Failed Root Canal - malpractice?

[fosterp]

I had tooth #19 that needed a root canal about 6 months ago and went through with it and all seemed ok, except at the end after the crown was placed the tooth seemed still slightly sensitive to pressure and just didn't feel right. I never really chewed on that side because the tooth above it was also undergoing RC treatment after so it was easy to ignore and hope it goes away.

Forward 6 months it was still bugging me and I am getting braces on in a month so I had to ask my dentist about it and he took some xrays and said it looks like their filling didn't go far enough into the root so he was going to retreat it. That kind of made me sad since I had to drill through a brand new crown. So today they did the retreatment and he pulled my xray up to show me and pointed out that for some reason (he thinks because maybe I missed an appointment during the several appointments needed to complete the RC and restoration) they did clean out the canal, and the appointment to fill the canals was never done, and he put in the post, core, and then crown, without the canal being filled.

My question then is, how could such an oversight be allowed in dentistry like this? I don't know all what is involved in a root canal, but how is it possible that my dentist could not be aware the canal was not filled when putting in post, etc? If perhaps there was a mess up in scheduling and the office ladies may have just scheduled the post and core buildup after I had missed the canal filling appointment, is there no obvious way for my dentist to realize that the canals were never filled outside of an xray?

When my ortho consultations did my panoramic xrays and I saw them I noticed that the canals didn't look like they were filled with anything. I googled some images of other RC xrays to see what it should look like and indeed there was a big difference in the solid color down the canals that my tooth seemed to be missing.

Is my dentist incompetent/not paying attention or what? I have had this dentist since I was about 11 and I trust him fully, and hes one of the most expensive in the area, but I go there because I trust him, but should something like this be a reason to question his ability? Or is it an easy mistake to miss because of clerical errors?

There is an xray to show you what the finished restoration looked like a couple months ago.

teeth7g.jpg (22.33 KiB) Viewed 240 times

[mbornfeld]

Dear fosterp,

First, allow me to disabuse you of some erroneous presumptions indicated by your mark-ups of the photo, which I took the liberty of cropping for the sake of clarity. First-- I could be wrong, but I don't think your dentist put a post at all in your tooth. Even a resin/fiber post would appear more radio-opaque than what is residing in the root canals your tooth... which brings us to what actually is in the canals. Those canals which supposedly do not contain fillings-- DO contain fillings. Admittedly, they are the faintest, most wispy, ghost-like root obturation fillings I've ever seen, but your dentist obviously made some attempt to fill those canals-- albeit, on what must have been a really off day for him.

This may not materially change the general picture, but at least the premature placement of a crown on your tooth was not the result of your dentist having amnesia or even dementia. More likely, it is due to his setting the bar very, very low when it comes to root canal therapy. It is the standard of care for a dentist to take a postoperative x-ray of a completed x-ray to assess the quality of the root canal filling. If he hadn't taken that x-ray, he would have deviated from that standard of care. And if any competent dentist had taken an x-ray and bothered to take a look at it, there would have been no way that he wouldn't have known that this tooth is in serious need of additional endodontic work prior to moving forward on a crown.

Of course, a really trustworthy appraisal of your dentist's competence depends heavily on the specifics of the events. Chronology is important-- there is no date on your x-ray, and the date at which your services were provided were not supplied. But if your x-ray truly reflects the state of affairs at the conclusion of your previous root canal treatment-- at the time when your dentist exultantly declared "mission accomplished", to borrow a phrase from our former president-- he is similarly mistaken. I will leave it to the lawyers to determine whether this meets the definition of malpractice, but it certainly was not one of your dentist's prouder moments.

It is every dentist's responsibility to know the limits of his abilities, and to refer a patient elsewhere if those limits are not up to a particular challenge. In this regard, your dentist seems to have dropped the ball.

As an aside, you should know that the x-ray you have provided shows quite a few other decayed areas scattered around your mouth. It would be important for you to have that decay treated, and that root canal on tooth #15 completed, prior to initiating active orthodontic therapy. After you are all strapped up with wires and brackets, it will be much more difficult to access those cavities in order to repair them. You should also prevail upon your dentist to implement additional decay prevention strategies, such as the use of prescription-strength fluoride products, because tooth decay tends to become more prevalent while wearing orthodontic appliances.

Good luck!

