Resolving pulpitis

RE: Resolving pulpitis

Evelyn Barbour-Hill — Thu, 13 Feb 2020 16:01:35 GMT

Thanks for posting!

RE: Resolving pulpitis

Rob Davis — Thu, 13 Feb 2020 12:08:08 GMT

[quote userid="2235" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/23315/resolving-pulpitis/143580"]I will update in a few months.[/quote]

Ok, so it's quite a few months later, but here is a current radiograph:

Pulp system in 304 now pretty much completely obliterated and no sign of any periapical pathology. This dog has now added to its list of interesting oral issues, but I write this up as a tangent....

RE: Resolving pulpitis

Rob Davis — Thu, 24 Sep 2015 10:33:39 GMT

[quote user="Peter Southerden"] I think that represents irregular narrowing of the canal which is common in teeth that have had chronic pulpitis - can't be certain though.[/quote]

I guess we won't know unless the tooth is either opened or extracted at some point in the future - I will update in a few months.

[quote user="Peter Southerden"]We've been using ultrasonic activation (using Endocentre from Acteon) of our irrigant for the last couple of years and think that we have seen fewer failures since then.[/quote]

That looks pretty cool, but sadly I'm not sure I can justify the cost unless my endo caseload significantly increases.... maybe one to save up for!

RE: Resolving pulpitis

Peter Southerden — Thu, 24 Sep 2015 09:51:27 GMT

Hi Rob

Thanks. I think that represents irregular narrowing of the canal which is common in teeth that have had chronic pulpitis - can't be certain though.

Re your speed at endodontics - pedantry is a great quality for a dentist. I think that you are absolutely right to take your time. IAs the prime reason for shaping a canal is to facilitate flushing/cleaning there is limited shaping that you need to do in a wide canal but lots of flushing and you should have a minimum of 30 minutes contact time with your bleach. We've been using ultrasonic activation (using Endocentre from Acteon) of our irrigant for the last couple of years and think that we have seen fewer failures since then.

RE: Resolving pulpitis

Rob Davis — Thu, 24 Sep 2015 08:59:29 GMT

Here is what I have called the lateral view - apologies if this is not the correct terminology! I have ringed the area I think has parallel lines of increased opacity running parallel to the pulp:

[quote user="Peter Southerden"]If I was pushed for time I would probably have done just the first stage of the root filling (pulpectomy, flushing and temporary CaOH obturation). [/quote]

Fair enough, and something I will bear in mind in the future. As a novice, I am still fairly slow - I probably spend more time cleaning and shaping than I need to, but I'm fairly paranoid about leaving bits of necrotic pulp behind.

RE: Resolving pulpitis

Evelyn Barbour-Hill — Thu, 24 Sep 2015 01:50:21 GMT

[quote user="Peter Southerden"]Have I missed a lateral view of the canine? On the occlusal I could see that the narrowing of the root canal was irregular but wasn't convinced that I could see tramlines or evidence of calcification or mineralisation within a wide root canal.[/quote]

It shows best on the occlusal view. I ringed the most obvious bit in red. Perhaps tramlines is a poor metaphor. It's more like a big long island with the river running either side of it.

[quote user="GrooveJet"]I'm interested to know if there is any evidence to indicate whether these teeth are painful or not? Owners generally are of the impression that these teeth are not bothering their pet. I reckon this must be painful, but how bad, and for how long? Any thoughts?[/quote]

A very good point. Conventional GP vet wisdom is if they don't seem to be painful they can be left to wait and see. Conventional dentalvet wisdom is that they must be painful so they have to be treated. I think we all make too many assumptions sometimes. However, the owner suddenly noticing that the animal is "so much better, so much happier" after treatment (even if it's extraction ) is a common phenomenon.

When there's pulpitis, logic suggests, and extrapolation from the human experience suggests, that there is pain. Inflamed tissue, and contained in a rigid space too.

When the pulp has died it ceases to be painful.

But, when the pulp has died periapical pathology will follow (or perhaps not, sometimes?) and that will presumably always be painful – probably with a lowgrade chronic pain.

I explain to owners that the dog will have a low, grumbling but constant toothache, which even the dog may not realise he has until it's taken away.

