Depth Of Pulp

[smb1993]

hi, i am new to this forum
and i thought i would start off my asking this question

what is the depth of the pulp from the central pit of a molar?
i am currently studying dental and have started working on patients..kindly reply

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[SoulPower]

hi, i am new to this forum
and i thought i would start off my asking this question

what is the depth of the pulp from the central pit of a molar?
i am currently studying dental and have started working on patients..kindly reply

you'll need to estimate using a radiograph, it will vary as well with age of the patient.

 

[Duriel]

you'll need to estimate using a radiograph, it will vary as well with age of the patient.

/thread

 

[smb1993]

thank you for the reply, i am asking for the average distance in a molar

 

[djeffreyt]

An average won't give you very good information frankly, but I'd say on average, you have about 6-7 mm from the central pit of a molar. But like was said, that varies so greatly by person and age and situation.

If you use a generalization for all patients, you'll make a lot of errors that you could avoid.

 

[smb1993]

thanks you so much sir
thing is i am still a third year student and have started my clinical postings now
and i accidentally exposed the pulp in one of my patients while preparing a class 1 cavity for amalgam and have lost my confidence 🙁
this lead me to finding out the average depth of the pulp chamber as it is not possible to take radio graphs for each and every case

 

[goffdent]

Answer.. the depth of the pulp is..... oops.. heme. But seriously.. whenever you hit pulp due to caries.. just think... "The caries beat me there.. it was inevitable" Maybe the caries was deep, and you prepped to within microns of the pulp chamber.. but didn't perforate it, but you could see red through the dentin.. chances are.. 99/100 that it's not favorable anyways.. because the bacteria are crafty and the anatomy of the tooth doesn't help it's cause.. The will be contamination to the pulp and it's already too late. no reason to beat yourself up about it. Maybe the patient thought a filling would be all it would take, and maybe they can't afford a root canal at this point. You attempted what you could, you gave it a last ditch fighting effort and lost the battle on behalf of the patient. I understand that if you feel emotionally responsible for the financial abilities and the tx outcomes of the patient, it will eat you up. But it's not something you should do because it's not your fault. Your patients control their own destiny.

 

[FSUpredent]

I think you'll find your answer in this article.

Morphological Measurements of Anatomic Landmarks in Human Maxillary and Mandibular Molar Pulp Chambers

Allan S. Deutsch, DMD, and Barry Lee Musikant, DMD

JOURNAL OF ENDODONTICS
VOL. 30, NO. 6, JUNE 2004

 

[smb1993]

Answer.. the depth of the pulp is..... oops.. heme. But seriously.. whenever you hit pulp due to caries.. just think... "The caries beat me there.. it was inevitable" Maybe the caries was deep, and you prepped to within microns of the pulp chamber.. but didn't perforate it, but you could see red through the dentin.. chances are.. 99/100 that it's not favorable anyways.. because the bacteria are crafty and the anatomy of the tooth doesn't help it's cause.. The will be contamination to the pulp and it's already too late. no reason to beat yourself up about it. Maybe the patient thought a filling would be all it would take, and maybe they can't afford a root canal at this point. You attempted what you could, you gave it a last ditch fighting effort and lost the battle on behalf of the patient. I understand that if you feel emotionally responsible for the financial abilities and the tx outcomes of the patient, it will eat you up. But it's not something you should do because it's not your fault. Your patients control their own destiny.

thanks sir for motivating me 🙂 i felt really bad after this incident especially because this was my pulp exposure and i dont want to repeat the same thing with another one, which is why i am asking the doubt.
thanks again 🙂

 

[Contach]

While it is probably not the OP's fault that the pulp was exposed, I would argue that there are many things dentists can do to prevent adverse outcomes like 'pulping out'. Saying that the patient's destiny is in the patient's hands isn't doing justice to the power of quality dental work. There is always room to improve - if you think you are never at fault, you will never improve. Blaming the patient is not the answer. There is a lot that dentists can do to try and hold on to teeth. Ever heard of indirect pulp capping? Vital pulp therapy has better than 1% success rate. Not saying that this was indicated in this case, we have no idea. But goffdent's post rubbed me the wrong way.

