Dentist Hits The Nerve

[cheeryble]

Hi there

I've completed three (or is it four?) sessions towards a root canal, post, and re-crown on a molar with three roots. It is now derooted and filled I believe.

I'm slightly concerned.

The last two times the injections have been very uncomfortable indeed. The first time (or two) only meant very uncomfortably probing around with the needle for about two minutes into what seem to be many positions....seemed to be twisting it to different angles without withdrawing ) and I got and ulcer or at least inflammation afterwards at the needle area.

The last two times she hit the nerve. I'm sure she hit the nerve because the first time I got like an electrical jolt down my tongue.

The last time I made a roaring noise which would have been a scream if my mouth hadn't been full of stuff, and got the shock in a line along the outside of my mouth underneath and to the right side of the lower lip.

Each time she has done the amazingly annoying Thai (Chinese actually) thing of smiling or even giggling, but apologized saying she wanted to get as near the nerve as possible (each time seems to have been surprised that my tongue wouldn't go as numb as she expected).

Now I don't want to unfairly give her a bum rap, but I nver had a nerve hit in my life and if it goes on I'll get kind of scared of the dentist. I already am!

Is this all fair enough? Is it just a chance I take for effective anaesthesia?

Cheeryble

Edited May 24, 2011 by cheeryble

[cheeryble]

Quick I have to go back Friday morning!

[moe666]

My dentist does the same here in the states but after he has injected me we just wait a while for the stuff to take effect. There doesn't seem to be a reason to get close to the nerve as the shots numb that half of my face in about 10 to 15 min.

[cheeryble]

My dentist does the same here in the states but after he has injected me we just wait a while for the stuff to take effect. There doesn't seem to be a reason to get close to the nerve as the shots numb that half of my face in about 10 to 15 min.

Thankyou Moe

but I think I haven't made myself clear.

It's my dentist who's hitting the nerve with the novacaine needle. Twice running!

I mean if she hit it dead centre would it be possible to sever it?

Me no like.....

[payanak]

Hope I can help here.

Since you are getting work done on a bottom molar you are getting what is called a mandibular block injection. This single injection involves numbing two nerves. The first is the lingual nerve (going to the tongue) and the second slightly deeper is the main mandibular nerve (going to the nerve inside the canal of each tooth).

In school we are taught the detailed anatomy of all structures of the head. This allows the dentist to give an injection into the jaw where the nerve is "supposed" to be located ideally. The great majority of times it is done without too much excitement. However, some patients do not have the anatomy of the average patient and the nerves are somewhat out of place. This can result in no anesthesia because the nerve is far out of place or in your case hitting the nerve dead on. This does not mean the injection was done incorrectly. This happens to every dentist occasionally. I have had this happen, averaging less than once a year but never twice on one patient. Some adjustment in the position of the needle during injection is normal but excessive movement as you describe can damage tissue and even cause muscle trismus (cramping) for several days.

I have never heard of the nerve being permanently damaged by the needle tip hitting it. Your experience of a sudden electrical type shock of very short duration is the norm. At the very worst case a patient could have a paresthesia of the tongue or lip for a month or two. This would be quite rare.

Most root canals, even three and four canal molars, are completed in a single appointment, about an hour. This is an average number, of course. The post (seldom used these days), buildup, and crown preparation are done a second appointment, and the new crown delivered on a third appointment.

In summary, it appears your dentist was probably operating within acceptable limits in spite of your bad experience. Dentists come in all different flavors just like any group of people. Some have a great touch and great hands and other ... well less so. I am sorry I don't have any way to tell you how to find the former.

[cheeryble]

Hope I can help here.

Since you are getting work done on a bottom molar you are getting what is called a mandibular block injection. This single injection involves numbing two nerves. The first is the lingual nerve (going to the tongue) and the second slightly deeper is the main mandibular nerve (going to the nerve inside the canal of each tooth).