RE: Resolving pulpitis

Miriam Lodewyks — Wed, 23 Sep 2015 21:23:21 GMT

I'm interested to know if there is any evidence to indicate whether these teeth are painful or not? Owners generally are of the impression that these teeth are not bothering their pet. I reckon this must be painful, but how bad, and for how long? Any thoughts?

RE: Resolving pulpitis

Peter Southerden — Wed, 23 Sep 2015 18:02:22 GMT

Hi Rob

Have I missed a lateral view of the canine? On the occlusal I could see that the narrowing of the root canal was irregular but wasn't convinced that I could see tramlines or evidence of calcification or mineralisation within a wide root canal.

Interpretation of dental/oral CT images is quite straightforward.

I tend to place a bone graft (allograft) in large cysts, where the mandible has been expanded and the cortices are thin. Follow up imaging usually shows impressive new bone formation but I can't give you hard data to back up my preference.

If I was pushed for time I would probably have done just the first stage of the root filling (pulpectomy, flushing and temporary CaOH obturation). I

Hope this helps

Cheers

Pete

RE: Resolving pulpitis

Rob Davis — Tue, 22 Sep 2015 16:12:46 GMT

[quote user="Evelyn Barbour-Hill"]I do have in stock a very few copies of the issue in question. Rob, yours is on its way.[/quote]

Many thanks

[quote user="Evelyn Barbour-Hill"]One irritating thing: he writes "teeth received exodontic therapy" when he means they were extracted. What pomposity.[/quote]

I will forgive him as he has written a series of very useful articles which are freely available online!

RE: Resolving pulpitis

Evelyn Barbour-Hill — Tue, 22 Sep 2015 14:32:02 GMT

[quote user="Anthony Dennison"]

Is the VDJ available online?

[/quote]

I think so, in the form of scanned pdfs, up to a certain date.

I do have in stock a very few copies of the issue in question. Rob, yours is on its way.

Hale, F.A. (2001) Localised Intrinsic Staining of Teeth Due to Pulpitis and Pulp Necrosis in Dogs. Journalof Veterinary Dentistry vol 18 no.1 pp 14-20

One irritating thing: he writes "teeth received exodontic therapy" when he means they were extracted. What pomposity.

RE: Resolving pulpitis

Anthony Dennison — Tue, 22 Sep 2015 14:09:42 GMT

Is the VDJ available online?

RE: Resolving pulpitis

Evelyn Barbour-Hill — Tue, 22 Sep 2015 13:52:40 GMT

[quote user="Rob Davis"]

[quote user="Peter Southerden"]Fraser Hale published a paper in the VDJ in 2001 in which he showed a strong correlation between tooth discolouration and pulp necrosis.[/quote]

Evelyn, you wouldn't be able to forward me a copy of this could you (I know the usual charges apply!)

[/quote]

Yes unless it's sold out. Which it may well be.

Otherwise you can get a photocopy from the RCVS Library.

[quote user="Rob Davis"]I will hopefully soon have access to CT,[/quote]

Lucky you.

RE: Resolving pulpitis

Rob Davis — Tue, 22 Sep 2015 09:10:48 GMT

Many thanks, Pete, for your input - all very interesting.

[quote user="Peter Southerden"](you have stated that it's the left mandibular canine however if this is viewed in the standard way and the crowns of the mandibular canines were pointing upwards this would appear to be the right mandibular canine)[/quote]

Oops - sorry for the non-standard orientation - the tooth on the right of the picture as viewed is the left mandibular canine.

[quote user="Peter Southerden"]Fraser Hale published a paper in the VDJ in 2001 in which he showed a strong correlation between tooth discolouration and pulp necrosis.[/quote]

Evelyn, you wouldn't be able to forward me a copy of this could you (I know the usual charges apply!)

[quote user="Peter Southerden"] Here I think that there is evidence of significant narrowing of the pulp chamber and root canal and this is likely to be a reflection of increased odontoblast activity associated with chronic low grade inflammation of the pulp.[/quote]

What do you think about Evelyn's "tramline" theory - I hadn't spotted this initially, but I can see what he means, particularly on the lateral view.

[quote user="Peter Southerden"] I would certainly want to see orthogonal views and I would consider CT as this would be more sensitive.[/quote]

I will hopefully soon have access to CT, so this could be a possibility. As yet I have no experience of "normal" CT images - is interpretation likely to be fairly straightforward?

