Causes of root canal treatment failure. - Reasons why completed endodontic therapy may prove to be unsuccessful. -

An overview of the kinds of procedural difficulties and errors most frequently associated with failed cases. - What can go wrong? Why? What can be done?

Missed
canals.

Link to endodontic failure due to missed canals section.

Tooth
cracks.

Link to endodontic failure due to tooth cracks section.

Why has your tooth's root canal treatment failed?

This page explains issues that are frequently identified as being the causative factor(s) in the failure of a tooth's endodontic therapy.

  • Some of these are diagnostic and procedural issues/errors that might have been handled more successfully.
  • Other issues involve factors related to characteristics of the tooth, its root canal system or condition at the time of its treatment that made your case more of a challenge or less predictable.

 

Why cases fail.

Unsuccessful cases generally involve a situation where there is some type of deficiency associated with one (or both) of these fundamental goals of endodontic therapy:

  • The cleaning aspect of the tooth's procedure has been incomplete or ineffectual. With the irritants that remain inside the tooth causing the case's failure.
  • The seal created for the tooth (either by its root canal procedure or by its final restoration) has not been successful in keeping contaminants from seeping into, or out of, the tooth.

    The seal might have been deficient initially, or was initially intact and has since deteriorated.

 

It may be that procedural shortcomings or complications have prevented the completion of the tooth's work according to the standards needed. Or issues associated with the tooth's preoperative condition may have created obstacles that prevented the tooth's successful treatment.

What can be done for failed cases?

With each reason for endodontic failure, we also explain how the tooth's situation might be remedied. Generally, there are only two options, extraction or case retreatment (conventional or surgical). This page explains in greater detail what those options may entail: What's the fix for failed root canal treatment?


Examples of specific reasons why root canal treatment may fail.

 

Reasons why root canal treatment fails.

1) Missed canals.

Different types of teeth (molars, premolars, canines, incisors) characteristically have differing numbers of roots and root canals. But unfortunately for the treating dentist, there are no hard rules about the configuration that actually exists.

  • Specific roots of some types of teeth are well know for having, or frequently having, multiple canal configurations, and because of this should always be suspected of having more than one.
  • Even beyond what might generally be expected, it's always possible, no matter how rare, that the anatomy of a tooth's root canal system is simply atypical.

 

The back root (root "a") of a lower molar may have one or two canals.

Picture of an x-ray showing a lower molar's root canal anatomy.

If it has two but both aren't found, its root canal treatment will fail.

A dentist's due diligence.
The problem/question that arises is how much effort a dentist should reasonably expend in searching for these, possibly rare, variations.
As a point of fact, additional canals are frequently tiny in size and as such difficult to identify. Additionally, they may have a location inside the tooth that's strange or unexpected.
  • At a minimum, looking for possible variations takes additional time. Although, this should just be a minor consideration for the dentist.
  • Worse, searching a tooth exhaustively can involve trimming away aspects of its interior that can result in structural weakening. Of course, this is especially disappointing when no additional canals are discovered.

 

For these reasons, it's easy enough to understand why a dentist might not be astoundingly inquisitive if the configuration they have already discovered lies within the parameters of what can be considered normal for the tooth involved.

The underlying problem.

The crux of this issue is simply that any untreated (overlooked, undiscovered) canals, no matter how minute in size, will remain a locus of persistent infection.

And as such, that leaves the expectation that they will lead to the failure of the tooth's root canal treatment.

Picture of a dentist using a surgical microscope during root canal treatment.

An endodontist using a surgical microscope.

Incidence rates.
  • A study by Iqbal determined that missed canals are a major cause of root canal failure (around 18% of failed cases), and most commonly associated with treatment provided by general dentists as opposed to specialists.

    (It's common for an endodontist to use a surgical microscope as a visual aid in their search for additional canals. Also, a specialist is more likely to be familiar with what variations might exist, and more likely to be able to adequately treat very tiny canals. See discussion and link below.)

  • A study by Hoen evaluated 337 failed root canal cases and determined that overlooked canals played a role in 42% of them.

Section references - Iqbal, Hoen

What's the solution for failed cases involving missed canals?

