by Richard Mounce, DDS
I recently received this letter from a reader who asks an important and clinically relevant question:
“I enjoyed reading your most recent article in DE®. One of my biggest problems is the diagnosis of root canals. In most cases when a patient presents with a toothache, I diagnose irreversible pulpitis. I was wondering if you could briefly help me with the proper diagnosis of teeth and what treatment I should administer. Your help would be kindly appreciated.”
Endodontic diagnosis generally falls into three categories that require treatment: irreversible pulpitis, necrotic pulp, and failure of previous treatment (that might require retreatment, surgery or extraction).
The third category is beyond the scope of this column.
If it looks like a horse, smells like a horse, and runs like a horse, it’s a horse. Translated to endodontics, if the patient exhibits the above symptoms, a diagnosis should be made with confidence and verified by a comprehensive exam. Hoping that the patient will improve in the presence of clear signs and symptoms is contraindicated.
An endodontic exam should include a comprehensive history and multiple radiographic angles (ideally using digital X-rays, DEXIS Digital Radiography, Alpharetta, Ga.) taken from the buccal, mesial, and distal. Percussion, palpation, mobility, and probings should be recorded for all teeth in the quadrant and possibly the arch as indicated. The offending teeth should be tested to cold and heat as indicated, including the contralateral tooth.
The patient’s chief complaint must be duplicated. For example, if the patient complains of lingering pain to cold, applying cold should make the patient report a lingering sensitivity to cold that matches his or her chief complaint.
Irreversible pulpitis is marked by:
- pain to hot or cold that lingers.
- spontaneous pain, especially pain that wakes the patient from sleep.
- pain with chewing, especially if it is accompanied by one and two above.
- pain that is generally sharp and acute.
- pain that arises relatively recently after a) the placement of a new restoration b) multiple restorations in the same tooth and c) deep restorations relative to the pulp. The greater the number of insults to the pulp, aside from restorations (bruxism, abrasion, erosion, caries, etc.), the higher the probability of irreversible pulpal damage.
Pulp necrosis may or may not have symptoms. While a lesion of endodontic origin may be observed radiographically, a lesion does not have to be observable to have a non-vital pulp, depending on whether the toxic byproducts of pulpal breakdown have reached the apical tissues.
If a non-vital pulp is symptomatic there can be 1) pain to chewing, 2) spontaneous pain that is generally dull and less localized than that of irreversible pulpitis, 3) a lack of response to thermal testing, 4) palpation sensitivity, or 5) swelling.
If the pulp necrosis is asymptomatic, there:
- may or may not be an observable radiographic lesion. If there is no observable lesion radiographically, caution is advised. If the tooth requires a new crown and there is concrete evidence that the pulp is necrotic, it is optimal to perform endodontic therapy before placing the crown. If the tooth was once symptomatic with clear signs of irreversible pulpitis (especially spontaneous pain) and later became asymptomatic with or without a lesion, the tooth should be treated.
- may be a lack of response to thermal pulp testing.
Some argue that non-vital teeth without lesions should not be treated arbitrarily if the diagnosis is certain. I disagree. If a pulp is non-vital and asymptomatic, it is almost certain after time it will become symptomatic, which can be excruciatingly painful. Elective management is much more preferable than the alternatives.
The best remedy for both irreversible pulpitis and necrotic pulps is immediate root canal treatment. Indications for one visit vs. multiple visit treatment are beyond the scope of this column. But if treatment must be split into two visits, it is desirable at the first visit to remove as much of the pulp or necrotic tissue as possible. After straight line access, and ideally under a surgical operating microscope (Global Surgical, St. Louis, Mo.), the majority of the pulp and necrotic tissue can be removed from the tooth rapidly and safely to the level of the first root curvature if the canal will easily accept an orifice opener such as the K3 Shapers (SybronEndo, Orange, Calif.). Calcium hydroxide is easily applied into canals with the Navi Tip (Ultra Cal, Ultradent, South Jordan, Utah).
I welcome your feedback ...
Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at [email protected].
