|Case of the Month
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May 2003 – Misdiagnosis Almost Results in Unnecessary Endo!
May's Case of the Month features a case that was sent to me for Endodontic treatment of an apparent problem with a Mandibular first molar. The 37 year old male patient claimed to have a history of swelling and palpation sensitivity in the area, approximately one week prior to being referred for treatment. The referring Dentist had placed the patient on Pen Vk antibiotic medication and referred the patient to me for endodontic treatment of the previously crowned first molar. The patient's swelling and symptoms had since resolved and he was completely without symptoms upon presentation.
Upon arrival the suspect tooth exhibited no signs or symptoms of endodontic involvement. The preoperative radiograph that was provided by the referring dentist showed good crown margin adaptation and a complete lack of PDL thickening or indications of periapical pathology. (Fig.1) Cold tests confirmed normal pulp responses. Periodontal probing was negative and there were no obvious periodontal areas that indicated that a foreign body may have at one time become lodged in the crestal gingiva causing a Periodontal abscess. These findings were very perplexing and I was having serious difficulty justifying the need for endodontic access. Nevertheless, the patient insisted that he did have previous swelling and serious discomfort that had since resolved.
( Furthermore, the patient had just driven 3 hours one way in order to see me and was NOT interested in just an examination at this point. He wanted definite treatment with no repeat of his previous swelling !)
Fig. 1 - Referral Dentist's film - Vital Tooth with NO Pathology visible
I explained to the patient that the presence of localized swelling and symptoms of periapical involvement could not be associated with this vital tooth. My tests showed that the tooth was NOT endodontically involved,. It appeared to have a normal pulp and endodontic treatment was contraindicated. BUT that still left the swelling unexplained. What was the problem?
One of the most important rules that can be leaned by any Dentist is NOT to second guess the diagnosis. Believe what your test are telling you, if you can reproduce them reliably. In this case, this tooth was definitely vital and that just didn't correspond with the presence of apparent periapical involvement.
The Second most important rule is ALWAYS TAKE ANOTHER RADIOGRAPH of the area. ( With thanks to Dr. Seymour Melnick - a Boston U. Mentor!)
Fig. 2 - My Film - Showing Retained Root Tip and Large Lesion
Sure enough, the second film explained the problem. (Fig. 2) The patient had a history of previous extraction of the second molar in another office,( not the referring Dentist's office) performed approximately one year previously. The patient remarked that the Dentist had told him that the extraction was difficult. At the time of extraction, the patient was not told of the retained root tip but the root tip and associated pathology are plainly visible in the film. (Red arrow)
At the request of the referral, arrangements were then made for the patient to have the root tip removed by an Oral Surgeon. The case of the mysterious "Apparent Endodontic Involvement" was solved.
This patient had been scheduled for a single appointment exam/endodontic procedure because of the extensive distance that had to be traveled in order for me to see him. There was great pressure on me to open this tooth and simply perform the endodontic treatment that was requested by the referral. However, after only a few moments, I suspected that there was a problem with the diagnosis. The patient's description of his symptoms and the reason for the referral simply did not correspond. When this happens - STOP AND REASSESS !!
At that point, the prudent clinician "starts over" and begins his investigations from scratch. He disregards any apparent information that may have been given to him and insists on confirming his own findings in the chair. By following proper diagnostic protocol, we ensure that patients such as this one are properly diagnosed and are not subjected to unnecessary and incorrect Endodontic treatment.