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In order to give you a better understanding of whether or not you need a root canal, its best if you first understand a few facts as they relate to tooth nerve pain and root canals diagnosis.


 Pain Is Subjective

No Pain


Silent Problems With No Pain

The expression of pain in general including toothache pain is subjective. Each patient uniquely has a different pain tolerance, and will express levels of pain differently. It’s not uncommon, given the same recognizable clinical signs: the tooth nerve is exposed (necrotic) and root canal therapy is indicated, that one patient has extreme pain 24/7 and can’t even sleep, while another patient has no pain at all.


Tooth Pain Can Be Poorly Localized

Treating the Wrong tooth is a Bad Idea But Double Checking Is Not

Dental pain can be poorly localized, i.e. it may be difficult to locate the tooth or teeth that are causing the pain. Tooth pressure Proprioception or ability to sense the orientation or tooth-jaw relationship is very complex and highly evolved, but connecting the specific tooth to a random pain signal is not well learned and may be difficult to communicate. At times it’s like locating the bad bulb in an old strand of lights. Treating the wrong tooth is a bad idea but double-checking to confirm it’s the correct tooth is not.



Multifactorial In Origin

A Complex Combinations of Problems Will Complicate Diagnosis

Dental pain or symptoms can be a result of multiple combined causative factors. One tooth can have a necrotic pulp with a pressurized root tip infection in the bone: symptom =  throbbing pain. While an entirely different tooth can have an extremely sensitive exposed root surface: symptom = pain from hot, cold, or from the touch. Patients often mistake the tooth with the extreme root sensitivity as the tooth which is also causing the throbbing bony pain. There are numerous other complex combinations that complicate diagnosis. With multiple symptoms and multiple causes patients need to keep an open mind during the diagnostic steps. In all cases avoid jumping to a quick diagnosis. Allowing the dentist to methodically complete several tests is a very important first step. The goal is to locate the tooth or teeth involved and to allow the dentist to systematically locate as many of the potential causes as possible.


Diagnosis Can Be Ambiguous

Systematically Eliminate the Mimics

Other dental problems or conditions have symptoms that mimic those of root canals. For example, the presences of a traumatic bite, or parafunctional habits, or even food impaction between teeth commonly cause symptoms that may lead to a miss diagnosis and false recommendation for root canal therapy.

See the “10-Common Dental Problems That Mimic Root Canal Like Symptoms” List Below



Avoid The “Catch-All” Misdiagnosis

Avoid the Invisible “tooth crack syndrome” concocted and used as a “catch-all” diagnosis that becomes the solution for the distressed patient.



Case In Point

Image you’re the doctor and the patient you are seeing today has extreme debilitating pain and has not slept for days. The symptoms expressed are similar to other patients who you have seen and definitively diagnosed the need for root canals. You have gone through all standard clinical tests you learned in dental school, yet there is still no definitive clinical evidence to support the need for a root canal. Without the knowledge or experience of the list of “10-Common Mimics” below, you may just humanely recommend a root canal. Without 100% proof, the “cracked tooth syndrome” diagnosis is given as the reason and the root canal treatment is recommended as a humane solution for the suffering patient. The up side is, the tooth nerve is removed and in most cases the pain is greatly reduced. But here’s the down side: in the case of a misdiagnosis, in addition to the unnecessary cost and unneeded treatment, the root canal treatment is a temporary fix. Other problems and symptoms will likely return.




The “Cracked Tooth Syndrome” Diagnosis


In the presence of vague clinical evidence, it can be difficult to arrive at a definitive root canal diagnosis. Without a definitive diagnosis some doctors may present the catchall “cracked tooth syndrome” diagnosis and recommend a root canal. On the Internet, the “cracked tooth syndrome” is described as a symptomatic tooth “usually having fractures that are too small to be seen on X-rays.” The words: “usually” and “too small to see” should be enough for most patients to seek a second opinion. Certainly it’s possible there may be tooth cracks that are too hard to see. But this diagnosis is used way too often. And as a rule of thumb, its best to use advanced diagnostics in order to first rule out other more commonly occurring conditions, which produce root canal like symptoms, before speculating that the problem is caused by something you can’t see.


