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A 47-year-old female patient attended our endodontic specialist clinic complaining of generalized pain from her teeth. The pain started a few months ago (sometime from April 2017). It was triggered upon taking cold, hot, and sweet food and drink. At the initial stage, she reported that even taking in a large breath through her mouth could evoke the pain. The pain was throbbing, severe in nature, and was continuous for more than a few minutes before it subsided. She claimed that the pain occurred in multiple teeth, and she was not able to pin point any particular tooth. Because of the pain, she refrained herself from taking cold, hot, or sweet food. She was not on painkillers as the pain would only appeared upon stimuli.
The medical history revealed that the patient was diagnosed with ulcerative colitis in 2008 and had been on azathioprine (75 mg) and mesalazine (1 g tds). She suffered from a severe case of pyoderma gangrenosum in November 2016 and had to be hospitalized for 4 months. A high dose of prednisolone (30 mg bd) for 4 months was administered to treat this condition followed by tapering dose of 5 mg/week until the end of May 2017 when the pyoderma gangrenosum lesion healed. The patient was a medical practitioner (with a doctorate degree in pharmacology), so she was able to give an accurate medical history.
During the examination, the patient kept complaining of severe pain when short blast of cold air from the 3-in-1 syringe was used to dry the teeth for inspection. Clinical examination revealed that she had good oral hygiene, with minimal plaque accumulation at the upper anterior teeth [Figure 1a and andb].b]. The gingiva appeared pink and healthy. Basic periodontal examination revealed probing depths of normal limit (2-3 mm).
Defective amalgam restoration was noted on the disto-occlusal aspect of tooth 36. The restorations on teeth 15, 27, 45, and 47 were sound [Figure 1c]. The rest of the teeth had normal clinical crowns without the presence of attrition on the occlusal surfaces [Figure 1c]. Minimal root exposure could be detected on tooth 32 only, while no evidence of abrasion was observed from any of the teeth [Figure 1a and andb].b]. Responses from sensibility tests (cold test and electric pulp test) indicated that tooth 36 was vital. It was tender neither to percussion nor palpation. The periapical radiograph showed that the restoration was near the pulp horn, but there was no abnormality at the apices [Figure 1d].
The differential diagnosis for this patient was DH although we could not ascertain the possible etiology for the condition at the first visit. The finding from patient’s dental history was insignificant. The treatment plan was to replace the amalgam restoration on tooth 36 to rule out possible pulpal pain followed by treatment for DH. Local anesthesia (scandonest 2%) via inferior dental block on the lower left side was administered. Upon removal of the amalgam using a high-speed handpiece with water, the patient experienced intense generalized pain from the other teeth, and the amalgam filling was removed intermittently until completion. The Visual Analog Scale score at this time was 10/10. The patient could not stand the pain, and a zinc oxide eugenol temporary filling was placed [Figure 1c]. Calcium hydroxide was not placed as there was no pulpal exposure and the pulpal floor appeared adequate.
Based on the differential diagnosis, it was decided to apply sodium flouride (SF) varnish (Colgate® Duraphat® Varnish 50 mg/ml dental suspension 2.26% SF) to all teeth to manage the pain. Application of the varnish was performed by quadrant starting from the upper right, upper left, lower left, and lower right quadrant. The buccal and lingual surfaces of all the teeth in each quadrant were dried with gauze after which the varnish was applied with the use of a disposable brush to form a single, uniform, and thin coat over the cervical area of the teeth. She was advised to use the desensitizing toothpaste every time she performed toothbrushing. The patient was reviewed 3 days later, and the application of varnish was repeated. Another similar application of the varnish was repeated 3 days after the second visit. She reported that the pain became more bearable after the varnish was applied although it did not disappear completely if she took cold or hot drink.
The patient was then reviewed 6 months after the last visit. She reported that she was now able to tolerate cold and hot food and drink much better than previously. Clinical examination revealed intact temporary filling on tooth 36. There was more calculus accumulation at the lingual areas of the lower teeth and upper posterior teeth [Figure 2a and andb].b]. This inability to remove plaque totally may be due to the pain the patient experienced during toothbrushing throughout the “active pain” period. Tooth 36 was restored with composite filling, and all teeth were scaled and polished during this visit [Figure 2c and andd]d] without any complications. The varnish application procedure was not repeated at this visit.