Tricky diagnosis:acrylic temporaries:acute responses
From: Randy Hedrick
Sent: Mon 28/11/2005 13:33
Subject: [roots] Tricky Dx
The patient was referred for evaluation and endodontic treatment of
teeth #19 & 20 which were in acrylic temporaries. The patient reported
tooth ache pain in the lower left molar area with radiating pain onto her
temporal region especially with hot foods including her oatmeal that
morning. She also reported sensitivity to brushing around #19 & 20 with
Examination revealed temporary crowns on #19 & 20 that had been in place
for several months. Radiograph revealed no apparent apical pathology.
Buccal margins #19 & 20 were short with dentin exposure. Periodontal
probing, percussion, and bite testing were all normal for the mandibular
left posterior teeth. Cold testing to the buccal and lingual surfaces
also caused normal acute response to #18 & 21. Teeth #19 & 20 exhibited
delayed acute responses when the cold was applied to the acrylic
temporaries. Air sprayed on the buccal dentin of #19 & 20 caused acute
discomfort as did touching with an explorer. I arrived at a tentative
diagnosis of normal pulpal responses for all of the lower left posterior
teeth so I took a radiograph of the upper left posterior teeth and
initiated pulp testing of the upper left teeth.
Periodontal probing, percussion and bite testing were all normal for the
maxillary left posterior teeth. Cold testing to buccal and lingual
surfaces also caused normal acute response from #13, 14, & 15.
Tooth #12 did not respond to cold when the cold was applied to the buccal
or lingual. Air and explorer contact with buccal root surfaces did not
elicit any responses. Heat was applied to the buccal of #12 and a vague
familiar pain was caused. Heat applied to the lingual surface of #12
caused a strong familiar pain on her left temporal and lower left molar
regions. I advised her that the pulp in #12 was degenerating and causing
referred pain to her temporal and molar areas but dentin sensitivity was
causing the sensitivity to tooth brushing. She was doubtful because the
pain was in the lower molar area. I suggested diagnostic anesthesia over
#12 to see if her pain would go away. She agreed and the pain resolved
within 1 min after 1/3 carpule of anesthetic was infiltrated over #12.
At that point she consented to endodontic treatment of #12.
Diagnosis: #12 irreversible pulpitis. Upon access the buccal pulp horn
was necrotic and the lingual pulp was degenerating, pulp in root
was vital. Treatment was completed and the patient was given Sensodyne
as an interim solution for dentin sensitivity until the temps were remade
or the final crowns were cemented. An evening call confirmed that her
pain had not returned and she thanked me for getting the right tooth and
what a surprise it was that it was an upper and not one of the
Apical prep #55 LightSpeed
Obturation with Epiphany/Resilon Simplifil obturators and backfill with
Resilon in Obtura gun - Randy Hedrick
Nice work - good, systematic, diagnosis ... it's always a bit of a relief
when the pain doesn't come back though, isn't it? - Simon
Oh, Nice diagnosis and care! - Alan
Looks like the treatment plan SHOULD have been up-righting 19 and 18 before
any new crowns were planned and if one wants LONG term temps they need to
fit as close to the margins as possible. Those do not. 'course the last
crown is open also. How did my patient get to you? ;-) - Alan Cady
PS I know the patient may squelch the ortho bit, but still long term temps
need to look like they 'grew there'.
Could that be some condensing osteitis around the apical region of the UL4?
Might be worth a few more points in the diagnostic point gathering
procedure - Stephen Day
Stephen, It's possible on the preop radiograph but doesn't appear on the
post op. I don't really place much faith or reliability to condensing
osteitis in making diagnoses. The eye can read in so many things into a
radiograph that sometimes aren't significant. I know others place a higher
degree of importance in the diagnostic value of condensing
osteitis than I do - Randy
Randy, is the patient going to have permanent lower crowns soon or at least
new temporaries? - Marcos Arenal
New Crowns - Randy
We have talked precious little about the value of diagnostic local
injections on this forum but it’s value cannot be overlooked. I recently
had a patient who swore on a stack of bibles that a lower left lateral
incisor, #24 in ada nomenclature, was killing him. This guy is the kind
of patient that when he does us the courtesy of his once every 3 or 4
or 5 years visit to our office, we set up either for endo or extraction.
Incisors were virgin teeth other than perio. I started l.a. backwards
from 24 to 22 to 19, when I got all the way back to the block, the patient
exclaimed, that’s it. Lower 2nd molar was necrotic.
Patient was off 3 inches - Gary
Just be sure to use the anesthetic test as your last test,
not your first one - Terry
Yep, I recently had a similar irreversible pulpitis with pain ireferred
to the upper molar area ... I did everything to reproduce the Sx but
couldn't, including the individual hot water bath with the dam. Starting
to run out of time on the consult and anesthetizing teeth from anterior
backwards with intralig ... got all the uppers numb with no effect/relief.
Started looking at the lowers, testing again with inconclusive results,
until finally got anesthesia/pain relief with an intralig to the the distal
of the lower 2nd molar. This was 40 minutes later .... then she went to the
oral surgeon, had it exo'd .... the pain went away but she got a
dry socket! - Simon
Lol! This is east coast, not west coast. We have our fecal matter together.
Good point though when discussing on open forum - Gary
Randy, Nice catch, shows that a thorough diagnosis is so important.
Do you know what was the reason for the long term temps? It's not as if
things are going to get better just by leaving them there. Do you think
that pulpal health will be maintained once the definitive crowns are cemented?