[fosterp]

From what I understand the dentist pulled up an xray of the tooth two days ago that they took that day after he had drilled through the crown and then showed it to me on my screen which looked very similar to the panoramic one I linked to, and then pointed to what I indicated as the post, as being the post, and then indicating the lack of filling material inside the canals. I'll admit its a very poor x-ray so maybe its too hard to tell from the image I gave since that kind of xray is not very good for diagnosing tooth condition.

He basically said he was able to leave the post in for retreatment as he was able to file past the post, so there must be something in there. I guess my own self diagnoses was the fact that the roots of my tooth looked just like the roots of my other untreated molars.

Also, you mentioned areas of decay on other parts of my mouth. I am curious as to which you were referring to, because at the moment the only thing left in my treatment plan was the obvious root canal on 14, and then replacing the filling on the premolar next to 19. Is my dentist missing a whole bunch of other cavities in my mouth?

[mbornfeld]

Dear fosterp,

This is what I mean when I said that the chronology is important. I have no idea when this panoramic film was taken relative to the initial root canal treatment, the placement of the post, or the placement of the crown. (There is a crown in place on #19, but I have no way of knowing whether it was replaced by a second crown.) I also have no idea just what other services were provided after this film was taken, so you may or may not still have all these cavities. However, assuming that your radiograph is not suffering from certain visual artifacts (it does happen), I see decay on teeth #2, 4, 5, 12, 13, that unfinished pulpotomy on #15, #18, an open margin on that crown on #19, and #20. I would definitely have your dentist take another look at that x-ray, or seek a second opinion in person to put your dentist's work in proper perspective. There's only so much one can infer from one x-ray.

Good luck!

[fosterp]

This panoramic is the most recent full x-ray of my mouth taken a couple months ago. No other dental work was done on my teeth except the root canal on #14 (i know it looks like 15 from the way its tipped, no idea why its like that), and the reopening of the crown on 19. It is indeed the final result of the first round of root canal therapy on 19, with a porcelain fused to metal crown, post, etc. It is when I mentioned the crown being slightly sensitive to pressure that my dentist took another look at #19 with a new xray and then said he has to go back in and redo the filling in the root. After he accessed the root he basically said he didn't know why there was no filling going into the roots, only explanation being a screw up with scheduling or note taking. What really annoys me about the situation is that I don't think my dentist would have even noticed if I hadn't mentioned sensitivity, and the tooth could have just been left like that for who knows how long, causing who knows what kind of problems. He was "glad I mentioned it to him" which gives me the impression that I need to start looking at my own xrays to diagnose my own problems.

I am glad you mentioned other areas of decay in my mouth...even though its really disheartening to have to find a new dentist since this one I've trusted since I was a child, but it seems to me this guy just doesn't care whats going on in my mouth or being too cautious when it comes to addressing potential problems. I really don't see any other explanation for what has happened these last few months. Thank you for the help!

[fosterp]

Just wanted to follow up to my situation, and I have yet another question that is nagging me...yes I know I look up too much stuff and get myself psyched out. Basically I had them print out my history of appointments that sort of shows the description of each appointment and what procedures were done on each tooth and what not.

The most recent tooth #14 which is healing normally had my first appointment labeled as #14 Root canal therapy - molar. Then a week later, #14 RC Inst & fill. And then in two days I have scheduled #14 prefab post&core in add to crn.

On the history for #19 I have #19 Root canal therapy - molar. Then a week later I have a failed appointment, and then three days after #19 prefab post&core in add to crn.

So basically I know it wasn't done properly because there is no #19 RC Inst & fill...But my nagging question now is sort of related to that tooth #19. Let me give you a bit of history on it. The tooth had been WAY overdue for a root canal since I was a teenager, but since I had no money or insurance and I didn't want to remove it because my dentist says it could be eventually salvaged in the future provided I baby it and try to avoid chewing on it. It sat with one of those medicated temporary fillings in it for I don't even know how many years, at least five. During that five years it started hurting onceand I had it retreated with the same medicated temp to hold off the pain, but other than that I never chewed on it. The tooth was badly broken down on one side almost to the gumline, and the temp covered it for most of the time until towards the end the edges were becoming exposed and I finally had the resources to fix it. I can't remember if the tooth was ever sensitive to pressure since I never bit on it, but I do believe it was slightly sensitive to pressure in the couple months before I treated it finally. So then back in august I had the RC (which we now know was screwed up), and then the post and crown placed. Also of note when they tried to take off the temp crown for the permanent placement, the prying of the crown caused an unbearable amount of pain and they had to numb me up just to take it off which seemed very unusual. Since the tooth was back in occlusion (although not totally because #14 above it was also broken down) it was obvious the tooth was mildly sensitive to pressure. I let it be because I thought it just needed time to heal, but now here in february when I finally asked my dentist what the deal was, he admitted a mistake was made. I was confident the retreatment would be the solution, but now its been about a week after retreatment and the tooth does not feel any different. Now I am reluctant to have him restore the crown with a permanent filling when the tooth still isn't right.

