Case• 47. Molar endodontic treatment
A 52-year-old man presents with pain from a tooth in the lower left quadrant. What is the cause and how will you treat him?
This patient complains of pain from a tooth in the lower left quadrant, but is unsure which tooth is the cause.
History of complaint
▪ What specific questions would you ask with regard to the history of pain?
Relevant questions are shown below, together with the patient’s answers.
|When did the pain start?||About 8 months ago|
|Did anything start or provoke the pain?||Initially hot and cold food and drink brought the pain on|
|How long did the pain last at that time?||Only for a few seconds|
|What is the character of the pain?||Initially sharp but now dull and throbbing|
|Other than the change in the intensity of the pain, has it changed in any other way?||The pain is still brought on by hot and cold foods and now lasts for hours|
|Does the pain start spontaneously? Does it wake you up or keep you awake at night?||Initially no, but as the pain intensity has increased over the last 2–3 days it has woken me at night|
|Does anything make the pain better?||Paracetamol has a mild relieving effect|
|Is the tooth painful to bite on?||No|
The patient is new to your practice but has always attended the dentist regularly.
The patient is fit and well.
▪ On the basis of what you know already, what is the likely diagnosis?
The pain is almost certainly pulpitis. It is brought on by hot and cold and is poorly localized. It has progressed from intermittent pain, suggesting reversible pulpitis, to a severe pain that lasts hours. The severity and duration now suggest that pulpitis might be irreversible.
▪ What is irreversible pulpitis?
Irreversible pulpitis is a concept rather than a well-defined clinical condition. Pulpitis is usually chronic and progresses intermittently and unpredictably with or without acute phases. At some stage the pulp must be irretrievably damaged, probably because pressure from inflammation compresses the pulpal veins and arteries. This causes loss of vitality. The ability to predict that a pulp will die would be useful when deciding possible treatments. Unfortunately, the clinical symptoms that accompany pulpitis are very variable, especially in multirooted teeth, and pain is a subjective sensation. Severe pain of long duration, spontaneous pain and waking at night are usually taken to indicate the irreversible stage of pulpitis but predicting the future is never reliable and making this diagnosis involves an element of uncertainty.
The temporomandibular joints appear normal and there are no submental, submandibular or cervical lymph nodes palpable.
On examination you discover poor oral hygiene with gingivitis around posterior teeth. The dentition is heavily restored, with multiple crowns, but only the third molars are missing.
In the lower left quadrant there are two likely causes for the pain. The first molar has a metal ceramic crown with a defective margin and caries distally. The second molar tooth has a disto-occlusal composite restoration with poor occlusal contour and a large distal ledge. The premolars appear sound.
▪ What parts of the examination would be most useful? Why?
Teeth should be percussed to establish whether any are tender. Adjacent, apparently healthy control teeth should be percussed first for comparison. Tenderness indicates inflammation in the periodontal ligament and causes would include very late stage irreversible pulpitis or a necrotic pulp.
Palpation of the mucosa overlying the tooth apices with a fingertip. Tenderness indicates extension of inflammation from the periodontal ligament to the surrounding bone and the activity of any inflammation present. Compare with apparently normal teeth. Lower molar apices are close to the lingual mandibular cortex and must be palpated lingually as well as buccally.
Mobility should be assessed. Mobility is increased slightly if there is inflammation of the periodontal ligament. If a periradicular abscess or acute inflammation is present, the tooth may be raised in the socket. You must exclude increased mobility caused by periodontal disease, root fracture, recent trauma, and premature occlusal contact.
Periodontal probing to detect loss of attachment or exposed dentine. Dentine hypersensitivity would not cause such severe, long-lasting pain. However, pocketing or previous periodontal treatment could have exposed a lateral canal or canal in the furcation, allowing bacteria access to the pulp.
Search for a sinus. This would indicate periradicular infection. Sinuses may heal and present as a small fibrous nodule indicating past or intermittent infection. The search must include lingual alveolar mucosa because the apices of lower molars lie closer to the lingual than buccal cortex.
On examining the patient you find that no teeth are mobile, tender to percussion or have apical tenderness. There is no detectable sinus. Inflammation appears limited to the pulp. No periodontitis is present.
▪ What investigations would you perform?
Tests of pulp vitality are required to increase confidence in your assessment of the status of the pulp. Electric, and hot and cold thermal testing are available and a stimulus that usually provokes the pain is recommended. If tests give equivocal responses, a test cavity without local analgesia should prove conclusive.