I could not diagnose the problem


Joined
Feb 13, 2021
Messages
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Hi, I am a dentist who recently graduated.

last week there was a patient and he had pain in the lower jaw. On pressure of the 3rd lower molar (by biting), the pain relieved.

Upon examination, the third molar was inclined towards the 2nd molar and there appeared to be caries on the xray distally from the second molar.
I wanted to extract the third molar and restore the second molar, but because it was inclined and hooked under the 2nd molar, I sliced the third molar mesially to extract the third molar without pulling the second molar out.

However the pain got worse even though the mandibular block was good.

the upper third molar had a huge cavity and was almost gone, there was also a radiolucency apically from the upper third molar.
his entire face was hurting on this side, the pain was radiating from his lower jaw to the temporal muscle.

I did not know where the pain came from and started to doubt myself, so I aborted the procedure and referred him to a specialist.

I suspected a sinusitis because of the atypical symptoms.
What could it have been and did I do the right thing?
 
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honestdoc

Verified Dentist
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Jun 14, 2018
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When patients have pain, it can be difficult to find the source since it can be referred (from a different source if the x-rays do not clearly show). I like to start palpation and percussion on teeth slightly outside the suspected area and work into the suspect area. You may have to do cold tests with a cotton ball (not a Q-tip since it will not get cold enough and will get a false negative). If the pain is from the upper posteriors, I have the patient bend forward to knee level to rule out sinus pain. Last resort is to anesthetize the suspect tooth. Many times if all the teeth look normal and they all have symptoms, patients may be grinding and or clenching. That can be remedied by Over-the-counter night guard or even better with a custom occlusal guard (more expensive).

When you are taking out the lower 3rd molar, it is very difficult at times to achieve profound anesthesia. I usually give the mandibular block and Gow Gates (aim for the ear hole), wait until all the pain is gone and give supplemental lingual & buccal infiltration to anesthetize possible mylohyoid and Buccal nerve branches. I usually refer lower 3rd molars because the whole process takes longer and can get potential complications. Upper 3rds usually comes out with minimal trauma.
 
Joined
Feb 13, 2021
Messages
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thank you man, it was really difficult to diagnose.
the patient called again today, still in pain, and I referred him to a colleague of mine, I hope he is fine now.
I feel lots of guilt for being such a retard.
 
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honestdoc

Verified Dentist
Joined
Jun 14, 2018
Messages
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We've all been there. I still have cases where it's harder than I thought. My view of dentistry is how do you achieve the desired results with the least amount of trauma? I've been a dentist for 23 yrs and I'm always trying to learn and get better.
 

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