10-Common Dental Problems Or Conditions That Mimic Root Canal Like Symptoms

  1. Occlusal Trauma (Unbalanced Bite Forces)
  2. TMD Symptoms: i.e. ear and jaw pain, or sore throat pain caused medial Pterygoid muscle.
  3. Parafunction (Day Time Habits Or Night Time Grinding that cause tooth nerve pulpitis & muscle pain.
  4. Hidden Decay, Gum Recession or Root Exposure
  5. Food Impaction Wedged Deep Between Teeth (Food impaction causes a lot of pain and is very common). 
  6. Extra Canal Invasive Resorption (ECIR)
  7. Gum Infections That Produce Swelling In Your Face Or Cheek
  8. Sinus Problems
  9. Post Treatment transient tooth sensitivity, i.e. Reversible pulpitis caused by New Dental Restorations.
  10. Painful Herpes lesions: Typically Extraoral or on hard tissue


If you have received the “cracked tooth syndrome” diagnosis” it’s a good idea to seek a second opinion at our office, even if you have to travel a bit to get to us. If the cause is not obvious at first, we will complete numerous tests including but not limited to the 10 conditions listed above. As we clinically proceed, Dr Landers fills out a copyrighted wide-ranging root canal exam sheet, systematically documenting your symptoms and test results. Additionally, we use 3D/4D dental images to confirm or rule out root cracks or other related dental problems. Our advanced diagnostics commonly save teeth from root canals. It’s always our goal to determine a recognizable clinical cause. Call us; we would like to help you.


Hidden Dental Problems Exposed By 3D Dentistry

One-dimensional x-rays may not show all of the dental problems. With 3-D dental imaging the doctor can explore in all three dimensions to see through dental anatomy and ultimately to expose hidden problems behind, under, or in the middle of the tooth or tooth supporting bone.

3-D dental images are like having superman’s  X-ray vision. The doctor can see through dental anatomy to find hidden objects

“The Shell Game” -Three shell tops -Now find the hidden pea.


Why not have all of the information, it takes the guesswork out of finding the problem.


3-D Images -Cross Sectional View of Root Tips


Anatomical Variations -High Pulp Horns

Nerve Exposure – Chewing Surface Looking Down

Pulp horns are tiny horn-like extensions of the pulp that lengthen in the direction the anatomical tooth cusps. Filled with dental nerves, there can be one to several horns per tooth and numerous individual configurations.

Why is this important to root canal diagnosis? While pulp horn anatomy is not well represented in medical illustrations, these horns exist and anatomically extend higher for some. To further complicate matters, these pin-size extensions are rarely visible on 1D dental X-rays and may be unknowingly exposed by hidden cavities or when the dentist removes deep decay in a patients tooth. Sometimes nerve horns are so tiny, the dentist doesn’t even notice the exposure (small pink dot shown in the image to the left). An adult tooth with an exposed nerve horn is prone to infection and will need a root canal or an extraction. If you have a history of deep fillings, or have problems after a new filling, it’s another diagnostic possibly for your problem.

Pulp horns are longer in children and due to age-related continuous production of secondary dentine (calcification of the tooth pulp), the tooth pulp and pulp horns decrease in size.


“Tooth Nerve Damage Is Cumulative” Often With No Clear Etiology (Cause For The Problem)

The Straw that Broke the Camel’s Back Analogy

The tooth nerve is centrally located inside the tooth in a small-restricted room called a pulp chamber. The nerve is anatomically shaped like a tree: there is a trunk, limbs, and thousands of tiny branches that radiate into the surrounding tooth structure (radiating dentinal tubules which send pain and other signals via Odontoblast receptors, nerves, or hydrodynamics). If you have a history of nerve trauma, chronic irritation from habitual tooth to tooth forces, history of multiple fillings, deep decay, lots of dentistry etc. (See List below), it’s likely and common that these chronic irritants will cause additive calcific changes to the tooth nerve space. In turn, reducing the pulp room/nerver space. Over time, these cumulative calcific changes reduce the size of the room and have the potential to constrict or choking off the blood supply to the vital tissues of the pulp and canals of the roots. Not every tooth that has a calcified pulp needs a root canal, but it should be noted that the tooth pulp has a very delicate blood supply.