[quote user="Peter Southerden"]Did you place a bone graft after extirpation of the cyst?[/quote]

The cysts were not filled, just closed over. I have long been considering purchasing some osteoallograft periomix or consil, but they are very expensive and am yet to be convinced that they are necessary. Do you routinely fill these (or canine extraction sites)? Is there any evidence that it makes a clinically significant difference? I guess it would be possible to use an autograft, but I would still need to be convinced that it was worth the effort and increased morbidity.

[quote user="Peter Southerden"]I have never seen recurrence of a dentigerous cyst after surgical removal - has anyone else? [/quote]

I haven't, though I am sure I have treated far fewer of these than you have!

[quote user="Peter Southerden"]It is debatable whether the epithelial lining of the cyst is secretory and it seems likely that the cyst enlarges through osmosis therefore recurrence of the cyst if a small portion of the cyst is left in situ would not be inevitable (though I do always aim to remove the cyst in it's entirety).[/quote]

That's interesting. I had always believed that it was a secretory epithelial lining.

[quote user="Peter Southerden"]I may have elected to treat this tooth endodontically at the time of treating the cyst in order to reduce the likelihood that endodontic disease would compromise healing of the dentigerous cyst. [/quote]

I have to confess that one of the reasons for not doing the endodontic treatment initially was lack of time. I'm sure that you are considerably quicker than me at both cyst surgery and endodontics - doing both was definitely more than I could manage in the time I had!

RE: Resolving pulpitis

Peter Southerden — Mon, 21 Sep 2015 23:47:07 GMT

Hi Rob

That's an interesting case that raises a number of issues that warrant discussion.

The first X-ray that you have posted seems to show that the affected tooth (you have stated that it's the left mandibular canine however if this is viewed in the standard way and the crowns of the mandibular canines were pointing upwards this would appear to be the right mandibular canine) has a wider root canal but possibly a narrower pulp chamber than the contralateral tooth.

The subsequent radiograph appears to show almost complete obliteration of the pulp chamber and significant yet slightly irregular narrowing of the root canal.

Fraser Hale published a paper in the VDJ in 2001 in which he showed a strong correlation between tooth discolouration and pulp necrosis. A significant minority of these teeth showed no radiographic evidence of periapical bone loss. A similar correlation between tooth discolouration and pulp necrosis has been shown in people.Therefore the perceived wisdom is that discoloured teeth should be extracted or root filled.

My experience is that when most or all of a crown is discoloured then pulp necrosis is usually evident radiographically or when the tooth is opened and I routinely treat these teeth. If just a few mm of the cusp is discoloured then I often see evidence of pulpitis in the crown pulp demonstrated by obliteration or irregular narrowing of the pulp chamber but the root canal often appears normal. I monitor these teeth and if the root canal continues to narrow normally and there is no evidence of periapical pathology I am happy to leave these teeth. I occasionally see teeth similar to the one that you have radiographed. Here I think that there is evidence of significant narrowing of the pulp chamber and root canal and this is likely to be a reflection of increased odontoblast activity associated with chronic low grade inflammation of the pulp. What we don't know is whether the pulpitis has resolved completely. Conventional endodontic treatment of these teeth is very difficult. I monitor these teeth but in the absence of periapical radiographic change or symptoms of pulpitis usually elect not to treat them. It is possible that conventional intraoral radiographs are not sensitive enough to demonstrate early periapical bone loss. I would certainly want to see orthogonal views and I would consider CT as this would be more sensitive.

If there was evidence of periapical bone loss I would perform surgical endodontic therapy or extract the tooth.

Your second x-ray doesn't show evidence of periapical bone loss but there is a suggestion of some osteosclerosis around the root apex. This could be associated with the treatment of the dentigerous cyst. I would monitor this.

Regarding the result of the treatment of the dentigerous cyst. One side appears to have healed very well. On the other side there is a lucent area which probably represents an area of incomplete re-ossification rather than a recurrence of the cyst. Did you place a bone graft after extirpation of the cyst? I have never seen recurrence of a dentigerous cyst after surgical removal - has anyone else? It is debatable whether the epithelial lining of the cyst is secretory and it seems likely that the cyst enlarges through osmosis therefore recurrence of the cyst if a small portion of the cyst is left in situ would not be inevitable (though I do always aim to remove the cyst in it's entirety).

