Endodonticstown message board Stats on pulpitis calming down Atlee | Total Posts: 102 | Member Since: 2/11/2004 | Location: Washington Township, NJ | Posted: 1/4/2005 8:28:12 AM | Post 0 of 44 What are your opinions on pulpitis after crowns or deep fillings calming down? I did a crown last week that was very deep on the distal. I saw some blushing but no exposure. Bonded crown on with Variolink and Brush&Bond. He came in today with a blazing toothache, sensitive to everything, couldn’t sleep, the whole bit. I offered to either start RCT, or place him on steroid (either Medrol or Deca). Pt. couldn’t stay for RCT, and didn’t want Rx due to him having to “give a sample” for in vitro fert. next week. He’s coming back tomor- row for RCT, but is this jumping the gun? What are my options? Will steroids help or just mask the problem? Don’t want to lower occlusion on my awesome new crown, and don’t want to do RCT if it’s not necessary. I think this is my most uncertain area of practice. So I ask you, do they calm down or what? Thanks. bmusikant | Barry Musikant | Endodontist | President, Essential Dental Systems, Inc. | Total Posts: 3,730 | Member Since: 6/8/2001 | Location: New York, NY | Posted: 1/4/2005 9:58:36 AM | Post 2 of 44 Atlee, it sure sounds like root canal. However, I would still do the routine tests of sensitivity to cold, check the occlusion. If there is a prolonged reaction to cold or no reaction to cold along with percussion sensitivity that would make it all the more likely that the patient needs RCT. Blushing plus symptoms also sounds like it’s RCT. I don’t think you would be jumping the gun if you started RCT now. Most of the time a diagnosis for root canal is not that much of a mystery. Patient comes in either with symptoms or complains about various stimuli producing symptoms. If you can duplicate the symptoms by applying some form of stimulus (heat, cold, percussion, palpation) and the pain lingers you can be pretty sure the pulp is going. If you cannot duplicate the symptoms and the patient is not in severe pain at the moment, time will generally make the diagnosis more accurate so you don’t have to rush to a decision. Been doing it that way for 35 years. oleg | Oleg Borshch, DDS | Total Posts: 48 | Member Since: 11/21/2004 | Location: Brooklyn, NY | Posted: 1/4/2005 10:52:19 AM | Post 6 of 44 I had few cases identical to yours––I kept adjusting occlusion, but ended up doing endo. However, if the patient was comfortable with the temporary––then the discomfort may be due to an error in bonding proto- col and probably will go away with time. Looking ahead, if you’ll decide on the endo (and your new crown looks perfect in every aspect), would you do the RCT through the crown, or redo the crown after the endo? kenh | Ken F. Heritage, BDS | Total Posts: 86 | Member Since: 3/28/2004 | Location: Ireland | Posted: 1/4/2005 1:53:57 PM | Post 14 of 44 I agree, always forecast a possible endo, especially in deep cavities, previous restorations etc., but also on virgin teeth. My rule of thumb is to do the endo first when I am sure it is indicated, or as above, advise the patient an endo may be necessary, and either use long-term temps (3 mths+) or cement the permanent crowns with temp cement mixed with Vaseline, then you can assess at your leisure, and if an endo is needed, the patient has already been half expecting it, and you just slip off the crown instead of having to cut through it. Some time back on a full-mouth rehab, I started by warning the patient that one or more of the existing heavily filled teeth, or previously crowned teeth, might end up needing endo. In fact only one did, but it was the first tooth I touched (#1) and it pained within 3 days, but like I said, the patient was warned at the start and just returned and said, “You were right!” Good luck with the case, and start the RCT as soon as possible. bmusikant | Barry Musikant | Endodontist | President, Essential Dental Systems, Inc. | Total Posts: 3,730 | Member Since: 6/8/2001 | Location: New York, NY | Posted: 1/4/2005 2:22:34 PM | Post 15 of 44 It’s interesting. When patients are sent to us for endo we are always in one way or another telling the continued on page 32 30 dentaltown.com April 2005 Continued from page 30 Endodonticstown >> message board patient that the dentist did not do something wrong. After all, every day a person dies, does that mean a physician has committed an error? Things do happen. There seems to be a general trend in this country, at least, where nothing can go wrong without someone being at fault. That is definitely a manmade (lawyer’s) concept. Despite the many advantages of modern society, to me, this concept adds daily stress to our lives. tab | Total Posts: 136 | Member Since: 12/20/2002 | Location: Lancaster, CA | Posted: 1/5/2005 11:11:27 AM | Post 23 of 44 Great discussion here, how many of us have had that 1 in a hundred situation where we are sure which tooth it is, but with testing it turns out to be the one in front or behind. I hate to torture patients also, but I would hate to open the wrong tooth and pay for 2 RCTs and [anger] the patient. I found early on to warn patients and document in chart if decay is close, then I can tell them “I warned you” haven’t quite gotten to the point of warning all crown preps though…I am considering it. JLSchweitzer | Jordan L. Schweitzer | Total Posts: 356 | Member Since: 6/19/2003 | Location: Arlen, TX | Posted: 1/5/2005 4:43:36 PM | Post 29 of 44 Brandon, as one of those who said to go ahead and do the endo, I think you bring up some good points. I like to think I am conservative when it comes to diagnosis. If I cannot reasonably prove to myself that the patient needs endodontic treatment, then I send them away and tell them to come back if the problem per- sists. As a matter of fact, several of my referring doctors make it a point of telling their patients that if Dr. Schweitzer doesn’t think you need a root canal, he won’t do it. Now, having said that, endodontic diagnosis is part art, part science. I agree that thermal testing and radiographic evaluation are the “two biggies” so to speak, but there are elements involved in arriving at a diagnosis, such as the clinical exam and dental history. Seltzer, Bender, and Ziontz found that a past history of pain was highly correlated with pulpal degenera- tion. So one of the questions I ask my patients is, “Has this tooth ever hurt in the past?” Frequently patients will say, “Yeah now that you ask, it hurt last month and there was another time it hurt.” And as we’ve all heard, they say that the pain lasted a few minutes/hours/days and then it went away. I meant to go see the dentist but when the pain went away, I thought I was OK. When I hear this, this gives me further confidence to proceed with endo if the tooth has lingering pain to cold or is tender to percussion. In Atlee’s first post, he mentions he started a crown that was very deep on the distal, presumably because of deep restoration, which was preceded by deep decay (past dental history). Then he says, “He [patient] came in today with a blazing toothache, sensitive to every- thing, couldn’t sleep, the whole bit.” As you mention in your post, you think about endo if there is aching at night, which there was in this situation. To me, this certainly sounds like an indication for endodontic treatment. Now, if the patient had come in and said, “it ached at night, but I was able to go to sleep,” I would start to think that maybe his toothache might be from the trauma of tooth preparation. Also, in your experience, how severe is a toothache when it’s due to occlusion? Typically I ask patient’s to rate their pain on a scale of zero (meaning no pain) to ten (the worst pain they’ve ever had). Most of the patients where I’ve thought their T/A is from occlusion rate their pain a 2 or 3. My interpretation of how much pain Atlee’s patient had put the scale up around a 6 or 7. Also, as an endodontist I see cases where a dentist has adjusted and adjusted the occlusion, some to the point where they’ve removed all the porcelain, and the FREE FACTS, circle 1 on card continued on page 34 dentaltown.com 32 April 2005 Continued from page 32 Endodonticstown >> message board patient continues to have discomfort over an extended period of time. Some are exhausted by the time they get to me. And many of these cases mimic the one Atlee’s described. bclements | Brandon R. Clements | St. Simons Island Dental Associates, P.C. | Total Posts: 90 | Member Since: 4/10/2003 | Location: St.