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January 2003 The Importance of Taking a Good History

Here is an interesting case that I saw a couple of days ago. The patient was referred to me by her Generalist. She was a 27 year old female in good health who had never had any restorations placed in her mouth. She had a totally virgin pristine mouth. After consuming vast amounts of oral analgesics (T#3) the evening before, she ended up in the emergency room of the local general hospital where she was in so much pain that they finally administered Morphine to her. She was referred to me the next morning with a focus on the maxillary right first molar.

What was striking about this patient was that her mouth was absolutely perfect ( from a lack of caries or “crack” point of view). Transillumination showed no cracks and the tooth was totally without any visible defects. Perio probing showed a discrete 9 mm pocket on the mesio-palatal that coincided with a diffuse radiolucent area in the MB midroot.

Although the Generalists films weren’t perfect, we do see enough in the PA to know that the apical areas appear to be relatively normal. Yet her extreme discomfort suggested an endodontic rather than periodontal cause. (Perio lesions usually don’t get sore enough that you need Morphine to dull the pain.) That sounded like an end stage pulpitis to me but I just couldn’t figure out why this had occurred. Why did this pulp “go south”?

I didn’t know until I asked the right question….Did she have any 2nd premolars extracted? The answer was YES. Evidently, the 2nd premolar was somewhat impacted against the mesial-palatal of the first molar. The tooth was removed surgically from the palatal side a few years ago. ( Look at the angle of the first premolar.)

From this it appears that the blood supply to the MB root may have been affected, or that the periodontal defect that was left after the surgery caused ingress of the bacteria into the MB root through the apex or lateral canal. Thermal tests showed no response. A cavity test was negative. When the tooth was finally accessed, the pulp had the typical “watery” mushy pulp look, consistent with end stage pulpitis. (Ouch!)

Although there was no outward indication that this tooth was heading toward necrosis, clinical examination confirmed that result. A pulpectomy was performed and the tooth was scheduled for completion of endodontic treatment. The patient subsequently reported dramatic improvement after the emergency procedure. Needless to say, her initial exposure to the consequences of pulpal problems left her with an appreciation for how uncomfortable such cases can be!

The moral of the story…it is essential get a good history from patients like this. Even in the “perfect” mouth, history of extractions, trauma etc can contribute to pulpal necrosis in what outwardly appears to be a pristine dentition. Pulps don’t just “die” on their own. There’s gotta be a reason for it and it is up to you to find it BEFORE you make access and commit the patient to endo. It will be interesting to see if we can get bone fill in that 9 mm pocket area after the endo is completed. Otherwise, she may have to see the Periodontist as well.