Diagnosing Dental Pain: The Phantom Menace

Have you ever had a patient with what seems like phantom pain, meaning that, despite your best efforts, you were unable to determine the source of their pain? My guess is yes.

In this article, I would like to share with you a case of mine in which I had to deal with exactly this issue in hopes that it may help you when you find yourself in this situation.

This case dealt with someone who, at the time, was a new patient who came in on an emergency exam (she is now an excellent long-standing patient) complaining of a toothache on her upper left first molar. She reported that she had been to her previous dentist more than 30 times in the previous six months trying to resolve her discomfort. Interestingly, she had her own written notes on each and every visit. Needless to say, she was frustrated and exhausted of attempting to resolve her pain. Her quote to me at this point was that she was "done" with this tooth and wanted it "ripped out."

My exam showed no remarkable findings. The PA and bitewing we took looked good. Yes, tooth #14 had endodontic treatment, but it appeared to have been done well and did not appear to have any pathology associated with it. Additionally, the teeth appeared to be in proper occlusion, and she had no muscle tenderness, percussion sensitivity or thermal sensitivity. Probing depths were also within normal limits.

She and I discussed that, prior to "ripping out" her tooth, I recommended a CBCT scan to further evaluate things. Interestingly, the CBCT clearly showed pathology not evident on her 2-D radiographs or hinted at in her exam. The CBCT not only showed radiolucency on the distal buccal root of #14 but also on the mesial buccal root of #15. After discussing our findings and discussing her treatment options, much of her chief complaint was resolved by removing #14 and replacing it with an implant. Yes, endodontic retreatment may have also been successful, but she declined this. The remainder of her symptoms were resolved after endodontic treatment on #15.

Could we have successfully treated her without the aid of the information we attained with the CBCT? The answer is, of course, yes, but successful resolution would have likely been delayed. It's very possible unnecessary treatment would have been done as we would have, to some degree, been taking "shots in the dark" as we could make no definite diagnosis based upon our findings without the CBCT.

(Click this link to read more dentistry articles by Dr. John Carson.)

John R. Carson, DDS, PC, Spear Visiting Faculty and Contributing Author www.johnrcarsondds.com