Sir, acute coronary syndromes (ACS) are the most common cause of malignant arrhythmias leading to sudden cardiac death and can be encountered in dental practice.1 Usually signs and symptoms of ACS are typical such as radiating chest pain, shortness of breath or sweating, but atypical symptoms or unusual presentations may occur with even craniofacial pain as the sole symptom of cardiac ischaemia.2 This may result in missed diagnosis and treatment delay.

An 80-year-old man presented to the dental emergency department of a general hospital complaining of pain in the area of a dental extraction radiating to his forehead and neck. With a past history of hypertension and diabetes mellitus he had had teeth 14 and 17 extracted 12 days previously and clearly identified the procedure as the cause of the pain.

Extra-oral and intra-oral examination showed that there was no sign of alveolitis and oral palpation did not provoke pain. There was a general, moderate alveolar bone loss but no caries or other obvious pathology. Careful questioning revealed that symptoms had begun three days previously and that the craniofacial pain was accompanied by chest pain on walking, suggestive of angina pectoris. The patient was transferred to the medical emergency department for an electrocardiogram, where he was diagnosed a myocardial infarction with ST elevation. He was admitted to an Intensive Cardiac Unit and an angioplasty of the circumflex coronary artery with implantation of a sirolimus-eluting stent was performed without any complication.

Dentists may well have to deal with acute coronary syndromes with unusual presentations and atypical symptoms, sometimes as a toothache or craniofacial pain. It is crucial that, faced with this situation, detailed questioning is undertaken, especially if a dental context cannot explain the pain.