Dental - Pathways of the Pulp - S. Cohen, R. Burns

747 Pages·2006·16.7 MB·English

Contents
PART ONE: THE ART OF ENDODONTICS
1 Diagnostic Procedures, 2
Stephen Cohen
2 Orofacial Dental Pain Emergencies: Endodontic Diagnosis and Management, 25
Alan H. Gluskin and William W. Y. Goon
3 Nonodontogenic Facial Pain and Endodontics: Pain Syndromes of the Jaws that Simulate
Odontalgia, 51
Lewis R. Eversole
4 Case Selection and Treatment Planning, 60
Samuel (). Dorn and Arnold H. Gartner
5 Preparation for Treatment, 77
Gerald Neal Clickman
6 Armamentarium and Sterilization, 110
Robert E. Averbaeh and Donald J, Kleier
7 Tooth Morphology and Access Openings, 128
Richard C. Burns and I.. Stephen Buchanan
8 Cleaning and Shaping the Root Canal System, 179
John D. West, James B. Roane, and Albert C. Goerig
9 Obturation of the Root Canal System, 219
Nguyen Thanh Nguyen, with section by Clifford J. Ruddle
10 Records and Legal Responsibilities, 272
Edwin J. Zinman
PART TWO: THE SCIENCE OF ENDODONTICS
11 Pulp Development, Structure, and Function, 296
Henry O. Trowbridge and Syngcuk Kim
12 Periapical Pathology, 337
James H. S. Simon
13 Microbiology and Immunology, 363
James D. Kettering and Mahmoud Torabinejad
14 Instruments, Materials, and Devices, 377
Leo J. Misercndino, with section by Herbert Schilder
15 Pulpal Reaction to Caries and Dental Procedures, 414
Syngcuk Kim and Henry O. Trowbridge
XI
Xll Contents
PART THREE: RELATED CLINICAL TOPICS
16 Traumatic Injuries, 436
Stuart B. Fountain and Joe H. Camp
17 Root Resorption, 486
Martin Trope and Noah Chivian
18 Endodontic-Periodontal Relations, 513
James H. S. Simon and Leslie A. Werksman
19 Surgical Endodontics, 531
Gary B. Carr
20 The Management of Pain and Anxiety, 568
Stanley F. Malamed
21 Bleaching of Vital and Pulpless Teeth, 584
Ronald E. Goldstein, Van B. Haywood, Harald O. Heymann, David R. Steiner, and John D. West
22 Restoration of the Endodontically Treated Tooth, 604
Galen W. Wagnild and Kathy I. Mueller
23 Pediatric Endodontic Treatment, 633
Joe H. Camp
24 Geriatric Endodontics, 672
Carl W. Newton
25 Endodontic Eailures and Re-treatment, 690
Adam Stabholz, Shimon Friedman, and Aviad Tamse
PART FOUR: ISSUES IN ENDODONTICS
26 Ethics in Endodontics, 730
James T. Rule and Robert M. Veatch
Answers to Self-Assessment Questions, 737
Daniel B. Green, H. Robert Steiman, and Richard E. Walton
PART ONE
THE ART OF ENDODONTICS
Chapter 1
Diagnostic Procedures
Stephen Cohen
THE ART AND SCIENCE OF DIAGNOSIS quired before diagnostic examination or clinical treatment is
The dictionary* defines diagnosis as "the art of identifying undertaken. Some patients require antibiotic prophylaxis be
a disease from its signs and symptoms." Although scientific fore clinical examination because of systemic conditions like
devices can be used to gather some information, diagnosis is heart valve replacement, a history of rheumatic fever, or ad
still primarily an art because it is the thoughtful interpretation vanced AIDS. Patients who daily take anticoagulant medica
of the data that leads to a diagnosis. An accurate diagnosis is tions may need to have the dose reduced or dosing suspended
a result of the synthesis of scientific knowledge, clinical expe if the clinician is to conduct the thorough periodontal exami
rience, intuition, and common sense. nation, which is integral to a complete endodontic workup.
