The dentist’s decision on whether to treat a carious tooth by an ordinary filling, endodontics or extraction depends on the state of the pulp. If it is dead, endodontics or extraction is necessary.
If it is alive and unexposed, an ordinary filling will suffice.
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The state of the pulp is not always apparent and vitality tests are often required to determine whether it is alive, dying or dead. These tests depend on the painful response of the pulp to temperature extremes or electrical stimulation, and are fully discussed in Chapter 12. If the pulp responds to these stimuli it is vital or dying; if not, it is probably dead.
In addition, a periapical radiograph can also be used as an indicator of the health of the tooth.
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A widened periodontal ligament space indicates some level of inflammatory response present, although it may not always result in tooth death.•
A crown fracture or deep cavity may be seen to be in contact with the pulp chamber, or very close to it.•
A root fracture will be visible as a black line across the root.•
A periapical abscess will appear as a radiolucent area around the apex of the tooth (Figure 15.34).Often, a tooth will have been giving symptoms for some time before deteriorating into irreversible pulpitis, and this is especially true when caries is the cause as it is a progressive infection of the dental hard tissues, rather than a sudden event such as trauma.
The patient usually experiences symptoms that gradually increase in severity until the tooth dies.
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Occasional sensitivity to cold, then to hot and sweet stimulation.•
Develops into spontaneous intermittent spasms of pain.•
Becomes a continous throbbing pain with time, which prevents use of the tooth.•
Eventually not affected by hot, cold or sweet stimulation.•
Becomes hypersensitive to vitality testing as the pulp is dying, and then becomes unresponsive as it dies.•
No longer tender to percussion (TTP) when tapped.Figure 15.34 Radiograph showing periapical area.
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Treatment option considerations
There are many factors to be considered by both the dentist and the patient (or their guardian) when discussing treatment involving non-surgical endodontics.
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Usefulness of the tooth in occlusion – if the tooth stands alone and is not routinely used for mastication or involved in the retention of a prosthesis, then it could be argued that there is little point in trying to save it from extraction.•
Tooth restoration possibilities – if the tooth is badly broken down with little structure remain- ing for restoration, the possibility of restoring it to full function is lessened.•
Dental health of the patient – if this is poor generally, with a lack of good oral hygiene and poor diet control, the tooth is unlikely to survive for any reasonable length of time.•
Patient co-operation – both child and adult patients may refuse the treatment offered for whatever reason, and their right to do so has to be respected by the dental team.•
Medical history of the patient – some medical conditions contraindicate endodontic treatment due to the risk of a residual infection occuring.○ Diabetes.
○ Acquired valvular heart disease and other heart conditions.
○ Congenital heart defects.
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Other medical conditions contraindicate extraction.○ Epilepsy – dentures should be avoided in these patients if possible, to avoid their fracture and choking risk during a seizure.
○ Bleeding disorders – especially haemophilia where haemostasis may be difficult to achieve.
○ Cleft palate.
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Cost of treatment – successful endodontic treatment usually culminates in the tooth being crowned eventually to preserve it for as long as possible, and both treatments can be too expensive for some patients to consider.All these considerations need to be fully and clearly discussed with the patient, or their guardian in the case of children, before the decision can be made whether to proceed or not. Dental terminology may have to be avoided with some patients, to modify the necessary explanations to their level of understanding or language. However, this must never result in full information not being given, nor the patient being patronised. It is possible to issue patient leaflets in various languages nowadays to help explain dental treatment, and their availability should be investigated in your local area.
In addition, some specific information about possible complications and procedure details must be given to the patient or guardian to enable them to be fully informed, and therefore give consent to endodontic treatment.
Complications
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The procedure carries a 70–80% chance of success, so extraction may ultimately be necessary in some cases.•
Endodontically treated teeth become brittle with time, so long-term restoration is likely to involve a crown to protect the tooth and prevent future fracture.•
If the root apices are close to underlying nerves (especially lower molars), there is a possibility of nerve damage from overinstrumentation or from the medicaments used.•
If the root apices of upper molars are close to the floor of the maxillary antrum, there is a risk of creating an oroantral fistula.Chapter 15 Levison’s Textbook for Dental Nurses