Clinical Case SeriesDentistry

Clinical case series: Introduction and Case 1#: Why is this happening to me?

Hello dentistry students and welcome to the beginning of MSO’s clinical case series!

The idea of this case series to invite dental students and graduates form all years and experiences to work together to explore and use our problems solving skills to dissect a series of scenarios based on common clinical scenarios you might/ have encountered during your dental years.

Each month or so,will be writing and uploading a brief introduction/ setting the scenario, possibly a picture if I can and some initial questions to get the ball rolling. These questions may be what diagnostic tests are indicated, what further questions would you ask etc. I hope everyone will drop by, read and contribute/ We can bounce off each other’s comments to continue the discussion and work our way forward. If the discussion is running dry or to make it more interesting, I will step in and add some information/further the scenario, or others can feel free to do the same and make the discussion in another direction.

This is aimed at all dental students, regardless of year/ experience so hopefully the junior students will learning something for more experienced students and senior students/graduates contribute things they have learnt from their own clinical experience. Don’t be afraid to ask questions or contribute ideas! It’s a learning and problem solving activity.

In order to help people gauge an idea of what kind of information/level of knowledge would be useful for the scenario, I will indicate an approximate year level at the beginning of the scenario in which I think it appropriate. That is not to say people who are in the lower years cannot contribute, I would welcome and encourage it.

Lastly, if anyone has any ideas of scenarios that they would like the explore, hit me up with a PM and I’ll see what I can do, or otherwise, write one yourself and send it to me (I would love that more!)

Ok. lets get to it!

Scenario #1 – Why is this happening to me? (High caries risk)

Approx year level: ~1-2+

Scenario
Jason is 19 years old and has attended your practice on a Saturday morning for a check up. He explains he hasn’t been to the dentist for a check up since year 6 when the dentist came to his school to ‘check everyone’s teeth’, but his father has made him come today. When asked is he has any concerns, Jason tells you a lower left filling has fallen out and is cutting and irritating his tongue, otherwise he says he is ok. Upon further questioning, we find out the filling was placed a year ago when he was in a lot of pain due to hot and cold drinks, but never went back to that dentist despite being advised to. Jason has no medical problems that he is aware of.
What further questions would you ask and why?

Examination
Jason has areas of moderate gingivitis but no calculus is visible. A perio exam reveals pocketing of ~3mm generally. The lower LHS first molar is grossly carious and cavitated. There is no other restorations present, and Jason has all of his teeth excluding his 3rd molars. You spot some staining on the occlusal surfaces of his molars and premolars. There are some white dull lines around the gingival margins of most of Jason’s posterior teeth. The mucosa seems to be healthy, but there seems to be a pimple of the attached gingiva on the lower left.
What other examination would you do initially?
What further diagnostic tests would you perform and why?

 Fig. 1: Jason’s teeth

This sounds like an interesting idea :)<br />
<br />
I invite the junior students to have a go and get the ball rolling!<br />
<br />
[OFFTOPIC]totally irrelevant sidenote - seems a little advanced for 1st or 2nd year :O[/OFFTOPIC]
    <blockquote>This sounds like an interesting idea :)<br />
    <br />
    I invite the junior students to have a go and get the ball rolling!<br />
    <br />
    [OFFTOPIC]totally irrelevant sidenote - seems a little advanced for 1st or 2nd year :O[/OFFTOPIC]</blockquote><br />
    <br />
    Well yeah, I figured I'll put something in there for them to learn to its not just a typical class room exercise. :p
    Examination? *looks*<br />
    <br />
    Yup, looks like he has teeth...
