What Really Hurts!
ALL TOO OFTEN does a patient present with symptoms of “pain” from a maxillary tooth. The patient is insistent that the pain is emanating “that tooth.” However, when the practioner evaluates the radiograph, the tooth appears “normal” without any striking dental conditions that could be producing the symptoms reported. Many times, the practitioner becomes engulfed in a quagmire. The patient is relentless, complaining to the practioner of the “perceived pain” that must be treated. But, how?
“Tooth” pain can be a symptom of sinusitis. Sinusitis is usually caused by bacterial or fungal infections that can be acute and chronic. In sinusitis there is an inflammation in the lining of the nasal cavity. Also, the sinuses are filled with mucus because the natural drainage of mucus is blocked. Sinusitis symptoms may include postnasal drip, odontalgenic pain, vague headaches, and sore throats. Very often overlooked is the sinus infection originating from odontogenic infections. A thin buccal alveolar wall is a structural characteristic that makes communication between bacterial infection from a tooth and sinus possible.
Pathology that is dental in origin can easily be missed due to its location around the root. A tooth’s pathology can be easily superimposed within the maxillary sinus, making differential diagnosis difficult. Furthermore, many times the maxillary molar’s roots are in the sinus cavity. Maxillary molars and premolars are the most likely odontogenic sources. The palatal root of the first molar is the root most frequently associated with odontogenic sinusitis. Being able to identify periapical pathology’s relationship to the maxillary sinus can be challenging.
How does one determine whether the pain is from a tooth or not? Listening to the patient’s history of pain is helpful. Also, the CBCT scan is a very useful aid in evaluating the offending tooth in three dimensions. The slices allow the practitioner to evaluate multiple views of the tooth not available in conventional two-dimensional images. Furthermore, the CBCT scan allows for imaging of the sinus floor and its relationship with the tooth’s apex and its periapical tissue. The CBCT scan is a useful aid in determining whether a patient’s pain is from an odontogenic source or due to sinusitis.
When a patient complains of pain, but the radiograph doesn’t indicate a reason for the chief complaint, a CBCT scan would be useful. We are not only hoping to solve our patient’s mystery about where the pain is originating, but we are also looking forward to referring the patient for the proper treatment. Sometimes, what really hurts is the tooth—but sometimes it’s not.
July - September 2011