There is definitely something to be said about a dentist taking his/her time, using spoon excavators and slow speeds as much as possible, providing quality restorations at the expense of time and providing quality dental care.

 

[smb1993]

i did direct pulp capping on the patient and thankfully it was successful 🙂
but i still want to know how do i realise when i am nearing the pulp..you cannot always rely on the patient's symptoms/sensitivity..

 

[peterngu]

I go by pulpal floor blushing, which has worked a few times for me. The color of the dentin is decidedly different in some instances when you're <1mm or so from the chamber. BUT, if the dentin is unhealthy then it's all that go******* brown color, and then it's like goffdent said, the bacteria beat you there. I know I took it pretty roughly when I exposed a pulp on 15DO, and then had to extract it right then and there. Maybe you could pulp a ton of teeth to get used to the feeling? And at the same time rack up your endo procedures? >.>

 

[Wax n Relax]

This is why pedo is awesome.

 

[smb1993]

I go by pulpal floor blushing, which has worked a few times for me. The color of the dentin is decidedly different in some instances when you're <1mm or so from the chamber. BUT, if the dentin is unhealthy then it's all that go******* brown color, and then it's like goffdent said, the bacteria beat you there. I know I took it pretty roughly when I exposed a pulp on 15DO, and then had to extract it right then and there. Maybe you could pulp a ton of teeth to get used to the feeling? And at the same time rack up your endo procedures? >.>

sir..i couldnt really follow the colour different that you mentioned.
could you kindly clarify it?

 

[jay47]

I think you'll find your answer in this article.

Morphological Measurements of Anatomic Landmarks in Human Maxillary and Mandibular Molar Pulp Chambers

Allan S. Deutsch, DMD, and Barry Lee Musikant, DMD

JOURNAL OF ENDODONTICS
VOL. 30, NO. 6, JUNE 2004

Haha, just looked up this article the other day for a presentation.

On average it is 6.3 mm from pulpal ROOF to cusp TIP, so around 2mm less for a fossa (a little more for mandibular, 6.36, and 6.24 for maxillary).

It was a great article and one of the only ones that I could find. In reality, accessing the pulp chamber is based much more on knowing the anatomy of the tooth and "feeling it". Many endodontists will "feel" with the bur and the file when they are accessing the tooth- but just for fun, 6 mm is about the length from the tip to the shaft of a #4 round bur.

 

[goffdent]

While it is probably not the OP's fault that the pulp was exposed, I would argue that there are many things dentists can do to prevent adverse outcomes like 'pulping out'. Saying that the patient's destiny is in the patient's hands isn't doing justice to the power of quality dental work. There is always room to improve - if you think you are never at fault, you will never improve. Blaming the patient is not the answer. There is a lot that dentists can do to try and hold on to teeth. Ever heard of indirect pulp capping? Vital pulp therapy has better than 1% success rate. Not saying that this was indicated in this case, we have no idea. But goffdent's post rubbed me the wrong way.

There is definitely something to be said about a dentist taking his/her time, using spoon excavators and slow speeds as much as possible, providing quality restorations at the expense of time and providing quality dental care.

I dont understand how it could rub you the wrong way. I have perforated and.felt terrible about it. I want to save teeth more than anything.. But when you're given bombed out tooth to work on, you go into it knowing that it may not have a viable prognosis. You do what you can... I don't have super powers.. Do you?? Give me a cup of flower and some baking soda.. What kind of cake can make with that? A pretty nasty one. Give me a bombed out tooth with poor oral hygiene, diet, bad margins.. and I cant guarantee you a great outcome there either.

"Patients control their own destiny" is true any way you spin it. Seeing the dentist once or twice a year doesnt equate to a quality dental care if their at home care is lackluster.

Pulp capping can be beneficial... Sometimes.... but to say that your pulp cap was successful 3 Weeks later is not quality. Or to say that its successful merely because a patient doesnt complain about it doesNT mean its a healthy or vital pulp anymore. Essentially, you may be delaying the inevitable, and that doesnt make it low quality, just unfortunate.

 

[smb1993]

Haha, just looked up this article the other day for a presentation.

