Stressed Pulp: “How to Kill a Tooth”
to Gordon Christensen, “Some dentists report that they would
like to have endodontic therapy on all teeth requiring crowns
before accomplishing any fixed prosthodontic procedures”.
Certainly, treating any tooth without a potential pulpal problem
would make dentistry very easy, however, that is not reality.
that we, as endodontists, like to convey to the patient is that
all operative procedures are cumulative with regard to inflammation
that may compromise pulpal vitality. The more trauma the pulp
has to recover from, the greater the chance for irreversible pulpitis.
Abou-Rass once termed this “the stressed pulp” and
advocated elective endodontic treatment prior to the restoration
of teeth with prior deep preparations or histories of multiple
restorations. Realizing that this approach may not be practical
or appropriate, consider these factors that will preserve the
vitality of the fragile pulp tissue.
MATERIALS – Currently, the most popular build-up
materials are composite resins. Consider the proximity of the
build-up material to the pulp since resin based composite are
more prone to leakage than traditional amalgam build-ups. Size
of the build-up will be directly proportional to the impact on
the vital pulp.
– The fit, seal, and longevity of temporary crowns will
have a direct impact on post-tooth preparation pulpal vitality.
Limit the amount of time that a tooth is provisionalized and ensure
that a bacteria free seal is present. If the patient has significant
post-preparation pain while in the provisional stage, consider
endodontic treatment before cementing the final restoration.
DURING CROWN PREPARATION – Cutting dentin is cutting
“vital” tissue. The dentinal tubules are directly
connected to the pulp tissue. A crown preparation exposes virtually
the entire dentinal surface to movement of dentinal fluid and
infiltration of bacteria. Heat generated by cutting without water
coolant is immediately damaging to the pulp.
PULP VITALITY – Be certain that the tooth is vital
prior to restoration. Simple pulp testing for a cold response
is a quick and adequate test. Hypersensitivity prior to preparation
should be considered a problem as inflammation of the pulp may
already exist. All teeth prepared for crowns should be examined
with a current periapical image to determine possible apical pathosis
from non-vital pulp.
Without being pessimistic, include the possibility of future endodontic
treatment in your discussion of informed consent with all extensive
restorative procedures. Patients are much more understanding when
that is discussed prior to treatment.
GJ. How to kill a tooth. J Am Dent Assoc 2005;136:1711-1713
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