👤 Patient’s chief complaint
Age: 27
The patient presented after multiple consultations with other dentists. Her main complaint was spontaneous pain and pain on biting in the area of tooth 26, persisting for approximately one month.
According to her history, tooth 26 had been treated endodontically under a microscope over a year earlier. She had visited three dental offices where extraction of tooth 26 followed by implant placement was recommended. She sought a second opinion to confirm whether such an invasive approach was truly necessary.
🔍 Clinical examination
Clinical examination revealed no tenderness to percussion of tooth 26. No signs of acute periapical inflammation were observed.
However, secondary caries beneath a restoration was detected in tooth 36 on the same side in the mandibular arch. Tooth 36 showed no response to cold testing, suggesting pulp necrosis.
🧠 CBCT imaging
Cone beam computed tomography revealed:
- Tooth 26
- four properly filled root canals
- no periapical pathology
- normal maxillary sinus mucosa
- Tooth 36
- periapical inflammatory lesions
- no prior endodontic treatment
The imaging clearly demonstrated that tooth 36 was the causative tooth, despite the patient perceiving pain in the maxillary arch.
📋 Diagnosis
- Referred pain
- Pulp necrosis of tooth 36
- Chronic apical periodontitis
- Tooth 26 with no indication for retreatment or extraction
💡 Treatment Plan
A planned single-visit microscopic root canal treatment of tooth 36 was scheduled to eliminate the source of infection and resolve referred pain.
⚙️ Step-by-Step Treatment
The procedure was performed under local anesthesia and rubber dam isolation to ensure asepsis and patient safety.
The existing composite restoration and underlying caries were removed. Mechanical preparation of three root canals was carried out using modern rotary instruments designed for safe and predictable endodontic treatment.
Following canal shaping, thorough chemical disinfection with bactericidal irrigants was performed. The cleaned canal system was obturated with a biocompatible MTA-based material with antibacterial and bioactive properties.
The tooth was restored with a contemporary composite material, ensuring proper coronal seal and anatomical reconstruction.
All stages of treatment were performed under a Zeiss operating microscope, allowing precise visualization and cleaning of even the smallest canal structures.
Case discussion
This case was diagnostically challenging because the causative tooth was located in the mandibular arch, while the patient reported symptoms in the maxillary arch. This represents a classic example of referred pain, which frequently leads to misdiagnosis.
Limited diagnostics and a narrow focus on tooth 26 resulted in recommendations for extraction and implant placement in other clinics. Comprehensive evaluation and CBCT imaging allowed accurate identification of the true pain source and prevented unnecessary extraction of a healthy tooth.
📍 Before & After
Before
- Pain localized in the area of tooth 26
- Recommendation for extraction of a healthy tooth
- Unrecognized referred pain
After
- Infectious source eliminated
- Complete resolution of pain
- Tooth 26 preserved
Accurate CBCT diagnostics prevented unnecessary extraction and enabled etiology-based treatment.
“Pain after root canal treatment does not always indicate failure. The key lies in accurate diagnosis.”
📌 Follow-up and outcome
At the one-year follow-up visit, the patient reported complete resolution of symptoms.
Control CBCT imaging demonstrated full healing of the periapical tissues. The endodontic treatment was fully successful, and tooth 26 remained intact.
Persistent pain after root canal treatment does not automatically indicate endodontic failure or the need for tooth extraction. When technically correct microscopic root canal treatment shows no periapical pathology, full-arch CBCT diagnostics are essential to identify referred pain and locate the true causative tooth. Comprehensive endodontic diagnosis allows clinicians to avoid unnecessary extraction of a healthy tooth and to implement etiology-based treatmentrather than symptom-based decisions.