To be a good diagnostician a clinician must learn the fun When patients report being infected with communicable dis
damentals of gathering and interpreting clinical information. eases such as AIDS, hepatitis B, or tuberculosis, dentist and
An inflamed or diseased pulp is a common, straightforward, staff need to be especially attentive to the use of protective
and nonurgent condition. Systematic recording of a patient's barriers. In case endodontic therapy is required, the clinician
presenting signs and symptoms and careful analysis of the find must know what drugs the patient is taking so that adverse drug
ings from clinical tests inevitably lead to a correct diagnosis. interactions can be avoided. In such cases, consultation with
There arc instances, however, when a patient presents with an (he patient's physician is recommended. Patients who present
acute situation, conflicting signs and symptoms, or inconsis with mental or emotional disorders are not uncommon. Some
tent responses to clinical testing. Chapter 2 explores the meth patients are aware of their disorder and inform the dentist. Oth
ods for diagnosing and testing these endodontic riddles. Chap ers may have undiagnosed psychological or emotional prob
ter 3 discusses the ostensible toothache of nonodontogenic or lems; abnormal or highly inappropriate behavior may suggest
igin. the presence of illness. In these cases, too, medical consulta
tion before the diagnostic examination would be in the best
Medical History interests of patient, doctor, and staff. A brief summary of these
Even though there are virtually no systemic contraindica consultations with treating physicians and an outline of their
tions to endodontic therapy (except uncontrolled diabetes or a suggestions should be recorded and dated in the patient record.
very recent myocardial infarction), a recent and succinct, com
Dental History
prehensive preprinted medical history is mandatory (see box
on p. 3). It is only with such a history that the clinician can After completing the medical history the clinician should de
determine whether medical consultation or premedication is re- velop the dental history. The purpose of a dental history is to
create a record of the chief complaint, the signs and symp
toms the patient reports, when the problem began, and what
Unless otherwise indicated, the illustrations in this chapter were prepared by the patient can discern that improves or worsens the condition.
Dr. Albert Goerig.
*Wehster's ilurd Imem.ahona! Dicuonaiy. Springfield. Mass. 1976. Merriam- The most efficacious way for the clinician to gather this im
Webster Inc. portant information is to ask the patient pertinent questions re-
garding the chief complaint, and to listen carefully and sensi establish the location, nature, quality, and urgency of the prob
tively to the patient's responses. For example, the doctor might lem and encourage the patient to volunteer additional infor
begin by simply asking the patient. "Could you tell me about mation that completes the verbal picture of the problem. The
your problem?" To determine the chief complaint, this ques clinician may be able to formulate a tentative diagnosis while
tion should be followed by a series of other questions, such as taking a dental history. The examination and testing that fol
"When did you first notice this?" (inception). Affecting fac low often corroborate the tentative diagnosis. It is then merely
tors that improve or worsen the condition should also be de a matter of identifying the problem tooth/1'7
termined. "Docs heat, cold, biting, or chewing cause pain?" In the gathering of a dental history, common sense must pre
(provoking factors). "Does anything hot or cold relieve the vail. The questions outlined here, along with other questions
pain?" (attenuatingfactors). "How often does this pain occur?" described in Chapter 2, should be asked if the diagnosis is elu
(frequency). "When you have pain, is it mild, moderate, or sive. If the clinician can see a grossly decayed tooth while sit
severe?" (intensity). The answers to these questions provide ting and talking with the patient and if the patient points to
the information the dentist needs to develop a brief narrative that tooth, the dental history should be brief because of the
description of the problem. obvious nature of the problem. Furthermore, if the patient is
The majority of patients present with evident problems of suffering from severe distress, with acute symptoms (Chapter
pain or swelling, so most questions should focus on these ar 2), the dental history should be brief so the clinician can re
eas. For example, "Could you point to the tooth that hurts or lieve the pain as soon as possible.
