How to explain to patient that you have done a carious exposure ?

[leclecBDS]

Hi there, I just had a young patient who has multiple deep carious teeth. She had pain before but not feeling any pain at the moment when I saw her. I tried to take pain history but she could not remember the type of pain and the rest of the information was quite vague. I should have done vitality test to confirm vitality of the pulp but I did not (for some reason..... i forgot)

The X-ray shows that the radiolucency has gone into the pulp (ie radiolucency merges with the radiolucent pulp area). This second molar was heavily broken down, I knew that I was very close to the pulp so I was using only my excavator. After I cleaned away most of the soft dentine on this second molar (still have some on the floor), I got my supervisor to check and she told me to temporarily dress it with GIC (no dycal). We did explain to her that this was to wait and see if the pulp can settle down itself. And for the first molar in front, I opened up the tooth and investigated how deep the caries had gone. Again, just using excavator, and there I go, pulp exposure and blood gushing out. And that first molar ended up needing an endo.

5 days later, the patient came back with pain on the second molar where there was no exposure. Diagnosed with irreversible pulpitis that will need endo as well.

So, my question are
1. Should the X-ray finding (that the carious lesion extends into the pulp) indicate that there is actually no need to even try to do indirect pulp capping, does it simply indicate the teeth will need endo? (of course if I have vitality test the teeth, it gives me better ground to start endo)
2. Would you do anything different? Or was it my fault that I went too deep?
3. How would you explain to the patient? (I did not see her last appt when she came with the pain on 2nd molar, but will be seeing her again. It seems like I was to blamed for the pain as she was not having pain when I saw her and only after I drilled and messed around with her teeth and she will need endo. )

Thanks x

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[cmcner]

Hi there, I just had a young patient who has multiple deep carious teeth. She had pain before but not feeling any pain at the moment when I saw her. I tried to take pain history but she could not remember the type of pain and the rest of the information was quite vague. I should have done vitality test to confirm vitality of the pulp but I did not (for some reason..... i forgot)

The X-ray shows that the radiolucency has gone into the pulp (ie radiolucency merges with the radiolucent pulp area). This second molar was heavily broken down, I knew that I was very close to the pulp so I was using only my excavator. After I cleaned away most of the soft dentine on this second molar (still have some on the floor), I got my supervisor to check and she told me to temporarily dress it with GIC (no dycal). We did explain to her that this was to wait and see if the pulp can settle down itself. And for the first molar in front, I opened up the tooth and investigated how deep the caries had gone. Again, just using excavator, and there I go, pulp exposure and blood gushing out. And that first molar ended up needing an endo.

5 days later, the patient came back with pain on the second molar where there was no exposure. Diagnosed with irreversible pulpitis that will need endo as well.

So, my question are
1. Should the X-ray finding (that the carious lesion extends into the pulp) indicate that there is actually no need to even try to do indirect pulp capping, does it simply indicate the teeth will need endo? (of course if I have vitality test the teeth, it gives me better ground to start endo)
2. Would you do anything different? Or was it my fault that I went too deep?
3. How would you explain to the patient? (I did not see her last appt when she came with the pain on 2nd molar, but will be seeing her again. It seems like I was to blamed for the pain as she was not having pain when I saw her and only after I drilled and messed around with her teeth and she will need endo. )

Thanks x

If I'm not like 100% sure it's a small cavity I always tell the patient before I start drilling this might need a root canal but I'll try to avoid if if I can. Don't blame yourself, they made the cavity not you, your job is to prepare them before you start drilling because they think you're just screwing them if you wait until you hit the pulp and raise the cost of saving the tooth by like $2000 without warning. And when it doesn't get there I say looks like I avoided that root canal for you and they love that.

 

[Daurang]

Hi there, I just had a young patient who has multiple deep carious teeth. She had pain before but not feeling any pain at the moment when I saw her. I tried to take pain history but she could not remember the type of pain and the rest of the information was quite vague. I should have done vitality test to confirm vitality of the pulp but I did not (for some reason..... i forgot)

The X-ray shows that the radiolucency has gone into the pulp (ie radiolucency merges with the radiolucent pulp area). This second molar was heavily broken down, I knew that I was very close to the pulp so I was using only my excavator. After I cleaned away most of the soft dentine on this second molar (still have some on the floor), I got my supervisor to check and she told me to temporarily dress it with GIC (no dycal). We did explain to her that this was to wait and see if the pulp can settle down itself. And for the first molar in front, I opened up the tooth and investigated how deep the caries had gone. Again, just using excavator, and there I go, pulp exposure and blood gushing out. And that first molar ended up needing an endo.

5 days later, the patient came back with pain on the second molar where there was no exposure. Diagnosed with irreversible pulpitis that will need endo as well.

So, my question are
1. Should the X-ray finding (that the carious lesion extends into the pulp) indicate that there is actually no need to even try to do indirect pulp capping, does it simply indicate the teeth will need endo? (of course if I have vitality test the teeth, it gives me better ground to start endo)
2. Would you do anything different? Or was it my fault that I went too deep?
3. How would you explain to the patient? (I did not see her last appt when she came with the pain on 2nd molar, but will be seeing her again. It seems like I was to blamed for the pain as she was not having pain when I saw her and only after I drilled and messed around with her teeth and she will need endo. )

Thanks x

You mentioned this is "patient who has multiple deep carious teeth" so the risk of exposure was high to begin with. Should have just recommended RCT and not poke around. I know you meant well but you'll learn that patient won't appreciate it and you'll get more aggravation out of it.

