Re: Treatment plan advice


"Mark & Steven Bornfeld" <bornfeldmung@xxxxxxxxxxxxxxx> wrote in message
news:5U_le.3396$zb.1106@xxxxxxxxxxx
> Minder wrote:
>> A PT attended the emergency dental clinic complaining of pain associated
>> with reversible pulpitis, but in the last few days it had kept her up at
>> night, in the UR quadrant.
>>
>> On intraoral examination, UR 4 had an MOD amalgam, which had a serious
>> deficient margin on the distal side.
>> When viewed buccaly, it was evident that there was 2° caries;.
>>
>> UR5 had an MO amalgam, with some slight deficiency of the margin.
>>
>> I used ethyl chloride to perfrom a vitality test. UR3 responded, UR4 did
>> not, UR5 gave a short sharp pain.
>>
>> Neither the 4 or 5 was TTP.
>>
>> I took a PA of 4 and 5.
>>
>> On 4 there was V. deep caries close to the pulp. On the 5, there was a
>> medium degree of caries.
>> As I only had 20 mins, I removed the MO amalgam, and placed a ZOE temp. I
>> asked the PT to come back 5 days later and see how they get on.
>>
>> She returned and she was out of pain. However my tutor told me to tackle
>> the 4, as this was the next thing that might cause her pain.
>>
>> I removed the MOD amalgam, and there was very very deep caries.
>> The PA showed that the canals look slightly sclerosed as well.
>>
>>
>> On that basis I stopped, and told the PT what I had found.
>> I told them that I could either stop and temporize, or perform RCT.
>> My rationale for the RCT, was that by operating, this would induce
>> pulpitis, possibly make the pulp hyeraemic, and give severe pain.
>> The PT told me that she didnt mind if I went ahead and extirpated the
>> pulp.
>>
>>
>> I located both the B and P canals no problem, and the buccal was
>> sclerosed. I had difficulty passing a no 15 file. But using fileeze.
>> EDTA, and NaOCl, I was winning.
>> I placed hypocal on a file. coated the walls of the canal and temporized
>> in a unique way.
>>
>> DO and MO RMGIC Fuji leaving a gap in the middle. I then filled this gap
>> with ZOE, to make things easier for removal at the next visit. Plus I
>> didnt want the tooth to fracture.
>>
>> What I want your opinions on guys is was the RCT really necessary? Did I
>> make the wrong clinical judgement?
>>
>>
>> Thanks for your input.
>>
>>
>
> You are not clear as to whether #4 had a carious exposure, although I
> infer that there was NOT.
> You also don't report whether you saw signs of vitality once you decided
> to enter the pulp of #4.
> Based on your description, #5 appears to have been responsible for the
> pain. I think you did the right thing by addressing the apparent cause at
> the first visit. The issue of #4 is separate and distinct; it is possible
> I would have agreed that rct was necessary on #4, but I haven't seen the
> x-ray or the patient.
>
> Steve
>
> --
> Mark & Steven Bornfeld DDS
> http://www.dentaltwins.com
> Brooklyn, NY
> 718-258-5001


UR 4 didnt have a carious exposure, however I was ~<1mm away from the pulp.
That dentine didnt appear like the texture of sound dentine, although it did
feel softer, I felt I wasnt able to excevate with an excervator without
inducing an exposure.

When I entered the pulp, there was a fair degree of bleeding. I had to give
intrapulpal LA to reduce this. I wouldnt call it hyperaemic, but I would
have thought that an inflamatory stimulus induced by bacterial invasion was
probably responsibe for this.
One thing i forgot to mention was that the patient did notice "a twinge to
dull ache" over a period of time from that area, but couldnt say from what
tooth.
The radiograp showed no evidence of widening of the PDL or loss of lamina
dura, but I suspect had things been left as they were, this may have
happened.


.

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