the area that you think is swelling?" (location). "When cold
{or heat) causes pain, docs it last for a moment or for several Pain
seconds or longer?" (duration). "Do you have any pain when Because dental pain frequently is the result of a diseased
you lie down or bend over?" (postural). "Does the pain ever pulp, it is one of the most common symptoms a dentist is re
occur without provocation?" (stimulated or spontaneous). quired to diagnose.14" The source of the pain is usually made
"What kind of pain do you get? Sharp? Dull? Stabbing? evident by dental history, inspection, examination, and test
Throbbing?" (quality). Questions like these help the clinician ing. However, because pain has psychobiologic components—
4 The art of endodontics
physical, emotional, and tolerance—identifying the source is patient's eyes should be observed for the pupillary dilation or
at times quite difficult. Furthermore, because of psychological constriction that may indicate systemic disease, premedication,
conditioning, including fear, the intensity of pain perception or fear. Additionally, the patient's skin should be observed for
may not be proportional to the stimulus. When patients present any lesion(s) and, if there is more than one, whether the le
with a complaint of pain that is subsequently determined to be sions appear at random or follow a neural pathway.
of odontogenic origin, the vast majority of these cases reflect After a careful external visual examination the clinician
conditions of irreversible pulpitis, with or without partial ne should, with the aid of a mouth mirror and the blunt-ended
crosis.19'23 handle of another instrument, begin an oral examination to
Patients may report the pain as sharp, dull, continuous, in look for abnormalities of both hard and soft tissues. With a
termittent, mild, severe, etc. Because the neural portion of the head lamp and good magnification the lips, cheek pouch,
pulp contains only pain fibers, if the inflammatory state is lim tongue, palate, and throat should be briefly examined (Fig.
ited to the pulp tissue it may be difficult for the patient to lo 1-1, B). Because it is easier to observe abnormalities when tis
calize the pain. However, once the inflammatory process ex sues are dry, the liberal use of 2x2 inch gauze, cotton rolls,
tends beyond the apical foramen and begins to involve the peri and a saliva ejector is strongly recommended (Fig. 1-1, C).
odontal ligament, which contains proprioceptive fibers, the pa During the visual phase of the examination the clinician should
tient should be able to localize the source of the pain. A also be checking both the patient's oral hygiene and the integ
percussion test at this time to corroborate the patient's percep rity of the dentition. Poor oral hygiene and/or numerous miss
tion of the source will be quite helpful. ing teeth may indicate that the patient has minimal interest in
At times pain is referred to other areas within, and even be maintaining a healthy dentition.
yond, the mouth. Most commonly it is manifested in other Visual inspection of the teeth begins with drying the quad
teeth in the same or the opposing quadrant. It almost never rant under examination and looking for caries, toothbrush abra
crosses the midline of the head. However, referred pain is not sion (Fig. 1-1, D) (cervical lesions occasionally are over
necessarily limited to other teeth. It may, for example, be ipsi- looked), darkened teeth (Fig. 1-1, £), observable swelling
laterally referred to the preauricular area, or down the neck, (Fig. 1-1, F), fractured or cracked crowns (Fig. 1-1, G), and
or up to the temporal area. In these instances the source of defective restorations.
cxtraorally referred pain almost invariably is a posterior tooth. The clinician should observe the color and translucency of
Ostensible toothache of nonodontogenic origin (i.e., resulting the teeth. Are the teeth intact or is there evidence of abrasion,
from neurologic, cardiac, vascular, malignant, or sinus dis attrition, cervical erosion, or developmental defects in the
eases) is described in Chapter 3. crowns?
Patients may report that their dental pain is exacerbated by A high index of suspicion must prevail during examination
lying down or bending over. This occurs because of the in for numerous types of soft-tissue lesions.8,20 This also means
crease in blood pressure to the head, which increases the pres looking for unusual changes in the color or contour of the soft
sure on the confined pulp. tissues. For example, the clinician should look carefully for
The dentist should be alert for patients who manifest emo lesions of odontogenic origin such as sinus tracts (fistulas)
tional disorders as dental pain. If no organic cause can be dis (Fig. 1-2, A) or localized redness or swelling involving the at
covered for what appears as dental pain, the patient should be tachment apparatus. The presence of a sinus tract may indi
referred for medical consultation. Patients with atypical facial cate that periapical suppuration has resulted from a pulp that
pain of functional rather than organic cause may begin their has undergone complete necrosis in at least one root. The sup
long journey through the many specialties of the health sci purative lesion has burrowed its way from the cancellous bone
ences in the dentist's office. through the cortical plate and finally to the mucosal surface.