Once the untreated canal(s) has been identified, conventional retreatment of the case is frequently successful.

2) Unfilled accessory and lateral canals.

The anatomy of the root canals inside a tooth can display variations.

Animation showing lateral and accessory root canals.

Variant root canal anatomies.

  • An accessory canal is any branch of one of a root's main canals that leads off to its own exit point on the root's surface.

    Somewhat arbitrarily, accessory canals are typically defined as canal branching found in the apical end (tip portion) of a tooth's root (last 1/3 of the root or so).

  • A lateral canal is also technically an accessory canal. But, and again arbitrarily, usually defined as branching that occurs in the upper 2/3rds of a tooth's root.

    As a point of difference, lateral canals often run horizontally from the central canal directly to the root's side. In comparison, accessory canals might be considered to have a more split-off/branched configuration (see animation).

 

The underlying problem.

With both of the above variations, it's common that the division of the canal isn't identified (they typically aren't observed on x-rays). And even when detected, it may be difficult, or even impossible, for the dentist to adequately treat (clean, shape, fill) the branch.

If that's the case, and just like with missed canals discussed above, the result will be one where some of the tooth's root canal system is left ineffectually treated. As a result, the deficient portion can provide a location where infection can persist and therefore act as a continued irritant to the tissues that surround the tooth's root, ultimately leading to case failure.

Incidence.

The root canal systems of any and all teeth have the potential to include accessory canals in their configuration. (They form when tissues that play a role in root formation become entrapped during the calcification process.) And their existence is quite commonplace.

An evaluation of 493 extracted teeth by Ricucci determined that 75% of them had accessory/lateral canals.

The question then arises, if they are so common, and they are difficult to clean and fill, why aren't they a dominant factor in root canal failure.

As one might expect, studies suggest that the size of the accessory canal and the contents they harbor (such as microorganisms and their byproducts) are key determinants in the outcome for the tooth.

Section references - Ricucci

What's the solution for failed cases involving untreated lateral or accessory canals?

Once the untreated canal(s) has been identified, it may be possible to successfully retreat the case conventionally. In some cases, surgical retreatment (a process where the problematic portion of the root is trimmed off) may be needed.

A cracked molar.

Some cracked teeth may not be treatable.

3) Cracked roots.

Cracks that extend into a tooth's root can be colonized by bacteria. But unlike root canals that can be cleaned and sealed off, there's no way to treat the minute spaces created by cracks.
That means that once they've been invaded by bacteria, the infection that results due to their colonization can't be cleared up. It will be a persistent source of irritation to the tissues that surround the tooth's root.

As such, the tooth's outlook is one of case failure. Short of amputating the affected root (if this option exists at all), case retreatment/further treatment is generally not possible.

Difficulties.

There are several issues that can make dealing with cracks especially difficult:

  • When performing a tooth's endodontic therapy, a dentist may be unaware that a crack exists (they can be very difficult to identify), or underestimate the extent of the ones they see. Either way, the tooth's problems won't be resolved by its treatment.
  • It may be that the crack that has caused the tooth's failure formed after it received its endodontic treatment.

    This might be because an inadequate "final" restoration was chosen for the tooth (such as one that didn't provide a strengthening effect), or its permanent restoration was not placed soon enough (the damage occurred while the tooth's provisional restoration was still in place).

  • It's also possible for what seemed to be a minor, manageable crack at the time of the tooth's treatment to progress.

    Beyond cases like those just mentioned, this scenario is even possible with seemingly appropriately restored teeth (e.g. crown placement), if the chewing or clenching forces they're subjected to are intense enough.

Section references - Torabinejad

What's the solution for failed cases involving cracked roots?

Tooth extraction is often the only option. With multi-rooted teeth, it may be possible to salvage the tooth by cutting off the problematic root (root amputation).

4) Inadequate root canal seal.

The integrity of the seal created inside a tooth during its root canal procedure is an important factor in treatment success.

  • It serves as a barrier to the seepage of bacteria and other contaminants into or out of the tooth.

    (This is important in preventing recolonization of the tooth's root canal system by microorganisms. Also, any leakage from the tooth would serve as a source of constant irritation to the tissues that surround its root.)