      F
      • F
        frootloop
      • November 12, 2012
      Initial examination: Wallet biopsy. <br />
      [offtopic]Sorry, sorry, I'll stop with the trolling :p . *buts out*[/offtopic]
      Lol @<a href="http://www.medstudentsonline.com.au/member.php?u=5638">Havox</a> .<br />
      <br />
      Chief Complaint <br />
      + Check up<br />
      + Left lower filling fallen out --> cutting & irritating tongue<br />
      <br />
      I would ask how long ago the filling fell out? As well as if he experiencing any sensitivity? after it fell out<br />
      Is the pain due to cold or hot fluids/ food?<br />
      Is the pain short, dull, intermitting?<br />
      <br />
      Examination<br />
      Intra-oral examination: Note the location & size of the pimple and determine its diagnosis and cause? Could be a sign of Herpes I or an abscess?<br />
      Odontogram: Determine any other carious lesions or areas that need to be watched?<br />
      Dietary Analysis: Staining could be due to acidic foods? Also determine carbohydrate intakes and types of foods normally eaten.<br />
      Salivary analysis: Determine caries risk. Low, moderate or High. <br />
      Radiographs: Establish the extent of the grossly cavitated lesion in the first molar<br />
      Plaque Index to see if the moderate gingivitis is plaque induced or by other means? Since no calculus is present. Can the probe collect biolfim? <br />
      White spots along incisal edges and gingival margin. Ask questions about possible flourosis? Bottle feed, fluoride tablets etc? Weakened enamel can increase risk of caries. <br />
      Oral Hygiene Habits: Ask about their current habits/approach and see if any changes needed to improve the health of the gingiva etc<br />
      <br />
      This is all over the place at the moment. These are just some thoughts I had from the main points given. Normally when doing a check up I would go through a sequence of examinations but I am trying to just address the main points given. Not even sure if this answer is right, but hopefully I'm on the right track :p
        Ok cool. Thanks hutch for contributing!<br />
        <br />
        You say some radiographs to determine the extent of the lesion. Which in particular and why? Would an panoramic radiograph be indicated in this instance?<br />
        <br />
        As for the white spots, ok. A differential diagnosis for them includes fluorosis. What other diff dx? Looking at the history and the location of the lesions, I would suggest incipient caries could be a very likely possibility here.<br />
        <br />
        I would also suggest doing an extra oral exam, though there isnt any particular indication for it.
          <blockquote>As for the white spots, ok. A differential diagnosis for them includes fluorosis. What other diff dx? Looking at the history and the location of the lesions, I would suggest incipient caries could be a very likely possibility here.</blockquote><br />
          <br />
          The way those lesions are distributed and demarcated (esp on the lower canine, doesn't follow the gingival contour) would make me immediately consider orthodontic associated caries first off. Would be quizzing the patient about that (most people don't forget they have had braces :p).
          <blockquote>The way those lesions are distributed and demarcated (esp on the lower canine, doesn't follow the gingival contour) would make me immediately consider orthodontic associated caries first off. Would be quizzing the patient about that (most people don't forget they have had braces :p).</blockquote><br />
          <br />
          Yeah, well thats very true. If the patient was unsatisfied with the aesthetics of those white spot lesions, what could you do about it?
          <blockquote>Yeah, well thats very true. If the patient was unsatisfied with the aesthetics of those white spot lesions, what could you do about it?</blockquote><br />
          <br />
          I'd want to know how long they've been there - i.e. when the braces came off.<br />
          <br />
          I'm assuming those lesions are too severe to get much aesthetic improvement from remin agents (e.g. CPP-ACP). A low visc resin infiltrant may be more effective in that department. Microabrasion *might* be an option.<br />
          <br />
          Absent cavitation, extensive dentine involvement or surfaces that weren't cleansible for another reason, I'm thinking any kind of tooth-coloured restoration would best wait until some OHI and risk factors were sorted (im thinking he's not totally keen on the toothbrush, or isn't down with technique at the moment). Don't want to add any margins, potentially retentive surfaces in just yet.<br />
          <br />
          hehe help!
          I have experience with cases of fluorosis where air abrasion plus CPP-ACP has worked really well. Not sure how far along carious lesions would have to be to discount this.<br />
          <br />
          Basically any conservative I think is best, and to make sure it does aggregate the condition to a worse state.
          I have had no exposure to any type of air abrasion yet, will add that to my LO's :) <br />
          <br />
          So potentially, we could actually get a good aesthetic result with that and CPP-ACP. That's cool!
