Clinical exam revealed nothing concrete to go on. The patient was certain she needed a root canal on tooth #14. I dug deeper in her history. At no time was there hot or cold pain listed in her chief complaint. Every tooth tested was vital and responsive to cold so I certainly would expect some thermal discomfort if #14 was experiencing a pulpitis. I noticed she seemed to have a cold. At first she said it was her allergies, then corrected herself and said she had been feeling a bit run down for a week. Coincidently, her pain began around that same time. I felt her sinuses may be involved. I dismissed her and instructed her to come back when her cold cleared up so we can re-evaluate the teeth.
The patient called 2 days later and said the pain had intensified. She returned to our office on emergency. I decided to take a CT and see what I was missing. Axial, coronal, and sagittal slices are seen below the radiograph.
 |
|
axial view
|
|
|
| coronal view |
|
|
| sagittal view |
I dismissed the patient and scripted her with augmentin 875mg bid for 10 days as per a conversation with an ENT colleague, as well as instructed her to use OTC decongestants. Patient scheduled to see the ENT. She called back 4 days later to inform us the pain had subsided and she was feeling much better and thanked me for not doing the root canal. She had not seen the ENT as of yet but assured me that she would.
The radiology report confirms sinus inflammatory disease, as indicated by near complete opacification with bubbly fluid secretions. No PAP was noted in any of the surrounding teeth in the CT.
CLOSING THOUGHTS:
1. DIAGNOSIS IS EVERYTHING!!!
-rushing into #14 would have proven a big mistake here. Remember, the patient is in pain and wants relief NOW!!!, even at the expense of a root canal. Never take their word for it.
2. DON'T FORGET ABOUT THE SINUSES.
-Remember those big black spaces in the skull that we were trained to fear and avoid as dental students? I for one will never forget the first time I removed a tooth in the emergency dental clinic at UF and saw the bubbling darkness at the bottom of the socket; I can't remember which 4-letter word it was but I certainly wasn't eager to visit this place again!
The direct interaction between the sinuses and the dentition is well documented. Inflammatory processes in one can affect the other. CT scan is an invaluable tool in properly identifying and diagnosing such processes, as well as monitoring them for resolution. In contrast to the above case, the lower study is of a failing RCT directly affecting the maxillary sinus. The radiology report confirms odontogenic
chronic polypoid sinusitis related to PAP, with direct sinus communication.
 |
| sagittal view |
 |
| coronal view |