  • The filling materials physically occupy the space of the root canal system. (When the full extent of a root canal is not filled in and sealed, tooth space remains that can harbor bacteria.)

 

It may be that the tooth's intact seal has deteriorated over time. Or that the placement of its filling materials resulted in shortcomings initially (due to underfilling, the presence of voids, etc...). And while there can be technical reasons why underfilling a canal has occurred, deficient fills can generally be expected to correlate with the level of clinician expertise.

A study of 90 failed cases by Iqbal determined that 1/3rd involved underfilling the tooth's root canal space.

Section references - Iqbal

What's the solution for cases that have failed because they have lost their endodontic seal?

Conventional retreatment is often successful with these types of cases.

5) Overextension of the tooth's filling material.

Studies have shown that in cases where the materials used to fill in and seal a tooth's root canal system extend out beyond its root's tip (overfilling, overextension), the likelihood of endodontic failure is increased. (Tabassum)

  • In an evaluation of 337 failed root canal cases, Hoen determined that overfills played a role in 3% of them.
  • Iqbal's evaluation of 90 failures found that overfilled canals played a role in 10% of cases.

 

The cause.

The basic problem involved with this issue is one of bioincompatibility. Due to the presence of the materials, a foreign body/inflammation response may be triggered in the tissues surrounding the root's tip.

This response doesn't occur in all cases. And in fact, it's possible for normal and complete postoperative healing to occur in the presence of an overfill.

As a final point, while it's true that in clinical practice unforeseen events sometimes occur, generally speaking, the ability to properly confine root canal filling materials within a tooth must be considered a factor that correlates with the clinician's level of experience and skill. (See specialist vs. general dentist discussion below.)

Section references - Tabassum, Iqbal, Hoen

What's the solution for cases that have failed related to the overextension of root canal filling materials?

Successful conventional retreatment of the case may be possible. In situations where the gross overextension of materials can't be retrieved, surgical retreatment may be necessary.

6) Inadequate coronal seal.

A defective or inadequate final restoration (the "permanent" one placed after the completion of a tooth's endodontic treatment) can allow bacteria and other contaminants to reenter the inside of the tooth. (The x-ray graphic above shows an example of this situation.)

This phenomenon is referred to as "coronal leakage" and it is a major cause of root canal failure. For more information, use this link: What is Coronal Leakage?

Even the highest quality root canal work can't survive (resist reinfection of the root canal space) if its tooth's permanent restoration doesn't provide an adequate seal. The study by Hoen cited above reported that 13% of failed cases involved complications with coronal leakage.

What's the solution for cases that have failed because they have lost their coronal seal?

Since the tooth's root canal system is now recontaminated, case retreatment (usually conventional) is needed.

7) Other types of technical shortcomings with the tooth's procedure.

Beyond the clinician-associated issues mentioned above, other technical/procedural errors and complications can arise and have a detrimental effect on the treatment outcome of a tooth. This might include:

  • Failure to treat the entire length of the tooth's canals. - An important aspect of the root canal process is establishing the length of each of a tooth's individual root canals, and then treating this entire distance.

    Falling short can result in leaving debris and contaminates behind that can be a constant source of irritation to the tissues that surround the tooth's root, thus resulting in treatment failure.

  • Problems caused when shaping the canals - A dentist's use of root canal files may inadvertently create an internal configuration that deviates from normal canal anatomy. (Applicable terms include: canal ledging, apical transportation or zipping.)

    This kind of alteration can make the process of cleaning and/or sealing the affected canal(s) difficult or impossible.

 

  • Perforations - When using drills or files, a dentist may inadvertently create a hole (perforation) that penetrates the side of the tooth's root.

    Depending on the size and location of the perforation, some can be repaired successfully. However, in some instances the presence of the opening may make it difficult or impossible for the dentist to slide their tools and sealing materials beyond that point, thus inhibiting complete (proper) canal cleaning and sealing.

  • Broken instruments - The files that a dentist uses to clean a tooth's root canal system sometimes break. It's generally attributed to manufacturing defects, fatigue from usage, or with rotary instruments, creating a situation that places too much torque on the file.