          Ok, to continue the discussion.<br />
          <br />
          The staining on the occlusal surfaces of the teeth.<br />
          <span style="font-style:italic;">How could you determine if these are carious or not?</span>
          This is just beautiful! Thanks muse. I guess I could learn something about dentistry even though I'm not currently studying it. ^^
          <blockquote>This is just beautiful! Thanks muse. I guess I could learn something about dentistry even though I'm not currently studying it. ^^</blockquote><br />
          <br />
          Haha, well sure. Please read and ask questions. If there is something you dont understand, ask :)
          <blockquote><br />
          <span style="font-style:italic;">How could you determine if these are carious or not?</span></blockquote><br />
          <br />
          I'm actually not sure about distinguishing stain from fissure caries :( <br />
          I suppose a visual examination - looking for matte, 'frosty', opaque enamel associated with the stain and a matte appearance on the stain. Check it out and compare wet and after 5sec air drying. A tactile exam is probably not going to be useful in the base of a fissure Im guessing? <br />
          <br />
          Look for progression into dentine on BWs. Transluminate the tooth.<br />
          <br />
          I'm wondering, would it ever be appropriate to remove the fissure stain operatively to check? E.g. use a small slow speed bur, check enamel, place fissure sealant. I mean if there was no evidence of progression into dentine, then the treatment would be the same in this case - fissure seal - which arrests lesions in enamel.<br />
          <br />
          Thanks for making this thread btw :)
          <blockquote>I'm actually not sure about distinguishing stain from fissure caries :( <br />
          I suppose a visual examination - looking for matte, 'frosty', opaque enamel associated with the stain and a matte appearance on the stain. Check it out and compare wet and after 5sec air drying. A tactile exam is probably not going to be useful in the base of a fissure Im guessing? <br />
          <br />
          Look for progression into dentine on BWs. Transluminate the tooth.<br />
          <br />
          I'm wondering, would it ever be appropriate to remove the fissure stain operatively to check? E.g. use a small slow speed bur, check enamel, place fissure sealant. I mean if there was no evidence of progression into dentine, then the treatment would be the same in this case - fissure seal - which arrests lesions in enamel.<br />
          <br />
          Thanks for making this thread btw :)</blockquote><br />
          <br />
          Lol, no problem. I agree with you methods of determining the caries. As for tactile, my 2nd year tutor liked to describe the feeling as being 'sticky', although I would never stick a probe in the fissure with presure as you might break the surface enamel and cavitate the lesion.<br />
          <br />
          As for opening up the fissures, yes we do, its called fissure exploration. A lot of MI-based people dont like this, but its still done a lot. I have done it, but you need to be really careful not to take away too much tooth structure. :)
          It can be a bit tough to distinguish, but what I do is get the explorer and gently (it's not really gentle per se, but it's not a whole lot of force either ... ) stick the probe in the fissure and if it feels 'sticky' when you're removing the explorer, then it's carious.
          <blockquote>It can be a bit tough to distinguish, but what I do is get the explorer and gently (it's not really gentle per se, but it's not a whole lot of force either ... ) stick the probe in the fissure and if it feels 'sticky' when you're removing the explorer, then it's carious.</blockquote><br />
          <br />
          How reliable is that though? I mean, a probe can stick depending on the fissure morphology. Or is there a subtle tactile difference?
          <blockquote>How reliable is that though? I mean, a probe can stick depending on the fissure morphology. Or is there a subtle tactile difference?</blockquote><br />
          <br />
          I think you need to make a judgement as a clinician. No test is going to give you 100% certainty, but with other evidence you could decide either way.<br />
          <br />
          If you are unsure, I think the best thing to do if leave it and try to remineralise the area, or at least pull the balance away from demin. Also, you could just fissure seal over it, which can block off the nutrients to the fissure system and stop the bacteria from causing further decay. But you need to be 100% certain you did a great fissure seal, with good moisture and coverage in order to achieve this. And even then, you can never be 100% certain it will work.
          I don't know if this is true but I heard they brought out this product where you can apply it onto tooth surface and it will change a certain colour to show whether caries have been detected or not? My friends dad who is a dentist in NZ told me about it but I really don't know much about it yet.
