Sometimes It’s Not What You Think, So Trace It!

by | Jan 16, 2019 | Endodontic Case Study | 8 comments

What do sinus tract tracing, proper diagnosis, and patient education have in common? They’re all the star of the show in this blast-from-the-past tooth story!

I’m not shy about loving advanced diagnostic technology. I adore my cone beam technology more than words can say—the imaging makes it so easy to figure out exactly what is causing a patient’s pain. But as much as I love keeping up with the latest tech, there’s something satisfying about good old-fashioned diagnostic methods. This case is a great example of how effective sinus tract tracing is in endodontic diagnosis.  

This isn’t the first time I’ve gotten on my soapbox about sinus tracts, and how important it is to trace them every single time. Sinus tracts can give you clues to where an infection is located before your patient experiences any pain at all. Sinus tract tracing is such an incredible diagnostic tool that I thought it was well worth it to dedicate another blog post to the topic. Get ready for a real throwback case—this was before the time of my precious CBCT! 

A Sinus Tract Tracing Surprise

As I said above, sinus tracts don’t normally cause patients any pain on their own, and this one was no different. When I examined the patient, he wasn’t in any discomfort, but he had a bump on his gums that was driving him crazy. His referral slip said to treat tooth #13, so I assumed that tooth was the primary culprit behind the sinus tract.  

Take a look at the patient’s preoperative radiograph.

See how there’s a periapical radiolucency from the apex of tooth #11 to tooth #14? This radiograph seemed to confirm that tooth #13 was behind the sinus tract, and the patient was already expecting to only have that tooth treated. But again—I always trace the sinus tract first, no matter how open-and-shut a case appears, just to be safe. So, that’s what I did here. And man, am I glad I did! 

The sinus tract tracing revealed that the sinus tract actually belonged to tooth #14—it traced right to that tooth’s MB root. So, the patient’s 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 tooth #13, and the MB2 in tooth #14.

Getting The Patient On Board

Now it was time for the hardest part: dropping the bomb on the patient that he needed retreatment on two teeth instead of just one. I knew that he had only been on board with treating tooth #13, so I knew I had to be strategic in how I broke the news. I focused on two things: telling the patient his tooth story, and focusing on his own chief concern. 

I don’t use tooth stories just to educate other dentists—I use them to educate my patients about the treatments that will benefit them the most. I find that explaining diagnoses to patients this way makes it more likely that they will accept all the recommended treatment. In this case, I walked the patient through everything I just described, including explaining how I used sinus tract tracing to link the infection to tooth #14 instead of tooth #13. 

Now, the patient was understandably not too thrilled at the prospect of having two teeth retreated rather than just one. To help him accept the treatment, I focused on the implications for his chief concern: the bump on his gums. I explained that if I only treated tooth #13, as his original dentist had recommended, the sinus tract would remain right where it was, and the bump on his gums wouldn’t go away. He quickly changed his mind and agreed to having both teeth treated. 

If your referred patient ends up needing a different treatment than expected, I always recommend explaining your process very clearly and relating it back to their primary concern. It’s so important for the patient to understand the long-term implications and effects of different proposed treatments, especially as they relate to the things they care about most. 

Trace Every Tract

The biggest takeaway from this case study is to always double and triple check your diagnoses! I know that it’s easy to get lazy and jump to conclusions, especially when you’re part of a busy practice. In this situation, many of us would have assumed that #13 was the culprit tooth, and wouldn’t have bothered to complete sinus tract tracing. But that would be doing the patient—and your practice—a huge disservice. 

Sinus tract tracing is an inexpensive and extremely teachable diagnostic tool. It proves that you don’t need to spend thousands of dollars on a CBCT machine or other advanced technology to get an accurate diagnosis. All you need is to invest a little extra time and effort into your patient. 

So, the next time you see a sinus tract, don’t make an exception—trace it! You never know when it might save the day.

 

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