an interesting case

last friday i was double booked with an emergency, my colleague's patient was coming to see me for "extreme facial pain that kept her up all night." mrs. s, a woman in her mid-late thirties, presented with a dull, throbbing ache that originated at her left TMJ and would periodically radiate sharp, stabbing and almost debilitating pain all the way through to her left upper midline. her medical history was unremarkable. she was in the process of seeking orthodontic treatment for a collapsed bite, which had been "corrected" by her previous dentist by placing composite resin on the occlusal surfaces of her molars to open up her VDO. percussion of the upper teeth was negative, all of her teeth in the lower arch were mildly percussion positive, and there was noticable TMJ crepitus on the left side. perio pocketing was within normal limits. her recent dental history was unremarkable, except for a resto that was placed by my colleague on #36 back in september that had some "sensitivity for a while" and she was meaning to come back to have evaluated but just didn't have the time. radiographic examination was also unremarkable. just as i left the room to discharge my other patient, she had another attack of debiliating pain that shot across her upper midline again, to the point that she was reduced to tears. i quickly got out some hot towel compresses (we keep them in the office as a comfort measure for patients) and the pain started to subside with its application.

at this point i had a suspicion that it might be TMJ-related or neuromuscular and she was only in my schedule for a look-see, so i spent a few minutes trying to find an oral surgeon that could see her immediately for evaluation. luckily i did, and i sent her off with a script for motrin and percocet to be taken alternately. i knew she was going to someone capable and competent. but after she left i had sneaking suspicion about that "sensitive" #36. no way, i told myself, i've never seen referred pain radiate that far on an upper. nonetheless, i quickly spoke to the oral surgeon and asked her to evaluate the six (i had performed all diagnostic tests but one, as my office had run out of endo ice, a fact which i was not all to pleased with, that's another story for another time) but i was pretty sure that wasn't it. however, there was still that nagging feeling and i felt more comfortable having someone else take a look.

the OS called me back to follow up after she was seen. she had examined her, no, it was not the TMJ but her symptoms were consitent with trigeminal neuralgia and she was referred to a neurologist for further evaluation. when i thought about it, it made sense because tic deleraux does manifest itself as brief, intense and episodic pain. the OS was also certain that it wasn't the six, either. she would have done the same thing i had done - pain meds and a referral. okay, i did the best i could with it, i hope she felt better and i wished her the best of luck. eek, still that nagging feeling...

on monday i get a call at home from my office manager. mrs. s was seen at the ER today for sub-mandibular swelling, she was placed on antibiotics, can she come in tomorrow for an evaluation. absolutely, i said, i'll come in early to see her. when she came in on tuesday, she looked like hell. her submandibular nodes were rock hard, there was noticable swelling on her left side, and she was having trouble swallowing. she was given a script for clindamycin 300 mg tid, real big guns. this time i had endo ice ready to go (i pretty much had chewed out my staff for not ordering it after i had written it on the dry-erase board a week and a half ago when we were running low, but again, another story for another time) and i tested all the teeth in her lower arch. sure enough, #36 had no response to cold and was precussion positive. my diagnosis was acute apical abcess. i told her to stay on the antibiotics she was on, and we booked RCT for the next friday. as she was very anxious about having a root canal, this was her first one, i gave her a script for halcion 0.125 mg to be taken 40 minutes before the procedure, and the night before, if necessary. on friday i got in early again, we medicated her and i completed the pulpectomy. sure enough, i opened up the tooth and completed the pulpectomy and while there was no pus, it stunk to the high heavens. the patient was nice and relaxed, left in wonderful spirits, and is coming back tomorrow to complete the treatment. she said afterwards that it was the first time she had slept in over a week and that she had actually enjoyed herself during the procedure. she also gave us invitations to her jewelry sale next saturday!

i really learned a lot from this case. first, i learned the really wacky patterns of referred pain, and it only reinforced the importance of testing BOTH arches when a patient presents like that. i learned that even only moderately deep resins can have very detrimental effects on pulp health, all the more reason to caveat when placing such restorations. i also realized just how vital and critical endo ice is in diagnosis, and that pulp testing can give you such surprising and conclusive results - hence my mild discomfort and unease at dismissing her last week without having used it. i also learned that sometimes pain and infection sometimes cannot be diagnosed immediately, that at times things have to localize. and last by not least, i learned to just trust my instincts - that sometimes a doctor's intuition is dead on, even when you're not sure of yourself. sometimes i actually do know what i'm doing!