In school we are taught the detailed anatomy of all structures of the head. This allows the dentist to give an injection into the jaw where the nerve is "supposed" to be located ideally. The great majority of times it is done without too much excitement. However, some patients do not have the anatomy of the average patient and the nerves are somewhat out of place. This can result in no anesthesia because the nerve is far out of place or in your case hitting the nerve dead on. This does not mean the injection was done incorrectly. This happens to every dentist occasionally. I have had this happen, averaging less than once a year but never twice on one patient. Some adjustment in the position of the needle during injection is normal but excessive movement as you describe can damage tissue and even cause muscle trismus (cramping) for several days.

I have never heard of the nerve being permanently damaged by the needle tip hitting it. Your experience of a sudden electrical type shock of very short duration is the norm. At the very worst case a patient could have a paresthesia of the tongue or lip for a month or two. This would be quite rare.

Most root canals, even three and four canal molars, are completed in a single appointment, about an hour. This is an average number, of course. The post (seldom used these days), buildup, and crown preparation are done a second appointment, and the new crown delivered on a third appointment.

In summary, it appears your dentist was probably operating within acceptable limits in spite of your bad experience. Dentists come in all different flavors just like any group of people. Some have a great touch and great hands and other ... well less so. I am sorry I don't have any way to tell you how to find the former.

Wow Payanak thanks for the great info.

Strange that one of the shocks should have been on the outside of my face (very clearly felt it going down a line)

It's a three root molar and she says the roots are very long.

It's been three or four sessions now I think four, and it's now filled.

She intends to do a post.

Is this now outdated for some reason? Should I do something about this?

(Unfortunately the appointment is at 10am Friday so may be too late.)

thanks again and she seems to be recommending the more expensive palladium or gold based crowns whereas as it's a back tooth I'm tending to the cheapest. Is it worth the extra money? The whole deal for the cheapest is already going to be a bit more than 18,000 baht which I think's plenty for Thailand.

cheers Cheeryble

Edited May 26, 2011 by cheeryble

[cheeryble]

I'd also add that i noticed neither she nor a dentist I visited last year has to my knowledge done a comprehensive inspection of my mouth which i thought would be standard. In fact i noticed a pain poking around with a toothpick on the opposite side.

[cheeryble]

Another question.

Apart from the dentist using my eyeball as an handrest and a couple of choking fits yesterday's 2 hour session went off OK and we now have "post" in and the mould taken for the new crown. As Payanak suggested it wasn't a post but a fibre thingy inserted down into to the "root" to strengthen it with nothing protruding.

She has asked me what type of crown I want.

Regular 7000

Palladium alloy base 10000

Gold alloy base 15000 up.

My question is....do I need more than the regular?

The thing I mentioned in my other post about her not having done a comprehensive exam, like the first thing they would always do in the old National Health system in England was fill in a tooth chart.

I mentioned it, and she said oh she would do it at the end. Hmmm. Be that as it may she looked at the other-side-molar I pointed out on which I have some sensitivity if I poke it with a toothpick or if she blows cold air on it. She examined it and said

"Oh it's a very big cavity." She said "We might as well take it out, the tooth opposite is missing."

I said, politely worded perhaps

"Errr that's what you said 9 years ago"(I had now decided it was the same dentist I saw that one visit long ago)

I told her how I had later, considerably later, gone to see my dentist friend in England about the "urgent" problem and he had told me it was an arrested cavity and to do .....nothing.

"Ohhh" she said.

What's more I said the tooth has moved over to a considerable angle where, excuse me I know you're the dentist and all that, but where it's clear it's doing useful work against the tooth not quite opposite and well worth having.

"I could fill it" she asked. "Would you like me to fill it?".

She asked in the way so many medical people in Thailand ask patients what they suggest.

So.

To fill or to extract or to leave. What's the worst that's statistically likely to happen if it gets worse? I have to have it out? Not too much chance of another root canal?

Thanks a million

Cheeryble

Edited May 28, 2011 by cheeryble

[payanak]

Cheeryble,

I am somewhat at a loss to give you the precise answer you would like. You are asking for a specific diagnosis and recommendation without me seeing your mouth or even an X-ray.

