A couple of years ago, I had a very upset patient. The reason? I was the second specialist that he was seeing for the same tooth. 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!!
It was my first patient on a Monday morning, and having an unhappy patient first thing in the morning is not my favorite way to kickstart a week. When you greet them with a cheery, “Hi, good morning! How are you?,” you don’t really expect a negative response. So what’d he say? “Not good at all.”
His Chief Complaint
The patient’s chief complaint was that his dentist told him had a bump on his gum and had 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.
That was a little clue for me… because whenever, I see a sinus tract, I always trace it. 100% of the time.
Tracing a Sinus Tract to the Source of the Infection
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. However, they usually do very well, as long as you give them a little warning as to what’s coming. You’ll want to 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.
He was Frustrated with His General Dentist
Unfortunately, this patient was so upset with his general dentist that 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 the dentist that he had been loyal to for so long. (And he didn’t feel like it was fair to have to pay for two evaluations, since his general dentist didn’t diagnose the problem accurately.)
You know, I know many dentists who don’t like to do endo at all in their practice. However, 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. The necrotic pulp is the source of the infection and the draining sinus tract. Because this is a primary endodontic lesion, that sinus tract should be gone within a week of doing the root canal. This patient had a Necrotic Pulp with Chronic Apical Periodontitis, and all it needed was a root canal.
Always Look for the Sinus Tract
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.
Remember, we, as specialists, are here to confirm your diagnosis, but it’s also important to keep the shuffling around of your patients 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 Take Away
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’m always grateful for those who give me feedback so that I can better my practice, and I hope you feel the same!)
That said, there are two lesson here:
Lesson 1: 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.
Lesson 2: Make sure you can confidently diagnose your patients’ pain, even if you don’t like to perform root canals. When you can diagnose correctly, you help your patients get the treatment they need…and they keep trusting you as a clinician.
Need some help with diagnosis? Download my free Pulpal & Periapical Diagnosis Checklists!
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