If the dentist can determine the onset, duration, frequency, All sinus tracts should be traced with a gutta-percha cone (Fig.
and quality of the pain and the factors that alter its perception, 1-2, JS to E) to locate their source, because occasionally the
and if the dentist can reproduce or relieve the pain by clinical source can be remote.13
testing, then surely the pain is of odontogenic origin. The pa All observable data indicating an abnormality should be re
tient will usually gain immeasurable psychological benefit if corded on the treatment chart while the information is still fresh
the clinician provides caring and sincere reassurance that, once in the clinician's mind. If a tooth is suspected of requiring en
the source is discovered, appropriate treatment will be pro dodontic treatment, it should be assessed in terms of its re-
vided immediately to stop the pain. storability after endodontic treatment, its strategic importance,
and its periodontal prognosis.
EXAMINATION AND TESTING
The inspection phase of the extraoral and intraoral clinical Palpation
examination should be performed in a systematic manner. A When periapical inflammation has developed as an exten
consistent step-by-step approach, always following the same sion of pulpal necrosis, the inflammatory process may burrow
procedure, helps the clinician develop good working habits and its way through the facial cortical bone and begin to affect the
minimizes the possibility of inadvertently overlooking any part overlying mucopcriosteum. Before incipient swelling becomes
of the examination or testing. The extraoral visual examina clinically evident, it may be discerned by both the clinician
tion should begin while the clinician is taking the patient's den and the patient using gentle palpation with the index finger
tal history. (Fig. 1-3, A). The index finger is rolled while it presses the
Talking with the patient provides an opportunity to observe mucosa against the underlying bone. If the mucoperiostcum is
the patient's facial features. The clinician should look for fa inflamed, this rolling motion wiil reveal the existence and de
cial asymmetry (Fig. 1-1, A) or distensions that might indi gree of sensitivity caused by the periapical inflammation.
cate swelling of odontogenic origin or a systemic ailment. The To improve tactile skill and learn the full extent of normal
Diagnostic procedures 5
FIG. 1-1 A, Swelling around the right mandible can be readily observed by the clinician
while preparing the dental history. B, The Designs for Vision fiberoptic headlamp along with
2'/2 to 3'/2 x magnification allows the clinician to examine the soft tissues and teeth without
any shadows. C, A thorough tissue examination is facilitated by drying with cotton rolls, 2
X 2 inch gauze, and a saliva ejector. The initial examination of the teeth and surrounding
tissues is conducted with the patient's mouth partly open. With good illumination and mag
nification, as shown in Fig. 1-1 B, changes in color, contour, or texture can be determined
by a careful visual examination. D, Class V caries lesion, or abrasion, not always detectable
radiographically, can be observed. E, Tooth discolored following a traumatic incident. Al
though the tooth appears necrotic, vitality tests should still be conducted because the pulp
could remain vital, F, Intraoral swelling from periapical disease usually appears around the
mucobuccal fold; however, the entire mouth must be thoroughly examined because swelling
from periapical disease may occur in unusual locations (e.g., the palate). G, With careful
visual examination the clinician may observe crown fractures that may not appear in radio
graphs.
6 The art of endodontics
FIG. 1-2 A, Sinus tract (fistula). B, When a sinus tract is detected, it should always be traced
with a gutta-percha cone to its source. In this case, the sinus tract appeared between the first
and second premolars. C, The source of the sinus tract was the lateral incisor, as the gutta
percha probe indicates. D, Gutta-percha cone used to trace a sinus tract discovered on the
palate. E, An occlusal jaw radiograph revealed that the sinus tract crossed the midline. The
source was a cuspid. F, After numerous unsuccessful dermatologic treatments, this patient
consulted a dentist. G, The dentist discovered the source.