Over time, with cumulative calcification, the pulp becomes prone to necrosis. If the irritants produce irreversible changes to the pulp, the dying rotting tissue inside of your tooth wash into the periapical boney tissue though the root canals, and form infections in the bone around the root tips. On the other hand, chronic irritants may accompany reversible on and off clinical signs and symptoms, but not cause tooth nerve necrosis and not cause an infection.



Is the Nerve Inflammation Reversible or Irreversible?


Any type of trauma or irritant to the tooth nerve can cause some degree of minor or major swelling of the nerve and tissues inside the tooth.

10 Common Irritants that Causes Of Tooth Nerve Inflammation (Potentiating Calcific Changes Of The Pulp)

  1. Deep Decay near or bacteria irritant near or into the Tooth Nerve
  2. History Of Multiple Fillings Near The Tooth Nerve
  3. Beyond Normal Tooth Forces: Oral Habits, Bad Bite Relationship, Daytime Clinching, Nighttime Grinding, Excessive Gum Chewing Etc. See Full List
  4. Normal Tooth Forces distributed atop of just a few teeth
  5. Acute Trauma To The Jaw Or Tooth
  6. Sensitive Exposed Tooth Roots
  7. Orthodontic Forces on Teeth
  8. Tooth Cracks Into or near The Nerve
  9. Transient Post Treatment Sensitivity (Mild To Severe) i.e. New Filling or Crown
  10. Natural Process of Aging

As a reminder, sometimes the patient will experience pain, and other times these low-grade tooth nerve inflammations are sub-clinical in nature and do not cause pain! In short, patients can have the same problems but different symptoms.

With or without pain, dentists universally refer to tooth nerve inflammation as pulpitis. As a general guide, pulpitis is categorized into two subcategories: “reversible” or “irreversible” and there is a lot of “gray area” in between.


Reversible Pulpitis



In general, if you have reversible pulpitis your symptoms are:

  • Initially the tooth can be very painful (i.e. with new dental work) but typically gets better quickly (i.e. 1-7 days).
  • Pain is not spontaneous and is only initiated by a stimulus i.e. chewing, hot, cold or sugar (Pain typically is not 24/7)
  • After tooth is stimulated, the pain is of short duration i.e. stops after 30 seconds or less


New Dental Work –Worthy of Note
Patients with reversible pulpitis will usually get considerably better after a few days following a dental visit. Most often these patients will not require any further therapy. It is normal for patients with reversible pulpitis to experience small amounts of sensitivity for as long as a few weeks or even months. In this case, desensitizing toothpaste is a great option. Remember, when symptoms continually get better, it’s likely you are going through the normal healing process.

In all cases, it’s important to make sure your bite feels normal. Remember, you were numb when you had your new filling or crown placed and may not have been able to mark your bite accurately. If your bite does not feel normal you must return to the dentist for an adjustment! If it is left untreated, a tooth high in the bite is a chronic irritant to the dental pulp and will produce root canal like symptoms and reversible tooth mobility.


 Rule out:
☺ Extreme flash of Sharp pain upon biting-Cause: possible Cracked Tooth

 FYI a tooth with uneven bite forces or a new restoration that produces a bite interference can exhibit extreme sharp pain upon biting, extreme hot and cold sensitivity, or pain to the touch. This information is educational in natural. Patients should avoid self-diagnosis and defer to a professional opinion.