          <blockquote>I don't know if this is true but I heard they brought out this product where you can apply it onto tooth surface and it will change a certain colour to show whether caries have been detected or not? My friends dad who is a dentist in NZ told me about it but I really don't know much about it yet.</blockquote><br />
          <br />
          Well we sometimes use a similar thing which stains infected dentine so you can see where there are bacteria still in a cavity? Not sure about a clinical test without cavitation though.
          Laser fluorescence (Diagnodent) can also be a useful tool for diagnosing pit and fissue caries. However it should never be used in isolation as it produces a lot of false positives (low specificity).<br />
          <br />
          How does the diagnodent work?<br />
          What are some examples of false positives?
          <blockquote>Laser fluorescence (Diagnodent) can also be a useful tool for diagnosing pit and fissue caries. However it should never be used in isolation as it produces a lot of false positives (low specificity).<br />
          <br />
          How does the diagnodent work?<br />
          What are some examples of false positives?</blockquote><br />
          <br />
          Mmm Correct me if I am wrong, but diagnodent uses transmitted light which reflect on mineralised substances back to the device so it can use that to find where less dense mineral is....that doesnt sound quite right, but enlighten me!<br />
          <br />
          False positives would really be anything that isnt true, turns up as true. So you would get a reading for caries in that area, when by the gold standard (ie cutting up the tooth) would reveal there is none.
          <blockquote>Mmm Correct me if I am wrong, but diagnodent uses transmitted light which reflect on mineralised substances back to the device so it can use that to find where less dense mineral is....that doesnt sound quite right, but enlighten me!<br />
          <br />
          False positives would really be anything that isnt true, turns up as true. So you would get a reading for caries in that area, when by the gold standard (ie cutting up the tooth) would reveal there is none.</blockquote><br />
          <br />
          Close but no cigar! I'll leave this one open for anyone else that whats to give it a try. :)<br />
          <br />
          Yes, that's exactly what a false positive is but what was trying to ask is for some specific examples of what might get a positive response when it is infact not carious at all. (The key to this is understanding how the diagnodent actually works)
          <blockquote>Close but no cigar! I'll leave this one open for anyone else that whats to give it a try. :)<br />
          <br />
          Yes, that's exactly what a false positive is but what was trying to ask is for some specific examples of what might get a positive response when it is infact not carious at all. (The key to this is understanding how the diagnodent actually works)</blockquote><br />
          <br />
          Excitation wavelength from diagnodent is absorbed by dental tissues and emitted at a longer wavelength. This emission wavelength is relatively consistent in non-diseased tissue. This fluorescence is higher in carious tissue.<br />
          <br />
          Cleaning would be the biggest issue. The fluorescence excitation isn't very specific in terms of the things that can be found in the mouth - many things could indicate a positive reading. Plaque, food debris, fissure seals etc. A good clean needed beforehand.
          <blockquote>Excitation wavelength from diagnodent is absorbed by dental tissues and emitted at a longer wavelength. This emission wavelength is relatively consistent in non-diseased tissue. This fluorescence is higher in carious tissue.<br />
          <br />
          Cleaning would be the biggest issue. The fluorescence excitation isn't very specific in terms of the things that can be found in the mouth - many things could indicate a positive reading. Plaque, food debris, fissure seals etc. A good clean needed beforehand.</blockquote><br />
          <br />
          I know I'm being annoying (must have inherited it from my lecturers), but what component of the carious tissue does it detect?<br />
          <br />
          Answer:<br />
          [offtopic]Diagnodent sends a 655nm wavelength of light and detects bacterial porphyrins (metabolic byproducts). Hence the false positives for non-carious substances like plaque and calculus. Diagnodent does not measure the amount of mineralisation. Opposite for chemical dyes![/offtopic]<br />
          <br />
          Nice work! Interestingly the pulp also gives some fluorescence so caution must be taken if using it in a deeper cavity.
          <blockquote>I know I'm being annoying (must have inherited it from my lecturers), but what component of the carious tissue does it detect?.</blockquote><br />
          <br />
          No, that's good - should endeavour to know those sorts of details. I wasn't sure beyond there being a difference between the emission of dental tissues and those infiltrated by bacteria. <br />
          <br />
          Good to know, thanks Rickthetrick.
