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DIAGNOSTIC TRIVIA: History of long lasting nagging pain

From: "Christian Diegritz" To: "roots" Sent: Thursday, December 08, 2011 2:34 PM Subject: [roots] DIAGNOSTIC TRIVIA: Patient with a history of long lasting nagging pain Dear rooters, a lil diagnostic trivia for you: Patient was referred to me last wednesday; med history: non contributory patientīs need: "Getting rid of the long history of nagging pain attacks in the 1st quadrant" special anamnesis (copy of the patients file by the referring doctors:) September 2010: Patient describing pain and discomfort Tooth 15 (European (2.Bicuspid), Pocket probing pal 15/16 5-6mm BOP, percussion 15 positive, sens reduced (general difficulty to judge the sens in this quadrant); XRay periapical: apical region of 15 without any pathological findings, periodontal ligament widened, no caries; Therapy: curretage and dontisolon; control appointment if pain still lingers June 2011 (next dentist): Patient still in pain, percussion - in the whole 1st quadrant, BOP 16/17 (1st and 2 Molar) CHX + curettage, control next week July 2011: (another dentist) Patient still in pain; percussion 15, vitality testing 16+, 15+, 14+; Diagnosis: occlusal trauma, occlusal adjustment, chx + cürretage control appointment 2 weeks 6th of october 2011: (3th dentist): Patient still in pain on tooth 16, no pathological findings 27th of october (4th dentist): Tooth Sens EPT perk chewing pain/rebound tenderness(donīt know the exact word in english) 16 + 28 - - 15 - 48 - + 14 - 32 - - but no restoration no caries no pathologic signs visible on tooth 15 so pulp necrosis not very likely -> monitoring So after reading all this and looking at the attached x-rays: WHAT WOULD YOU DO? Patient is fed up went to 5 dentists and is IN NEED FOR HELP! He canīt sleep anymore he is really fed up with all dentists because nobody seems to help him. What is causing his pain and discomfort? 1st molar 1st bicuspid or second bicuspid or is it something else? and what is the correct diagnosis? Kind regards from Munich - Christian diagnostic trivia

diagnostic trivia could you tell us how patient describes the pain? and if its characteristics have changed during this year? Iintensity? characteristics? things that raise or relieve the pain? history of swelling? From the information extracted from previous dentist tooth 1.5 changed from a positive to a negative response to cold test and perio treatments and occlusal adjustmen were ineffective - Javier Pascual Hello Javier, When the patient presented to me he told me that the pain is getting worse and worse- pain (scale 1-10): 7 sometimes 8 or 9, specially at nights and in the morning. Started as sharp pain attacks now mostly dull. Pain area is diffuse between 15-17 No real change over the years only from intensity standpoint right now not bareable anymore (2 nights without much sleep) No history of swelling, And yes you are right, perio and occlusal adjustment only gave short periods of relief - Christian What about thermal stimulus? Has the patient experienced sensibility to cold or hot meals/drinks during this year and/or right now? Is pain related to decubitus position? Has he been treated recently with antibiotics or pain killers? if yes which? were they effective? - Javier I would also take a bitewing in order to explore more accurately pulp chambers and fillings - Javier Have seen patients like this where the doctor started endo at one end of the quadrant under pressure from patient and ended up doing endo on all of the teeth to no avail. I have had a couple of cases like this and treated them using nortriptyline daily for a month, pain went, teeth still vital - Dez Austin headaches? generalized attrition? episodic pain? abfractions (now called nccl, i think)? i'd consider making some sort of a palliative/diagnotistic nightguard/orthotic/ampsa/temporary_splint and reeval.. Nareg Apelian

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