Loss of vitality in an unrestored, caries-free, lower premolar

This is a case report of a patient presenting in pain of two-weeks' duration localized to the lower right premolar region. Whilst the LR5 was heavily restored, the adjacent unrestored LR4 was tender to percussion. This case report presents the clinical management of diagnosis and treatment of an apical abscess at an apparently sound virgin premolar tooth. The authors discuss how they made a differential diagnosis and the likely reasons for disease arising.

A 67-year-old female patient with type II diabetes presented with a constant dull ache localized to the LR45. The pain radiated through the right-hand side of the mandible, keeping the patient awake at night. There was no associated suppuration or sinus tracts. The LR5 had a large distal occlusal (DO) amalgam and was not tender to percussion. The virgin LR4 was tender to percussion. The patient could not differentiate the pain between the two teeth. The LR4 appeared free from any restoration or dental caries (Figure 1). Clinical examination did not reveal discoloration of either tooth. There was no mobility nor was there any periodontal pocketing greater than 3 mm. Sensibility testing with both ethyl chloride and electric pulp tester of the LR45 showed a positive but not exaggerated response at LR5 and no response at LR4.