Tooth Story #18: Teeth Diagnosis Can Challenge Doctors

Who says a dentist isn’t a doctor?

Sometimes I wish that medical schools included a dental component to their curriculum. I know that sounds crazy, but you’ll understand why I say this after our next tooth story. It just might blow your mind! When it comes to medical issues that have dental components but don’t obviously involve teeth, other physicians can have trouble making the correct diagnosis. They don’t always realize they should refer their patients to a dental professional, and this ends up hurting their patients.

When I went to the Dentsply Sirona Key Opinion Leader meeting in 2019, I was super impressed when my friend and colleague, Dr. Michael Thompson, shared this mega tooth story about the importance of teeth diagnosis. Because it made such an impact on me, I want to share it with you now!

This teeth diagnosis case is about a 17-year-old female patient.

Besides an allergy to penicillin, she was medically healthy. In 2014, she presented to her primary care provider (PCP) with pain in her left ear. The PCP diagnosed the patient with an earache (acute otitis externa) and treated her with several rounds of topical and oral antibiotics and analgesics.

Unfortunately, the patient had no resolution of her symptoms and subsequently she developed submandibular swelling. She returned to her PCP with continued symptoms, and her provider referred her to a plastic surgeon.

The plastic surgeon suspected a cyst in the submandibular region and removed what they thought was the cyst in question. Unfortunately, the surgical site did not heal, and the patient had several more rounds of antibiotics.

The saga continued from referral to referral.

In 2015, the patient saw an ENT, who gave her a prescription for yet more antibiotics and also ordered a CT. The radiology report indicated a “periapical cyst involving the left mandibular molar compatible with odontogenic disease, draining to the skin in the left submandibular region,” and the ENT recommended a dental evaluation for a teeth diagnosis.

The ENT referred the patient to OMFS, and then OMFS finally referred the patient for an endodontic consult. By this point it was 2016, and the poor young woman’s chief complaint was that “pus had been oozing out of her neck for about a year.”

Upon clinical evaluation, there was a visible draining cutaneous sinus tract in the submandibular region.

Here are the radiographs from the patient’s general dentist.

The CBCT evaluation looked like this.

And here’s the 3D rendering, showing the resorption of the mandible.

All her probings were within normal limits, there was no mobility, and she had no pain to percussion or palpation. Tooth #18 did not respond to cold. Therefore, her dentist diagnosed tooth #18 with a Necrotic Pulp and Chronic Apical Abscess.

Finally, the patient would have a root canal.

The patient’s dentist knew Dr. Thompson was just the dental professional to do it! Because this case needed extra attention, he completed this root canal treatment in multiple visits.

He used calcium hydroxide as the intracanal medicament. Two weeks later, he invited the patient back for a follow-up and another round of calcium hydroxide. You can see that the soft tissue was starting to respond well.

And here is a CBCT view of the postoperative root canal.

At 7 months, Dr. Thompson recalled the patient again and was pleased to see everything was responding perfectly. The soft tissue was most definitely healing, and the bone was also starting to regenerate around the apex.

At her 18 month recall, she was still improving, and the tooth had been restored. Surely, she was relieved to have saved her tooth and for the lesion under her chin to be resolving!

Takeaway: The Importance of Teeth Diagnosis

This tooth story hurts my heart, and I honestly relate to it, given my own referral nightmare. Unfortunately, since physicians in other medical specialties don’t always consider the impact of teeth, diagnosis becomes a wild goose chase in these instances. This only hurts the patient at the end of the day.

It’s hard just thinking about what this young lady went through physically, socially, and financially for over 2 years. I’m glad she eventually got a referral to Dr. Thompson, who has been able to give her the relief she’s needed for so long.

Yes, I know it’s impossible to completely eliminate stories like these, but I want to encourage and challenge my colleagues to create more overlap between the medical and dental worlds. As we better understand each others’ specialties and keep the door open to communication and referrals, we can all do our part to keep these stories to a minimum.

-Sonia

Born and raised in the northwest Chicago suburbs, Michael attended the University of Illinois in Urbana-Champaign and received a B.S. in Cell & Molecular Biology. He then attended the University of Illinois in Chicago College of Dentistry, where he developed his affinity for Endodontics. Following dental school, Michael joined the U.S. Army, practicing as a general dentist for 4 years.

Michael performed his specialty training in Endodontics at Fort Gordon, Georgia and received his certificate in 2008. Following his Army commitment, Michael purchased a private practice in Litchfield Park, Arizona. As his practice grows, Michael is currently serving as an advisory board member for the Spear Endodontic Master’s Program.

While not performing Endodontics or attending his daughters’ swim club events, he and his family enjoy exploring the beauty of the Southwest.