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Endo tips    Better Endo    Endo abstracts    Endo discussions

Tricky diagnosis:acrylic temporaries:acute responses

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From: Randy Hedrick Sent: Mon 28/11/2005 13:33 To: ROOTS 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 lukewarm water.
tricky diagnosis
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.
tricky diagnosis
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 temporized teeth.
tricky diagnosis
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 radiolucency. 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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