Given the history and the patient's reported symptoms, I figured that I was dealing with your run-of-the-mill acute apical abscess - in this case, likely resulting from a failing RCT. And naturally, my focus turned to the oral cavity. Yet to my surprise, there were no signs of intraoral infection. Specifically, there was no redness or swelling in the upper or lower gingiva. Moreover, all upper and lower teeth on the right side tested WNL; specifically, #s 3, 30 and 31 all tested negative to percussion, palpation, and bite. Radiographs of the region further failed to illuminate the cause of her pain, as all three root canals were very nicely completed with intact restorations, and there was no evidence of periapical pathology.
As I began probing further into the patient's history of symptoms, however, I realized that my initial diagnostic hunch had been tainted by my "ENDO bias". Additional questioning began to reveal key clues that I had previously overlooked or failed to elicit. Firstly, the patient mentioned that although she had been in severe pain for several days, the pain really only reared its head when she was eating. Moreover, the pain was not provoked or worsened by chewing or temperature changes; as a matter of fact, the patient had been eating mashed potatoes for a couple of days, and the pain was still as strong as ever when she did so. Secondly, she mentioned that the swelling was tender to touch, as was the inside of her cheek. When prompted to point to these areas of tenderness, the patient pointed to an area posterior to the angle of the mandible as well as the area surrounding the exit point of Stenson's Duct.
Almost immediately, I realized what had originally eluded me. I wasn't looking at a traditional endodontic issue, but instead, I was dealing with a salivary (Parotid) gland issue that no amount of Gutta Percha could cure. Realizing the limits of nickel titanium, I called a local oral surgeon and arranged for the patient to immediately head over to see him. Within hours, he had confirmed my initial suspicions, diagnosing the patient with sialadenitis and changing her antibiotic to Augmentin. Follow-up with the patient after 2 weeks revealed that all her signs and symptoms had resolved, and our patient was ecstatic to be back to "normal".
So what lessons can we take back from this case?
1) It is important to watch out for pain that is provoked by eating, but without the need for chewing and irrespective of temperature. This is often a sign of glandular or ductal pathology.
2) If there is a suspicion of salivary gland pathology and dental pathology can be ruled out, it is important to contact the appropriate avenues for proper patient triage.