 

[bigstix808]

So, my question are
1. Should the X-ray finding (that the carious lesion extends into the pulp) indicate that there is actually no need to even try to do indirect pulp capping, does it simply indicate the teeth will need endo? (of course if I have vitality test the teeth, it gives me better ground to start end)
dont do a pulpal dx from an X-ray alone. I've done this, sent to endo, endo removes decay and no pulp exposure. i almost gave pt un needed rct. always document pulp dx before starting.
2. Would you do anything different? Or was it my fault that I went too deep?
i think you did just fine. sometimes when you disrupt the caries environment it can cause more irritation/inflammation and lead to more discomfort than when you started. and your fault?? absolutely not! you didn't put those cavities there! your pt needs to own their problems ... and that will be an ongoing battle .... forever.
3. How would you explain to the patient? (I did not see her last appt when she came with the pain on 2nd molar, but will be seeing her again. It seems like I was to blamed for the pain as she was not having pain when I saw her and only after I drilled and messed around with her teeth and she will need endo. )
if you think AT ALL that the decay will be close to nerve, tell the pt. always say that post op discomfort can occur (i.e.: sensitivity, etc) (its not normal, but thats another discussion), and if it progresses then further treatment will likely be needed. now, if they leave, feel nothing, you're the bad ass that avoided the pain and need of rct and your pt loves you.

Thanks x

 

[leclecBDS]

If I'm not like 100% sure it's a small cavity I always tell the patient before I start drilling this might need a root canal but I'll try to avoid if if I can. Don't blame yourself, they made the cavity not you, your job is to prepare them before you start drilling because they think you're just screwing them if you wait until you hit the pulp and raise the cost of saving the tooth by like $2000 without warning. And when it doesn't get there I say looks like I avoided that root canal for you and they love that.

You mentioned this is "patient who has multiple deep carious teeth" so the risk of exposure was high to begin with. Should have just recommended RCT and not poke around. I know you meant well but you'll learn that patient won't appreciate it and you'll get more aggravation out of it.

Thank you all for replying.
For cases like that, is there any statstic out there about the success rate of indirect pulp capping for deep carious lesion?
If I just clean the ADJ and the walls of the cavity without even touching the floor, put dycal on the floor and do a stepwise appraoch, there is a better chance that the teeth won't be needing RCT, is that right?

 

[arlmay]

Thank you all for replying.
For cases like that, is there any statstic out there about the success rate of indirect pulp capping for deep carious lesion?
If I just clean the ADJ and the walls of the cavity without even touching the floor, put dycal on the floor and do a stepwise appraoch, there is a better chance that the teeth won't be needing RCT, is that right?

From what I have been told research supports indirect>direct pulp cap if you're trying to avoid endo. If you're likely going to need endo then you're probably wasting your time. If it's a carious exposure you're more than likely talking endo, I think mechanical exposures are the real candidates for pulp caps.

 

[dyesht]

Hi there, I just had a young patient who has multiple deep carious teeth. She had pain before but not feeling any pain at the moment when I saw her. I tried to take pain history but she could not remember the type of pain and the rest of the information was quite vague. I should have done vitality test to confirm vitality of the pulp but I did not (for some reason..... i forgot)

The X-ray shows that the radiolucency has gone into the pulp (ie radiolucency merges with the radiolucent pulp area). This second molar was heavily broken down, I knew that I was very close to the pulp so I was using only my excavator. After I cleaned away most of the soft dentine on this second molar (still have some on the floor), I got my supervisor to check and she told me to temporarily dress it with GIC (no dycal). We did explain to her that this was to wait and see if the pulp can settle down itself. And for the first molar in front, I opened up the tooth and investigated how deep the caries had gone. Again, just using excavator, and there I go, pulp exposure and blood gushing out. And that first molar ended up needing an endo.

5 days later, the patient came back with pain on the second molar where there was no exposure. Diagnosed with irreversible pulpitis that will need endo as well.

So, my question are
1. Should the X-ray finding (that the carious lesion extends into the pulp) indicate that there is actually no need to even try to do indirect pulp capping, does it simply indicate the teeth will need endo? (of course if I have vitality test the teeth, it gives me better ground to start endo)
2. Would you do anything different? Or was it my fault that I went too deep?
3. How would you explain to the patient? (I did not see her last appt when she came with the pain on 2nd molar, but will be seeing her again. It seems like I was to blamed for the pain as she was not having pain when I saw her and only after I drilled and messed around with her teeth and she will need endo. )

Thanks x

From what you're describing, it sounds like she initially had irreversible pulpitis on that second molar that you indirectly pulp capped. What you should have done, was do a vitality test on it before excavating the tooth. I'm pretty sure it would have given you a hyper responsive cold test for irreversible pulpitis. What's the reasoning to start drilling into a tooth before doing a pulp test???

 

[leclecBDS]

From what you're describing, it sounds like she initially had irreversible pulpitis on that second molar that you indirectly pulp capped. What you should have done, was do a vitality test on it before excavating the tooth. I'm pretty sure it would have given you a hyper responsive cold test for irreversible pulpitis. What's the reasoning to start drilling into a tooth before doing a pulp test???

Ya, when I reconsidered what I have done, I knew that I should have done a vitality test.
Lesson learnt... Lucky that I am still in school and don't need to worry about telling the patient about the cost of the tx

 

[dyesht]

Ya, when I reconsidered what I have done, I knew that I should have done a vitality test.
Lesson learnt... Lucky that I am still in school and don't need to worry about telling the patient about the cost of the tx

What do you mean you dont have to tell the patient?

 

[leclecBDS]

What do you mean you dont have to tell the patient?

I am a year 4 BDS in the UK.
Every patients we see at school won't be charged, they got free treatment, free endo, free crown, free dentures etc
So money is not a concern for patients here in the dental school in the UK.