    As a worst-case scenario, the broken piece may be lodged inside the tooth and cannot be retrieved. If so, while leaving the fragment inside the tooth is never the dentist's first choice, the point during the treatment process when the incident occurred may be a mitigating factor.

    If the file separation has occurred after the canal's cleaning process has already been completed, then possibly the canal can still be adequately sealed even with the fragment present. If the incident occurred during the cleaning process and inhibits its completion, the prognosis for the tooth's treatment is much less favorable.

 

Statistics.

The study of 90 endodontic failures by Iqbal cited above determined that about 6% of the cases could be attributed to problems associated with perforations, and 7% broken instruments.

What's the solution for these types of failed cases?

If the dentist thinks that they can overcome or correct the previous difficulty, then endodontic retreatment is indicated. If not, the tooth will need to be extracted.

8) Lack of clinician expertise.

Research suggests that treatment performed by endodontists (root canal specialists) tends to have a higher success rate than that provided by general dentists.

For example, the study by Iqbal cited above that evaluated failed cases determined that roughly 80% of them had been attempted by general dentists. (See additional statistics below.)

Why referral to a specialist may make sense.

Any dentist can tell you, providing endodontic therapy for some teeth will prove to be amazingly straightforward, and then for others surprisingly involved. Unfortunately, a tooth's level of difficulty can't always be predicted.

For this reason, some dentists may feel they can boost their patient's chances of success by referring suspect cases on to an endodontist before complications arise. Per the data found on our failed root canal statistics page, this might be an especially prudent choice for certain types of teeth (like molars).

Additionally, our page "Endodontist vs. General Dentists- Which makes the best choice, and when?" discusses this issue in detail.

A periapical radiolucent lesion.

A tooth with a periapical radiolucency.

Teeth having pre-op radiolucencies may be more likely to fail.

9) Preoperative tooth pathology.

A tooth's initial status may play a role in the ultimate success or failure of its endodontic work. One such concern involves teeth that have a "periapical radiolucent lesion" (see picture).
These types of lesions may continue to harbor bacteria despite the successful completion of the tooth's root canal treatment. If so, this (external to the tooth) locus of infection will be a persistent irritant to the surrounding tissues.

The Iqbal study cited above suggests that the success rate of teeth having this initial condition (vs. those that don't) may be lower, on the order of 20%.

What's the solution for these types of failed cases?

In cases where the dentist's evaluation of the quality of the tooth's previously performed root canal treatment seems acceptable, the solution for this situation may be a minor surgical procedure referred to as an "apicoectomy with retrograde filling."

During this procedure, the tip of the tooth's root is trimmed away (an apicoectomy is performed). The exposed root canal opening on this trimmed surface is then sealed by placing a filling (a "retrograde" filling).

10) Contributing / Complicating factors.

It's possible that your tooth's root canal treatment has been successful but the tooth itself has problems due to other factors.

a) The tooth has broken or fractured.

Teeth that have undergone root canal treatment are typically considered less structurally sound than they were originally, possibly substantially so. And for this reason, they often require the placement of a dental crown for strengthening and protection.

If an endodontically treated tooth does break, it's not always a big problem.

  • Assuming that the damage is confined to just the crown portion of the tooth (not its root), it's quite likely that the tooth can be rebuilt. (In some instances, the repair may require the placement of a dental post and core.)
  • If the crack extends into the tooth's root, an evaluation will need to be made to determine if the likelihood of making a successful repair seems possible (see above).

 

b) The tooth has extensive decay or gum disease.

Just like any other tooth, teeth that have had root canal treatment are at risk for the formation of tooth decay and gum disease. And if allowed to advance, either of these conditions can ultimately lead to the tooth's loss.

What's the solution for these types of failed cases?

If the tooth's condition can be corrected or overcome, then endodontic retreatment is indicated. If not, then the tooth will need to be extracted.

 
 
search

 Page references sources: 

Hoen MM, et al. Contemporary Endodontic Retreatments: An Analysis based on Clinical Treatment Findings.

Iqbal A. The Factors Responsible for Endodontic Treatment Failure in the Permanent Dentitions of the Patients.

Ricucci D, et al. Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures.