So this sort of case does pose a number of questions and I don't think there is an absolutely right or wrong way of treating it. I may have elected to treat this tooth endodontically at the time of treating the cyst in order to reduce the likelihood that endodontic disease would compromise healing of the dentigerous cyst. As it stands I would agree that taking follow up radiographs in six months to monitor this case is indicated.

Best wishes

Pete

RE: Resolving pulpitis

Miriam Lodewyks — Mon, 21 Sep 2015 21:16:44 GMT

Seriously interesting post. Will follow this one closely. Would indeed be interesting to hear what Pete thinks too...

RE: Resolving pulpitis

Rob Davis — Mon, 21 Sep 2015 08:42:25 GMT

[quote user="Evelyn Barbour-Hill"]Can you test the sensitivity of the tooth, by tapping with a metal instrument, and by applying an ice cube out of the freezer?[/quote]

Unfortunately this dog is a lunatic - I didn't even spot the dentigerous cyst on initial presentation, only seeing it when I went to intubate. The chances of it staying still long enough to test for any sensitivity in the tooth are fairly minimal.

[quote user="Evelyn Barbour-Hill"]I'm not sure how one could find out more without opening the tooth.... and then you have the problem of negotiating the canal.[/quote]

If this does go on to develop any radiographically visible periapical pathology, then I will either extract the tooth (which would give me an opportunity to see what's going on inside) or refer as I think accessing this canal is beyond my capabilities! I will obviously post updates in the future.

I'm very interested to hear any other opinions on what's going on here.

RE: Resolving pulpitis

Rob Davis — Mon, 21 Sep 2015 08:34:40 GMT

I see what you mean with the "tramlines"..... interesting!

RE: Resolving pulpitis

Evelyn Barbour-Hill — Sat, 19 Sep 2015 20:54:07 GMT

RE: Resolving pulpitis

Evelyn Barbour-Hill — Sat, 19 Sep 2015 17:26:37 GMT

Well, first off, so far.

The remaining lucent area, surely you can now just wait and see what transpires?

The 304:

I can't see any periapical lucency or other periapical abnormality; which may not rule out periapical inflammation with absolute certainty, but it does suggest there is none.

People do argue over whether a coronal discolouration with no fracture – anything from "No, the pulp may well recover" to "No, every tooth with such an appearance must have endodontic treatment" – always means irreversible pulpitis. But I don't dispute your diagnosis and treatment plan in this case.

Looking carefully at the tooth, there seems to be, in the middle third, not a single lucent line for a pulp but a double "tramline" pair. Looking harder, I can convince myself that this is not a canal narrowed by dentine deposition on its walls. I think the broad canal is still there, but mostly occluded by a plug of some mineralised material within it. This could be feeble disorganised dentine, or calcification of a blood clot, or calcification of mummified pulp, or maybe just a free lump of calcified material......

So, you may have pulpitis still going on, or it may have ceased because the pulp has by good fortune undergone necrosis without any bacterial invasion, and remains sterile. Of course a sterile necrotic pulp can still result in periapical pathology, but perhaps by more good fortune nothing has leaked from the apex, or perhaps it has but with only minimal periodontal inflammation.

I may have it all wrong, but I don't believe that the pulp has laid down any more proper dentine since the injury. But I do believe that a large wodge of calcified material has appeared within the canal.

Can you test the sensitivity of the tooth, by tapping with a metal instrument, and by applying an ice cube out of the freezer?

I'm not sure how one could find out more without opening the tooth.... and then you have the problem of negotiating the canal.

Yes, let's see the other radiograph, why not?

I hope Mr. Southerden, or Miss Perry, or any other of our European Diplomates, will be along soon.

RE: Resolving pulpitis

Rob Davis — Sat, 19 Sep 2015 15:38:18 GMT

Yes. I have lateral bisecting angle views too if you want to see them.

RE: Resolving pulpitis

Evelyn Barbour-Hill — Sat, 19 Sep 2015 14:52:39 GMT

Nice one for discussion.

Before we go any further, can you confirm that the 304 is the one on the right of the radiograph as we look at it here?