While all is not equal with x-rays and a cone beam, having both tools available is a priority for me. However, sometimes, even these tools don’t show the whole picture. Why?
Well, people always say “Don’t judge a book by it’s cover.”
I always say, “Don’t judge a tooth by its x-ray.” Also, don’t assume the worst. Give things a chance.
That’s how I practice endodontics. I never say “never,” and I always give teeth a chance. I won’t know if something is going to work until I try. Let’s look at a specific case that highlights the need for both tools!
Patient: 35 year old woman with pain in a tooth that had already had a root canal
Diagnosis: Previously Treated and Symptomatic Apical Periodontitis
X-Rays and a Cone Beam: I Do Both
My philosophy served a recent patient well. She came to me as an emergency case, experiencing lots of pressure and pain on a tooth that had already had a root canal. Usually, I try not to “meet and treat” my patients, because I need time with them — they have questions that I want to answer. I like to make sure the patient understands their treatment and treatment options, and I want to make sure I am treating the right tooth.
Getting the patient to understand the why is key, and that takes communication, transparency, and patience.
However, if the patient’s pain is characterized by intense pressure, and they are in tears, I reassess the situation and treat immediately. I know that their tooth is trying to drain, and I want to make that happen for them.
When a patient comes to me and their tooth already had a root canal, my protocol is to take not just x-rays but a cone beam as well. (Now do you see why x-rays and a CBCT go hand-in-hand? Or at least in MY practice, they do!)
Different Pictures: X-Rays and Cone Beams
Some dental professionals would have said that the cone beam was suggestive of a vertical root fracture… and that was possible (and most definitely a part of my differential diagnosis). But I could not be certain.
The x-ray imaging looked like the previous root canal had been done well. But since I had no history of the tooth — and the patient didn’t remember any details — I had to keep in mind that it was possible that the tooth had a new bacterial infection that had nothing to do with a crack. It can be easy to blame pain and infections on cracks when treatment isn’t working, but bacteria is a more likely culprit.
So Many Unknowns
There are so many variables I did not know about the initial treatment. Was a rubber dam used? Was full-strength sodium hypochlorite used? How long did it take the patient to get her crown?
I gave the patient her treatment options: retreatment with another root canal, or extraction with an implant. I explained to her that, even if she chose a second root canal, I could find a fracture in the tooth and it would still need to be extracted. She wanted me to try it anyway. Complete transparency before starting procedures is extremely important to me and to my patients.
When X-Rays and a Cone Beam Aren’t Enough
What I found surprised me. I opened the tooth to find black, black and black. I was so surprised to see the level of infection in the tooth. The gutta percha was so contaminated by infection that it turned black.
Once I removed the gutta percha, the infection started to drain. And THIS is the key to helping a patient feel better. Instant gratification for both me and my patient.
An Informed Decision
I understand that there’s a learning curve to reading cone beam images, and they can be misinterpreted. Some would have thought to take this tooth out because of a possible fracture (since root fracture can cause pain after a root canal).
If you’re not 100% definitive in the cause of root canal failure, then access the tooth for a visual assessment to be sure. Sometimes we don’t know the answer before going into the tooth. But if you prepare your patient for the potential outcomes, then you have given them the option to take the chance with you.
Thankfully, I had both the x-ray and the cone beam images to help inform me. Every tool and process plays an important role, and the more you stick to your gut and evaluate the different options, the better chance you have of saving teeth. (That said, don’t forget the “sticking to your gut” part, because your tools may not always show you everything.)
X-Rays and a Cone Beam Image: Each a Part to Play
The cone beam for this patient did not look good, but if I had judged the tooth by its x-ray, I would have done a total disservice to this patient. It would’ve been a complete misdiagnosis, because the root canal infection didn’t show up on the X-ray.
I was lucky that the patient wanted to try and save the tooth. It was the right choice for her and her health.