To basically describe the symptoms, it is VERY MILD sensitivity to pressure and nothing else. But it is sensitive enough to know it is not like the other teeth, and I cannot effectively chew anything that is somewhat hard on the tooth. When I clench my teeth together moderately, a sort of dull ache originates from the area that lasts a couple minutes. The amount of sensitivity seems to increase or decrease throughout the day. Waking up in the morning is when it is most sensitive, and sleeping on my side with that tooth kind of causes the same dull ache. Oddly the tooth is sensitive to biting pressure but not lateral pressure when I wake up but the biting sensitivity goes down a lot, but then the sensitivity from pushing on the tooth laterally goes up. It just seems that if I push down on the tooth, it becomes less sensitive to the pushing from the top, but then very sensitive from pushing on the side. I can even push on the roots of the tooth through the gums (this is not sensitive) and then push back down on the tooth from the top in which its very sensitive at first. I know this is way overly too descriptive, but its basically seems as if my tooth is moving slightly around inside its periodontal ligament(for lack of a better word), it is very sensitive to movement, as if its inflamed somehow.

There are only three things that I can think of that could be causing this, and I was hoping you might have some opinion on possibilities, even though the information is limited. My first thought is that I have a vertical root fracture, since the mild sensitivity and sensitivity to lateral pressure were possible symtoms, and during one of my cleanings two months ago there was an isolated 6mm periodontal pocket on one side of that tooth which is also a classic symptom. But from what I know I dont think there were any signs of a periodontal abscess, which would also be present in the case of a VRF?

My second guess would be the fact that the way my teeth contact on that side is kind of abnormal. Since tooth #14 is out of occlusion due to the root canal in progress, #13 is the only tooth that contacts with 19. Additionally, I have a bit of a crossbite on that side so the contact between 13 and 19 is a bit different. Could this kind of malocclusion cause this tooth to be overly sensitive in this manner even though the nerves are gone? None of the other teeth in the area are sensitive though, and the teeth on the opposite side that are sort of in the same crappy situation with a missing tooth have no problems with sensitivity (its the side I always use to chew coincidentally).

My third guess is the fact that this tooth sat half broken for years and years and years just sort of ruined the supporting ligaments underneath...somehow...Not sure if it this is a likely explanation but I don't think it helped any by leaving it with a temp filling in for 5+ years.

My only last guess and what I am hoping is the problem (but I doubt) is that the crown just needs the permanent filling placed. I am really hesitant to have it done though since I kind of doubt this will fix it (since I still had sensitivity before the brand new crown even had a hole drilled in it). The sensitivity is really not getting any better over time so its really driving me bonkers trying to figure out what it might be. I just hate waiting and I know this is extremely long post to read and I appreciate you taking the time, if you even made it this far lol. I am just afraid I am going to lose yet another molar, and I would even go as far as to just leave it as it is even while going through orthodontic treatment, until I can afford to have an implant placed immediately after extraction.

[mbornfeld]

Dear fosterp,

It is true that persistent symptoms after root canal could be due to root fracture, occlusal trauma, or some injury to the periodontal ligament. However, the list would not be complete without considering two more possibilities.

The unfortunate reality is that no therapeutic technique offers a 100% probability of success. This consideration is not unique to dentistry; some coronary bypass patients never make it to the recovery room, nor do a certain percentage of brain surgery patients. It is unrealistic to expect anything more from root canal. In fact, root canal therapy shares one characteristic with cancer therapy: the longer the disease remains untreated, the lower the likelihood of a favorable outcome.

On a more optimistic note, the other possibility is that you may be expecting too much too soon. That infection has been with you for...what-- two years? ten? Do you really expect any injury or disease of such longstanding to instantly resolve? I've seen teeth manifest some residual symptoms for several months after what ultimately prove to be successful root canals, so you can't infer either success or failure only one week after your re-treatment.

Because of the uncertainty of the prognosis of your tooth, I would strongly advise you to hold off on any additional restorative efforts until you have seen definite signs of improvement in the symptoms. Be ready to cut your losses if signs of infection persist or re-emerge, because you will need to conserve your resources of time, money, and resolve for your other treatment.

Good luck!