The idiom “red herring” is used to refer to something that misleads or detracts from the actual or otherwise important issue. In the dental office, a red herring is a set of signs and symptoms which can confuse or obfuscate the diagnosis resulting in a course of treatment which does not address the patient’s chief concern.
As a root canal specialist, a major red herring we see is occlusal trauma presenting as pulpitis type pain. Classically this patient’s chief complaint is of moderate to severe pain exacerbated by hot and/or cold stimuli. These patients also complain of pain on biting. The pain is often spontaneous, radiating, and difficult to localize for the patient resulting in sleep disruption. The difficulty for the dentist is to differentiate occlusal trauma from a true irreversible pulpitis.
Irreversible pulpitis is one of the most common reasons people seek out their dentist on an emergency basis. If you have ever experienced an acute pulpitis you don’t ever want to go there again. Typically the irreversible pulpitis patient’s symptoms include:
- Pain provoked by cold or hot which lingers
- Spontaneous pain which can keep the patient awake at night
- Pain on biting
Clinical signs can include:
- Teeth with recent dental interventions, heavily restored teeth
- Pain provoked by thermal challenge which is beyond baseline, this pain often lingers
- Pain to percussion
- Radiographically normal periapical bone
- Radiographically calcified pulp chambers and canals, deep restorations
- Observable evidence of wear, enamel fractures, broken restorations
The occlusal trauma red herring presents in essentially the same as a pulpitis with two clinical differences. Firstly, when performing the extra-oral exam you will often find masseter and temporalis muscles which are tender to palpation with cord-like knots in the muscles. This is especially true in the area of the muscle insertions. Often these muscles show evidence of hypertrophy from overuse. The second clinical sign is that more than one tooth is hyper-responsive to endodontic testing, especially with regard to percussion.
When patients present with signs and symptoms of irreversible pulpitis involving more than one tooth I’m always on the lookout for occlusal trauma. It is not unusual for these occlusal trauma patients to have severe pain with the patient imploring you to “do something”. Endodontic intervention with a primary occlusal trauma case never ends well. The tooth being treated will no longer be temperature sensitive but the percussion sensitivity will persist and the patients overall pain will not be reduced and in a lot of cases actually get worse with the endodontic intervention adding to the overall inflammatory load, further confounding the diagnosis. Not infrequently, when these patients get to my door they have had multiple endodontic treatments, weeks of pain, and are very unhappy.
When there is uncertainty about the diagnosis I want to see if I can eliminate occlusal trauma as the etiology by placing the patient in a “diagnostic splint”. In this case I fabricate an anterior deprogrammer (AD) for the patient. The deprogrammer, worn full time, will quickly eliminate bruxing/clenching from the picture allowing the muscles of mastication and hypersensitive teeth to rest and recover. I like to use the NTI device which can be ordered online at www.chairsidesplint.com.
Simply reline the NTI with cold cure acrylic and you have a quick and easy diagnostic splint. The NTI website has all the information you need to build the splint in your office.
I have the patient wear the AD full time for two days followed by 5 days of night only. I re-evaluate the patient in one week and retest all the teeth. I instruct the patient that the AD is only a diagnostic device and not a permanent solution. A full arch immediate anterior disclussion splint, with or without occlusal equilibration and/or reconstruction is the long-term answer. Patients who wear the AD longer than a couple of weeks are prone to having over-eruption of the posterior teeth which will exacerbate the problem. I also inform the patient that it is possible that there is a damaged pulp which may need endodontic treatment and if so, the AD will help to localize the tooth.
If symptoms have resolved significantly after one week then you can be pretty sure that occlusal trauma is the etiology. Still test the teeth to make sure that all are still vital. Fabricate a full arch splint with all teeth in contact in “CR/CO for the day” and well defined anterior guidance in all excursive movements. If the splint is working the muscles will relax and allow the TMJ to reposition. This results in new interferences and reduced splint effectiveness. The splint will need to be adjusted to re-establish anterior guidance. You may need to repeat this cycle a few times till the patients TMJ reaches a stable position before looking at more permanent solutions to achieve CR/CO. As always we are here to help you and your patient whenever you feel appropriate.
ABOUT THE AUTHOR, DR. HOWARD BITTNER, DMD, CAGS
Dr. Bittner was born and raised in the Surrey/Langley area. Following his pre-dental training at Simon Fraser University, he received his Doctor of Dental Medicine from the University of British Columbia in 1982 and his Certificate in Advanced Graduate Studies in Endodontics from Boston University’s Goldman School of Dental Medicine in 1995.
Dr. Bittner was in private practice in general dentistry for 11 years in Langley prior to his Endodontic specialty training. He has been practicing the Dental Specialty of Endodontics since 1995.
In his free time, Dr. Bittner loves to participate in a variety of sports including most recent, golfing! He also enjoys being a grandfather to 4, which if you ask him is just the best!