Tabassum S, et al. Failure of endodontic treatment: The usual suspects.

Torabinejad M, et al. Endodontics. Principles and Practice. Chapter: Longitudinal tooth fractures.

All reference sources for topic Root Canals.

Comments

Part of r/c tool may be left inside tooth toothpain

had root canal 8 months ago then new crown put in tooth has pain if I bite hard or floss in dentist said part of a file might be in the tooth. Sent X-ray to dentist who did the r/c. What now?

* Comment notes.

Elaine

If you have a tooth that is still sensitive 8 months out, it should be evaluated.

You mention you have a new crown on the tooth. If something is amiss about the crown's "bite", that could be the cause of the tooth pain/sensitivity you notice.

In regard to having a broken root canal file inside a tooth. Sometimes beyond the dentist's control, root canal files do break. Generally a broken file is not a favorable situation and may lead to treatment failure. But only your dentist can determine this.

Continued Tingling Discomfort in Root Canalled Molar

I developed painful sensitivity in my upper left back molar. The tooth had a large silver filling that had been present for at least 40 years. Negative xrays during a couple of visits to my general dentist. Referred to an endodontist and had positive longitudinal tap sign and positive cold testing. He did a root canal that was painless and I assume did a temporary filling.

It felt painless for two weeks until I saw my general dentist again. His plan was CAD/CAM in the office. He shaped my tooth, did the scans and impressions, but the milling machine software crashed. He sent me out without a temporary, I avoided chewing on that side, came back 4 days later and he made the CAD crown and cemented it. It was hitting really high as soon as I started eating and it sadly took about 5 visits before he got the bite right. I have have tinging discomfort in it to both longitudinal and lateral pressure (tongue and finger) and with chewing.

Endodontist took another full mouth X-ray scan (kind off like a CT). He says the root canal work looks fine and can not justify retreating. No obvious cracks are seen. He ground the crown a bit more. My bite feels fine but the tingly pain persists. HOWEVER, I took the Medrol dose pack that he prescribed and the tooth started to feel completely normal. But the discomfort returned a day or two after I completed the dose pack. Endodontist has pretty much relegated my tooth as one of the “few” that don’t behave and he assumes I’ll elect to have it extracted. I’m just about ready to do this but feel like there has to be a solution. Plus, I’ve “invested” quite a bit. Any analysis would be appreciated.

* Comment notes.

sgmorr

We're not going to have much to offer. While Googling around, we kept bumping into a statistic that suggests that roughly 5% of treated cases are still mired with some level of persistent pain that's not possible to resolve.

It sounds like your endodontist has checked your tooth out as well as can be. In regard to what you mention about taking Medrol (the only item that seems to create an improvement) ...

The use of the Medrol (a steroid) has the effect of limiting inflammation. With your case, the question would be is the persistent inflammation (that the steriod when taken helps to minimize) associated with some type of treatment failure/inadequacy (missed canal, undetected additional canals, cracked root, etc...), all of which have been searched for but can't be identified by your endodontist and therefore they can't treat.

Or is the inflammation still due some type of occlusal traumatism (as in the shape of the crown still isn't right).

In the sense of grasping at straws, in theory even though your bite feels right, during left and right excursions there could be some prominence that gets hit and therefore still traumatizes your tooth. A scenario could be that this occurs as you grind your teeth at night.

If the only alternative is extraction, there seems little harm in trimming the crown down just out of occlusion as a try. Possibly it already is.

Pain after recent crown and root canal of molar

Last year I was experiencing some pain with #15 molar, particularly with compression. My dentist took x-rays and said there was nothing conclusive but perhaps either a crown or root canal would fix it; he did also say a cracked root could be the problem but couldn't be sure. I opted for a crown. A couple months later, I was still experiencing pain and was referred to an endodontist for 3D scans and a root canal. The scan didn't show any cracks and a root canal was performed. Now in the last month or so I'm getting headaches from the dull pain, which comes and goes. The tooth hurts more when compressed or when I apply pressure on the sides. Another x-ray at the dentist showed cloudiness above the tooth, and the dentist again mentioned it could be a cracked root. My tooth has never felt right even after all the work and $ spent. Is it safe to assume this tooth needs to be pulled after all? Who can definitively tell me whether the root is cracked or not? I might add the dentist is somewhat new to me and I've never used the endodontist before.

