July 26, 1980. Initial exam.		Sixteen days later.

Clinical: On July 26, 1980, a 28yr old female presented to the office. She claimed she had lived through a "nightmare" of pain during the previous three weeks. She explained that she had presented to her dentist with severe pain in the mandibular right quadrant. The pain had kept her up at night, and nothing gave her relief.

Her dentist examined the area. He concluded the pain she was experiencing came from a periodontal problem and that surgery was needed to treat it. He performed flap surgery that same day, debrided the area, placed sutures, and prescribed penicillin. However, the same acute pain persisted throughout the night. The following day, the dentist cut the sutures, reflected the same flap, and debrided the wound a second time. As before, the patient did not experience any relief. On the third day, the patient was referred to an oral surgeon for an evaluation of why the acute pain persisted.

The oral surgeon also confirmed the patient had a periodontal problem. He, too, cut the sutures, reflected the flap (for the third time in three days), and debrided the area. During this procedure, the oral surgeon explained that he "saw" a root canal problem. Without any pulp tests, he made an access preparation to tooth # 29 (which had never had a restoration and did not have caries), and extirpated the pulp. The patient continued on penicillin and Percodan for the next ten days. Eventually the pain subsided.

The patient presented to this office some three weeks after her pain went away, seeking reasons for what happened. By that time, the pain had dissipated. Nothing was clinically evident except the presence of isolated periodontal pockets (5-7mm) and subgingival calculus remaining on the roots in this quadrant. Her medical history was unremarkable. Upon hearing what happened, the only comment that could be made was that periodontal pockets do not cause the severe pain the patient experienced, and that there was no apparent reason for what had transpired.

The patient was told to finish the root canal treatment. Sixteen days later, she returned to initiate periodontal treatment.

Flap reflected # 27-28.		Four-month reentry.

When the patient presented to the hygienist to begin her initial scaling, she complained that the tissue was tender between teeth #’s 27-28. (Her previous problem was more posterior). Inspection revealed a pocket extending to the apex of # 27, when none had been present 16 days earlier. As can be seen on the two x-rays above, the bone appeared normal at her initial exam. Sixteen days later, it was gone.

In questioning the patient, she revealed that whenever her gums bothered her, she turned her water irrigating device to the highest setting and "blasted" the area. This is probably what precipitated her previous emergency.

Dx: Foreign body reaction

What to do? The assumption is that if it’s a foreign body reaction, the rapid bone loss will reverse itself. A second assumption is that no bone graft is necessary, since this is not periodontal disease and the bone, if the irritant is removed, would be expected to regenerate by itself.

Tx: Once the pulp was tested and proved vital, a full-thickness flap was reflected, revealing a large lesion between the canine and first premolar. Though the apex of tooth # 27 was curetted from the distal, root canal treatment was not suggested for this tooth. The area was debrided, and the flap replaced.

Four months later, a flap was elevated. As can be seen in the above picture, bone was regenerated without the use of a bone graft or membrane.

Discussion: Rapid breakdown often equals rapid repair. When seeing acute lesions, attempts should be made to regenerate lost tissues. The periodontium heals better than expected when the breakdown is not chronic.

Could the initial "nightmare" experienced by the patient have been avoided? Probably. It seems no one listened to the patient’s complaint. She stated she was experiencing severe pain that kept her up all night. By the time she saw her dentist, she was still in pain. She did not have any deep periodontal pockets. She did not have any swellings in her mouth, especially in the surgical area.

So what did she have? An osteitis. The patient had inadvertently driven bacteria deep into the tissues with the improper use of a water irrigating device. These bugs found themselves in foreign territory, and the body created an acute response to deal with them. The pain, if anything, mimicked a pulpitis, not a periodontal abscess. Why? Periodontal abscesses do not hurt! They may be sore and uncomfortable, but they usually do not keep anyone up all night. The thing to have done was to pulp test the teeth in the area. Presumably none were stressed. Without an apparent periodontal abscess to treat, and with no pulp needing root canal treatment, what could have been done to help the patient?

Consider treating her symptoms. Prescribe pain medication and wait to see what happens. Perhaps, this is one of those rare instances when antibiotics should be prescribed, even though nothing is clinically evident. What usually works when we can’t relate the symptoms to our clinical findings is "time." Time is a wonderful diagnostician; it often helps point to what is wrong and makes us better diagnosticians.

It is said that hindsight is 20:20. That’s true, but a better logic tree existed for this patient’s symptoms than what she received at the hands of two experienced clinicians.

The other interesting dynamic to this case is how the bone grew back after four months. Since the breakdown could be documented as rapid, and the party line was that rapid breakdown should result in rapid repair, the defect was left to fill in by itself. It did…without benefit of a bone graft or a guided tissue membrane.

Surgical Lectures | Hygiene Club | Dentists Only

Park Avenue Periodontal Associates
532 Park Avenue, New York, NY 10021
Telephone (212) 838-0940   Fax (212) 355-4784
E-Mail Contacts

Copyright © 2000-2005, Park Avenue Periodontal Associates. All rights reserved. Please read our legal disclaimer.