For Dentists

For Dentists: Topics Related to Endodontics

Diagnosing Pain

Avulsed Teeth

I. Management at Site of Injury

Replant immediately, if possible. If contaminated, rinse with water before replanting.

When immediate replantation is not possible, place tooth in the best transport medium available

II. Transport Media

• Hank’s Balanced Salt Solution (H.B.S.S.)
• Salt
• Saline
• Saliva (buccal vestibule)

If none of the above is readily available, use water.

III. Management in the Dental Office

A. Replantation of Tooth

• If extraoral dry time is less than 2 hours, replant immediately.
• If extraoral dry time is greater than 2 hours, soak in a topical fluoride for 5 – 20 minutes. Rinse with saline and replant.
• If tooth has been in any physiological storage media (such as H.B.S.S., milk, or saline), replant immediately.

B. Management of the Root Surface

• Keep the tooth moist at all times.
• Do not handle the root surface (hold tooth by the crown).
• Do not scrape or brush the root surface or remove the tip of the root.
• If the root appears clean, replant as is after rinsing with saline.
• If the root surface is contaminated, rinse with H.B.S.S. or saline (use tap water if above are not available)
• If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and or gently brush off debris with a wet sponge

C. Management of the Socket

• Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline.
• Do not curette the socket.
• Do not vent socket.
• Do not make a surgical flap unless bony fragments prevent replantation.
• If the alveolar bone is collapsed and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position.
• After replantation, manually compress (if spread apart) facial and lingual bony plates.

D. Management of Soft Tissues

Tightly suture any soft tissue lacerations, particularly in the cervical region.

E. Splinting (indicated in most cases)

• Use acid-etch resin alone or with sofl arch wire, or use orthodontic brackets with passive arch wire.
• Suture in place only if alternative splinting methods are unavailable. (Circumferential wire splints are contraindicated.)
• Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits.
• Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).
• Home care during splinting period should encompass:
• No biting on splinted teeth
• Soft diet
• Maintenance of good oral hygiene

IV. Adjunctive Drug Therapy Considerations

• Systemic antibiotics
• Referral to physician for tetanus consultation within 48 hours
• Chlorhexidine rinses
• Analgesics

V. Endodontic Treatment

A. Tooth with open apex (divergent apex) and less than 2 hours extraoral dry time:

• Replant in an attempt to revitalize the pulp.
• Recall patient every 3-4 weeks for evidence of pathosis.
• If pathosis is noted, thoroughly clean and fill the canal with calcium hydroxide (apexification procedure).

B. Tooth with open apex (divergent apex) and greater than 2 hours extraoral dry time:

• Thoroughly clean and fill the canal with calcium hydroxide.
• Recall the patient in 6 – 8 weeks.

C. Tooth with partially to completely closed apex and less than 2 hours extraoral dry time:

• Remove the pulp in 7-14 days.
• Medicate the canal with calcium hydroxide.
• Obturate canal with gutta percha and sealer after 7-14 days of calcium hydroxide.

D. Tooth with partially to completely closed apex and greater than 2 hours extraoral dry time:

• Perform root canal therapy either intraorally or extraorally.
• If treated extraorally, avoid chemical or mechanical damage to root surface.

VI. Restoration of the Avulsed Tooth

A. Recommended Temporary Restorations (placed prior to final obturation)

• Reinforced zinc oxide eugenol.
• Acid etch/composite resin

B. Recommended Permanent Restorations (placed immediately after final obturation)

• Dentin bonding agent.
• Acid etch composite resin.

Vll. Additional Considerations

• Avulsed primary teeth should not be replanted.
• Avulsed permanent teeth require follow up evaluations for a minimum of 2-3 years to determine the outcome of therapy.
• Inflammatory resorption, replacement resorption, ankylosis, and tooth submergence are potential complications when avulsed teeth are replanted.
• If the root appears clean, replant as is after rinsing with saline.
• If the root surface is contaminated, rinse with H.B.S.S. or saline (use tap water if above are not available). If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and or gently brush off debris with a wet sponge.

A. Management of the Socket

• Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline.
• Do not curette the socket.
• Do not vent socket.
• Do not make a surgical flap unless bony fragments prevent replantation.
• If the alveolar bone is collapsed and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position.
• After replantation, manually compress (if spread apart) facial and lingual bony plates.

B. Management of Soft Tissue

Tightly suture any soft tissue lacerations, particularly in the cervical region.

