Last week I had a very upset patient. The reason? I was the second specialist that he was seeing for one tooth. See, this patient was actually referred to me by a Periodontist, and the patient was NOT happy that he had to have the same tooth evaluated AGAIN!!
He was my first patient on a Monday morning (I don’t know about you, but having an unhappy patient first thing in the morning is not my favorite way to kickstart a week). When you say, “Hi, good morning. How are you?”, you don’t really want the response, “Not good at all.” So let me tell you what happened.
The patient’s chief complaint was that “My dentist told me I have a bump on my gum and an infection.” He had no pain and he didn’t even know that he had a deeper problem. Check out his preoperative radiographs…
On the radiograph I see a curvy mesial root and a periapical radiolucency around tooth #15. He had no pain to percussion and did not have a response to cold. Clinically, I saw that the teeth in the upper left quadrant have been restored with crowns and that a sinus tract was present over area #15.
Whenever, I see a sinus tract, I always trace it, 100% of the time.
Tracing a sinus tract is such an amazing diagnostic tool since it will trace right to the source of the infection. All I do is take a size 25 gutta percha and put it right through the sinus tract until it stops. Sometimes, I need to use a periodontal probe to create a glide path before I place that gutta percha. Keep in mind that my patient is usually not numb for this and they usually do very well, as long as you give them a little warning as to what’s coming. So let your patient know that this step will be a little tender. In this case, the sinus tract traces right to the apex of tooth #15.
Unfortunately this patient was so upset with his general dentist that he mentioned he did not want to go back to him for any further care. Why? He felt that his dentist should know how to make the right diagnosis to get him to the right specialist. The patient was losing faith in his dentist that he had been loyal to for so long, and he thought it wasn’t right that he should have to pay for two evaluations to find the problem.
I know many dentists who don’t like to do endo at all in their practice, but that doesn’t mean that they should simply forget about the diagnostic aspect of endo.
Diagnostics are something that we do in our practices everyday, and it can have a HUGE impact on our all of our patients. In this sense, we are doing endo all the time and are just not realizing it.
This case is sooo simple to diagnose. When you simply do a cold test, you will find out that the tooth is necrotic and the necrotic pulp is the source of the infection and the draining sinus tract. This is a primary endodontic lesion and within a week of doing the root canal, that sinus tract should be gone. This patient had a Necrotic Pulp with Chronic Apical Periodontitis and all it needed was a root canal.
Some other things to keep in mind when it comes to sinus tracts — they are usually incidental findings. Most patients don’t know they have them because there is very little pain associated with them. So, make sure that you look for them and DON’T prescribe an antibiotic when you see one.
I really want to high five this Periodontist!!! He saved this guy’s tooth by not doing any crazy surgery to try and fix it. He recognized that it was a primary endo lesion and not a primary perio lesion. I can’t tell you how many times I have seen a tooth like this AFTER a periodontal surgery has already been performed to treat it.
So, do your patients a favor and run through the diagnostic tests BEFORE you ever refer a patient out.
And remember that we, as specialists, are here to confirm your diagnosis, but we should aim at keeping moments of shuffling your patients around to a minimum. If you have a question, call us and perhaps discuss it with us before you make a referral so that you can save your patients time and money, and so they will come back to your practice as happy campers.
The reason I write some of these blogs is so that you can see what a specialist sees, and so I can give you a different perspective — your patient’s perspective. I know I am always grateful for those who give me feedback so that I can better my practice.
So, when you see a sinus tract, embrace it, because it’s your friend. It’s there to give you a clue, to tell you exactly where the infection is coming from, and it’s saving your patient from having any pain at all.
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