Ars longa, vita brevis

Ars longa, vita brevis

Hippocrates: ‘the art is long and life is short’. The art in question is medicine/diagnosis and the short life is our career and to make what we can of it. This case is a diagnostic challenge that I could have easily failed. Recently, a 58 year-old healthy Caucasian was referred because his hygienist noticed a sinus tract palatal to the 16. The tooth is asymptomatic and the gentleman was previously oblivious to the presence of the sinus tract. Clinically, the 16 has a shallow amalgam and a few craze lines. In addition to these two findings, the conical root form increases my suspicion of a vertical root fracture and/or pulp necrosis. No probing defects are present nor abnormal mobility. No tenderness to percussion, bite, chewing, or even palpation exists. Not unlike its neighbours the pulp of the 16 responds normally to cold and EPT. Radiographically the apical PDL is not widened and the sinus tract only traces to the apical third of the palatal root, not the apex.

No alt text provided for this image
No alt text provided for this image


Although obvious to me now, initially I did not identify the supernumerary tooth on the pre-operative PA’s. Flummoxed at the lack of defendable diagnosis, I requested CBCT imaging to allow a more detailed evaluation of the 16 and surrounding hard tissue.

The cone beam CT images confirms the presence of a hard tissue mass palatal to the palatal root. My treatment recommendation is extraction of the defect with a biopsy of the hard and soft tissue. Despite advising the patient a lack of pain is not synonymous with an absence of pathology, he decided to forgo treatment, preferring to see if anything changes over time. I advised the patient the defect is a liability and there is no discernible benefit to inaction.

No alt text provided for this image


The most common type of supernumerary tooth is a mesiodens (i.e. near the midline) and it is typically diagnosed in childhood. The prevalence of supernumerary teeth in permanent dentition for Caucasians is between 0.1 to 3.5%. It is slightly more common in Asian and sub-Sahara populations. Thus, this case is an uncommon form of a relatively rare condition. A supernumerary tooth is the most likely, but indeed not the only hard tissue defect possibly responsible for the sinus tract. Arresting the infective process and confirming the diagnosis are the rationale for recommending extraction of the mass and a histopathological sampling. Below is a synopsis of a few salient points from this case:

§ Always take two angled pre-op PA’s for possible endo cases

§ Always perform pulp and periradicular tests as well as a thorough clinical examination

§ Periodontally probe all teeth under consideration for endodontic treatment

§ Further investigation or a referral is warranted if the diagnosis remains ambiguous

I once heard: ‘there are five reasons for referring a patient: to diagnose, to reassure, to manage, to cure, and to punish.’ The fifth reason may not be to punish the patient but rather the unsuspecting clinician who has not embraced the art of diagnosis which can make for long work days indeed. It is cases like this that help all of us sharpen our clinical skills and shorten our work days, or at least it feels like that.  


Thomas Shackleton

General Dentist at TS Oral Health

5 年

Great article, Joel! Thanks for your advice and insights

要查看或添加评论,请登录

Joel Fransen的更多文章

  • Less is More, more or less

    Less is More, more or less

    Change is the only constant in life. Thermomechanically treated NiTi's, digital radiographs, CBCT's, electronic apex…

  • Radio Ga Ga

    Radio Ga Ga

    Sensational unsubstantiated claims in the media have fostered a culture of irrational fear regarding radiation to…

    3 条评论
  • Separation Anxiety

    Separation Anxiety

    A dentist who has never had a file break in a canal has not treated enough teeth. The incidence of instrument…

    1 条评论
  • Ms. Dx

    Ms. Dx

    Establishing an accurate diagnosis is the cornerstone of successful endodontic therapy. Its consistent and reliable…

  • Skookum Cola

    Skookum Cola

    This heavily restored 46 had a narrow 8mm probing defect on the furcal aspect of the mesial root and a J-shaped lesion…

    7 条评论
  • Difficile avec Clindamycin

    Difficile avec Clindamycin

    Difficile avec Clindamycin All antibiotics run the risk of causing a Clostridoides difficile (C.diff.

  • ECR ≠ Exo

    ECR ≠ Exo

    The cold test is not false. Surprisingly, the pulp is rarely necrotic even when an External Cervical Resorptive (ECR)…

  • Discomfit Dx

    Discomfit Dx

    A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis is rather common. Seldom does…

  • The Thin Dentine Line

    The Thin Dentine Line

    The diagnosis of previously treated with a chronic apical abscess does not allow for a description of the sizable…

    2 条评论
  • The Slick-Glick

    The Slick-Glick

    I first learned about the Silker-Glickman (S-G) rubber dam clamp (aka Slick-Glick) when I was a grad endo resident in…

    2 条评论

社区洞察

其他会员也浏览了