A difficult diagnosis – doing our best for patients in pain - Dr Michael Sultan

Diagnosing and treating pain is not always as easy or as straightforward as it may seem. Very often we find ourselves confronted by patients who may be sleep deprived, or who may have poor communication skills – both of which can be a hindrance to diagnosing the precise cause of the pain.

Another problem that we face is that pain is very emotional issue for all those concerned. When a patient presents with pain, clearly we want to relieve their suffering and help in any way we can. The problem is, as dentists we are often inclined to look for dental causes, though in some cases the pain may not be dental in origin at all. Though these cases are fairly rare, problems can arise when we intervene with the very best intentions, but are then faced with an issue that was never dental at all.

Do no harm

This topic reminds me of a feature posted on the BBC towards the end of last year. In the article we meet a patient, Ann Eastman, who unfortunately lost two teeth through misdiagnosis of her Trigeminal Neuralgia.^[1] This condition, which often mimics the symptoms of dental pain, is thankfully relatively rare, however this article shows it can be misdiagnosed – often with serious consequences for the patient.

As dentists, the first step with any treatment should always be to ‘do no harm’. As long as we are unsure of the diagnosis, we should avoid intervening for as long as possible, especially when intervention involves something as drastic as removing teeth. However, having said that, sometimes you do just have to make a call. It is a fine balancing act, and only with experience and understanding can we make a decision that is truly in the best interests of the patient long-term.  

Difficult diagnosis

When any patient presents with pain, there are a number of key questions we need to answer. Firstly, is the pain dental, or non-dental? If it is non-dental it may pain associated with the TMJ, the sinus, or something more sinister. If the pain is dental, is it pulpal or periodontal? If it is pulpal, is it reversible or irreversible? Is it vital or non-vital? Of course all of these things sound fairly straightforward until we are faced with a patient who is convinced that they have a tooth-ache, but can’t tell you whether it’s a top tooth or a bottom tooth. Even worse when on inspection you are faced with 24 crowns!

Clearly, communication is a key factor in determining the true cause of dental pain, though from our own experience, we know that pain is rarely easy to put into words. Descriptors such as ‘sharp stabbing pain’ could be pulpitic, but alarm bells should go off when the patient uses terms such as ‘electric shocks’, or if the burning pain is so severe they have to hold their face, or brings them to tears.

But even then things aren’t always black and white. There are a lot of grey areas, and a lot of different factors that we need to take into account. Though the temptation may be to ask the patient to ‘come back in a few days’ to eliminate some of the possible causes, this isn’t always practical. After all, the patient is suffering and wants an immediate solution to their problem!

No easy solution

So what do we do? As we have seen, the general problem with pain is that it can be very difficult to diagnose. Sinus pain can easily mimic a toothache – as can bruxing, or even a high restoration. The worst is atypical pain, and one of the most distressing is Trigeminal Neuralgia, especially if it appears to be a toothache. With a distressed patient who is at their wits end we really want to help, but we should not be hasty to act.

If unsure, first and foremost, we should always try and avoid intervening when the diagnosis is unclear. It’s soul destroying to see radiographs where a dentist has gone from root canal to root canal, or worse still, extraction to extraction. We should also be on the look out for ‘non-classical’ descriptors, and pain shifting around the mouth should make us particularly cautious. Better here to prescribe antibiotics to rule out infection, or cabamezipine if there is a possibility that it might be Trigeminal Neuralgia. After all, a diagnosis through medication is preferable to reaching for the drill (or the extraction forceps!)

Seek advice

As we know, great diagnosis is paramount to great practise, and does a lot to enhance our standing in the general community and to patients. Though the temptation will always be to act quickly, we need to be sure that we are always acting in the patient’s best interests. Treating pain is no easy matter, and while in most cases, the cause will be dental, if you are not sure it is always a good idea to ask a second opinion of a colleague. But if still in doubt, please, for patient’s sake, refer. 

For further information please call EndoCare on 020 7224 0999

Or visit www.endocare.co.uk

Dr Michael Sultan BDS MSc DFO FICD is a Specialist in Endodontics and the Clinical Director of EndoCare. Michael qualified at Bristol University in 1986. He worked as a general dental practitioner for 5 years before commencing specialist studies at Guy’s hospital, London. He completed his MSc in Endodontics in 1993 and worked as an in-house Endodontist in various practices before setting up in Harley St, London in 2000. He was admitted onto the specialist register in Endodontics in 1999 and has lectured extensively to postgraduate dental groups as well as lecturing on Endodontic courses at Eastman CPD, University of London. He has been involved with numerous dental groups and has been chairman of the Alpha Omega dental fraternity. In 2008 he became clinical director of EndoCare, a group of specialist practices.