Dx help

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 Dx help




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From: Jerry Avillion
Sent: Thursday, April 05, 2001 2:51 PM
Subject:Dx help

This patient has trigeminal neuralgia and has a sharp electrical pain on this side
of her jaw along with a 'deep' pain.   This root canal was done a few months ago and
she was referred to me to determine if this tooth could be causing any of her pain.
The endo isnt the greatest, but the tooth is not sensitive to percussion or palpation
nor can we elicit any pain with a bite stick.   I know I can improve on the endo via
re-treatment, but I don't think that will help her symptoms at all, so at this point
I don't think the tooth needs re-treatment.    Help!

Comments?

Also, does anyone know of a pain clinic associated with a dental school in this part
of the country?

She is considering a procedure that will zap the sensory portion of VIII because
the pain is so bad.

Thanks - Jerry



Photo courtesy of Jerry - www.rxroots.com



From: Hongjiao Ouyang 
Sent: Friday, April 06, 2001 20 20

Retx endo & either send the patient to a neurologist or put the patient on
Tegretol.



She's been on Tegretol (and a bunch of other stuff), right now she's taking
Neurontin 1500mg/ day. So far the drug therapy hasnt helped very much. - Jerry

From: Garry Nervo
Sent: Thursday, April 05, 2001 6:07 PM

Have you tried Tegretol, purely a s a diagnostic - Garry Nervo



From: Merritt, Grant W.
Sent: Thursday, April 05, 2001 4:32 PM

Jerry,  She may want a second opinion on ablation of the nerve.
Where are her trigger points?  How long has she experienced the pain?
How often does she experience it now? What is the duration of the pain once
it has commenced? Has she been medicated with tegretol or phenytoin.
Has she had a CT or MRI to rule out posterior fossa tumor?
I refer my trigeminal neuralgia patients to Dr. Andrew Kaufman, a neurosurgeon
here in Kansas City, 6420 Prospect, 816-363-2500.  I've had a half-a-dozen.
The last patient I referred was suicidal her pain was so intense.
He went in and placed a sponge between a vessel and the nerve in the fossa
and she not only is free of pain but still has an intact nerve.
It's been over 5 years and this high-powered lady is still running a big
business and seems to love life.  It may not apply to her but I thought
I'd mention it.  It was great meeting you in NO.  Hope we can get together
again soon.  Come see our school sometime.  Here are a few of our 2nd years
 maxillary bicuspids from their preclinical lab.  Thought you might enjoy
seeing what they can do with rotarys and warm gutta percha if they have no
preconcieved ideas about how to do endodontic shaping and cleaning.
Good Luck with your patient.  I hope she gets well soon,  2THSAVR




Other cases of  Yosef Nahmias (rxroots):

 Importance of lat canals  
 Protaper Case  
Curved Re-treat  
 Extra canal invasive resorption - Case 2  

From: Yosef Nahmias
Sent: Friday, April 06, 2001 03 43

Redo it man. Maybe the tooth is not the problem, but what if it is?
I would! Take a chance, you can easily justify doing it! If the symptoms
go away you are a hero, if they don't, at leat you removed one part
of the equation!  Pics of a surg I did today
sealed with a composite, too close to a post, actually is a resurgery )




Photos courtesy of Yosef Nahmias - www.rxroots.com





From: Guido Costa
Sent: Friday, April 06, 2001 04 14

Jerry IMHO if that particular tooth is not the cause of her problems,
I would retreat at this time either.  However, she must be informed and
recalled accordingly to reassess periapical healing.  Redoing the endo
will not do anything to relieve her symptoms produced by the neuralgia.



From: Molar Del Sud (Ace Dentura)
Sent: Friday, April 06, 2001 09 14

One sure way to find out........give her a block injection
and see if the pain disappears.



From: PBery
Sent: Friday, April 06, 2001 09 41

Sounds like your patient had the Janetta procedure (vascular decompression
of trigeminal nerve) developped in Pittsburgh. Interesting aside:
He (Janetta) introduced microscopy in medicine 'round 63. True genius.



From: John J. Stropko, D.D.S.
Sent: Friday, April 06, 2001 10:40 AM

Jerry,

The PDL disappears at the apex of the mesial root, so I believe there is a LEO.
So many times, over the years, when I take care of something obvious, the "wierd"
things go away.  I would suggest RTX but advise the parient of no guarantees.
The money spent on RTX is a lot less than the alternative.  besides that,
if the RTX doesn't take care of the pain, you wouldn't have done an uneccesary
procedure.  Also, take a few more angles. - John Stropko



From: Jerry Avillion
Sent: Friday, April 06, 2001 23 27

The previous endo was done 1 month ago.  I agree that there is a LEO present, but
I don't know if it's one that's healing or one that's getting worse.  Since all the
pulp and periapical diagnostic tests were normal, I figured that we could always
re-treat it at a later date.   At this point my main concern is the pain associated
with the trigeminal neuralgia. I never could elicit the 'deep' pain.  But it was very
easy to elicit the pain associated with the trigeminal neuralgia, just by touching the
trigger point (near her chin).  I just spoke with the patient and she wants to go up
to KC and see Grant Merritt and his neurosurgeon buddy.  I'll betcha a pizza that Grant
will figure it out.   :) - Jerry Avillion



From: Benjamin Schein
Sent: Monday, April 09, 2001 20 12

I sort of agree with John....the obvious first.
When a person is limping. The first thing that should be done is to make sure
that there is no stone in his shoe before ablating a leg nerve. The fact the
patient is not responding to Tegretol makes it imperative to discount possible
endo origin of the neuralgia. On the other hand I spent some time in a pain clinic,
and it was embarrasing as an endodontist to see patients with chronic
severe pain come to the clinic with a super-abundance of endo treatments
in their heads.  Patients always stated that the endodontists (usually several)
always had advised.....no guarantees. I now will not do any new endos or retx
until the patient has had a workout at a pain clinic ( fortunately 2 clinics
within 50 miles of my town) if the patient does not want or can not go to a
Multi-disciplinary clinic... I would let a endodontic colleague who
is good and willing retreat a case such as the one Jerry posted.
I've had many patients with....no guarantees warnings.... become a big problem.
I can not establish a rapport with the patient such as John is able to.
Perhaps with TDO, Drawings, Multimedia education, I could..... thinking about it.

I've always been puzzled with the Ratner bone lesions. In this case there is a
tooth missing, I wish Dr. Zurkow would jump into this thread.