Irreversible Pulpitis


As the name implies, Irreversible Pulpitis is permanent nerve damage and ultimately the tissues of the tooth will necrose or die. Some tips with regard to understanding symptoms of irreversible Pulpitis:


Possible Symptoms

  • Dull, throbbing, or Intense pain
  • Spontaneous Pain
  • Continuous pain
  • The Tooth may be Loose
  • Lingering pain with thermal changes (esp. cold)
  • Percussion sensitivity (tap your finger nail on each tooth)
  • Slight elevation of the tooth out of the bony socket (High bite)
  • Pus drainage around the tooth
  • Grey colored tooth with a history of trauma
  • Intra-oral or extra-oral “pimple-like” draining pump or sore.
  • Possible swollen Lymph nodes
  • Possible low-grade fever

Rule Out:

  • Common Mouth Sores
  • Gum Tissue Swellings (Periodontal Disease)
  • Extra Canal Invasive Resorption
  • Sensitive exposed tooth roots
  • Food Impaction between teeth
  • Day time &/or night time Clinching and grinding (Daytime Parafunctional habits)
  • Tooth Cracks (Clinical or as seen on 3D Images)
  • Traumatic Occlusion
  • Transient Post Treatment Sensitivity (mild to severe)


If you suspect Irreversible pulpitis, you should call and make an appointment as soon as is possible. You cannot ignore a tooth that is non-vital and it’s not advisable that you delay needed therapy. These infections can spread and damage other teeth and surrounding bone. It’s even possible, yet extremely rare, that boney root canals infections can become life threatening.


All Of The Gray In Between

In the presence of vague clinical criteria, it can be difficult to arrive at a definitively root canal diagnosis. With no definitive diagnosis, the doctor and patient may elect to watch the tooth in question for a few weeks depending on the severity of the pain. If the tooth in question is to be watched, it’s a good idea to consider treatments like adjusting or reshaping the tooth so it does not hit during normal function i.e. when you are eating or to avoid tooth to tooth contact as you swallow 2000 times pre day. We also recommend behavioral management for oral habits, and palliative treatments that may include using antibiotics, or NSAIDs like ibuprofen (Motrin, Advil).

Initial symptoms of “reversible Pulpitis” can be similar to the classic symptoms of “irreversible Pulpitis”. If you have extreme pain in the first 24-48 hours, you might decide you just can’t wait to find out whether or not you may be able to avoid a Root Canal. You may elect to begin the root canal therapy simply to relieve the severe pain. Remember your dentist does not want to see you suffer, if you are truly “sitting on the fence” between reversible and irreversible Pulpitis and are experiencing extreme pain, your dentist may agree and advise you to have a root canal. On the other hand, if you have extreme pain initially and you decide to ride it out in order to try and avoid root canal therapy, it’s possible you could have pain for some time and still end up needing the root canal therapy.

Assumed Risks And Tips For Patients Who Decide To Watch A Questionable Tooth

When advisable, it’s a good idea to play the odds and try to avoid a root canal. But patients hoping to avoid a root canal may:

  • Wait too long or simply not return for an agreed upon reevaluation appointments.
  • May discover over a period of time that the pain is disruptive to the quality of life, or renders one side of the mouth non-functional.
  • Consider the risk that symptoms can quickly and abruptly get worse and require emergency care.
  • Need to understand the importance of regular professional care to evaluate the potential silent progression of the dental problems. Which can unknowingly spread and damage adjacent tissues without symptoms.


Why Doesn’t My Dentist Just Take An X-Ray or Do A Pulp Vitality Test?

And Tell Me If I Need A Root Canal or Not?


Diagnostic Limits of Dental X-rays


Closeup of beautiful young mixed race woman smiling


Most of the time, your dentist will be able to clearly advise you based on your symptoms, clinical testing and regular dental x-rays. Unfortunately, necrotic dental nerves (pulps) may not produce radiographic changes in early stages, infections can be hidden behind other anatomical structures, and infections may be *diffuse in nature (difficult to see on any x-ray).

Root Tip Infections (Periapical Osteitis) Come in Two Forms:

  • Diffuse infections as the name implies dissolve widely through the bone. Defuse infections do not show up well on dental X-rays.
  • Localized cyst like infections are walled off and dissolve bone forming teardrop radiolucency’s commonly viewable on dental x-rays.