          My diagnosis............BAD BABYSITTING
          Ok, getting back to the case.<br />
          <br />
          I would do a set of bitewings to look for interprox caries and a PA (ideally with a GP point in the sinus) of the lower LHS molar. I would also suggest an OPG to assess the state if his 3rd molars, though this may be put off until later as there is no other indication for it at this stage.<br />
          <br />
          Here are Jason's RHS bitewing radiograph and PA of the tooth 36.<br />
          <br />
          RHS Bitewing<br />
          <br />
          <img src="http://www.dental-xray-equipment.com/wp-content/uploads/2010/07/bitewing-x-ray-300x232.jpg" alt=" " /><br />
          <br />
          PA of tooth 37 (Please kindly ignore the badly photoshopped caries, and the fact that there is a 3rd molar here.... it's really hard to find pictures to match the scenario!)<br />
          743<br />
          <br />
          <span style="font-style:italic;">What do you see?<br />
          <br />
          What is your final diagnosis?<br />
          </span><br />
          <span style="font-style:italic;">How would you prioritise your treatment?</span>
          Boo! No one is answering =[<br />
          <br />
          Pretty epic periapical lesion going on there associated with at least MO caries. Probably includes buccal and/or lingual aspect too.<br />
          <br />
          I would diagnose it as chronic periapical periodontitis.<br />
          <br />
          Someone else can answer how they would prioritise treatment :)!
          <blockquote>Boo! No one is answering =[<br />
          <br />
          Pretty epic periapical lesion going on there associated with at least MO caries. Probably includes buccal and/or lingual aspect too.<br />
          <br />
          I would diagnose it as chronic periapical periodontitis.<br />
          <br />
          Someone else can answer how they would prioritise treatment :)!</blockquote><br />
          <br />
          I will answer son if no one else does~<br />
          <br />
          I would diagnose it has a necrotic pulp with chronic periapical periodontitis, associated with a large MO carious lesion.
          <span style="color:#222222" class="colored"><span style="font-family: Times">Nice thread Muse.<br />
          <br />
          Couple important questions in private practice:<br />
          <br />
          Can the patient afford it? The RCT and the large restoration or crown following.<br />
          State of the rest of the dentition?<br />
          Is there an opposing tooth?<br />
          Any chance of the 8 erupting into a good position? (the p.a shows the 37 has a lesion ;)</span></span>
          OK, Sorry I have not moved this thread along in a while, uni has eaten up all my time. I will bring this case to a close with some thoughts written out and the last set of questions. You are free to add to them or disagree. The next case will be next week.<br />
          <br />
          <span style="font-style:italic;">How will you prioritise treatment and why?</span><br />
          <span style="font-weight:bold;">Immediate phase<br /></span>Discuss with patient of options of extraction or endodontics for lower left molar. If to keep tooth, caries removal of lower left molar, access for endodontics, drainage, irrigation (sodium hypocholarite) and placement of temp restorations (if not enough time in current appt to progress with instrumentation).<br />
          <span style="font-style:italic;">It is essential if the tooth is to be saved, and remove the course of the apical infection, as the infection has the potential to spread and become a serious health risk. There is also an urgent need to minimize further destruction of this tooth, as it may be soon unrestorable. The temporary restoration is needed for provide a stable structure for a rubber dam clamp in future endo, stabilise occlusion and stop any drifting of teeth.</span><br />
          <br />
          <span style="font-weight:bold;">Preventative tx</span><br />
          Dietary analysis, OHI, fluoride tx, further info on social hx<br />
          <span style="font-style:italic;">Should be started today, and reinforced throughout tx. Although there is no other signs of caries currently, this is a very critical time in a patients life as there are many changes as people gain independence and change lifestyles. Reinforcing good OHI and dietary factors may prevent any further caries in the future, and ensure the dentition remains intact in the long term.<br />
          <br />
          <br />
          </span>What kind of temporary material can be used in this case?<br />
          <span style="font-weight:bold;">Zinc Oxide and eugenol pastes or cements</span>- Bacterial, easy to mix, place and remove, some harden in contact with saliva, but usually not very strong. Ideal for most cavities provided there isnt excessive occlusal load.<br />
