Upload
tracie-yw
View
217
Download
0
Embed Size (px)
Citation preview
7/30/2019 Toothache on the Left Side
1/3
A PATIENT PRESENTS WITH TOOTHACHE IN THE UPPER LEFT SIDE OF THE
MOUTH. DISCUSS YOUR ASSESSMENT AND STEPS NECESSARY TO ARRIVE
AT THE CORRECT DIAGNOSIS. WHAT IS THE POSSIBLE AETIOLOGY?
In the couple of years I have trained, I have come to realize how easy it is for one to over-
enthusiascally hone in on one parcular diagnosis as the paent relates his inial complaint. With
that respect, it is necessary to start the paent assessment with open quesons to prevent
precluding the actual diagnosis or diagnoses. This allows the paent to give a broader scope and
formulate the complaint with his words. Open quesons include sentences such as:
How may I help you?
How are you?
Once the paent has given their complaint (which is the toothache in the upper le side of the
mouth) I would then ask the paent to describe the pain rstly with his own words and then I wouldgo through a detailed pain history. Informaon that would be useful in the pain history are:
Character of the pain Locaon Is it localised or diuse? Does it travel anywhere around the face(Radiaon) Is there a parcular tooth that is the source of the pain? Severity: the use of a pain scale could be useful however it is extremely subjecve and
relave to the paents tolerance of pain
Duraon of the pain Frequency of the pain Exacerbang factors e.g. hot, cold, sweet foods Precipitang factors e.g. when bing, on release of bing or spontaneous Relieving factors e.g. use of analgesia, pressure, eang on the other side
As I am taking the history, it is also worth visually inspecng the body language of the paent. If the
paent is in severe pain, he may be holding the side of the face that is painful. I would also ask if
there are further complaints that needs to be addressed.
Other informaon at the history taking that may prove useful include:
Medical history: General paent management, prescribing any medicaons Dental history: Anxiety, atudes to dental care Oral hygiene and habits: Assess the paents oral health, parafunconal habits is useful
informaon to the dierenal diagnoses.
Social history: Smoking and alcohol status, occupaonA full oral examinaon is necessary if I am seeing the paent for the rst me. This is necessary to
detect early if there is anything sinister the paent has not already menoned. With the extra-oral
examinaon, I would be checking the head and neck for:
Symmetry: obvious swellings Abnormal changes in colour and consistency of the skin e.g. redness if inammaon present Swellings or lumps on palpaon Funcon of the temporomandibular joint: to assess if trismus present or abnormal funcon
7/30/2019 Toothache on the Left Side
2/3
Lip formIntra-orally, I would examine the so ssues which includes the gingivae, oral mucosa, tongue, oor
of mouth, palate and tonsillar region for any abnormalies. I would then focus on the general state
of the denon:
Condion of the natural teeth How much restorave work has been done prior? Condion of the restorave work Is any wear signs present? Physiological or pathological Presence of plaque and calculus Presence of acve and arrested caries Periodontal status Occlusion
When examining the suspect tooth (or suspect teeth if the paent is unable to be locate one in
parcular), assessments I would make are:
Any obvious pathology present? E.g. caries, fracture, wear facets into denne/pulp, Any restoraons present? If so, how large and deep are these restoraons. Is there any
marginal leakage?
Periodontal support Mobility Is it in occlusion and if so, is it taking more stress than the other teeth?
With these invesgaons so far, I am able to lter out my dierenal diagnoses to the one or few
that remain. In order to further support the diagnosis or invesgate the treatment opons, special
invesgaon tests can prove useful. These are not diagnosc on its own. Special tests used
commonly in pracce are:
Radiographs: bitewings to assess any pathologies at the interproximal areas, a periapical ofthe tooth or region in queson may help to view the extent of pathology, if it involves the
periapical or marginal periodontal regions and bucco-palatal fractures, quality of root
treatment if present.
Vitality tests of the pulp such as the electric pulp test, cold test and hot test. These can bequite variable and one has to consider that they are not enrely conclusive. A heavily
restored tooth with a sclerosed pulp chamber may give a negave vitality even though vital
pulp ssue may be present in the canals. In contrast, it is possible for a dead pulp to give a
posive reading due to uids in the canal.
Percussion and palpaon tests is useful to check if the periodontal ligaments are inamed orin a fracture, painful due to being stretched or broken.
Dyes such as methylene blue could be used to detect cracks and non-displaced fractures.Once special tests have been performed, if necessary, the correct diagnosis can be reached and the
appropriate management of the problem and be made. Other necessary special tests can be made if
the aeology may be non-odonogenic in origin.
It is possible for a paent complaining of toothache to not actually have a toothache per se. The
aeology of the pain may come from the pulp, periodontal ligament, larger nerves (in the case of
neuralgia), referred pain from regional structures e.g. sinus, and psychogenic. Thus my dierenal
diagnoses would be:
7/30/2019 Toothache on the Left Side
3/3
1. Reversible pulpis2. Irreversible pulpis acute/chronic3. Periapical periodons acute/chronic4. Other periapical pathologies e.g. abcess, cysts5. Marginal periodons - acute/chronic6. Denne sensivity7. Occlusal trauma8. Referred pain e.g. in sinusis, osteomyelis9. Malignancy10.Trigeminal Neuralgia11.Psychogenic/idiopathic origin