How many times have you had a patient who was sensitive after their restoration, be it a filling or a crown?

How long do you wait until you make a referral? And what are your steps before you make your referral?

Do you rule anything out, like occlusion?

Well, here is a story for you…

It was the day after Christmas and all was peaceful.  I went into the office to do a little end-of-the-year cleaning, and was organizing my desk when one of my team members asked me if I could see a patient for an emergency evaluation. I didn’t mind because I didn’t want anyone to be in pain over the holiday.

The patient came in and stated that she had a new crown done about 8 days ago and now she couldn’t bite or tolerate anything cold.  When I asked her what her pain level was, she reported a 6 out of 10.  My diagnostic tests confirmed her symptoms of cold sensitivity with lingering pain, and pain to percussion, and the bite stick.  And I confirmed that her occlusion was totally normal.  I noted the mesial and distal decay on tooth #19. I was able to diagnose her with Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis.

Since she was in a good bit of pain at the evaluation, I offered to open her tooth right then and there.  I was concerned that her pain could get worse over the remainder of the holiday weekend.  So, I gave her a treatment plan, presented her the fees, and upon checkout she decided not to stay for treatment since she realized that her insurance had maxed out.  I guess her pain wasn’t that bad after all?

Fast forward a few weeks and now we are into the new year, when the insurance benefits roll over, lol.  The patient was back on my schedule for treatment. I was really surprised that she could tolerate the pain for so long!  I walked into the room and asked her how she was doing.  She said she was “fine” — she was almost TOO fine to be in my chair. So I asked her if she had been functioning on that side.  Her response was that she only had a little pain to heat, but that she could now chew on that side.  I decided to retest her.  She responded normal to cold with no lingering pain and no longer had any pain to percussion. Say what what?? She said she still has a little bit of pain to heat, but it is only for that moment and it disappears right away once the stimulus is gone.   

So I stopped my testing and discussed with the patient that we could do the root canal at any time.  But if time is making her feel better, then perhaps we have the opportunity for her to recover even more.  One piece of the puzzle that I didn’t know initially: she had a bite adjustment from her GP a few days before she came to my office the day after Christmas.  She insisted on a referral to my office just based on her previous experiences with tooth pain.  She finally mentioned it to me on her second visit, since she said her pain was initially an 8, then after the bite adjustment it was a 6 and then it went to a 3, and now she had no pain. No wonder why I didn’t notice that her bite was off at the time of the evaluation, because it was already adjusted!  All of her tests when she initially visited me indicated that she needed a root canal. I know now, because we waited, that her testing was a false positive. Do you see now how time could “heal all wounds”? It is something that you need to be aware of as a possibility.

She looked at me with complete gratitude that there would be no root canal today!  Yes, her buildup was deep, but so were some of the restorations on her other teeth. So, perhaps she can tolerate deep restorations.  Since the crown was on with permanent cement already, I wanted to wait for more definitive symptoms. Yeah, I lost some production that day, but it’s better for me to do it this way.  Man, am I glad that we waited for her treatment!

It just makes me wonder, how many root canals are we doing because we are not giving the patient the chance to recover from the normal postoperative period?

I often give the patient what I call a “two week check.”  So if a patient comes to me and has either symptoms that are not that bad or localized, or they recently had some dental work that could be the culprit, I usually have them wait before we start treatment.  I see them again at no additional charge (and I tell them that so they do come back).  I re-evaluate them and go through my diagnostic tests again, and then I compare the findings to my initial tests.  If they get better, then hooray — we move on!  But if their symptoms are not better, then we initiate treatment and at least we can confirm that treatment is needed.

 

Takeaways:

  1. Always give your patient time in order to decipher between normal postoperative sensitivity and a tooth needing a root canal.
  2. Don’t underestimate the power of a bite adjustment.  
  3. Make sure your treatment is warranted. Retest if you’re not sure! It may mean you don’t go through with the treatment. 

 

-Sonia

 

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