range to be expected, the clinician is urged to perform palpa If a mandibular tooth is abscessed, it is prudent also to pal
tion testing routinely. pate the submandibular area bimanually to determine whether
Other techniques involving extraoral bidigital or bimanual any submandibular lymph nodes have been affected by exten
palpation (e.g., palpating lymph nodes or the floor of the sion of the disease process (Fig. 1-3, B).
mouth) arc described in complete detail by Rose and Kaye.18 Finally, the cervical lymph nodes should be palpated bidig-
Occasionally a patient is able to point to a particular facial itally to discern any swollen or firm lymph nodes.
area that felt tender when shaving or applying makeup. The The use Of extraoral and intraoral palpation helps the clini
clinician can follow up by palpating in the mucofacial fold, cian determine the furthest extent of the disease processes.
which may help pinpoint the source of the tenderness. If a site
that feels tender to palpation is discovered, its location and ex Percussion
tent should be recorded as well as whether or not the area is The percussion test may reveal whether there is any inflam
soft or firm. This provides important information on the pos mation around the periodontal ligament. The clinician should
sible need for an incision and drainage. remember that the percussion test does not. give any indication
Diagnostic procedures 7
of the health or integrity of the pulp tissues; it indicates only
whether there is inflammation around the periodontal ligament.
Before the test, the patient should be instructed that making a
small audible sound or raising a hand is the best way to let the
clinician know when a tooth feels tender, different, or painful
with percussion.
Before tapping on the teeth with the handle of a mouth mir
ror, the clinician is advised to use the index finger to percuss
teeth in the quadrant being examined (Fig. 1-4, A). Digital per
cussion is much less painful than percussion with a mouth mir
ror handle. The teeth should be tapped in a random fashion
(i.e., out of sequence) so the patient cannot anticipate when
"the tooth" will be percussed. If the patient cannot discern a
difference in sensation with digital percussion, the handle of a
mouth mirror should be used to tap on the occlusal, facial,
and lingual surfaces of the teeth (Fig. 1-4, B). Using the most
appropriate force for percussing is one of the skills that the
clinician will develop as part of the art of endodontic diagno
sis. Percussing the teeth too strongly may cause unnecessary
pain and anxiety for the patient. The clinician should use the
chief complaint and dental history as a guide in deciding how
strongly to percuss the teeth. The force of percussion need be
only great enough for the patient to discern a difference be
tween a sound tooth and a tooth with an inflamed periodontal
ligament. The proprioceptive fibers in an inflamed periodontal
FIG. 1-3 Palpation. A, Bilateral intraoral digital palpation aids ligament, when percussed, help the patient and the clinician
the clinician in detecting comparative changes in contour or locate the source of the pain. Tapping on each cusp can, on
consistency of the soft tissue and underlying bone. A "mushy" occasion, reveal the presence of a crown fracture.
feeling detected during palpation around the mucolabial fold A positive response to percussion, indicating an inflamed
may be the first clinical evidence of incipient swelling. B, Bi periodontal ligament, can be caused by a variety of factors
manual extraoral palpation to tactilely search for the extent of (e.g., teeth undergoing rapid orthodontic movement, a recent
lymph node involvement when there is a mandibular dental in high restoration, a lateral periodontal abscess, and, of course,
fection. The clinician should palpate the submandibular nodes partial or total necrosis of the pulp). However, the absence of
(as shown here), the angle of the mandible, and the cervical a response to percussion is quite possible when there is chronic
chain of nodes. periapical inflammation.
Mobility
Using the index fingers, or preferably the blunt handles of
two metal instruments, the clinician applies alternating lateral
forces in a facial-lingual direction to observe the degree of mo-
FIG. 1-4 Percussion test to determine whether there is any apical periodontitis. If the patient
has reported pain during mastication, the percussion test should be conducted very gently. A,
First only the index finger should be used. The teeth should be percussed from a facial as
well as an incisal direction. B, If the patient reports no tenderness when the teeth are per
cussed with the finger, a more definitive, sharper percussion can be conducted with the han
dle of the mouth mirror.