Doug Kase
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 ELIEVE
IT OR NOT, this is not a builder’s guide to doing endodontics. As
a philosophy to help ensure dental success and patient satisfaction the
idea of building a good foundation may help steer us down a path to better
diagnosis and treatment. The good-foundation philosophy applies to all
phases of dentistry, but the focus of this Tale is endodontics, both pre-operatively
and post-operatively.
Many practitioners have had to deal with the discomfort
that a patient feels from a pulpitis after permanent crown cementation.
The situation is extremely frustrating for the dentist, and it is likely
to lead to patient dissatisfaction (and we all know the possible consequences
of that). We all tell our patients to wait it out and give it time.
“Don’t worry,” we say. “It will go away.” We make numerous
occlusal adjustments, grinding away the beautiful porcelain anatomy.
Although the tooth is symptomatically better, it is still uncomfortable.
The patient looks to us for answers, and sometimes the ultimate answer
may be endodontic treatment.
We all understand that developing a pulpitis is
a risk of any invasive restorative procedure. However, sometimes
the “riskee” is not as understanding. The dentist feels bad, and
the patient may feel worse. The patient experiences continuing discomfort,
a perceived esthetic compromise after the access opening has been filled,
and an investment of more time and money. If the crown becomes undermined
structurally, then the tooth may require a post and core and new crown,
imposing a burden of time and money on the dentist.
How can we avoid this pulpitis problem? The
unfortunate truth is that we cannot! However, we can try to minimize
the conditions that lead to it and the trouble that results from it.
What Can Be Done?
FROM A DENTAL-LEGAL point of view, communication is the key word.
Because an informed patient is ultimately a happy patient, it is important
to inform the patient of the possible risks. Signed consent is great,
but some consider it overkill. Tell your patients before you start
that there is a possibility of a pulpitis after a restorative change to
a tooth. Explain that the risk increases as the procedure becomes
more invasive (as for an onlay or crown), and that existing deep fillings
or fractures or current deep decay can also increase the risk. Let
them know that pulpitis may become irreversible and ultimately result in
the need for a root-canal procedure. Your patients should be active
participants in the decision-making process with you as their guide to
proper dental care.
So enough with philosophy and on to the clinical
nitty-gritty. Although not foolproof, there are some techniques we can
turn to so that we may be able to better forecast the pulpal future of
a tooth that is in need of dentistry that will be, from the patient’s point
of view, time-consuming and costly.
First and foremost, it is essential to pulp-test
the tooth before beginning your restorative procedure. Even if no
radiographic pathology or even clinical pathology is present before a filling
or crown change, the tooth may possibly already be non-vital or barely
vital. Finding this out before placing a crown would certainly avoid
your finding a periapical radiolucency three months after placing it.
A minimal positive pulp test as compared to adjacent and contralateral
teeth may predict future non-vitality and the need for preventive endodontic
therapy. If the pulp test shows that a tooth is extremely hypersensitive
compared with adjacent and contralateral teeth, it may have a present pulpitis.
Hypersensitivity often forecasts treatment difficulties, such as an increased
tendency to pericementitis, difficulty in attaining adequate anesthesia
during treatment, and prolonged temperature sensitivity that may come and
go. These hyperemic symptoms, which may be present in the temporary
crown stage, can disappear; however, after permanent cementation they have
a tendency to return and end in the need for a root-canal procedure.
Fracture lines are also predictors of the need for
preventive endodontics. Again, the presence of a fracture is not a guarantee
of ultimate pulpal demise; however, if you are unable to prep away a fracture
line in a restorative procedure, that should set off an alarm. Normal
pulp tests and lack of symptoms may make you feel that fracture lines alone
do not indicate a need for preventive endodontics at present; however,
you should still inform the patient of the future risk. If there
is microscopic communication to the deeper open dentinal tubules, the permanent
cementation procedure may ultimately be irritating to the pulp. If
the fracture lines are dark and on transillumination do not transmit the
light to other parts of the tooth, then this is a more severe fracture
that can influence pulpal longevity. A history of deep fracture close
to the pulp should also raise an eyebrow.
Calcifying receding canals can be another predictor
of the need for preventive endodontics. As the pulpal tissue calcifies,
it does so non-uniformly, and the calcifications can choke off the circulation
to other parts of the pulp, resulting in eventual pulpal death and eventual
abscess. This sometimes can be preceded by a severe symptomatic pulpitis.
From a practical point of view, it will always be easier to locate calcifying
canals before a crown is placed rather than afterwards through a conservative
access opening.
It also is important to look for signs of resorptive
changes on the radiograph. If asymptomatic internal resorption is
suspected, then endodontics is indicated prior to full coverage to insure
a better long-term prognosis.
Restorative history may also predict the necessity
of preventive endodontics. A tooth with a long and large history
of deep restorations is more prone to pulpal pathology. Obviously,
a small and short clinical crown preparation, which may be more prone to
fracture or loss of crown retention, would need endodontics for post placement
and core buildup.
The Dividend
UNFORTUNATELY, none of us possesses the great dental crystal ball.
(If I had it, I would have tuned it to stocks and sold two years ago.)
Don’t be afraid or shy about doing the endo if it’s needed or you strongly
suspect that it will be needed in the future. With the techniques
available, particularly the EZ-Fill® SafeSider™ instrumentation technique,
your clinical decision will have a safe and predictable outcome.
No dentist can absolutely predict whether a tooth will end up in “endoville”
soon after the new crown is cemented or when the patient is given his six-month
recall exam. However, the time and effort you invest in determining
whether there is a strong likelihood that endodontics will be needed will
certainly pay the dividend of alleviating some post-operative pains in
your gluteus area.
September-October 2002
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Many practitioners
have had to deal with the discomfort that a patient feels from a pulpitis
after permanent crown cementation.
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