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.

8 comments:

  1. Maybe there is an extra canal that was not instrumented in tooth #4, or #3

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  2. Yes, finally knew how necrotic tooth be soothed by cold and other related issue as well. Now it will be easy to understand how it works can be done necessary steps against it.

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  3. My gums are really swollen and one of my molars really hurts. I am not sure if something is stuck in my gums or if the tooth is decaying. Could a dentist be able to xray my tooth and find out?
    http://www.drcarolinedentist.com/index.php

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  4. Is there a possibility that the pain is coming from tooth #3 with the interproximal decay?

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  5. I was always hesitant of dentists because of many bad experiences as a child. However, from the first moment I met this Torrance dentist, I was at complete ease.

    ReplyDelete