CDA Essentials 2018 • Volume 5 • Issue 4

37 Issue 4 | 2018 | S upporting Y our P ractice How would you have managed this patient? Share your insights confidentially at oasisdiscussions@cda-adc.ca Consider adjunct tests for teeth at risk of fractures. There is no evidence that bite tests with a tooth sleuth or transillumination was performed. Such tests are useful for discovering coronal fractures. Periodontal probe all teeth being considered for endodontic treatment. Probing is necessary for all teeth undergoing endodontic diagnosis. One looks for a narrow probing defect, which could be an early sign of a root fracture. I suspect 37 had a crack with a necrotic pulp and this tooth was indeed the source of the initial pain for the patient. A proper endodontic evaluation and diagnosis may have revealed 37 had a necrotic pulp with catastrophic fracture that made its retention unviable. A simple extraction could have been all that was needed to resolve the symptoms and avoid such a horrible outcome for this patient. Consider angledX-rays and cone beamCTs. Angled PAs provided a wealth of information about canal anatomy as well as the size and location of apical radiolucencies. Cone beam CTs are also valuable tools for this and for exploring the health of the surrounding hard tissue. Be suspicious of roots with a conical shape. The 37 has a conical root form, which is associated with a higher chance of fractures than molars with roots that splay apart as they extend apically. A conical root form concentrates the occlusal force into a smaller surface area as the force is transmitted apically. A molar with splayed roots will distribute force over a larger area of the jaw and root surface. This 37 is a prime example of a fractured tooth: it is the most posterior tooth in the quadrant, it has an old, shallow amalgam, a conical root form, there is history of tooth loss due to trauma/ fractures, and severe pain has developed despite no recent dental treatment. If a patient’s response to treatment is poor or unexpected, seek assistance fromothers promptly. Root canal treatment not only failed to alleviate the symptoms but the patient’s condition rapidly deteriorated. Faith in the original diagnosis and treatment plan needs to be re-evaluated whenever adverse events happen. Early on there were numerous signs that, on their own, warranted further investigation and/or a second opinion. Some of these early clues include numbness of the jaw that continued to worsen with time, pain so severe it woke the patient from sleep and caused him to vomit, and fascial space involvement. Not every case of fascial space involvement requires medical attention but why was a referral to certified dental specialist not considered? In addition, the derogatory comments made by the emergency room physician about the patient’s dental care should have been rebuffed with either hard evidence, by the dentist, or a second opinion from a certified specialist. Avoid switching antibioticsmid-course. Oral tablets typically take 60 hours before they reach levels in the blood that are effective in treating bacterial infections. It would be better to add a second antibiotic rather than risk stopping one antibiotic and starting a new one. An interesting side note: E corrodens is resistant to clindamycin. Consider vertical incision and drainage. Horizontal incisions create a greater opportunity for secondary opportunistic infection than vertical incisions. Vertical incisions allow adequate access to achieve drainage but do not damage as many blood vessels in the soft tissue. The blood vessels run vertically and thus a vertical incision is a smaller wound that will heal fast. There was trauma to the tissue prior to the incision and drainage, which exacerbated the problem. Be aware of signs and symptoms of possible injury fromdental injections. The emergency room physician’s claim that the dentist’s injection had caused the patient’s numbness was fanciful. With an inferior alveolar block, the injection is given high on the ramus, and about 70-80% of needle stick injuries from these injections affect the lingual nerve, which is more exposed on the ramus. But the patient did not report feeling numbness in his tongue. Investigate periapical radiolucencies. The initial pre-op periapical X-ray of 37 had a radiolucency centred at its apex, which could have been a Stafne bone cyst or a sign of apical periodontitis. But this radiolucency was not noted in the chart. It is prudent to confirm the pulp status of such teeth and investigate further, if the responses do not make sense.