Chief Complaint

Sensitivity to cold and sweet drinks lasting for a few seconds, localised to the lower left quadrant. The pain had been present intermittently over the last few months, becoming progressively worse recently. There was no episode of nocturnal or spontaneous pain, and none of the teeth were tender on biting.

Medical History

Unremarkable.

Dental History

The patient had fair oral hygiene and was a regular attendee at her dentist. Periodontal probing depths in all four quadrants were 2–3 mm.

Clinical Examination

Extraoral examination was unremarkable. The patient had a moderately restored dentition, generalised tooth wear and large posterior edentulous areas.

LL4 was carious, but was not tender to percussion or buccal palpation. The cavity was tender to probe.

The cold sensibility test (Endo‐Frost) revealed heightened sensitivity lasting for 5–7 seconds compared to the lower left canine (LL3) and the contralateral premolar (LR4). The symptoms did not linger.

What did the periapical radiograph show about the LL4?

The periapical radiograph showed:

• Approximately 15% interproximal bone loss on the mesial aspect of the LL4 and 30% on the distal.
• LL2 and LL3 show tooth surface loss with intact and uniform periodontal ligament.
• LL4 extensive distal root caries in proximity to the pulp (Figure 1.2.1a) with intact and uniform periodontal ligament.
• LL5 has been replaced with an implant‐supported crown.

The LL5 implant‐supported crown was removed to allow direct assessment of the cavity on the distal aspect of the LL4 (Figure 1.2.1b).

What was the diagnosis?

The diagnosis for the LL4 was reversible pulpitis associated with a carious cavity.

What are the treatment options?

• Direct restoration with or without pulp capping
• Non‐surgical root canal treatment
• Extraction
• No treatment

The fact that the tooth sensitivity to stimuli was limited to a few seconds, spontaneous pain was absent and there was no tenderness to percussion indicated that the pulp was reversibly inflamed. Endodontic treatment was therefore not indicated. In the presence of contradictory or non‐specific signs and/or symptoms, cone beam computed tomography may be indicated to investigate the periapical status of the tooth. Previous studies have demonstrated that periapical lesions were present in teeth with reversible pulpitis, leading to high failure rates of vital pulp therapy when compared with teeth with no preoperative lesions. In this case, it was decided to perform a direct restoration of the tooth. If the pulp was exposed during caries excavation, a pulp capping or pulpotomy procedure would be considered.