Best overall care

Sir, I would like to draw the readers' attention to an interesting case which I recently encountered in practice. A fit and healthy 20-year-old presented to me as an emergency complaining of pain from a lower right molar tooth. The pain had started approximately ten days previously and had gradually got worse becoming a constant throbbing pain, which painkillers were not helping.

On examination I noticed that the only molar teeth in his lower jaw were the first permanent molars. He did not recall having any extractions done. The lower right molar was extremely tender to percussion, and he was 'gingerly' pointing to this tooth as the source of the pain. This tooth had a large amalgam restoration present, and it was grade 2 mobile.

A long cone periapical radiograph was taken which is shown (Fig. 1). As can be seen the lower right six has secondary decay impinging on the pulpal space and a radiolucent lesion associated with the mesial and distal root. The lower right seven is distally impacted in to the mesially impacted lower right eight.

Figure 1

Long cone periapical radiography

An OPG was taken to fully assess the extent of these impactions (Fig. 2). As can be seen, this patient has both the lower left and right second and third molars impacting into one another. He is also missing the upper lateral incisors.

Figure 2

OPG showing the lower left and right second and third molars impacting into one another

Upon further questioning the patient said that from time to time he has felt bilateral tingling sensations in his lower lip, which have increased in frequency, and there have been periods when part of his lower lip has gone numb. This could be explained by the proximity of the inferior dental nerve to these impacted teeth and the possible resorption of the bone. The patient has now been referred to the local oral and maxillofacial unit for further investigations and treatment.

In the meantime we have explained to the patient that it is prudent to try and save the lower first molar, and we have commenced root canal therapy on the lower right six and other necessary restorative work.

This case highlights the importance of good radiographic examination to provide the best overall care for patients.