisone patient should do qid fingersticks.
- if recent history of GI bleed: probably shouldn't do this. Some MDs automatically prescribe an antacid along with the prednisone. Ibuprofen is no better in this regard though.
- history of stroke, heart attack, or major psychiatric illness especially with psychosis or anxiety: I'd refrain from prednisone in these cases also.

BTW it's 10:30 pm and STILL almost no pain. Awesome.
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Re: Root canals

Post by Maddy » Thu Sep 07, 2017 11:06 pm

I've obviously heard of steroids for chronic inflammation, also for widespread, severe inflammation (e.g., as an adjunct to chemotherapy), but never for short-term, traumatic-type inflammatory pain. You've got me curious why you would bring out the big guns when a run-of-the-mill opiate and a couple of days' vacation would (presumably) do the job. I know virtually nothing about these drugs, but anything that knocks out your adrenals to the point where it requires tapering after a single dose? Geez. Sounds dangerous.

I had a cat, bless her heart, who was on prednisone long-term for IBD. A very common disease in cats, but very debilitating, and probably very painful, as it progresses. Initially she was given a steroidal concoction called depo-medrol, which is an injectable preparation in a gooey base that causes it to diffuse into the bloodstream over a three-month period. Some time later, a veterinary critical care specialist discontinued that drug with the comment, "The stuff ought to be outlawed." For several years thereafter, my cat was on oral prednisone. However, I was never warned about the need for tapering, and I'm sure that I discontinued and resumed it many times, trying to keep her on the least aggressive, yet still effective, protocol. You know, you do your absolute best to protect these helpless little creatures; then you find out something like this. God I hate vets.

Sorry to hear you've been through all this, WiseOne.
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Re: Root canals

Post by WiseOne » Fri Sep 08, 2017 3:24 pm

Maddy, did you get up on the wrong side of the bed this morning?? I wouldn't have imagined you'd try to argue that prednisone is more dangerous than narcotics so early in the day :-)

In this case, I figured out that the problem causing the pain was swelling in a limited space that was taking a long time to resolve (weeks). That's something that is best addressed by steroids, while NSAIDs and narcotics only mask the symptoms and have more side effects if they're used for that time period. And narcotics just weren't an option for me anyway - too sedating. So the steroid was the right tool for the job.
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Re: Root canals

Post by Maddy » Fri Sep 08, 2017 4:37 pm

WiseOne wrote:Maddy, did you get up on the wrong side of the bed this morning?? I wouldn't have imagined you'd try to argue that prednisone is more dangerous than narcotics so early in the day :-)

In this case, I figured out that the problem causing the pain was swelling in a limited space that was taking a long time to resolve (weeks). That's something that is best addressed by steroids, while NSAIDs and narcotics only mask the symptoms and have more side effects if they're used for that time period. And narcotics just weren't an option for me anyway - too sedating. So the steroid was the right tool for the job.
Sorry, I didn't mean to sound snarky. I'm genuinely interested in why you'd choose prednisone over a narcotic in this instance. Perhaps you assume that I know more about these drugs than I do.

Indeed my (lay person's) assumption is that steroids generally are a more dangerous class of drugs than narcotics. The dangers of narcotics seem to be all about their addictive potential, and I've never known any normal, squared-away person who comes home from the dentist with a script for Tylenol #3s to have that problem. To the contrary, the people whose lives have been ruined through dependency on opiates tend, curiously, to be simultaneously engaged in thirty-nine other addictive methods of ruining their lives. Also, there seems to be an agenda at play when the studies citing the prevalence of narcotic abuse in the general population include people who on a single occasion took a T#3 from a neighbor for a headache.

Ironically, I was thinking last night (quite tongue in cheek) that it would be just like the feds, fixated as they are on the issue of opiods, to issue guidelines putting every malingerer with a sore back on steroids.
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Re: Root canals

Post by WiseOne » Fri Sep 08, 2017 11:19 pm

At risk of straying off topic to answer Maddy's excellent questions...

There's no such thing as a 100% safe drug. Every drug has what's called an "LD50" i.e. a dose that's lethal to half the lab animals (usually mice) that are given it.

The word "dangerous" is a bit misleading I think. You really mean "side effects", and they're much more common with narcotics than with prednisone or NSAIDs. Mainly it's sedation, respiratory suppression, unpleasant GI symptoms, and a potentially life-threatening withdrawal syndrome if taken continuously for long enough (even if there's not an addiction per se). Then there's NSAIDs which most of us think of as harmless. One of the most common reasons for liver transplant in the US is Tylenol overdose, and for some people, an overdose can happen even if they follow instructions on the bottle. And if you take ibuprofen for a long enough time, you risk a whole host of side effects including rebound headaches (which I'm experiencing right now, what a lovely surprise), gastric bleeding, and liver or kidney damage that is often irreversible.

So I guess you could consider all of them dangerous, just in different ways and depending very much on how much you take and for how long, pre-existing medical problems, and individual susceptibility. I really don't like narcotics because they make me nauseated plus I can't afford to be sedated for even a day, let alone a week. On the other hand, some people might do fine on them and tolerate them better than NSAIDs. As far as prednisone goes, yes there are people who have had bad side effects like hyperglycemia, opportunistic infections, and significant weight gain, but that's typically from long term use.

BTW yes, sometimes Medrol packs are prescribed for back pain, depending on the cause. It's very effective for acute herniated discs, sciatica, and nerve entrapment syndromes. Also, prednisone is one of the very few drugs known to be safe in pregnancy, so it gets used quite a bit in that setting for everything from migraines to allergies.

I should mention that these aren't the only classes of meds out there that can be used for pain control, but I think I've now written enough on the topic. G'night!
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Re: Root canals

Post by Don » Sat Sep 16, 2017 8:22 pm

Coming to this website is a root canal.
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Re: Root canals

Post by Xan » Sat Sep 16, 2017 8:42 pm

Don, you're welcome to not read (and more than welcome to not comment on) threads that don't interest you.
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