          <span style="font-weight:bold;">Polycarboxide cements</span>- Adhesive to enamel and dentine, hard and durable, used when mechanical retention is poor<br />
          <span style="font-weight:bold;">GIC</span> - adhesive to enamel and dentine, reasonably hard an durable, fluoride release, aesthetic appearance, useful anterior and posterior
          • Sam
            Sam
          • January 22, 2013
          fluoride is how the govt controls the population~
          <img src="http://4.bp.blogspot.com/-Z1qTOQx-37Q/UHAiCZU8n2I/AAAAAAAAGvk/oy2w_yKQw5s/s1600/endodontics-lower-left-molar-lateral-root-canal-treatment-balcon-701-obturation-guttapercha.jpg" alt=" " /><br />
          <br />
          <span style="font-style:italic;">Here is a picture of the 37 a few months after completing RCT. What do you see and what long term problem could result from what is seen in the image?<br />
          <br />
          <br />
          Why don't we just extract the molar?</span>
          To answer the above questions,<br />
          <br />
          - The radiograph shows the 37 to have been root filled. The crown appears to have been fractured, at some point, to the CEJ. There seems to be a puff of cement extruding from the distal canal/ The mesial canal(s), seem to be short and over prepared. There is possible a perforation on the distal part of the mesial canal near the furcation area. There also seems to be a void in the coronal portion of the mesial canal. The mesial contact point on the 37 is lost, which might indicate mesial drift of the tooth. The 38 has had an occlusal amalgam restoration placed since the last radiograph was taken. There also seems to have been some loss of interdental crestal bone to the distal of the 37. Otherwise, there is good healing of the bone.<br />
          <br />
          - The fracturing of the cusp, if left can cause over eruption of either the 37 or 26/27. One might need to question hjow well the mesial canal was cleaned if there is such a short final obturation. The over preperation will result in weakened tooth stricture, and possible root fracture. The void in the GP might serve as a passageway for bacteria, which will ultimately reinfect the canal system. The puff of cement may create a tissue reaction, resulting in loss of bone around the apical area. The tooth may need a crown to avoid further fracture of the now brittle tooth strcture, and there seems to be substancial tooth structure lost already.<br />
          <br />
          Why not extract?<br />
          It definitely is a consideration, depending on cost factors, aesthetics and others. The prognosis of the other molars are important in making this decision, if they are poor, it might eb a good idea to try and save as many teeth as possible for functional value. Ultimately, a lot depends on the patient's wishes, although the patient's wishes now might be different to in the future, so the consequences of having an edentulous area must be made clear, and all other tx (eg fixed bridges, rem pros) must be explained and carefully evaluated by the patient.
        <blockquote>Note the location & size of the pimple and determine its diagnosis and cause? Could be a sign of Herpes I or an abscess?</blockquote><br />
        <br />
        When you have a chronic infection at the apex of a tooth (typically due to bacteria + toxins from unchecked decay that has made its way through the entire root system), pus accumulates and can try to be 'relieved' by following a path of least resistance. This usually leads to the buccal aspect.<br />
        <br />
        If this is true, then what do you think you can do to confirm this sinus tract and the source of the infection?
          <blockquote>When you have a chronic infection at the apex of a tooth (typically due to bacteria + toxins from unchecked decay that has made its way through the entire root system), pus accumulates and can try to be 'relieved' by following a path of least resistance. This usually leads to the buccal aspect.<br />
          <br />
          If this is true, then what do you think you can do to confirm this sinus tract and the source of the infection?</blockquote><br />
          <br />
          Maybe a bit beyond hutch's level, but correct me if I am wrong!<br />
          <br />
          I would suggest sinus tracking with a GP point then a PA to see where it leads. Also doing some pulp sensibility testing on the teeth in the area to see if a tooth is necrotic (important if it has a abscess underneath it). I think thats a pretty indicated thing in a patient so young, as a necrotic molar tooth is not all that common. Percussion would not be useful as the pressure is relieved by the sinus so there wouldnt be the acute pain would you expect, but possibly a little [MENTION=3313]l2009[/MENTION]?