E. Splinting (indicated in most cases)

• Use acid-etch resin alone or with sofl arch wire, or use orthodontic brackets with passive arch wire.
• Suture in place only if alternative splinting methods are unavailable. (Circumferential wire splints are contraindicated.)
• Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits.
• Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).
• Home care during splinting period should encompass:
• No biting on splinted teeth
• Soft diet
• Maintenance of good oral hygiene

VIII. Adjunctive Drug Therapy Considerations

• Systemic antibiotics
• Referral to physician for tetanus consultation within 48 hours
• Chlorhexidine rinses
• Analgesics

IV. Endodontic Treatment

A. Tooth with open apex (divergent apex) and less than 2 hours extraoral dry time:

• Replant in an attempt to revitalize the pulp.
• Recall patient every 3-4 weeks for evidence of pathosis.
• If pathosis is noted, thoroughly clean and fill the canal with calcium hydroxide (apexification procedure).

B. Tooth with open apex (divergent apex) and greater than 2 hours extraoral dry time:

• Thoroughly clean and fill the canal with calcium hydroxide.
• Recall the patient in 6 – 8 weeks.

C. Tooth with partially to completely closed apex and less than 2 hours extraoral dry time:

• Remove the pulp in 7-14 days.
• Medicate the canal with calcium hydroxide.
• Obturate canal with gutta percha and sealer after 7-14 days of calcium hydroxide.

D. Tooth with partially to completely closed apex and greater than 2 hours extraoral dry time:

• Perform root canal therapy either intraorally or extraorally.
• If treated extraorally, avoid chemical or mechanical damage to root surface.

V. Restoration of the Avulsed Tooth

A. Recommended Temporary Restorations (placed prior to final obturation)

• Reinforced zinc oxide eugenol.
• Acid etch/composite resin.

B. Recommended Permanent Restorations (placed immediately after final obturation)

• Dentin bonding agent.
• Acid etch composite resin.

VI. Additional Considerations

• Avulsed primary teeth should not be replanted.
• Avulsed permanent teeth require follow up evaluations for a minimum of 2-3 years to determine the outcome of therapy.
• Inflammatory resorption, replacement resorption, ankylosis, and tooth submergence are potential complications when avulsed teeth are replanted.

NICO Lesions

(Neuralgia-Inducing Cavitational Osteonecrosis)

The NICO lesion (Neuralgia-Inducing Cavitational Osteonecrosis, also know as Ratner’s bone cavity) was first described in the dental literature in 1920 by G.V. Black. The lesion consists of ischemic osteonecrosis found in the jaws of patients with symptoms of atypical facial pain or trigeminal neuralgia. Research has shown the lesions to be difficult to diagnose. The lesion will sometimes present very subtle radiographic changes often detectable only by a technetium scan or with multiple periapical radiographs. The overlying soft tissues show no changes.

Many etiologies for NICO have been suggested, but none have been substantiated through research. According to noted oral pathologist Dr. J.E. Bouquot, the typical NICO case occurs as facial pain many years after an extraction or an infection the area. Odontogenic infections and minor trauma have been suggested as initiators, and correlations to clotting or vascular abnormalities have been made based on anecdotal associations. No scientific studies have demonstrated a causative relationship between Endodontic therapy and the formation of NICO.

The recommended treatment for NICO is decortication and curettage of the bony tissues. While this practice has produced relief of pain in some cases, NICO has a strong tendency to recur and to develop in other jawbone sites.

Most affected sites with a postoperative NICO diagnosis have been in edentulous areas. However, some patients with long, frustrating histories of pain associated with Endodontically treated teeth have been presented the treatment option of tooth extraction followed by periapical curettage in an attempt to alleviate pain. The American Association of Endodontists cannot condone this practice when NICO is suspected. Because of the lack of clear etiological data, a NICO diagnosis should be considered only as a last resort when all possible local Odontogenic causes for facial pain have been eliminated. If a NICO lesion is suspected in relation to an Endodontically treated tooth, if possible, periradicular surgery and curettage should be attempted, not extraction.

In addition, the practice of recommending the extraction of Endodontically treated teeth for the prevention of NICO, or any other disease, is unethical should be reported immediately to the appropriate state board of dentistry.

Endodontic Diagnosis

The following outline provides a quick review of the steps taken in Endodontic diagnosis:

I. Chief Complaint

Record symptoms or problems expressed by the patient in his or her own words.

II. Health History

A. Medical History

Take a complete medical history for each new patient. Update the medical history or each patient of record.

B. Dental History

Summarize present and past dental treatment. May Provide subtle clinical findings or identify source of patient’s complaint Attitudes toward dental health and treatment may affect treatment planning.

