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Severe tooth pain - Courtesy ROOTS

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credited for the individual posts where they are - www.rxroots.com
From: "Dan Path"
Sent: Wednesday, January 23, 2008 4:36 AM
Subject: [roots] severe pain

Hello! This patient asked me to replace her old amalgam filling on tooth
#4.5. Upon removal, the pulp chamber was exposed and a guttapercha
cone was floating in a big mess... So...

* reconstruction of the distal wall with composite
* cleaning the canal space. during this phase, the patient started
to complain about a severe pain. Ca(OH)2 filling, cavit and I had
to remove the rubber dam.

Another mental nerve block: no improvement
Intraligamentary anaesthesia on #4.5 (29): no improvement
Opening the tooth, no cavit, no Ca(OH)2: no improvement

The pain included the whole right side of the patient's face
and it extended to her ear.
* vitality test: increasing pain on #4.7 (31)
* intraligamentary anaesthesia on #4.7 (31) calmed her pain completely.
* Pulpectomy on #4.7 (31), no Ca(OH)2 this time, just a cotton pellet
wetted with Rockle's.

2nd day
The pain reappeared whatsoever and gradually increased to the same
intensity within the next 24h and she was a little swelled. I've prescribed
amoxicillin and ketonal.

4th day
* the swelling developed a little more
* Percussion: positive on #4.5 (29) and #4.6 (30) (lesser) .
* Palpation: positive on #4.5 (29) area and distal
* intraligamentary anaesthesia on #4.5 (29) and #4.6 (30), no result, the pain
was still there, although the mucosa was anaesthetized
* incision to relief the pressure. To my surprise, no
purulent collection, just a gas. Patient reported a slight release

5th day
* Percussion: positive on #4.5 (29), slightly positive on #4.6 (30)
* Pus was slowly exiting through the incision line, some gas too
* Patient reported an improvement

later that evening: Patient complained on the phone that the pain
reappeared just as before and she has neck pains too now.

I've checked for a second canal on #4.5 (29), but I couldn't find
anything. On the other hand, I'm not behind a scope...

Any suggestions and criticism are welcomed.

OPG: before treatment
Rx: after

Dear Dan, you need to follow up with the patient to avoid the risk of developing space infection. He might developed a flare up on tooth# 4.5 but the sign was acute which could be related to NaOCl extrusion or over instrumentation. Nevertheless, other factors can play a role :e.g (1) Tooth # 4.8 is partially erupted (it has a risk of pericoronitis) (2) Tooth # 4.7 (look like C shape canal) (3) Tooth #4,6 (short filling and big posts ..etc.. it has a risk of fracture or acute apical periodontitis) There are other possibilities of referred pain (TMD or AAP), however I don't think that are the causes, because the pt. has a sign of infection (exudates) related to tooth #4.5. Not to mention that the Intraligmental Anesthesia could associated with post op. pain Advise for management: 1-The Anti Biotic is not showing effect, so you might need to replace it with Dalacin C (clindamycine) starting dose 300mg and then 150mg Q8H for 5 days ( it has better penetration in the bone) , or Augmentine 1 gm ( twice daily for 5 days) 2-As well, Pt. needs Pain killer (Brufen 600mg Q4h alternating with Tylanol III) 3- keep a drain 4-advise the pt. to rinse with warm water , and 5- relief the occlusion. 6-if it dose not improve; refer to another Endodontist for another opinion using a microscope - Khalid Merdad Hello! Thank you Khalid, the information you have provided was indeed useful and it is always helpful to get a second opinion :) The patient was already on Augmentin, forgot to mention that before. Today things were definitely better, the pain ceased mostly and the she didn't swell anymore. Hopefully the symptoms will regress from now on.- Dan
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