          <blockquote><span style="color:#333333" class="colored">I would suggest sinus tracking with a GP point then a PA to see where it leads.</span></blockquote><span style="color:#333333" class="colored"><br />
          Correct!<br />
          <br />
          </span><blockquote><span style="color:#333333" class="colored">Also doing some pulp sensibility testing on the teeth in the area to see if a tooth is necrotic (important if it has a abscess underneath it)</span></blockquote><span style="color:#333333" class="colored"><br />
          <br />
          Yep, an electric pulp test should be done to assess the molar. Given that that a sinus tract has actually formed, the infection is chronic and the tooth will most likely be non-vital. There's also a possibility that the infection will spread from the molar to the apex of other teeth. A PA of the area will show if there is any spread to other teeth.<br />
          <br />
          </span><blockquote><span style="color:#333333" class="colored">I think thats a pretty indicated thing in a patient so young, as a necrotic molar tooth is not all that common</span></blockquote><span style="color:#333333" class="colored"><br />
          <br />
          Not common in the sense that you don't usually see 19 year olds with really screwed teeth, but the presence of a periapical abscess in a tooth means that the infection has been there for quite a while so the pulp is probably necrotic.<br />
          <br />
          Quick note regarding periapical abscesses ... we know that they occur because bacteria has spread down root system to the apex of the tooth. From there, the abscess begins to form, but it won't actually appear on the radiograph until it's been there for quite a while. The reason for this is because there needs to be sufficient bone resorption before any periapical radiolucency will show (as the abscess grows, it resorbs bone).<br />
          <br />
          </span><blockquote><span style="color:#333333" class="colored">Percussion would not be useful as the pressure is relieved by the sinus so there wouldnt be the acute pain would you expect, but possibly a little</span></blockquote><span style="color:#333333" class="colored"><br />
          <br />
          That's correct. There may be a little pain or even none at all, as this scenario is described. There probably would've been a stage where they had raging acute pain every time they bit down or touched the tooth.</span>
          Thanks man. <br />
          <br />
          As for the lesion needing to be there for a while to make a periapical radioluscency visible, that would indicate a chronic abscess as you said. Though I find primary acute abscesses harder to determine...there would be pain from percussion and palpation yes...though there wouldnt be a PA radioluscency? How do you determine an acute apical periodontitis from a primary acute abscess? I know Abbott and Yu wrote an article about this classification which I read recently....should probably read that again..
          This discussion is really good guys. I'm learning quite a lot. I don't learn testing the vitality of teeth or in depth pathology till next year. We did an introduction to dental pathphysiology but probably not in enough depth to answer this case scenario. I actually did think of the extra oral examination but wasn't sure whether to note it down.
          <blockquote>This discussion is really good guys. I'm learning quite a lot. I don't learn testing the vitality of teeth or in depth pathology till next year. We did an introduction to dental pathphysiology but probably not in enough depth to answer this case scenario. I actually did think of the extra oral examination but wasn't sure whether to note it down.</blockquote><br />
          <br />
          And thats kinda the point of this. I hope people will learn from others, and really, it may help clarify things when you get to them.