You state the opposite tooth has a cavity that is at least 9 years old to your knowledge. Your English dentist said it was "arrested." I have no idea what this means. Decay never sleeps! The fact that you have some sensitivity to cold and a toothpick (stop using that thing) implies there could be some early communication of the decay to the pulp.

Whether or not it is worth it to you to save the tooth or invest any more money in it is a value judgement every patient has to make. As a dentist, of course, my kneejerk response is to tell you to save it. The talk I would have with a patient about the long term consequesces of progressive tooth loss is too long for this format.

Doing nothing will ultimately result in another root canal and crown being nedded. If finances are a concern (and they are for everybody) I might suggest to at least get the filling done. This will hopefully remove the decay, temporarily restore the tooth, and buy some time before you get a crown done. If the decay is too far gone and she cannot simply restore the tooth you can then decide to extract or go further.

The fact that she used a "fiber thingy" instead of a metal post suggeste that she is fairly current. However, failure to take a medical history before treatment is below the standard of care anywhere.

And finally, you asked about the choice of crown. Again this is somewhat of a value judgement on your part. I will assume you are talking about a porcelain crown with a metal substructure. All the crowns should, in theory, provide the same fit and longevity. The non-precious metal base crown is the one that the great majority of patients receive in the US. They are quite serviceable.

The time involved with the dentist is the same for any of these crowns. The amount of metal used in any of these "porcelain fused to metal" crowns is fairly small, a fractiion of an ounce. I don't understand the huge difference between the highest and least expensive. The only real downside with the non-precious metal is if it contains nickel (most do) and the patient has a allergy to nickel (not uncommon). This would result in a constant inflammation of the gums around the crown. If you have ever had any type of skin reaction to wearing cheap costume jewelry then you have a nickel allergy.

When faced with a choice of alternative treatments anywhere on your body I can give you one bit of advice. After listening to all the pros and cons of the alternative treatments simply ask the provider what would he do for a member of his family. I have only the high gold content in my mouth and that is what I have done for friends and family.

I hope this gives you something to go on and haven't just added to any confusion.

[cheeryble]

thankyou kindly for all the help Payanak

Interested that you hadn't heard of an "arrested" cavity.

My friend in England did mention "we now call it an arrested cavity" and (he's a gay) his boyfriend was a teaching and research professor so it may be new 9 years ago don't know.

Anyway thanks again interested that the dentist here didn't give me any good information about types of crown typical of what i experience with the medical profession here I'm afraid. I think I'll move on for further work.

Thanks again

Cheeryble

[cheeryble]

Abis an example of an arrested cavity. Despite the decay having advanced well into dentin, the exposed dentin was hard and shiny. The tooth had been in this state for at least 10 years.

This example is admittedly not very attractive (to say the least), but does show that tooth decay can heal even when it has advanced beyond the enamel and well into the dentin.

Note that while the decay has been arrested, the cavity does not infill.

From "Oral Histology: Development, structure and function", Dr A.R. Ten Cate, 2nd Ed., 1985. (click for larger image)

When a tooth is attacked by decay or suffers an injury such as a chip, if nutrition is good, it responds by depositing what is referred to today as reparative or tertiary dentin. (In Dr Mellanby's time it was called secondary dentin). The reparative dentin forms only in the area affected by decay or injury, and is an attempt by the tooth to protect the pulp.

Teeth containing large cavities, which ordinarily would have an area of softened dentin surrounding the zone of destruction, were found instead to be very dense.

Open cavities showed no signs of progress

months after they were first observed.

Dr J.D. Boyd, MD and Dr. C.L. Drain, DDS, 1928

In active decay the tissue for some distance below the surface is more or less depleted in minerals and feels "soft" to the dental probe. In early stages of arrest the surface zone may feel rough or leathery. In the next stage the surface is found to be hard but rough, and later the irregularities may be removed by mechanical abrasion. This process may take months or years, but eventually

the surface may become quite hard, smooth and polished

, but active decay may have stopped long before this stage is reached.

Dr May Mellanby, DSc, 1933

Happily mine doesn't show like the one above .....

Edited May 31, 2011 by cheeryble