Dental abscess
Joel M. Eichen
Abscess - someone inquired as to how to diagnose an abscess.
First of all, an abscess is a localized collection of pus
somewhere in the body. A periapical abscess is some pus
collecting around the root tip. (Specific dental abscess). We
also deal with periodontal abscess.
There's tapping, there's x-rays, there's response to
electrical stimulus, but the real question is, I think, when
to treat the abscess?
First of all, many doctors will treat any intense tooth pain
with root canal therapy. (No abscess yet!) Whether or not
this tooth will resolve on its own is a completely separate
question. The jury is still out on this one. I am reluctant
to begin root canal work before its time - only because it
leads into complicated and expensive therapy.
But an intentional root canal therapy on a vital tooth
(usually performed in one visit) is a pretty effective
therapy. It sure stops the pain! This is because there is no
abscess formed as of yet.
Now if you ignore this condition (no root canal!) for a
while, and the tooth begins to feel raised up and is also
relieved with cold (ice!), then you know that you have an
abscess. The treatment is definitely either root canal
therapy or ripping the offending tooth out!
Its what's in the middle - between these two conditions is
what gets a little tricky!
normal--------------->hyperemic-------?------> abscessed
tooth pulp tooth
The jury is still out on this one. For more information,
please see my posts on "pulpitis" at www.deja.com or just
request a repost right here.
Here's the tricky part.
I had a patient with a cheezy, Eastern European root canal
mummification. The top part of the pulp chamber was filled
with root canal cement and the root portion was not. There
was (as of then) no abscess.
The insurance companies generally request a pre-treatment x-
ray for authorization of a necessary crown. Some people call
this "pre-authorization" but that's just plain stupidity at
work. How do you "pre-authorize" something? You can't. You
can authorize it or not authorize it. That's all. Pre-
authorizing something suggests authorizing it before you
authorize it. Goofy, eh?
I send an x-ray. The consultant says, "What's this? A
really cheezy root canal? See regs." I say, "What are regs?"
He says, "Regulations." Okay. I get it. This means
regulations. REGS: Must be filled to within 1 mm of the apex
-root tip.
I explain the whole deal (narrative) which nobody believes
anyway and I also send the patient to an experienced root
canal specialist. Sometimes those guys meet with success
with these teeth. Other times no. Here's the report:
Joel:
I tried to gain access to the pulp chamber,
but this is clearly calcified and I cannot
drill through it. Right now there are no
symptoms and no abscess. If I try to get the
root filled to within 1 mm of the apex, I
will produce a nice x-ray, but I will most
likely destroy the tooth in the process.
I suggest that we leave this one alone.
Sincerely,
Dr. Root
So, I send a copy of this letter back to the dental
consultant and explain that this patient needs the crown
because right now it looks like he has a missing tooth
(although there is a good root in place) and this guy can't
get a decent job looking like that. If its not approved,
then I will have to suggest extraction and a 3-unit bridge
and who wants that?
So it gets approved (even with the lousy root canal). I do
the job and now the guy is a systems analyst and he's making
decent money besides.
That's why I determine abscesses based upon (1) clinical
symptoms or (2) radiological signs. I do not go looking for
trouble if it is not there.
Plenty of patients have non-vital teeth. I assume that there
has been some strangulation of the blood supply of the pulp
as the nerves, arterioles and venules pass through the tiny
opening into the tooth. I expect that some of these teeth
will develop on to become abscessed which will require root
canal therapy. Other times, there is a natural
"mummification" of the nerve which precludes or limits a
focal point for the bacteria. (Focus of infection theory).
This is not scientific and this is based only upon my own
interpretation of what works, clinically. Whether or not
there is such a thing as natural mummification, I do not
know. But I do know that no abscess develops in certain
instances. Why not? I am not sure.
When business is slow, I have friends who do plenty of root
canal, post and crown pretty much on demand, wherever they
can. Its not too hard for find a few instances in
practically anybody's mouth, especially so if they have Cigna
(Connecticut General) insurance. But my indications for root
canal therapy are more stringent.
Cheers,
Joel
Joel M. Eichen, D.D.S.
PS- Please see pix - next post!
Pre-authorization, regs? Why not say the words like they
really are meant to be spoken? I could say to the dental
consultant, "YAABFI," and he would not know what I mean
either. It means that I am telling the dental consultant,
"You Are A Big Fat Idiot."
See regs? Does this mean your brain is working too slowly to
pronounce a four syllable word? Do I have to start shouting,
Yaahhbb-FI! Yaahhbb-FI! to get a little respect?
I cut across all socioeconmic lines with this stuff. I was
instructed to call our Department of Public Works to request
that they pick up a refigerator sitting on our curb.
"What's it supposed to be?" the guy asked.
"Its not supposed to be anything at all. However, it IS a
refrigerator. Could you please send a truck around to pick it
up?"