My patient's chief complaint included pain to hot food and liquids. Hot dental stopping was not doing the trick. I needed to verify he was actually heat sensitive. Hot water was brought to the patient for rinsing. ALWAYS LET THEM TEST THE TEMPERATURE FIRST WITH A FINGER TO PREVENT UNNECESSARY BURNING OF THE ORAL TISSUES.
He rinsed and he was right-it hurt like hell! I used single tooth rubber dam isolation on every tooth# 29-31 and dripped the same hot water that got him to jump. All tested negative. At this point I am thinking it is a maxillary tooth. I just have to find it, then prove it to him. Upper teeth looked OK. He had one smallish amalgam on #3 which looked intact. Can you guess what happened when I started applying hot water with RD isolation to the UR posteriors? My patient however is still convinced it is coming from #31, in spite of all signs pointing elsewhere. What I found interesting was that all UR posteriors were free of percussion as well. Typically I expect at least a little bit of something when I tap on a tooth with an IP that has been around for this long.
This part is my favorite. ONLY DO THIS WHEN YOU ARE CONVINCED YOU HAVE ISOLATED THE CORRECT QUADRANT. IF YOU ARE WRONG, YOU MAY NOT BE ABLE TO FINISH THE DIAGNOSTIC TESTING ON THIS VISIT. PATIENT'S GENERALLY DONT LIKE BEING SENT HOME WITHOUT A SOLUTION TO THEIR PROBLEM! I was sure it was #3. I gave the patient a full block on the lower and took the LR out of the picture. Once I was sure he was numb (positive soft tissue signs as well as NR to cold for all LR teeth) I had him rinse again. Can you guess what happened next?
Other that the very long working lengths (25-29mm) and the extra canals, it was a very straightforward case. A mesial axial wall fracture was found on access, as well as a very hot pulp! The patient was instructed to return to his general dentist right away for a crown. We also recommended replacing his worn out lower restorations with crowns (due to their extensive nature) to prevent possible fractures, decay, etc. I think the patient didn't really believe I had done the right tooth until he had his morning coffee the next day.
Once again, DIAGNOSIS IS EVERYTHING! "Tincture of Time" will usually work in our favor if we cannot figure out right away what the problem is. Unfortunately some patients may lose faith if we do not figure out their problem ASAP, especially if they are convinced that they know what it is. However, with open conversation and education, most will appreciate your thorough efforts to come to the correct solution.
-FAUSTI
