Cracked Tooth Diagnosis and How to Handle Them
August 1, 2021
Tricky Taurodont Treatment: A Tooth Story
August 10, 2021
Sinus tract tracing, proper diagnosis, and patient education are all the big players involved in this incredible tooth story!
It is NO surprise that I love all of my advanced diagnostic tech (I gush about my cone beam technology every chance I get)! When imaging so directly helps me figure out the source of pain plaguing my patients, it’s worth investing my time and energy into the latest tech. But keeping things old-school has its value too. I want to show you a case where a classic diagnostic method—sinus tract tracing—proved invaluable in my endodontic diagnosis.
This isn’t the first time I’ve gotten on my soapbox about sinus tracts, and how important it is to trace them every single time. Sinus tracts can help pinpoint an infection BEFORE any pain starts flaring up. It’s an amazing diagnostic tool, worthy of another blog post!
So let’s go back to a time before my precious CBCT to see how sinus tract tracing helped save a tooth.
A Sinus Tract Tracing Surprise
Let’s make sure we’re on the same page: sinus tracts don’t normally cause patients any pain on their own. This one was no different. When I examined the patient, he wasn’t in any discomfort, but he had a bump on his gums that was driving him crazy. His referral slip said to treat tooth #13, so I assumed that tooth was the chief suspect behind the sinus tract.
Take a look at the patient’s preoperative radiograph.
See how there’s a periapical radiolucency from the apex of tooth #11 to tooth #14? This radiograph seemed to confirm that tooth #13 was behind the sinus tract, and the patient was already expecting to only have that tooth treated. But these things can be tricky, so I always trace the sinus tract first, just to be safe. I performed the tracing, and wow! We could have missed something really big if we’d called it good then and there.
The sinus tract tracing revealed that the sinus tract actually belonged to tooth #14—it traced right to that tooth’s MB root. So, the patient’s diagnosis was Previously Treated and Asymptomatic Apical Periodontitis #13 and Previously Treated and Chronic Apical Abscess #14. Both of these teeth had failing root canals due to a missed canal in each tooth—the palatal canal in tooth #13, and the MB2 in tooth #14.
Getting The Patient On Board
Unfortunately, now was the make-or-break point with the patient. I told him we needed to operate on two teeth, not just one, a thing nobody wants to hear. Until now, he was only expecting problems with tooth #13, so I knew I had to be strategic in how I broke the news. I focused on two things: telling the patient his tooth story, and focusing on his own chief concern.
I don’t use tooth stories just to educate other dentists—I use them to educate my patients about the treatments that will benefit them the most. I find that explaining diagnoses to patients this way makes it more likely that they will accept all the recommended treatment. It’s a matter of setting proper expectations and reasons.
In this case, I walked the patient through everything I just described, including explaining how I used sinus tract tracing to link the infection to tooth #14 instead of tooth #13. Now, the patient was understandably not super thrilled at the prospect of having two teeth retreated instead of one. To help him accept the treatment, I focused on the implications for his chief concern: the bump on his gums. I explained that if I only treated tooth #13, as his original dentist had recommended, the sinus tract would remain right where it was, and the bump on his gums wouldn’t go away. This did the trick. He quickly changed his mind and agreed to treatment for both teeth.
If your referred patient ends up needing a different treatment than expected, I always recommend explaining your process very clearly and relating it back to their primary concern. It’s so important for the patient to understand the long-term implications and effects of different proposed treatments, especially as they relate to the things they care about most.
Trace Every Tract
I want to make sure that I do right by my patients, which is why I wrote this case study. Always, always double and triple check your diagnoses! It’s easy to assume we know the answers and jump to conclusions, especially when you’re part of a busy practice. In this situation, many of us would have assumed tooth #13 was the culprit, and wouldn’t have bothered to complete sinus tract tracing. But that would be doing the patient—and your practice—a huge disservice.
Sinus tract tracing is an inexpensive and easily teachable diagnostic tool that deserves a place in any practice. It proves you don’t need to spend thousands of dollars on a CBCT machine or other advanced technology to land an accurate diagnosis. You only need to do what we must all strive to do: invest a little extra time and effort into your patient.
So, the next time you see a sinus tract, don’t make an exception—trace it! You never know when it might save the day.
-Sonia
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19 Comments
Would you isolate 13, 14 and treat both in one appointment in this case?
That is most certainly an option. But, in this case, financials were an issue and he had to do one tooth at a time.
-Sonia
I had a similar case but while traciing it with a gp the gp in radiograph is gng somewhere between two teeth i mean its gng in interdental region within bone….wat cud be probable reason may be i wl post my radiograh
Hi there. Try creating a “pilot” hole for your gutta percha with your periodontal probe. It may help you glide along the path better. But just remember to tell your patient that it will be tender. Keep in mind that when this trick doesn’t work for you that you have to use the data that you get from your other diagnostic tests. A sinus tract can only drain from a non-vital tooth. Hope this helps!
-Sonia
What size GP are you using to do this. I have also heard to use Resilon to trace them. I forget the reason for using resilon
Sonia,thank you for showing me a wonderful case!
Let me ask you two questions.
What kind of GP do you usually apply?
(Size, etc.)
Have you ever traced something like this? (In this case, both teeth were non vital
https://www.sizensika.jp/study/study_52.html
Pat,
Hey there. I typically use a size 25 GP point. I have never used Resilon, but GP works perfectly.
-Sonia
Hiroshi,
I use a 25 size GP point. Yes, I have seen cases just like the one in your link. Some time diagnosis can be really tricky.
-Sonia
For tooth #13, how do you differentiate AAP from “scar tissue” if tooth is asymptomatic?
Hi Dr. Chopra,
How do you differentiate AAP from scar tissue left from previously infected tooth that has been treated properly? Or as long as there is PARL, the diagnosis will be AAP and the tooth needs to be treated? Thanks!
I think that scar tissue is rare. You only get scar tissue from a tooth that is healing from a through and through lesion. To me a lesion means bacteria about 99% of the time.
-Sonia
Most of the time it is not scar tissue, but make sure that you are giving the tooth ample time to heal. Sometimes it can take a few years depending on the size of the original lesion.
-Sonia
Thanks for the clarification!
goofd info . thanks for the share ….
Hello Sonia
whenever I do sinus track its so hard to do it for me . You told in your previous comments that you use 25 GP do you numb the patient when you do this and how do you stabilize GP when they are taking x-ray it always move for me .
Thanks
Abinash,
Thanks for reading!
-Sonia
Rupinder,
Make sure you warn your patient that it will be tender. And sometimes you need to use your perio probe in order to make a pilot hole so that the GP goes in smoothly. Hope this helps.
-Sonia
what size taper do you use?
This is an .04 gutta percha!