Claudia Hoffman
 
 

    Irreversible pulpitis is often characterized by a painful, lingering response to cold. Irreversible pulpitis can be acute, subacute, or chronic; therefore, it can be partially or totally infected. The degree of inflammation in the pulp of a tooth with irreversible pulpitis is so diseased that root canal therapy is the treatment of choice. The signs and symptoms can vary, based on the extent and inflammation in the pulp; usually the patient feels spontaneous, intermittent, or continuous pain. The pain may be brought on by sudden temperature changes (usually cold), and elicit prolonged episodes of pain. This pain may be relieved by the application of heat or cold. Reversible pulpitis does not involve spontaneous pain; therefore, it is reactive only when stimulated, and the response does not linger after stimulus is removed. 
    Radiographs are not diagnostic in irreversible pulpitis because the inflammation is confined to the pulp. The radiographs can help with finding the etiology of the disease, such as deep caries or restorations. In late stages of irreversible pulpitis there may be a thickened PDL evident on the radiograph.
    The EPT is not diagnostic in symptomatic cases of irreversible pulpitis because the pulp is inflamed and still responds to electrical stimulus. 
    Irreversible pulpitis is the most likely to have referred pain.

MISCONCEPTION 2: When there is no area of rarefaction on the radiograph the teeth are OK.

    Areas of rarefaction are evident on a radiograph only when the destruction has eroded the cortical plate. Therefore, a tooth can be nonvital and have bone destruction around the apices but not be evident from radiographic examination. 
    This becomes evident when you obturate a nonvital tooth and there is a significant cement puff on the final film. This is a tooth that had apical bone destruction with no intact PDL, but the condition did not appear on the radiograph because the bone destruction had not broken through the cortical plate.

MISCONCEPTION 3: Leaving a tooth open is a good option if the tooth has drained and the patient is in pain.

    It is common to open an infected tooth and have purulent drainage. In most cases, after cleaning and shaping the canals the drainage will stop. The tooth should be allowed to drain under the rubber dam for up to 20 minutes. If the drainage stops, closing the tooth after treatment is the best procedure, because teeth left open are often involved in mid-treatment flare-ups (Seltzer, 1997). 
    In rare occasions when the tooth will not stop draining, a patient can be placed on antibiotics and a sponge or cotton pellet should be placed in the access. The tooth should be closed the next day. Teeth that are left open show higher levels of secretory IgA than teeth not left open, and this can lead to an increase in periapical cyst formation (Torres, 1994).
    The possibility of mid-treatment flare-ups and cyst formation illustrate the desirability of closing all teeth under the rubber dam after treatment whenever possible.

MISCONCEPTION 4: A patient who has a fistulous tract should be placed on antibiotics.

    If a patient presents with a fistula, the first step is to trace the fistula and obtain a radiograph.  After correct diagnosis is confirmed, and root canal therapy is initiated, when possible the tooth should be cleaned and shaped and packed with calcium hydroxide. The patient should be rescheduled for evaluation and completion of treatment in approximately ten days. It is best not to give the patient antibiotics after the first visit because as practitioners we would like to see the fistula resolve through the removal of the etiology of bacteria. If the fistula resolves with no antibiotic coverage, we know we have successfully removed the etiology of the infection. Antibiotic coverage can cause the fistula to disappear although the bacteria in the canal have not been removed, and can give a false sense of healing.
 

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