In Conclusion
Always be transparent with your patients. Give them all their options — and the “why” behind each option. If you rely solely on an x-ray to diagnose, you can make the wrong choice. Use all the information and clues you have.
Remember, a tooth can be contaminated, yet that won’t show up on x-rays and a cone beam. (In fact, I would recommend you assume that it’s contaminated over just trusting what the images say.) Be open to stepping outside your standard operating procedure if it allows you to better serve a patient… especially one who is in pain.
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This. Everyday!♡♡♡♡♡
Thanks JM! I feel the same!
Mam so irrigation was at fault in this case?
Patrick,
Bacterial contamination is the etiology. I don’t know whether or not a rubber dam was used, nor how they instrumented or irrigated. These are things we may NEVER know on a retreat, so I just proceed knowing that bacteria needs to be eliminated.
-Sonia
Great case..
Every tooth need the 2nd Chance…
Thank you Dr. – I’m glad we agree!
-Sonia
My main frustration with my Endodontist friends is when they tell me a tooth is fractured and hopeless, and I don’t agree. I am all for saving teeth. Sometimes I can see the reasoning behind the diagnosis, ie: difficult patient, questionable prognosis. It always pleases me when you do give the tooth a chance.
Thanks for all you do!!!
Hi Robert, I will be one of your Endodontist friends who agrees you can save a tooth!
I don’t think a difficult patient or a questionable prognosis should ever stop you. I think as long as you’re transparent with your patient and explain the possibilities, and then if they are still willing to try, then it’s worth the exploration.
Thanks for following!
-Sonia
Many years ago a dentist told me there were 3 types of lies;
1) Lie
2) Damn lies
3) Xray lies!
He was correct. we just cannot see everything and sometimes we just get fooled. I once saw a 3rd molar with a PERFECT looking 3 canal obturation done by a specialist. It was absolutely killing the patient. Upon extraction, I saw that each canal had 2 to 3 mm gutta percha overfill- but it looked perfect on the X-ray.
Most of my patients would have opted for extraction due to the cost of retreatment. This person already had the cost of RCT and crown in this tooth.
Was this case one where there was a temporary filling inside the access opening and they never had it sealed permanently?
Wayne,
I love the 3 types of lies! In this case, there was no temporary filling, it was permanent buildup. But they didn’t place the buildup all the way down to the gutta percha.
Thanks for following!
-Sonia
Thank You for the case study.
Thinking outside the box after “ listening “ to the patient and what the tooth is trying to tell you is often missed in a hurried, fast paced practices. Every day in practice we have opportunities to do good for the patient and walk away feeling gratitude and happiness.
Keep up the good work Sonia !
Hi Dr. Kamodia! It means so much that you’re reading these! Stay tuned for much more…
-Sonia
Dr Sonia thank you for constant updates….
Your blog gives me constant check and support to what all I decide as treatment plan, which is almost same way you do to much extent.
I keep myself up just to read your blog and that gives me strength, support and confidence as many of my fellow Endodontist colleague here in India differs.
Keep Up the good work !!!
Regards
Dr. Shanin Farista
MDS – Conservative Dentist and Endodontist
Laser Diplomate
Divas in Laser
India
Thank you so much for reading Shanin! This is my mission – to help spread knowledge that we all need to practice better everyday!
-Sonia
I just had my second opinion from an oral surgeon that they don’t see anything on my x-ray. First opinion was of my dentist was they don’t see anything on the x-ray. I don’t have the pain but a pulsating sensation and what I describe as nerve sensations up the left side of my face. It seemed as if the surgeon was thinking since I already had a root canal on the tooth I think is causing the problem that I would have these nerve sensations. I am so frustrated because I feel like whatever is happening is spreading to my ear and whoever knows where else and I am over it! I would have gladly let him pull the tooth but now I am taking matters in my own hands and finding anyone that will listen!
I’m so sorry you’re going through this, Michelle! I’m glad you’re advocating for your own dental health. You are empowered to make the right decisions for you!
