Thursday, February 12, 2015

How could a necrotic tooth be soothed by cold? Part 1

CC:  53 YO Male with a chief complaint of "I need my root canal finished, pointing to tooth #28.
HPI:  Pt had a pulpectomy #28 approx 6 months previous.  He has been asymp since.
Med:  No meds, no med conditions, -ve allergies, -ve tobacco

2 months ago, I completed endodontic therapy on tooth #28.  It had been initiated approximately 6 months prior and the finish was uneventful.  During a scan of the patient's radiographs, I noticed that #4 had a periapical radiolucency.  After pulp testing, I determined that the tooth was necrotic - we then planned to initiate endo treatment through the crown.

#4 shift shot

#4 Straight on PA
CaOH #4 (I'm not happy with the poor radio-opacity of the CaOH) Note interprox decay #5

6 days ago, I initiated treatment on tooth #4.  It was a standard pulpectomy:  instrumented the canal to a #25 file, 6 % NaOCl and QMix + Endoactivator.  I placed CaOH and helped splash it around the canal with the endoactivator.  I called the patient the day following, and other than the typical pain from anesthesia, he was fine.  6 days later, he presented with the following complaint:

My upper right tooth has been aching since this morning.  I need to drink cold water to keep the pain down.  It was ok during the weekend, but this morning, (day 6), I woke up and it started hurting.  My pain is approximately 6/10.

"Can you point with one finger where the pain is coming from", I asked.  He points to roughly between #3 and 4.

Ok - what am I thinking at this point?  "Cold water makes it feel better" -  classic remedy for irreversible pulpitis.  But wait, #4 was necrotic!  There was nothing in the tooth when I accessed it.  How could there be symptoms from a pulpless tooth?  I ran the following tests:

Extraoral:  No swelling, tenderness, pain, redness
Intraoral:  No swelling, fistula, pus

Tooth             Cold          EPT         Probing           Percussion       Palpation
#2                   -ve             80              <3mm             Norm               -ve
#3                   -ve             80              <3mm             Norm               +ve
#4                   -ve             80              <3mm             +ve                  +ve between #'s 3&4
#5                   norm          44              <3mm             Norm               -ve
#6                   norm          40              <3mm             Norm               -ve

So, there I sat, thinking about looking for a horse and not a unicorn.  I had just completed the pulpectomy on #4 and he was is asymptomatic following treatment, until a few days later.  Had I opened pandora's box?  What about that postural thing?  He felt fine sleeping until he woke up.  Sinus irritation issues secondary to instrumentation of #4?
So, just to make sure that there wasn't something out of the ordinary with the pulpectomy of #4, I decided to re instrument #4, remove the CaOH, and see what was up.  And as I expected.  Nothing.  No heme, no pus, nadda.  This was completed without anesthesia (the patient was totally comfortable), and the patient noted that his symptoms had been relieved (somewhat) following treatment.  I left the canal patent (no CaOH) "just in case", there may have been a need for expansion of fluid.  I mean, we're going against all the things that I had been taught in my residency - almost everything except for leaving the tooth open.  That, I did not!  The patient was dismissed and I was planning on calling him in the morning.

6 hours later.............the pain had returned....

To be continued.  Keep in mind the cold water thing.