I really enjoyed the November JADA case report by Drs. Tamar Roz, Leonard Schiffman and Sharon Schlossberg, "Spontaneous Dissection of the Internal Carotid Artery Manifesting as Pain in an Endodontically Treated Molar" (
JADA 2005;136:1556–59
).
I’m a general practitioner and see orofacial pain patients by referral, and I learned something new by reading this article. Hindsight is 20/20, but I wonder if a quicker and more exacting referral could have been made if Dr. Roz had used diagnostic blocking injections to give more information as to the site and source of the dental pain.
I find using anesthetic to be one of the most useful tools to help me figure out whether the site and source of pain are synonymous. In my experience, much time and many health care dollars are lost in the referral process. As general dentists, we are qualified to figure out the most appropriate referral.
An endodontist surely knows more about endodontics than I do, but may not know any more than a general practitioner does about the other causes of dental pain. If the general practitioner can find no objective findings to conclude a failed endodontic treatment, it most likely is not a failed endodontic treatment.
Using local anesthetic to anesthetize the suspect tooth would completely eliminate the patient’s pain if, in fact, the tooth was the source of the pain. In this case, it would probably only relieve a small part of the pain. We could go one step further and give a second division block. If the pain was from the sinus, the block would then relieve the pain.
When a patient has unrelenting pain, all structures that are the site of pain can quickly become sensitized, so that any sensory input is perceived in the brain as pain; that is, percussing the tooth caused pain. Also, the patient is usually convinced that pain is coming from the tooth, further confusing the issue. I use anesthetic blocking techniques often to help me determine whether the source of the pain is the site of pain, or whether it is from a distant structure.
Dentists are the ideal practitioners to use anesthetic to confirm site and source of pain. Anesthesiologists are up there, but we give more injections in the head than all other health care practitioners. Once you gather all the data, trust your feelings and skip the referral to the endodontist, oral surgeon and otolaryngologist if your findings lead you to believe that the source of pain is from more central structures. You might just save a life, as these good doctors did.
As long as the trigeminal nerve innervates dental structures and intracranial vascularity, there will be confusion. Anesthetic blocking techniques will help to clarify this. Good job to these practitioners for their astuteness and willingness to take the time to report it.