* Comment notes.

NO

Sorry to hear about your troubles. We would think that you need to let your endodontist evaluate your tooth and its current set of symptoms and make a recommendation about possible solutions.

"Who can definitively tell me whether the root is cracked or not?"
Your endodontist would be in the best position to make this determination, although the word "definitively" may not exactly apply.

We read through some published research papers that evaluated dentists' ability to diagnose cracks in sample groups of teeth using 2d and 3d x-ray imaging. It seems cracks were only identified on the order of 75 to 85% of the time.

One problem with a tooth having a crack is that it gives bacteria a location to live. And over time, their presence (the infection they cause) will tend to trigger changes in the bone that surrounds the tooth (you mention the "cloudiness" seen). So, that may help the endodontist determine if/where a crack lies.

---
"Is it safe to assume this tooth needs to be pulled after all?"
If the tooth is cracked, yes extraction probably is indicated.

A possible middle ground might be root amputation.
If the tooth has multiple roots (you mention that your problem tooth is #15), and the endodontist can determine which root lies at fault, it may be possible to cut that root off.

This isn't always possible or a good idea, your dentists will have to fill you in. But sometimes this provides a way of salvaging the work you've already had done.

Failed root canal

I have a failed root canal then did a retreat and now I have slight swelling and pus pocket (like the pic u have of a boil) on the gum by that tooth. X-ray shows now that there is a vertical fracture on that tooth. can this tooth be saved or is the best option just to extract it and have implant there?

* Comment notes.

EO

Generally speaking, the problem with a crack in the root of a tooth is that between the two parts there exists a space that bacteria can colonize yet your dentist can't get at them and clean them out (like they did with your tooth's root canal system).

The consequence of this scenario is that an infection will persist in the crack's space. The fact that you notice swelling associated with your tooth suggests that this is what's going on.

In that case, the tooth can't be successfully treated (the infection can't be cleared out), so extraction (with some type of artificial tooth placed, such as an implant) is the only alternative.

The single exception would be the case were the cracked (infected) root can be trimmed off (root amputation), leaving the remaining successfully root canaled/healthy portion of the tooth.

Obviously this option is only possible with multi-rooted teeth (molars, some premolars). If possible, it doesn't always make that great of a choice but it may. Only your dentist can advise you if pursuing this option makes a reasonable plan.

Failed RCRT attempt Upper Right 1 (Incisor)

Brief history:
2000 - trauma to tooth playing squash - whacked in the faced from opponents backhand racquet. Now a dead tooth.
2004 - Huge Abcess drained + RCT. Evidence of root tip absorption. 2 attempts at RCT over 3 week period.
2017 - Abcess like symptoms returned. Dentist said watch & wait. Acute swelling & mild pain subsided without use of any meds.
2018 - (2 weeks ago) - full on abcess. Drained. Evidence of further root tip absorption. Procedure involved RC re-treatment. Thought was fine but..
Last few days - new swelling. X rays show that Accessory point pushed through beyond end of root tip by a good couple of mm. Most likely from new insertion rod pushing through old debris from first RCT up into cavity. This most likely causing existing bacteria to start brewing again without interruptions!

Have been referred under 'urgent' to local Dental Hospital for Endo-treatment plan and potential Apicoectomy. In the meantime 7 day course of Antibiotics - whilst it may not end infection it'll hopefully stop it spreading further.

Prognosis not great.. Especially with old debris not in cavity space above & beyond root tip...oh dear

* Comment notes.

Missed canal

Hi,
My endodontist saw a missed canal (on 3-D) imagery. My tooth is sometimes sensitive and doesn't hurt very much. There is no sign of infection on X-ray. I wonder whether I should wait and see or get it retreated. I am worried about the 10% risk of ending up with oral surgery for a tooth that doesn't cause much problems for now. Thanks!

