How a dentist determines what to do when a patient comes in for an emergency?


It's pretty common for a patient to come in complaining of pain emanating from a quadrant, but they are not positive which tooth is hurting. How does a dentist figure out which tooth is the one. When a patient comes in to my practice and isn't sure which tooth is causing their pain, I start by asking when it hurts? Does it hurt when they drink hot or cold? Does it hurt when they bite down on something relatively hard? Does it hurt after they eat?

After this brief discussion, I examine the quadrant with a bright light and my loupes. I am looking for broken fillings, and any visible cracks on the surface of their teeth.  Also I check which teeth have large fillings since often teeth with larger fillings are more likely to have problems. I may take the back end of my mirror and gently tap all the teeth in the quadrant and ask if any of the teeth feel different when they "percussed" ( tapped with the mirror handle). 

Usually I take a bitewing radiograph or two and a periapical radiograph as well.  Usually afterwards I have a reasonable idea which tooth is causing discomfort. If I still am not certain, I may ask my patient to bite on the wooden part of a cotton tipped applicator to see which tooth is hurting. I ask them to move it around until they find the culprit. 

If their complaint is sensitivity to cold application of ice or Endo ice to each tooth can often help determine which tooth is the most sensitive. Hot sensitivity is harder to test for because there is often a delay after applying heat for the patients pain to begin and often it is not clear which tooth is the actual one sensitive to heat. 

Most times it's clear which tooth is having a problem, but sometimes it is not clear and when I can't tell , often the best approach is to wait and see what happens over time since treating the wrong tooth is not a "good day for dentistry" and our patients are usually very unhappy when this happens. 

Once we determine which tooth is "unhappy", there is still a  need to figure why and what treatment if any should be performed, but the first step is making sure we have the right tooth before we try to plan  a course of action. Even when the painful tooth is obvious, figuring out the cause may not, especially if no obvious problems can be observed on the radiographs or during our visual inspection.

Not all problems are immediately apparent from our exam. Some patients can have pain from grinding their teeth and it doesn't show up on their radiographs or on the visual inspection. Some teeth often those with large fillings, may have cracks in the tooth under fillings, that won't show until the filling is removed. When the cause of the pain is not readily apparent, waiting for a few days may be  a good choice, since a certain percentage of these teeth seem to get better all on their own .

If the tooth bothering the patient has been recently filled, adjusting the bite in resting position and in excursions, is often a good option, since often this can alleviate the patient' symptom. If the tooth in question already has a crown on it , occlusal adjustment is can be the best initial option if their radiographs indicate no periapical pathology (periapical radioluscency  can be an indication of an infection in the pulp).

If a large carious lesion is observed, than this definitely can cause a tooth to be symptomatic and cleaning out the decay usually can help alleviate a patients discomfort, but if it is too deep and has a nerve involvement, root canal treatment maybe part of the solution.

Sometimes the clinical inspection shows an obvious visible fracture and if part of the tooth is freely movable on it's own, then the piece should be removed in order to determine if the tooth is still restorable or needs to come out.

Of course there are many more causes of tooth pain that I haven't mentioned, but to sum up , usually  a dentist can determine which tooth is causing a problem using clinical observation, examining radiographs and conversation with a patient, in order to come up with a course of action that will help the patient with their problem. Occasionally,when the appropriate course of action is not certain, waiting a bit is sometimes the best approach, since the problem may resolve or get worse. If it worsens, then the appropriate clinical action will become more certain and treatment can be initiated with the confidence that it is necessary and appropriate.


from Ask Dr. Spindel - http://lspindelnycdds.blogspot.com/2018/10/how-dentist-determines-what-to-do-when.html - http://lspindelnycdds.blogspot.com/

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