C. Present signs and symptoms

III. Diagnostic Evaluations

Subjective Examination

• Obtain information by question and answer regarding history of the present illness and symptoms.
• Location- In Some cases the patient may be able to identify
• Intensity-The more the pain disrupts the patient’s lifestyle, the more likely it is caused by irreversible pathosis.
• Duration-Does Pain linger after the stimulus is removed?
• Stimulus-Pulp tests should be chosen based upon what provokes the patient’s chief complaint.
• Relief-Medications or actions (such as sipping ice water) taken to relieve pain.
• Spontaneity-Pain occurring without stimulus.

Tentative Diagnosis

After taking histories and identifying signs and symptoms, the practitioner may reach a tentative diagnosis. The objective examination will gather the information necessary to confirm this diagnosis.

Objective Examination

A. Extraoral Examination

Check general appearance, skin tone, and facial asymmety. Note any swelling, redness, sinus tracts, tender or enlarged lymph nodes, or tenderness or discomfort upon palpation or movement of the TMJ.

B. Soft Tissue

Examine the mucosa and gingiva visually and digitally for discoloration, inflammation, ulceration, swelling, and sinus tract formation.

C. Dentition

Examine teeth for discoloration, fracture, abrasion, erosion, caries, large restorations, discoloration or other abnormalities.

D. Clinical Tests

Most tests have inherent limitations. They require care on application and interpretation. The objective is to discover which tooth is different from the patient’s other teeth. Always test healthy control teeth first.. .

I. Periradicular Tests

Percussion-a painful response is an indicator of periradicular inflammation. Palpation-same as above

II. Pulp Vitality Tests

These determine response to stimuli and may identify the offending tooth with an abnormal response. Always include stimuli similar to those that provoke the patient’s chief complaint.

1. Cold Test

Intense, prolonged pain indicates an irreversible pulpitis. Necrotic pulps do not respond. A false-negative response may occur with constricted canals.

2. Heat Test

(same procedure as for cold test)

Electric Pulp Testing

Contrary to popular opinion and persistent notion, different response levels in electric pulp testing do not indicate different stages of pulp degeneration. Electric pulp testers do not measure the degree of health or disease of a pulp. A “yes or no” response is merely a rough indicator of the presence or absence of vital nerve tissue in the root canal system.

3. Electric Pulp Testing

Before testing, clean dry, and isolate the teeth, then place a small amount of toothpaste or other conductor on the electrode. Be sure to follow your manufacturer’s instructions for establishing an electrical circuit and to ensure accurate measurement with your instrument. Sensation may be described as tingling, stinging, or a feeling of heat, “fullness,” or pressure.

4. Cavity Test

This may be helpful, especially for a tooth with a porcelain-fused-to-metal crown (PFM). Sudden, sharp sensation when the bur cuts dentin indicates that the pulp contains vital tissue.

5. Peridontal Examination

Periodontal probing cannot be overemphasized, since pulpal and periodontal pathosis sometimes mimic each other and must be differentiated

Radiographic Examination

1. Limitations

• Pathologic vital pulps are not visible on radiographs.
• Necrotic pulps may not produce radiographic changes in early stages.
• To be visible, the inflammatory process must spread to cortical bone.

2. Peridacular

Periradicular lesions of pulpal origin tend to have three characteristics:

Loss of lamina dura apically Radiolucency remaining at the apex regardless of cone angle Radiolucency resembling a “hanging drop”

A. If a radiolucency is in the periradicular region of a tooth with a vital pulp, it cannot be of pulpal origin and will be either a normal structure or another type of pathosis.

B. Follow up or biopsy may be required with radiolucencies not of pulpal origin.

3. Pulpal

Radiographically visible pulpal pathoses are only rarely related to irreversible pulpitis. Internal resorption or extensive diffuse calcification in the chamber may indicate long-term, low-grade irritation. “Obliteration” of canals (usually with history of trauma) does not, in itself, indicate need for treatment.

Special Tests

If special circumstances prevent making a definitive diagnosis, additional tests may be indicated.

1. Caries Removal

In an asymptomatic vital case, caries is removed as a final test. Penetration into the pulp indicates an irreversible puplitis requiring root canal treatment.

2. Selective Anesthesia

Useful in painful teeth, particularly when the patient cannot isolate the offender to a specific arch.

3. Transillumination

For identification of vertical crown fractures, since fractured segments do not transmit the light similarly. Dark and light shadows appear at the fracture site.

Analyze the Data that You Have Obtained

Findings may not always be consistent, and the process of arriving at a final diagnosis depends heavily on the practitioner’s critical evaluation of the findings.

Formulate an Appropriate Diagnosis and Treatment Plan

In addition to diagnosing pathoses and their indicated treatments, the practitioner must take into account the patient’s overall needs, know the indications and contraindications for root canal therapy, and recognize those conditions that make treatment difficult.