Contrary to common belief, some tooth cavities and infections in tooth supporting bone do not always show up on routine dental x-rays. Likewise, the exact size of an identified cavity or the extent of an infection is not always known before treatment either. Finally as covered above pulp horns are rarely visible on 1-D X-rays. The conclusion is: it’s possible the decay has spread into the tooth nerve.

Finally, radiographic diagnostics like calcific changes of the pulp, calcific root canals, and widening of the periodontal ligament space, all signal the dentist to watch a tooth because its prone to future problems, but not every tooth that has a these problems needs a root canal.

Other clinical testing and your symptoms may place you into the in “Gray area.” This is when clinical experience, advanced diagnostics, and clear patient communication play a major role when determining your best care treatments.



Diagnostic Limits of Nerve Vitality Testing

If your tooth nerve is dead you will need a root canal to clean out the dead necrotic tissue. Ideally this should be done before the debris is allowed to spread into the bone. This is why in questionable situations a nerve Electric pulp vitality testing (EPT) is a valuable diagnostic option.



What is Electric Pulp Vitality testing (EPT)?

EPT is completed using a dental instrument that sends mild electrical tooth pulses to check for nerve vitality. At our office, Dr Landers uses a manually controlled dial that is very slowly increased all the while assuring our patients comfort.


It’s common sense that patients with a vital nerve will feel this test pulse. And one would also assume that If the patient does not feel the pulse, its diagnostic for a necrotic nerve. But here’s the problem, sometimes a dental nerve can be part alive and part dead. With partial necrosis, the vital tissue elicits a response and the patient signals that they feel the stimulus. But this is a false misleading positive response, because a tooth with a partially necrotic pulp will still need a root canal. Conclusion: pulp vitality tests are only diagnostic when the nerve is 100% dead and the patient does not feel the EPT stimulus.


Note From Dr L

If there were some test that could help dentists in all clinical situations, determine the need for a root canal with 100% accuracy, then all of the dentist would use this test. Unfortunately, there is no such test. In borderline situations, the clinical judgment of the dentist, advanced diagnostics, along with your input is what ultimately helps you and the doctor to determine the therapy needed.

Multiple Opinions & Different Advise

If you are truly in the gray area you will likely get different advice from a variety of dentists. One dentist might say, “I’m 100% sure you need a Root Canal”. While still another may review your symptoms, explain you options, and support your decision. By the way, I’m the second dentist. Using advanced diagnostics, experience and a systematic approach, I will give you the best odds of an accurate diagnosis.

Swelling around a tooth, tooth mobility, or pimple like draining bump on the gums is good reason to set up a consult at our office. For further understanding please review our online emergency section: toothache

Please be aware that the 2 most common clinical problems that confuse doctors leading to a misdiagnosis are:

  1. Reversible pulpitis caused by Daytime or nighttime clinching or grinding.
  2. Reversible pulpitis caused by traumatic bit or unbalance bite forces after a new filling.

I have studied these topics extensively. And will offer Advanced Diagnostics along with all modern treatment options: including 3D diagnostics and computerized root canal therapy. The end result is an accurate diagnosis, less time in the dental chair, increased comfort, and predictably accurate therapy.


Untreated Dental Infections Can Be Life Threatening

Infections in the tooth supporting bone have the potential to move fast or slow. With slow chronic infections patients may not experience or feel pain. If left undiagnosed these bone infections may unknowingly spread into the soft tissues of the body and may change course at any time.

Ludwig’s angina is potentially life threatening, rapidly expanding diffuse inflammation, which invades the submandibular (lower Jaw bone) and sublingual (under tongue) spaces. It occurs most often in young adults with dental infections but can occur at any age.

Link: Rapid Swelling under Tongue & Jaw (Onset: 1 – 2 days)

If you have a swelling on the inside of the lower jaw call our office right now. If we are not in, please go to the hospital ASAP.


If you suspect you need a root canal, you should call for an appointment as soon as you can.

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