On average it is 6.3 mm from pulpal ROOF to cusp TIP, so around 2mm less for a fossa (a little more for mandibular, 6.36, and 6.24 for maxillary).

It was a great article and one of the only ones that I could find. In reality, accessing the pulp chamber is based much more on knowing the anatomy of the tooth and "feeling it". Many endodontists will "feel" with the bur and the file when they are accessing the tooth- but just for fun, 6 mm is about the length from the tip to the shaft of a #4 round bur.

thnks a lot sir 🙂

 

[Maka]

Look at radiograph, make mental note (pulp appears to be at lvl of CEJ, etc), prep, rinse our prep every mm or so as you approach your mental guide post, make sure your dentin does not seem like it's a rosy hue. If everything looks kosher, i'll use a round for excavation, but if I know I'm right on top of a horn or something, spoon it away.

 

[bsp1013]

Stop when you see red.

 

[smb1993]

u mean blood? 😛

 

[goffdent]

u mean blood? 😛

Strawberry jam...

 

[Contach]

I dont understand how it could rub you the wrong way. I have perforated and.felt terrible about it. I want to save teeth more than anything.. But when you're given bombed out tooth to work on, you go into it knowing that it may not have a viable prognosis. You do what you can... I don't have super powers.. Do you?? Give me a cup of flower and some baking soda.. What kind of cake can make with that? A pretty nasty one. Give me a bombed out tooth with poor oral hygiene, diet, bad margins.. and I cant guarantee you a great outcome there either.

"Patients control their own destiny" is true any way you spin it. Seeing the dentist once or twice a year doesnt equate to a quality dental care if their at home care is lackluster.

Pulp capping can be beneficial... Sometimes.... but to say that your pulp cap was successful 3 Weeks later is not quality. Or to say that its successful merely because a patient doesnt complain about it doesNT mean its a healthy or vital pulp anymore. Essentially, you may be delaying the inevitable, and that doesnt make it low quality, just unfortunate.

Where did anyone say that it was a bombed out tooth. The OP said "I accidentally exposed the pulp." It is not always the patient's fault. Dentists are not god, and it can be a dentists' fault.

 

[apapercup]

So, this is something that has been bothering me for a while... as a dental student just beginning their experience with deep carious lesions:
How would you treat the following cases

A few case based questions:
(1) You're excavating occlusal caries and you are approximately 2.3mm deep. An ideal class 1 form is made, and there are a few sticky gray areas on the floor of the prep. You take a round bur and slow speed to excavate these soft gray areas. You've successfully reached hard gray areas as verified by explorer. Do you leave these areas? or do you excavate further to totally remove them? (There is no rosy hue)

(2) You're excavating caries on a Posterior mandibular molar. The tooth has a distal operculum and cannot be isolated with Rubber Dam.
The patient has a minor occlusal caries that turns out to mushroom. You excavate to 3mm and notice a rosy hue at the pulpal floor.
You dont want to probe the floor with an explorer due to fear of exposing the pulp should you be so close.... You're even afraid to press too hard with a spoon...
What do you do?

General Question:
How do you distinguish the orange hue of caries from the rosy hue of the pulp?
What do you do if you pulp out without Rubber Dam Isolation?

Thanks!

 

[toothfixeralex]

In my experience (and the experience of my faculty mentors back in d-school) the pulp almost always starts at the level of the CEJ. Over time it will get deeper, but in general the CEJ is the best guide that I've ever used.

So, this is something that has been bothering me for a while... as a dental student just beginning their experience with deep carious lesions:
How would you treat the following cases

A few case based questions:
(1) You're excavating occlusal caries and you are approximately 2.3mm deep. An ideal class 1 form is made, and there are a few sticky gray areas on the floor of the prep. You take a round bur and slow speed to excavate these soft gray areas. You've successfully reached hard gray areas as verified by explorer. Do you leave these areas? or do you excavate further to totally remove them? (There is no rosy hue)

(2) You're excavating caries on a Posterior mandibular molar. The tooth has a distal operculum and cannot be isolated with Rubber Dam.
The patient has a minor occlusal caries that turns out to mushroom. You excavate to 3mm and notice a rosy hue at the pulpal floor.
You dont want to probe the floor with an explorer due to fear of exposing the pulp should you be so close.... You're even afraid to press too hard with a spoon...
What do you do?

