Jay Vuong
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 HEN
I FIRST STARTED doing referral-based endodontics, I was surprised by the
number of complaints that some patients had about their general dentists.
One group of complaints would center on typical issues, such as how rough,
uncaring, and unavailable their dentists could sometimes be. The
other main group of complaints would center on how the patients had gone
to their dentists for routine treatment and then for some unknown, unexplained
reasons, they now had severe toothaches or infections. Making matters
worse, these two types of complaint would often go hand in hand as the
patients asked whether I could refer them to another dentist. Of
course, I wouldn’t and still don’t. After a little persuasion and
encouragement, on my part, the patients would feel better about their dentists;
that is, they would feel better about their judgment in choosing their
dentists in the first place and then feel comfortable about giving their
dentists “another try.”
Why do patients get upset in the first place?
From complaints like the ones described above, it sometimes appears that
the patients’ dental experiences fall short of their expectations.
With reasonable patient expectations and a little sensitivity and foresight
on the dentist’s part, stressful situations like the upset patient with
a toothache can often be avoided. One clinical situation that tests
the patient/dentist dynamic is the recognition, presentation, and treatment
of the “stressed tooth.” Often, the patients who give their dentists
compliments when they present in our endodontic practice are patients of
dentists who recognize the stressed tooth and present it through their
treatment plans. These patients are usually well informed or informed
enough to enable them to rationalize the reason for their now needing a
root canal, especially after just getting a new restoration. The
patients’ dental pain and blame is vented on their own dental situation
rather than on the ability of their general dentists. The dentists
are seen, by these patients, as the wise caretakers who foresaw the stressful
predicament that the patient is now in. These dentists had taken
their patients’ expectations into account and, as a result, their patients
are not surprised or confused by their current position of needing a root
canal.
What is a “stressed tooth”? On an endodontic
level, I see the stressed tooth as a tooth (without prior root canal treatment)
that has a significant risk of developing an irreversible pulpitis or abscess
once additional procedures are performed on the tooth. Examples of
the stressed tooth might include a tooth with a deep amalgam filling, once
replaced with a “white filling” or crown that now has a persistent sensitivity
to cold, then to heat, with the sensitivity finally turning into a full-blown
toothache. Another example is the periodontically compromised tooth,
crowned years ago, which with a recent root scaling then develops an acute
endodontic abscess. The stressed tooth, as seen in these examples,
tends to be recognized once the endodontic problem arises. Wouldn’t
it be nice to recognize the stressed tooth before it becomes a problem
to you and your patient? One way to increase one’s recognition requires
the dentist to view the tooth biologically.
It is often practical and productive to see
the tooth as an inert solid that the dentist can manipulation in a way
that a craftsman or artist manipulates a piece of wood or marble.
A problem with this view of the tooth arises, however, when you take the
pulp into account. Biologically, dentin can be seen as an extension
of the pulp. The dentin, which is not solid at all, but rather porous
because of is tubule construct, houses the extensions of pulp odontoblast
in a delicate fluid dynamic. Drilling into dentin can then be viewed
as cutting into a living tissue. Lacerations in dentin, like lacerations
in skin, result in an inflammatory process. In the tooth, if the
inflammatory process is significant it leads to permanent changes in the
low compliance environment of the pulp. These changes in the pulp
can compromise the ability of the pulp to recover from further inflammation
resulting from injury. The tooth’s inability to recover translates
into clinical symptoms when the patient develops temperature sensitivity
then percussion pain that doesn’t go away and only gets worse. Sometimes
the pulp or nerve dies, often without symptoms (sometimes in the presence
of a temporary sedative) until an abscess develops in the future.
To recognize the stressed tooth, one must
be able to recognize all the past “injuries” the tooth has undergone
and all the suggestive clinical symptoms the tooth has now.
Injuries to the pulp are usually revealed by looking at the dentin.
Usually, they can be seen in the radiographic and clinical evidence.
Carious lesions; extensive restorations in dentin; periodontal defects
adjacent to dentin; and clinical evidence of abrasion, attrition, erosion,
and recession may be evidence of injury sustained by the pulp.
In addition to these factors, you might also
be able to recognize changes in the pulp directly. These changes
may include thinning or calcification of canals and chamber, pulp stones,
thickening of the PDL, or opacity of the bone beneath the root (i.e., condensing
osseitis). These pulp changes alone may not present a risk to further
restorative insult. However, when they are present in conjunction
with other previous dentinal injuries, the situation should be questioned.
The patient should also be questioned and
listened to. Has the tooth ever bothered the patient in the past?
Does the tooth bother the patient in any way now? If you see an accumulation
of the factors above in an individual tooth, you can define the tooth as
a stressed tooth. The stressed tooth has the potential to inflict
endodontically related pain when a further significant restorative or periodontal
procedure is performed on the tooth.
Once a questionable tooth is recognized, the
dentist who informs the patient about the situation is one step ahead of
the game. The decision to perform or not to perform “prophylactic
endodontic treatment,” however, requires a good understanding of treatment
planning in conjunction with an accurate assessment of the patient’s risk
tolerance . . . and your own.
January-February 2002
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What
is a “stressed tooth”? On an endodontic level, I see the stressed
tooth as a tooth (without prior root canal treatment) that has a significant
risk of developing an irreversible pulpitis or abscess once additional
procedures are performed on the tooth.
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