A "HOT" tooth - a not so hot experience

I'm sorry that today I have to share an experience that is NOT the most positive - but I CAN state that I learned MANY positive lessons today that I will share with you.
I have heard from many people that dental pain is on a pain scale all to its own. I hope and pray that I never have to experience it. You hear of people getting cuts and bruises, and spraining or breaking their ankle from sports injuries, even hip and knee replacements - which to me sound VERY painful. But it is my experience that there are people that would rather experience a broken ankle, or replace a hip joint, rather than experience dental pain. And today I vicariously lived through one of my patients who today was experiencing what we in the dental world non-scientifically term a "hot tooth". You ask: What is a "hot tooth"? Please read on...
You can find me, almost every Tuesday s at the VA Dental Clinic (veteran's affairs dental clinic) seeing patients and taking care of the homeless and drug rehabilitation patients. And today was no different and I was going through my day without significant incident. But then, this afternoon I took an emergency walk-in patient. As I passed the waiting room I could see a young man - his shoulders slouched, his head in his hands - very obviously uncomfortable. We brought him back and even before he sat down in the chair immediately he began moaning and said he was in SEVERE pain and had been off and on the past 3 weeks! Just as immediately he mentioned that he was a heroin addict - had been a user for many years and experienced a lot but NEVER in his life had he experienced this kind of pain.
I tried to remain calm - assured him that we would help him the best we could today and ordered an xray to be taken so we could see the problem. With just one look at the xray I knew the source of his pain was that one of his lower right molars had a HUGE cavity that had deteriorated to the nerve and had spread down below the bone. In short - we couldn't save the tooth and it would have to be extracted.
Now before presenting the options to the patient, I'd like to say that ALL the options would include giving him antibiotics and pain medication BUT in terms of actual treatment to get him out of pain today were: 1) administer local anesthetic to get the area numb and give him a little relief from the throbbing pain and give him a few days for the tooth to calm down and the bacteria to start to be flushed away 2) get him numb and do what is called a "pulpotomy" which is the first start to a root canal and relieve the pressure, still anticipating that the tooth would need to be removed, and 3) get him numb and extract the tooth.
But options 2 and 3 would be very difficult in this case and like MANY dental cases, this patient brought with him a little more complication.
WHY you ask? Why don't we just get him numb and get the tooth out?? Because there are many things to consider:
1) FIRST and MOST IMPORTANTLY this tooth is causing this patient SEVERE pain (on a scale of 1-10, 10 being the worst, this patient scaled his pain as 10) - meaning it is termed in the dental world as a "hot tooth". What do we mean by hot? Unfortunately it does not mean that it is attractive or sexy, but that it means that the bacteria have infiltrated the nerve so severely that it is causing a raging painful infection. When bacteria infiltrate and agitate the nerve so much, the environment changes to an ACIDIC pH environment. The ability for local anesthetic to work in an acidic environment is VERY difficult. The nerve fibers don't absorb the local anesthetic the same as if there were no infection - and therefore - the patient does NOT get numb as quickly, and sometimes doesn't get FULLY numb (which is why you hear people saying that they could feel everything) - and we DO NOT want that.
2) this patient has a history and current history of drug use and abuse. Most of these patients have a VERY high pain threshold and because of the recreational drugs (and sometimes even prescribed pain medication) many times these patients take MUCH longer to be affected by local anesthetic. Many times, the illness of recreational drug use prevents dental anesthesia to be as effective and the metabolism of anesthetics is different.
3) this patient exhibited dental phobia and was in severe pain - rationale and reasoning went out the window. Getting himself out of pain was his main objective. And when your sole objective is to get out of pain you are NOT making rational decisions, nor are you in control of your hands and motions.  Dental phobia, drug use, swearing and pain do NOT a great patient make. I understand completely that being in pain is not something ANY person would smile about - I'm just stating that if a person is normally afraid of the dentist WITHOUT an infection - imagine what they feel WITH an infection.
4) Lastly from a personal safety perspective - this patient was very strong, muscular, MUCH BIGGER than me, and had a history of drug abuse. While I'm quite strong, me standing next to this man, I could see myself swashed like a bug. Generally speaking (and I recognize that this is not always true) it is common to see many recreational drug abusers with many types of infectious diseases - some so severe as HIV and Hepatitis B and C (causing irreversible life changes and quality of life issues). Knowing that I would have to give an injection to a patient who was in severe pain with a sharp needle, inside his mouth, was NOT something I was jumping up and down to do. I COULD do it, but I didn't feel a 100% safe. And neither did my assistant. And listening to myself and safety is a top priority for me and for the future of my family. No matter the job - it is not worth the risk of doing a procedure if I don't feel safe.
So what did I do!?!
I did what any responsible clinician would do. I asked for help. Thankfully working at the VA I am surrounded by more experienced dentists that I can turn to for help. I asked one of my mentors, a staff dentist, to come in and help me. He agreed that antibiotics and pain medication were required. And agreed that the tooth was NOT saveable. But what he was able to do that I was not was that he was able to get the patient numb by giving him A LOT Of local anesthetic - to get the patient comfortable for a few hours until the antibiotics and the pain medication could enter his system and start fighting his infection.And he was going to see him tomorrow to get the tooth out. Because antibiotics and pain medication will only get a person so far, and then there is a possibility of the tooth getting reinfected again. He left, as happy as he could be in this situation, and MOST IMPORTANTLY: OUT OF PAIN.
I learned a LOT from this situation. There was the part of me was very disappointed that I could not do that myself - that my reservations and concerns based on my past experiences with "hot teeth" and knowing his medical history prevented me from going in and just giving him an injection to get him out of pain. BUT, I learned that listening to myself regarding saftey is not a weakness. I learned that asking for help is the responsible thing to do when I need it. I learned that I felt safer that who came to my aid in this situation was a STRONG CALM MALE (not necessarily that it has to be male but a dentist with a lot of dental experience) due to my concerns of SAFETY. And I learned that while I knew what the best plan of action was when a patient is experiencing a "hot tooth" that I shouldn't second guess myself about what to do. Next time I feel that I will know exactly what to do the next time a "hot tooth" and I cross paths...
Hopefully it will not be anytime soon.
image courtesy of: clipart.com