Objectives

At the end of this case the reader should be able to understand and differentiate the characteristic signs and symptoms of irreversibly inflamed pulps.

Introduction

A 33‐year‐old male presented to his dentist with severe sensitivity on his upper right first molar (UR6).

Chief Complaint

The patient complained of severe pain to cold and sometimes spontaneous pain that lasted for minutes. He was avoiding eating on the right side of his mouth due to this sensitivity.

Medical History

Unremarkable.

Dental History

The patient was a regular attender at his dentist. He had several restorations in the past and the UR6 was restored with an amalgam restoration more than six years ago.

Clinical Examination

Extraoral examination was unremarkable. Intraoral examination revealed no swelling or tenderness in the buccal sulcus associated with UR6. The oral hygiene was fair. The probing around the UR6 was 1–3 mm. The UR6 was tender to percussion. Cold sensibility testing (Endo‐Frost) elicited a severe pain response that lingered for over 30 seconds. Teeth UR5 and UR7 were both responsive to Endo‐Frost, with the sensation fully resolving on removal of the stimulus within a few seconds.

Radiographic Examination

• Alveolar bone levels were within normal limits.
• UR4, UR5, and UR8 amalgam restorations with intact and uniform periodontal ligament (PDL).
• UR7 occlusal amalgam restoration, intact and uniform PDL.
• UR6 amalgam restoration with distal overhang and proximity to the pulp chamber with distal pulp horn and root canal sclerosis, with no visible root canal in the mesio‐buccal or palatal roots, with a visible canal in the disto‐buccal root. There is loss of lamina dura on the palatal root apex with no apical radiolucency. The root apices overlie the maxillary sinus (Figure 1.3.1).

Diagnosis and Treatment Planning

Treatment

Root canal treatment was carried out in a single visit under local anaesthetic and dental dam. The working length was measured using an electronic apex locator. Canals were apically prepared with no. 15 K hand file followed by rotary instrumentation in a crown‐down technique. Patency was maintained with a no. 10 K file in all canals. Irrigation was carried out with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA) utilising passive ultrasonic activation.

The root canal system was obturated with gutta percha (GP) and root canal sealer using a warm vertical condensation technique (Figures 1.3.2 and 1.3.3). A composite resin was placed in the access cavity and the tooth was restored with a ceramic onlay. The one‐year follow‐up periapical radiograph revealed normal PDL and lamina dura, intact coronal filling and normal pocket depths (Figure 1.3.4). The tooth was not tender to percussion or palpation and was normally functioning.

Discussion