* Comment notes.

ksenija

Our interpretation of what you state is this:

1) You have an endodontically treated tooth whose treatment has an obvious deficiency (the missed canal).
2) You have noticed symptoms with your tooth, which could easily attributed to a waxing and waning persistent infection associated with the tooth (the untreated canal).
3) The x-ray doesn't show signs of infection. (An x-ray is only able to show signs of the effect of infection going on inside a tooth on the tissues that surround its root. It isn't evidence that there is no infection inside the canal (like a low-grade one that has little effect on the tissues).).

It's easy enough to state that if the tooth's original endodontic treatment was initiated because the tooth was infected, that the untreated canal (a part of that same root canal system) would still contain bacteria and therefore the tooth is in need of retreatment to resolve that.

The problem with the "make do until it gets worse" approach is that infections are unpredictable and their flareup may be a significant event.

We would think that if your endodontist favored treatment that their opinion would be based on much of what we've stated here. And it seems a textbook approach would be that the tooth requires attention and plans should be made to go ahead and treat it.

Lingering post-treatment inflammation, pulp stones

Thank you for putting together such a useful and informative resource, and for taking the time to answer all the questions people ask here.

Are you aware of cases where the inflammation and discomfort after root canal treatment takes a long time to resolve (more than a month)? If so, is this more likely if there was chronic inflammation present before treatment, e.g. due to a cracked tooth?

Have you come across situations where chronic inflammation due to a cracked tooth has caused the formation of pulp stones in the opposing or nearby teeth? Have you ever heard of pulp stones themselves becoming a source of inflammation?

As you might guess, these questions stem from my own symptoms. I have discomfort and pressure sensitivity persisting more than a month after root canal treatment on #18 (for a small crack above the gumline; there was inflammation, but it had not progressed to infection). Follow-up x-rays don't show any signs of infection, but did reveal pulp stones in #14 and #15.

* Comment notes.

Ken

>>Are you aware of cases where the inflammation and discomfort after root canal treatment takes a long time to resolve (more than a month)?

We have a number of pages that discuss complications and treatment failures. Scroll up this page, you'll find the menu of this topic's pages.

>>If so, is this more likely if there was chronic inflammation present before treatment, e.g. due to a cracked tooth?

The presence and magnitude of preoperative apical periodontitis seems to correlate with a poorer case prognosis. With apical periodontitis being caused by infection of the root canal system by microorganisms. We're not so sure this definition is the same as what you mention.

>>Have you come across situations where chronic inflammation due to a cracked tooth has caused the formation of pulp stones in the opposing or nearby teeth? Have you ever heard of pulp stones themselves becoming a source of inflammation?

The presence of pulp stone is not rare.

Here's from Cohen's textbook of endodontics:
"There is no clear evidence whether pulp calcification is a pathologic process related to various forms of injury or a natural phenomenon. The clinical significance of pulp calcification is that it may hinder root canal treatment."
"Therefore, from a clinical perspective, it would be very unlikely that a patient’s unexplained
pain symptoms are due to pulpal calcifications, no matter how dramatic they may appear on a radiograph."

Here's from Ingle's textbook of endodontics:
"Discrete pulp stones are not considered pathologic. Their only clinical significance is that they can add to the adventure of locating and instrumenting root canals."

Both of these books are listed as references for this page above.

>>I have discomfort and pressure sensitivity persisting more than a month after root canal treatment on #18 (for a small crack above the gumline; there was inflammation, but it had not progressed to infection).

A scenario could be where the crack is more extensive initially thought. Or has progressed since the time of the treatment (timing of final restoration, type of final restoration, see menu above).

Thank you for your detailed

Thank you for your detailed and thoughtful response.

My dentist and endodontist continue to investigate, but their diagnostics are inconclusive so far. Hopefully they will figure it out soon.

* Comments marked with an asterisk, along with their associated replies, have either been edited for brevity/clarity, or have been moved to a page that's better aligned with their subject matter, or both. If relocated, the comment and its replies retain their original datestamps, which may affect the chronology of the page's comments section.


Add new comment

Comments (especially personal narratives) that don't contribute to the learning/teaching intent of our pages will be deleted. Comments that don't relate to the subject of the page they are posted on especially well will be moved to a more appropriate one, or deleted, after a few days.

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
Please answer the question so we know you're a human.
Feedback