General Question:
How do you distinguish the orange hue of caries from the rosy hue of the pulp?
What do you do if you pulp out without Rubber Dam Isolation?

Thanks!

As for your case questions:
1) Detection of caries is more about a tactile (how it feels) response rather than a color/look of dentine issue. You have to distinguish between affected and effected dentin. Affected dentin is usually a darker color but it does not stick when an explorer is used in an up and down motion. This dentin has been affected by the caries, but is not carious itself and can be left. This sounds like your scenario. You could also have run into tertiary dentin, which can also be left. In general, a blind dentist should be able to feel if all the caries has been removed.

2) It only takes very very light pressure on an explorer to note a carious stick. So light that you shouldn't really risk exposure. If you're leaning on the explorer to find caries then you're begging for an exposure or can even get a false positive if you're explorer is too sharp. In my practice I will clean out the caries aggressively until I'm about 4-5mm deep into a molar and then I'll slow down to preserve pulpal health. If you can get the caries down to about 0.5-1mm in diameter and you're near the pulp then think about doing an Indirect Pulp Cap, otherwise if you're looking at 3-4mm in diameter still then even an IPC or DPC won't save the tooth at this point and it could be time to think about endo.

Consult with faculty though as they have the experience you need at this stage in your dental career.

The other thing to think about is that if you can see the occlusal caries on the radiograph then do a cold test before anesthesia to confirm the tooth is vital; don't waste your time trying to do a restoration on a non-vital tooth, go straight to endo.

 

[RootOfTheProblem]

What is the average volume of pulp in each tooth? Average volume of nerve tissue? Is this easy to ascertain? If not the average, then just an estimate.

Also, in a root canal, is the idea of the procedure to remove the nerve in order to protect the pulp?

Are the topical anesthetics injected into the actual pulp and nerve, as well as the gum tissue around the truth, or just one of them?

Thanks

Ben


PS my first post, like my avatar? I made it quickly lol

 

[Contach]

What is the average volume of pulp in each tooth? Average volume of nerve tissue? Is this easy to ascertain? If not the average, then just an estimate.

Also, in a root canal, is the idea of the procedure to remove the nerve in order to protect the pulp?

Are the topical anesthetics injected into the actual pulp and nerve, as well as the gum tissue around the truth, or just one of them?

No idea what the average volume is... You could probably do a study like this on extracted teeth.

In a tooth that needs RCT: there is a party of bacteria in the root of the tooth. This compromises the BV and nerve that run within the root (and cannot be distinguished from one another by the naked eye). The point of a RCT is to (1) remove the bacteria that are partying in the root and (2) remove the nerve that is sending pain signals. If you can do that, then (2) the nerve in the tooth will no longer be able to sense pain, b/c it no longer exists, and (1) the bacteria won't be able to spread into the bone that houses the tooth. If bacteria spreads into the surrounding bone: you can get a lot of pain and an infection of bone and soft tissues in your mouth which can lead to life threatening complications (either spreading of bacteria into important fascial planes which can lead swelling of your throat and closure of your airway, or bacteria spreading into the blood from the bone leading to things like endocarditis, sepsis, systemic inflammatory response syndrome, disseminated intravascular coagulation, fever).

Often times, you only need to inject anesthesia (local anesthetic - not topical), at the outside of the tooth (you aim for the tip of the root of the tooth - where you would imagine the nerve coming out from). This will block the nerve fiber from sending signals from the root of the tooth up the jaw and to the brain. Sometimes, b/c of the acid produced by the bacteria, the anesthetic doesn't work very well (in this area at the tip of the tooth), so a practitioner will inject anesthetic directly into the tooth's root from the opening he/she has drilled to access the root canal. It has been shown that the effectiveness of this injection is not due to the anesthetic itself, but instead, the pressure that is inflicted on the BV and nerve from the syringe. Thus you could inject water and it'd offer numbing benefits (interesting isn't it...).

You really need to know more about the anatomy around a tooth to understand this better... Your time will come.