You say that #14 had a normal acute response to cold, yet this tooth seems
have had an endo treatment in the past. Do you think this may need re treat
as well? - Bill Seddon
Bill, I didn't transcribe my chartings correctly, there was no response to
cold on #14, thanks for catching that. I won't suggest retreatment until it
becomes symptomatic or a new crown is planned. I don't know the reason for
the long term temps, this particular referral tends to get distracted into
other things before completing the task at hand. He asked me about the long
term prognosis for the pulps and I said that pulp testing has no predicitve
value for future vitality. I always tell patients and dentists who ask this
question that there is about a 20% chance of needing endo after a crown but
we don't know which ones will be in the 20%. What do others on this forum
estimate the chances for needing endo after a crown to be? - Randy Hedrick
About 20% or a bit less within a short (6 months or less) time and still
<50% at 5 years in my restorative office. BUT which side of the % will
these be on? :-) - Alan
Randy...can you state the literature for 20% of teeth needing endo after
crowns? - Joey D
I have not seen any lit, but that is a good maximum % for quick trips south
in my office. I would like to see reports in literature also if
someone can find - Alan
Saunders and Saunders did a radiographical study, came to close on 20% of
crowned teeth that had a lesion. Some had existing endo though - Bill
Br Dent J. 1998 Aug 8;185(3):137-40.
Comment in: * Br Dent J. 1999 Jan 9;186(1):9-10.
Prevalence of periradicular periodontitis associated with crowned teeth in
an adult Scottish subpopulation.
Saunders WP, Saunders EM.
University of Glasgow Dental School.
OBJECTIVE: To examine the periradicular status of crowned teeth in an adult
population in Scotland. DESIGN: Examination of full-mouth periapical
radiographs from 319 consecutive adult patients (7596 teeth) attending
Glasgow and Dundee Dental Hospitals for clinical examination.
METHODS: The periradicular status of teeth with a crown present was assessed
to determine the presence of a radiolucency which may indicate pulpal disease.
RESULTS: 63.3% (n = 202) of patients had at least one tooth that was crowned.
The total number of crowns assessed was 802, of which 458 (57.1%) were vital
preparations, and 87 (19.0%) of these had radiographic signs of periradicular
disease. The majority of the teeth (62.0%) had distinct widening of the
periodontal membrane space which is considered to be an early sign of
periapical disease. 42.9% (n = 344) of the crowned teeth had previous root
canal treatment of which 50.8% (175) had evidence of a periradicular
CONCLUSIONS: Pulpal damage may occur during procedures to provide a crown
which may require subsequent root canal treatment. Radiographic follow-up of
crowned teeth should be undertaken routinely.
Here is Goodacre’s findings, reporting about a 3% incidence.
Much lower than what I have been quoting - Gary
Joey D, No, that is just my personal estimate based on 8 years of
restorative dentistry and 14 years of endo. That is also why I was asking
for others to give their best estimate to see what others experiences were.
I know some who estimate as high as 50% but that seems to be way too high
unless they are doing something very wrong with their procedure. What has
been your experience? Do you think it is higher or lower? - Randy Hedrick
If you go way back into time....Langland did a great study...
and it was something like 5-7%...
But I recommend going to the J Prosth and getting the "Jackson Study"...
it's frequently quoted and I would consider it a classic....
It sez 5.7% - Joseph Dovgan
J Prosthet Dent. 1992 Mar;67(3):323-5.
Pulpal evaluation of teeth restored with fixed prostheses
Jackson CR, Skidmore AE, Rice RT.
Department of Endodontics,
West Virginia University School of Dentistry, Morgantown.
The literature demonstrates that each of the elements of crown fabrication
involves possible and probable insult to the pulpal tissues of the tooth.
Preparation of the tooth can result in pulpal inflammation or even burn
lesions. The impression technique can result in reduction of the
odontoblastic layer caused by drying of the dentin. Temporary coverage
of the preparation involves the use of self-curing resins and temporary
cements, both of which can irritate the pulp. The final restoration is
attached with cements that are often implicated in pulpal irritation.
Dental caries and the procedures necessary to remove it and restore the
tooth before preparation for a fixed prosthesis can injure the pulp.
This study was done to evaluate the effects of complete coverage fixed
prosthetic restorations on the dental pulp. A recall letter was mailed
to 1221 patients who had received a fixed partial denture or single
crown during the years 1984 1988. One hundred thirty patients were
examined. Each tooth was evaluated for pulpal health, periodontal
integrity, and clinical acceptability of the restoration. Of the 603
teeth examined, 166 had undergone root canal therapy before placement
of the restoration, leaving 437 that were crowned while vital.
Of these, 25 (5.7%) were in need of root canal therapy or had
undergone root canal therapy after cementation of the fixed prosthesis.
We just had a thread dealing with that recently, and I think you are
right on, 20 to 25% seems to be the most often quoted - Gary
Depends on how long the follow up period is. On short follow ups you
get less teeth needing endo. There are statistics
about this, but I don't remember them off hand - Thomas
Randy, Thanks, I thought that must be the case with the upper molar.
I think there is great value in pulp testing prior to starting the work
for the crowns, maybe as a rule, the teeth are more likely to become
non vital if not pulp tested before hand, especially if the crowns
look really nice as well :-)
I cannot imagine that long term leaking temps with unsealed dentine are
going to be a great help. I would definitely warn in this situation,
and cement with dam if possible, and a chlorhex / sterilox swab - Bill
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