Pulp capping

[Namsaman]

Hello recently i have restored tooth 36 with due to its broken amalgam, with icdas 05. I didnt put any pulp capping material as there was no pulp shadow seen and due to the sclerosed dentine shown in the radiograph. No post-op pain for about 2 weeks when i called him back to re-polish the restoration because he complained of roughness of the restoration. Immediately after that day, he complained of hypersensitivity that lingers around for more than 5 minutes and a slight tender to percussion. My concern is, would not placing any lining material causes this pain or if i have polished the restoration up to a point i have a leakage. Would this be a symptoms of irreversible pulpitis? Or i can still manage this case by redo the restoration.


Im a 4th year dental student. Attached is the cavity prep

---

Members don't see this ad.

 

[Gen. Beauregard]

I'm not sure if we're actually allowed to discuss cases here or not, so I'm gonna stay a little generic with the reply. It's also a little hard to Dx from photos and history sometimes.
Teeth are fickle and can die despite our best attempts. Sometimes it's due to heat and vibration from the bur even though we have air/water spray going. Sometimes it's from desiccation because there's a rubber dam on and a gunner sniped your place in line while waiting for your Attending to come check it out. Sometimes it's from a sneaky little pulphorn that you didn't even know got hit. Sometimes it's because a huge amalgam got put in where there used to be tooth and the pulp isn't used to that much thermal conductivity. Sometimes it's from a fracture which isn't visible on the radiograph or even direct visualization. Sometimes the patient is lying to get narcotics. Lot's of things happen, don't beat yourself up if you are.

Lingering sensitivity to cold is one of the things we use to Dx Irreversible pulpitis. Tenderness to percussion is more useful in diagnosing the environment around the apex. Abscesses don't like to get smooshed on by the root of the tooth as you tap on the crown with your mirror handle, regardless of whether the tooth has a vital pulp or not.

I would get the Pt back and look/feel all around for an open margin, especially in that area of what looks like decalcification at the bottom of the IP box, or where the restoration filled into the pucker on the tofflemire band where it goes into the clamp there at the MB lineangle. I'd pay attention to anything that replicates the pain while doing that. Your theory of leakage after polishing is a good one. I'd use the explorer to see if I could get the whole restoration to wiggle too. Not being able to see the restoration that got put in, it could be that there's a food trap going on and the pt is feeling periodontal pain from popcorn kernels, poppy seeds, and cool ranch Doritos. I'd then do some cold testing, maybe even get out the electric pulp tester to determine pulpal response, and be sure to compare it to control teeth elsewhere in the quadrant. I'd then see what the response is to percussion and palpation. I might even get a radiograph to see if something is afoot at the apex or if there's a huge gap in the restoration. If the tooth has definite signs of irreversible pulpitis I'd tell the Pt it's time for endo or extraction. If it's on the fence I'd offer to remove the restoration and place an IRM, remove the restoration and put in a liner and GI, or wait and see. If the restoration comes out I'd be sure to transilluminate anything I could looking for a fracture line. Those are all things to discuss with your attending and then ultimately do whatever they tell you to do. Hope some of that helped, congrats on D4!

 

[Namsaman]

Thanks for your reply, may i know if theres a page where i can discuss about cases like this?
In my case would not placing any pulp capping material would be the cause of the post-op pain?

 

[Gen. Beauregard]

Not placing a pulp cap could do it, but it's hard to determine in this case without looking at x-rays and seeing just how far things went. When in doubt a little bit of liner won't hurt. Usually in the case of a slow growing cavity the pulp has time to retreat and if they didn't have sensitivity with a giant festering cavity they won't have sensitivity to your nice new restoration, especially in older patients. If there's a lot of extension, either for preservation or retention of material, into otherwise unharassed dentin in a pulpal direction, particularly in a younger person, that's when I would start leaning towards blaming absence of a liner. I'm not convinced in your case yet.

 

[Ivy.ch]

Thanks for your reply, may i know if theres a page where i can discuss about cases like this?
In my case would not placing any pulp capping material would be the cause of the post-op pain?

DentalTown

 

[Namsaman]

Not placing a pulp cap could do it, but it's hard to determine in this case without looking at x-rays and seeing just how far things went. When in doubt a little bit of liner won't hurt. Usually in the case of a slow growing cavity the pulp has time to retreat and if they didn't have sensitivity with a giant festering cavity they won't have sensitivity to your nice new restoration, especially in older patients. If there's a lot of extension, either for preservation or retention of material, into otherwise unharassed dentin in a pulpal direction, particularly in a younger person, that's when I would start leaning towards blaming absence of a liner. I'm not convinced in your case yet.

The patient is around 30s
And below is the radiograph taken prior to the filling

 

[TanMan]

Hello recently i have restored tooth 36 with due to its broken amalgam, with icdas 05. I didnt put any pulp capping material as there was no pulp shadow seen and due to the sclerosed dentine shown in the radiograph. No post-op pain for about 2 weeks when i called him back to re-polish the restoration because he complained of roughness of the restoration. Immediately after that day, he complained of hypersensitivity that lingers around for more than 5 minutes and a slight tender to percussion. My concern is, would not placing any lining material causes this pain or if i have polished the restoration up to a point i have a leakage. Would this be a symptoms of irreversible pulpitis? Or i can still manage this case by redo the restoration.


Im a 4th year dental student. Attached is the cavity prep

Was the patient initially symptomatic or asymptomatic? Did you perform pulp testing prior to working on the tooth?

If the patient is complaining of hypersensitivity, is it sensitive to cold/hot, percussion, pain to biting or release, or spontaneous? When you mention pain to percussion, is there pain to occlusal biting or lateral percussion of the tooth? These questions would definitely answer the status of the nerve, ligament, and periapical tissue.

If the restoration was fine and became sensitive after polishing, what type of restoration did you polish, and how did you polish it? If you had your handpiece there for a long time, without water, it could have heated up the pulp and caused irreversible pulpitis. Opening up or creating a "leaking margin" will not result in lingering pain. Lingering pain to temperature or spontaneous lingering pain is a definite RCT for me. A lot of times, once you open up the tooth, you can tell the status of what really happened. Sometimes you may note a fracture into pulp chamber, root, sometimes it was already necrotic for a long time, or developed IP if you see extreme hyperemia. Once you do enough endos, you can usually tell the status of the tooth based on smell and appearance. VRF usually smells like fungus.