Sometimes It’s Not What You Think, So Trace It!
This blog is a quickie, but man is it a goodie! I am going to continue on my sinus tract soapbox. I can’t emphasize enough how important it is to trace your sinus tracts, and this case really outlines why. This is a throwback case — I did this one a long time ago, pre CBCT, but it makes such a good point I figured I would turn it into a blog. This is old school diagnosing at it’s finest.
This patient had no pain at all which is very typical when a sinus tract is present. However, the patient didn’t really enjoy having a bump on his gums, and getting rid of that sinus tract was his primary complaint.
Here is his preoperative radiograph…
You can clearly see that there is a periapical radiolucency from the apex of #11 – #14. This patient’s referral slip said to treat tooth #13, which seemed very obvious on the radiograph. So, I assumed that the discussion the patient had with his dentist was that tooth #13 was the primary culprit for his sinus tract. But, like I said, I always suggest that you trace it FIRST. So, that’s what I did.
Boy am I glad that I did, because it traced right to the MB root of tooth #14. This sinus tract belonged to tooth #14 and NOT tooth #13. So, if his primary complaint is getting rid of the “bump on his gum,” and I treat tooth #13, then the sinus tract will remain and I didn’t address his chief complaint. That would make one unhappy patient.
Note that this way of diagnosing and tooth storytelling is a great way to educate your patients to let them know what treatment they REALLY need. It allows your patient to accept ALL the treatment.
And when you have to drop the bomb that they need two retreatments instead of one, you get increased case acceptance. So in this case, his diagnosis was Previously Treated and Asymptomatic Apical Periodontitis #13 and Previously Treated and Chronic Apical Abscess #14. Both of these teeth had failing root canals due to a missed canal in each tooth — the palatal canal in #13 and the MB2 in #14.
This patient initially only wanted to treat tooth #13, but when I told him that the bump on his gums that was bothering him won’t go away without treating #14, he quickly changed his mind, and agreed to treating both teeth. I really had to set his expectations here.
It’s easy to get lazy and assume things especially when you get busy. In this situation, many of us would have assumed that the culprit tooth was the premolar.
In this case, as long as you cold test the quadrant, specifically tooth #11, and trace your sinus tracts, you will be in good shape. Tracing sinus tracts is easy to teach your team members how to do, and in my office they are the ones who do this step. It’s also inexpensive and it works — when you trace a sinus tract you don’t need to spend tens of thousands of dollars on a CBCT machine to give you the diagnosis.
So, make no exceptions and every time you see one, trace it. It just might save your butt one day.
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