Management of a severe toothache case

Dr Rosalind Ho BDS S’pore MFGDP (UK)

A patient, Mr. X presented with intense pain. He was unable to bite to chew on his upper right teeth.

His Medical History was normal and he had no history of tooth injury.

By Dr Rosalind Ho

On clinical examination, the upper right first premolar was very sensitive to electrical pulp test, cold and tender to percussion. He felt a sharp pain when biting on a cotton roll. There was no pain at night and pain was only elicited when biting.

It became evident when the oral camera revealed a channel running across the biting surface of the tooth.

Periapical x-ray by Dr Rosalind Ho

X-ray taken shows general bone loss and especially on the mesial of the upper right first premolar. No signs of root fractures. The tooth next to the painful one has some caries.


Crack tooth syndrome involving the upper right first premolar.

The upper second molar appears to have some pathology at the root tip and require further investigation.

Possible Causes: 1 Lack of posterior or back molars

2 Patient’s habit of biting very hard stuff

3 Night grinding


Advised to extract the tooth and discuss about options to replace lost tooth.

Three vials of Local anaesthetics were administered and anaesthesia was successfully achieved.

The tooth was carefully extracted, revealing two curved roots.

Socket toilet was done with curettage of granulation tissues. and syringed with saline. The patient was cautioned about the possibility of a dry socket.

An anti-coagulant socket sponge was inserted to expedite the clotting.

An internal cross suture was placed and post-extraction instructions were given.

A course of antibiotics and painkillers were prescribed and the patient was given an appointment to remove the stitch and for further management of other teeth.

During the post extraction follow-up by phone, patient was comfortable.

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