RO0211

I 23 case report _ endodontic zone I roots2_2011 IthenfeltlikeIwasinthe“TwilightZone”instead of the EZ. The patient had not reported thermal sensitivity and had pain referred beyond where dying pulp refers. But I was unable to reproduce the pain by palpating her muscles of mastication. At this point, I had no option but to turn to my standard process of pulp testing to rule pulpitis out as the aetiology of her symptoms (although the previousendodontisthadruledouttooth#19).Idid cold testing (with an H2O ice pencil formed in an autoclaved empty anaesthetic carpule) on all of her teeth on the upper and lower left side of her face, andwhiletheyallrespondedWNL,teeth#18,14and 15 responded sharply, but transiently—not defini- tive by any means. The possibility of more than one tooth being irreversiblyinflamedwasvirtuallyzero.Istilldidnot know what was going on, although tooth #14 was veryslightlysensitivetobitingpressureandpercus- sion. It had been restored recently with composite andwasnearlyincrossbiteandthereforemorelikely to be affected by bruxism. Therefore, I was left to my best next move in these kinds of situations. I heat tested all of the upperandlowerteeth(except#19ofcourse)withmy System B Heat Source (SybronEndo). SybronEndo sells a special heat-testing tip for Touch ‘n Heat and System B Heat Source that allows users to apply a sustainable heat stimulus to both quadrants of teeth in under a minute, with gutta-percha on the tip and the sources set to 200 °C. In my experience, using sustainable sources of thermal stimuli to test pulp is the sine qua non of endodontic diagnosis. With transient sources of thermal stimuli—spray refrigerants and flame- heated gutta-percha—the temperature is never the same,whichaddsanothervariabletoanalreadysub- jective data point. Additionally, it sometimes takes a bitoftimetoelicitaresponsewheninsulatingacrylic, porcelain or calcification of the pulp chamber delays theresponseofatoothwitharelativelyhealthypulp. Itestedteeth#18,20,21,12and13andachieved WNL responses (little or no response to heat is normal). However, when I heated #14, I reproduced the patient’s chief complaint exactly and it had a prolonged effect. This was a huge relief and far better than having to say “I just don’t know what is makingyoursister-in-lawmiserable.”Wescheduled the patient for an emergency appointment the nextday,asherpainwasatamanageablelevelwhen she had taken an adequate dose of ibuprofen and as my schedule was already full, with three other emergency appointments. My OS buddy called me the next morning to informmethathissister-in-lawwasnervousabout anotherpossiblemisdiagnosisanderroneoustreat- mentplan.Inmymind,thisconcernqualifiedheras passing the IQ test. I repeated the thermal testing just to be certain that I was not going to be the second endodontist that would perform a needless root-canal treatment on a dentist’s relative, while failing to resolve her chief complaint. Cold testing gavethesamevanillaresponses,butheattestingon the mesiobuccal (MB) line angle of #14 reproduced her pain, and it was also a bit more sensitive to percussion and bite. I felt even more confident in my diagnosis when the patient’s pain was totally alleviated by infiltra- tion with 1.5 carpules of 2% lidocaine 1/100k epinephrine on the buccal side of tooth #14 and 0.5 carpule on the palatal side—given comfortably with extremely slow administration of the anaes- thetic using the STA Anesthesia Delivery System (Milestone Dental)—in this very tight tissue. Asanaside:Ireallydonottrustlocalanaesthesia as a diagnostic procedure. It is not specific enough to rule out a single tooth, it may mask adjacent myofascial aetiology and, after giving any local anaesthesia,furtherdiagnosticworkisnotpossible. Fig. 3_CT axial view, showing the MB root of tooth #14 with two canals. Fig. 4_CT sagittal view, of the MB root from the mesial direction. Note the common orifice of the MB1 and MB2 canals that immediately bifurcate and are apically confluent where the canal terminates in a severe curve in the hidden palatal plane. Fig. 5_CT sagittal view of the DB root from the mesial direction. Note the multiplanar curvatures ending in an apical bend to the hidden buccal direction. Fig. 6_CT sagittal view of the palatal root, showing nearly perfect tapered canal shape. Fig. 3 Fig. 4 Fig. 5 Fig. 6