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Endo tips    Better Endo    Endo abstracts    Endo discussions

Dx help

The opinions and photographs within this web page are not ours. Authors have been credited
for the individual posts where they are.- www.rxroots.com
From: Jerry Avillion
Sent: Thursday, April 05, 2001 2:51 PM
Subject:Dx help

This patient has trigeminal neuralgia and has a sharp electrical pain on this side
of her jaw along with a 'deep' pain.   This root canal was done a few months ago and
she was referred to me to determine if this tooth could be causing any of her pain.
The endo isnt the greatest, but the tooth is not sensitive to percussion or palpation
nor can we elicit any pain with a bite stick.   I know I can improve on the endo via
re-treatment, but I don't think that will help her symptoms at all, so at this point
I don't think the tooth needs re-treatment.    Help!

Comments?

Also, does anyone know of a pain clinic associated with a dental school in this part
of the country?

She is considering a procedure that will zap the sensory portion of VIII because
the pain is so bad.

Thanks - Jerry

Photo courtesy of Jerry - www.rxroots.com
From: Hongjiao Ouyang Sent: Friday, April 06, 2001 20 20 Retx endo & either send the patient to a neurologist or put the patient on Tegretol. She's been on Tegretol (and a bunch of other stuff), right now she's taking Neurontin 1500mg/ day. So far the drug therapy hasnt helped very much. - Jerry From: Garry Nervo Sent: Thursday, April 05, 2001 6:07 PM Have you tried Tegretol, purely a s a diagnostic - Garry Nervo From: Merritt, Grant W. Sent: Thursday, April 05, 2001 4:32 PM Jerry, She may want a second opinion on ablation of the nerve. Where are her trigger points? How long has she experienced the pain? How often does she experience it now? What is the duration of the pain once it has commenced? Has she been medicated with tegretol or phenytoin. Has she had a CT or MRI to rule out posterior fossa tumor? I refer my trigeminal neuralgia patients to Dr. Andrew Kaufman, a neurosurgeon here in Kansas City, 6420 Prospect, 816-363-2500. I've had a half-a-dozen. The last patient I referred was suicidal her pain was so intense. He went in and placed a sponge between a vessel and the nerve in the fossa and she not only is free of pain but still has an intact nerve. It's been over 5 years and this high-powered lady is still running a big business and seems to love life. It may not apply to her but I thought I'd mention it. It was great meeting you in NO. Hope we can get together again soon. Come see our school sometime. Here are a few of our 2nd years maxillary bicuspids from their preclinical lab. Thought you might enjoy seeing what they can do with rotarys and warm gutta percha if they have no preconcieved ideas about how to do endodontic shaping and cleaning. Good Luck with your patient. I hope she gets well soon, 2THSAVR

Other cases of Yosef Nahmias (rxroots):
Importance of lat canals   Protaper Case   Curved Re-treat   Extra canal invasive resorption - Case 2  
From: Yosef Nahmias Sent: Friday, April 06, 2001 03 43 Redo it man. Maybe the tooth is not the problem, but what if it is? I would! Take a chance, you can easily justify doing it! If the symptoms go away you are a hero, if they don't, at leat you removed one part of the equation! Pics of a surg I did today sealed with a composite, too close to a post, actually is a resurgery )
Photos courtesy of Yosef Nahmias - www.rxroots.com

From: Guido Costa Sent: Friday, April 06, 2001 04 14 Jerry IMHO if that particular tooth is not the cause of her problems, I would retreat at this time either. However, she must be informed and recalled accordingly to reassess periapical healing. Redoing the endo will not do anything to relieve her symptoms produced by the neuralgia. From: Molar Del Sud (Ace Dentura) Sent: Friday, April 06, 2001 09 14 One sure way to find out........give her a block injection and see if the pain disappears. From: PBery Sent: Friday, April 06, 2001 09 41 Sounds like your patient had the Janetta procedure (vascular decompression of trigeminal nerve) developped in Pittsburgh. Interesting aside: He (Janetta) introduced microscopy in medicine 'round 63. True genius. From: John J. Stropko, D.D.S. Sent: Friday, April 06, 2001 10:40 AM Jerry, The PDL disappears at the apex of the mesial root, so I believe there is a LEO. So many times, over the years, when I take care of something obvious, the "wierd" things go away. I would suggest RTX but advise the parient of no guarantees. The money spent on RTX is a lot less than the alternative. besides that, if the RTX doesn't take care of the pain, you wouldn't have done an uneccesary procedure. Also, take a few more angles. - John Stropko From: Jerry Avillion Sent: Friday, April 06, 2001 23 27 The previous endo was done 1 month ago. I agree that there is a LEO present, but I don't know if it's one that's healing or one that's getting worse. Since all the pulp and periapical diagnostic tests were normal, I figured that we could always re-treat it at a later date. At this point my main concern is the pain associated with the trigeminal neuralgia. I never could elicit the 'deep' pain. But it was very easy to elicit the pain associated with the trigeminal neuralgia, just by touching the trigger point (near her chin). I just spoke with the patient and she wants to go up to KC and see Grant Merritt and his neurosurgeon buddy. I'll betcha a pizza that Grant will figure it out. :) - Jerry Avillion From: Benjamin Schein Sent: Monday, April 09, 2001 20 12 I sort of agree with John....the obvious first. When a person is limping. The first thing that should be done is to make sure that there is no stone in his shoe before ablating a leg nerve. The fact the patient is not responding to Tegretol makes it imperative to discount possible endo origin of the neuralgia. On the other hand I spent some time in a pain clinic, and it was embarrasing as an endodontist to see patients with chronic severe pain come to the clinic with a super-abundance of endo treatments in their heads. Patients always stated that the endodontists (usually several) always had advised.....no guarantees. I now will not do any new endos or retx until the patient has had a workout at a pain clinic ( fortunately 2 clinics within 50 miles of my town) if the patient does not want or can not go to a Multi-disciplinary clinic... I would let a endodontic colleague who is good and willing retreat a case such as the one Jerry posted. I've had many patients with....no guarantees warnings.... become a big problem. I can not establish a rapport with the patient such as John is able to. Perhaps with TDO, Drawings, Multimedia education, I could..... thinking about it. I've always been puzzled with the Ratner bone lesions. In this case there is a tooth missing, I wish Dr. Zurkow would jump into this thread.
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