-Sonia
What was the outcome? I am going through similar situation
Hi Bua, the patient did not come back for a recall, so I don’t know for sure. But I did this over a few visits and she was completely asymptomatic. Hope that helps!
I just had a root canal in May. Still in pain with cold and aching jaw pain. My dentist doesn’t see a failed root canal, so she sent me to an Endodontist. He did X-rays and endoice test. Endo says root canal was done well; however, says that there could be an infection inside the tooth, and that options would be to re-treat with a root canal, or extract the tooth. He says that there should be no pain or feeling in the tooth right now, so encouraged the root canal. Is this accurate? Can there be an unresolved or trapped infection? My dentist did give me antibiotics (maybe a month after the root canal), and that didn’t help. I feel like we doing another root canal as a shot in the dark, but I guess there isn’t another option?
Hi Liz, thank you for your question. It’s possible the root canal needs to be redone, or it’s a different tooth that needs to be treated. The answer depends on your symptoms and how your teeth test. I would trust your endodontist. In my own practice, I have had to retreat some of my patients’ root canals; they healed well afterwards. Wishing you the best. -Sonia
I have been having a toothache for the last 3 months. That tooth had root canal treatment. My dentist took xray and didn’t show anything as it is in your case. I was prescribed 3times antibiotics (amoxicillin then metronidazole) there is no progress on the healing. Still having the pain. I am just wondering if I am the same case as yours.
Ian,
There are many reasons why you may still be having pain. More antibiotics are NOT going to help. It sounds like you may need your root canal retreated. I would start there and perhaps see an Endodontist. I hope this info helps.
Best,
Sonia
I had a root canal done on mt tooth D30 in april. It’s been 7 months of pain, discomfort, sensitivity. Even my ear and my neck hurts and some noises even bother me.
Visited 3 endo specialist, 2 oral surgeon and 1 dentist.
All i got is the fillings are a bit overextended and a bite adjustment. Everything else is looks fine or it’s too early to tell.
I am literally desperate. Any ideas?
Antonio,
I am so sorry to hear that you are in pain. Has it gotten any better? It’s so hard to be able to give you advice when I can’t personally evaluate you. I hope that you understand. If it still hurts, then I would request that the tooth be re-treated, but again, I don’t have any imaging or anything to give you proper advice.
-Sonia
A good case for study Dr Chopra ! Those who have no access to a cone beam hopefully would’ve done the retreat .
Michael,
Thanks for reading! Yes, I always assume possible contamination.
Sonia
Hi Sonia I had a root canal treatment on my bottom back tooth on my right side in 2008. this was done after my crown came off, When the crown was put back in place with the paste or glue that was used I was in instant pain it affected my nerves somehow, I was put on amitriptyline to help with nerve regeneration. I then had root canal done apparently it was a success. My crown was refitted. About 2 years later my crown fell off one night so after hearing my story my new dentist put back with what he said was temporary paste. Twice over the coming years I was in pain with no infection or swelling but my dentist give me antibiotics anyway and the pain went away that I think in about 2016. This year the the intense pain came back but my dentist was closed due to COVID lockdown in the UK but he prescribed me antibiotics twice when the first didn’t seem to work he suspected an infection my pain went away again. Now in the last month the pain is back so I had an appointment and my examined me and took an X-ray and compared to the one taken in 2008 and could see no real difference but did put me on one round of antibiotics but this time the pain has not gone. Does this fit with the patient you had that showed good X-rays ? I apologise t’s such a long story but I would be interested in your thoughts if you have time. Thank you
Alistair,
Unfortunately, without xrays and a full clinical examination, it is so hard for me to give you feedback. I don’t want to misdirect you. I hope you understand. Please find an endodontist near you.
Best,
Sonia
Hi Dr. Chopra,
Great case !!
What conc. of sodium Hypochlorite do you use for irrigation ?
Thanks 🙂
Richa,
I do not dilute anything, so 5.25% to 6% works best!
Sonia