          <blockquote><span style="color:#333333" class="colored">Though I find primary acute abscesses harder to determine...there would be pain from percussion and palpation yes...though there wouldnt be a PA radioluscency? How do you determine an acute apical periodontitis from a primary acute abscess?</span></blockquote><span style="color:#333333" class="colored"> In acute periapical periodontitis, the infection has, at least, recently arrived at the apex. You do have the beginning of abscess formation. There would be quite a lot of pain from percussion and may be tender to buccal palpation. You shouldn't see a radiolucency, but you should be able to make the diagnosis with intra-oral examination + asking patient regarding any symptoms. So, some symptoms would be - 1) very tender to percussion (as we have mentioned) 2) tooth feels as though it's elevated in its socket 3) Typically not sensitive to hot or cold.<br />
          <br />
          </span><blockquote><span style="color:#333333" class="colored">This discussion is really good guys. I'm learning quite a lot. I don't learn testing the vitality of teeth or in depth pathology till next year. We did an introduction to dental pathphysiology but probably not in enough depth to answer this case scenario. I actually did think of the extra oral examination but wasn't sure whether to note it down.</span></blockquote><span style="color:#333333" class="colored"> Glad you're learning something! Most of the things we're discussing isn't really 2nd year material. More so 3rd year stuff. I recently came across this clinical operative dentistry guideline (I think it was from the Ohio University dental school) that would be <span style="font-weight:bold;"><span style="text-decoration:underline;">excellent</span></span>for 3rd year clinics. It's basically what to do in every likely scenario you'll get in treating patients (at least the ones that are sutiable for 3rd years). I'll try and dig it up later. <br /></span>
          <blockquote>Thanks man. <br />
          <br />
          As for the lesion needing to be there for a while to make a periapical radioluscency visible, that would indicate a chronic abscess as you said. Though I find primary acute abscesses harder to determine...there would be pain from percussion and palpation yes...though there wouldnt be a PA radioluscency? How do you determine an acute apical periodontitis from a primary acute abscess? I know Abbott and Yu wrote an article about this classification which I read recently....should probably read that again..</blockquote><br />
          <br />
          Funnily enough I actually asked Abbott about this a couple days ago!<br />
          <br />
          As far as I've learnt, everything you've said is correct. Primary apical periodontitis and primary apical abscess can be clinically difficult to differentiate since they both have no radiolucency, may or may not respond to sensibility testing (as it could be pulpitis or necrotic and infected) and acute abscesses don't always have intra/extra oral swelling. The main differentiating features are:<br />
          <br />
          - Primary apical abscess is usually much more severe level of pain ie. patient can't even stand you touching the tooth<br />
          - Primary apical abscess may have systemic effects ie. fever, malaise or facial cellulitis<br />
          - Primary apical abscess may be associated with extrusion<br />
          - Sometimes you still won't be able to make a final diagnosis until you open up the access and find pus draining in the canals.<br />
          <br />
          (Just had my endo exam yesterday)<br />
          <3 Endo
          <blockquote>As far as I've learnt, everything you've said is correct. Primary apical periodontitis and primary apical abscess can be clinically difficult to differentiate since they both have no radiolucency, may or may not respond to sensibility testing (as it could be pulpitis or necrotic and infected) and acute abscesses don't always have intra/extra oral swelling. The main differentiating features are:<br />
          <br />
          - Primary apical abscess is usually much more severe level of pain ie. patient can't even stand you touching the tooth<br />
          - Primary apical abscess may have systemic effects ie. fever, malaise or facial cellulitis<br />
          - Primary apical abscess may be associated with extrusion<br />
          - Sometimes you still won't be able to make a final diagnosis until you open up the access and find pus draining in the canals.<br />
          <br />
          (Just had my endo exam yesterday)<br />
          <3 Endo</blockquote><br />
          <br />
          Yay thanks! I had my last exam a week ago so its also still fresh in my mind :3
          I'd be glad to submit some clinical scenarios! Endo, ortho, perio, maybe oral med if I'm in the mood... I love this sort of stuff :D
          <blockquote>I'd be glad to submit some clinical scenarios! Endo, ortho, perio, maybe oral med if I'm in the mood... I love this sort of stuff :D</blockquote><br />
          <br />
          Awesome. Thats exactly what we need. Depending on the interest and level of activity, I guess we could do this more often, say every 2 weeks. It also depends on how I can handle it when I start again in Jan :3
          <blockquote>Awesome. Thats exactly what we need. Depending on the interest and level of activity, I guess we could do this more often, say every 2 weeks. It also depends on how I can handle it when I start again in Jan :3</blockquote><br />
          <br />
          [offtopic]4th year!! *squeee*[/offtopic]
          <blockquote>I'd be glad to submit some clinical scenarios! Endo, ortho, perio, maybe oral med if I'm in the mood... I love this sort of stuff :D</blockquote><br />
          <br />
          Omg yes please! :)
Awesome thread, very interesting. Cheers
C