Cracks, cracks, cracks
Today I had a case that taught me not to focus on the obvious cause of pain. A patient came in complaining of pain on the 25. the 24 had previously been filled by another dentist and I assume it must have been a carious exposure. Checking the xrays before the patient arrived I settled on the 24 as the probably cause of pain. She presented and was very sure that it was the 25 painful to hot and cold. There was an MOD amalgam in the 25 that appeared sound. I still thought it was the 24...
Cold test was very painful for both but more so for the 25. The curiosity was that there was an exaggerated response to pain on the 25 as it appeared sound. I was very ready to extract the 24, so much so that the needle was right near the tooth for LA. I decided to test the teeth once more and again a more exaggerated response from the 25. Still unsure if the patient was confused, I did a heat test for the first time. Rubber dam isolation of the 25 and washing of the tooth with warm water from a monoject syringe. This confirmed the patient's suspicions that it was the 25 that was painful. Still, I could not justify any treatment until I could find a cause., The Pa revealed no caries, a shallow amalgam and only mild-moderate bone loss. I decided that the only way that I could justify treatment was to explore the 25 amalgam to search for an apparent crack which could cause symptoms of irreversible pulpitis. I removed the amalgam and dried the cavity. I spied a slight crack on the floor of the cavity that was very hard to spot. The implication of this was that I could now justify treatment on this tooth. Then it was a matter of warning the patient excessively that I have found a cause but pain may also be coming from the 24. On extraction, the buccal cusp popped off along that crack line with a buccal pulp horn exposure. This more or less confirmed the presence of a crack and identified the 25 as the problem tooth. This was a surprising outcome as I immediately discounted the 25 as a cause of pain. however it taught me that pulp tests are important and xrays don't tell us anything. We have to consider all options to make sure we are treating the right tooth with the right treatment. Diagnosis is key.
Cold test was very painful for both but more so for the 25. The curiosity was that there was an exaggerated response to pain on the 25 as it appeared sound. I was very ready to extract the 24, so much so that the needle was right near the tooth for LA. I decided to test the teeth once more and again a more exaggerated response from the 25. Still unsure if the patient was confused, I did a heat test for the first time. Rubber dam isolation of the 25 and washing of the tooth with warm water from a monoject syringe. This confirmed the patient's suspicions that it was the 25 that was painful. Still, I could not justify any treatment until I could find a cause., The Pa revealed no caries, a shallow amalgam and only mild-moderate bone loss. I decided that the only way that I could justify treatment was to explore the 25 amalgam to search for an apparent crack which could cause symptoms of irreversible pulpitis. I removed the amalgam and dried the cavity. I spied a slight crack on the floor of the cavity that was very hard to spot. The implication of this was that I could now justify treatment on this tooth. Then it was a matter of warning the patient excessively that I have found a cause but pain may also be coming from the 24. On extraction, the buccal cusp popped off along that crack line with a buccal pulp horn exposure. This more or less confirmed the presence of a crack and identified the 25 as the problem tooth. This was a surprising outcome as I immediately discounted the 25 as a cause of pain. however it taught me that pulp tests are important and xrays don't tell us anything. We have to consider all options to make sure we are treating the right tooth with the right treatment. Diagnosis is key.
Last year
On presentation
Cracked cusp on extraction
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