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ePaper created 2018-03-06, 08:52:14 | version 1.38.0
Fig. 2 Fig. 3 Fig. 4 on by things that the patient likes eating the most. So, you are there looking at the patient, looking at the tooth, back at the patient hoping that tapping this tooth will provide a reaction to aid your tentative diagnosis of apical periodon- titis. Nothing from the patient, not even a whimper. “Hmm. Let’s take an X-ray … Long-cone periapical please.” You take your Hubble Telescope-type magnifiers and examine the radiograph. You change the contrast in the hope of seeing something of note, nothing. The patient protests: “I get the pain every now and then, but when it happens, it’s really something else … can’t you see anything?” You sit the patient back down again and look at the amalgam filling spite being fairly unconvinced with your antics. The next riddle is how to treat, if at all. Although you cannot be 100 per cent sure that there is a crack, it might not prop- agate, it may stay the “same” and the patient may not need any treatment as long as he avoids the tooth. What about their Snickers though? Some patients may accept this. Generally, patients are in two camps with whatever diagnosis we provide them with. Some are proactive “Right there’s a crack, you can’t mend it. Let’s whip it out—I’ve still got another six teeth in my top jaw I can chew on, no worries”, while others are “Patients need to stop themselves from grinding their teeth needlessly during the day and have to instigate strategies to reduce the likelihood of parafunction in the night.” with the suspicious eye. It looks the same as every other asymptomatic amalgam you have ever placed during your career; your thumbprint is uncanny. As your senses have been sparked, the eye of faith takes over: there is a bit of faceting on the cusps, there are some craze lines, the pa- tient does tend to wear her restorations. “It’s cracked, the tooth is cracked.” Your patient creeks their neck up to look at you more intensely: “Can you fix it?” You see our pa- tients, as much as we do, are perplexed by cracked teeth. The tooth looks “normal”, feels “normal” outside of the oc- casional painful episode; why can it not be “mended” or “stuck together again” like some old china vase? The diagnostic conundrum is over. On balance, you know what the problem is, as does the patient now, de- reactive “You know, let’s just sit on it and if it gives me a problem, then I’ll come back”, to which you may reply it could catastrophically snap or fracture. The alternative, and the evidence for this is fairly light on the ground at the current time, is to instigate strategies to reduce the like- lihood that the tooth will become more symptomatic—in other words, you want to brace the crack. Similar to my uncle’s wrinkly belt and his ever expanding waistline, you can hear the leather strain as he tucks into his pie. What did we get taught? Use a copper band or an orthodontic band, both of which may be difficult to source in primary care. Or we could crown the tooth and risk it going pul- pitic. I imagine that to be so humbling. Having fitted the crown, you drill straight through it two days later. Indeed, whatever you do, the tooth may be unsaveable. 36 roots 1 2018