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

Wow, you might be a novice dentist. But you sure are a pro at acronyms.
MHOTY. * I got a sense that you did OK. I like how you are planning for the
future -- repair the problem that is impending, but not yet painful.

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.

===============
* My hat's off to you.

#5 might have been the source of the pain because maybe the MO on #5
was in hyper occlusion.  A high restoration can give acute sensitivity
to cold.  If so, there is no point in removing the MO on #5, but just
to take out articulating paper and adjust the occlusion.  Another
remote possibility is that #5 amalgam was conducting cold rapidly into
the pulp, and therefore should be replaced with a more insulating
filling material or at least place an insulating base.  But removing a
filling because it is conducting temperature changes too much to the
pulp is not an evidense-based concept.  Also, it is bad to temporize
with ZOE, even though many do so.  ZOE has eugenol which is mildly
toxic to the dental pulp and interferes with bonding of composite resin
materials.  Also, what is the point of covering up any pain with #5
with an analgesic like eugenol?  Wouldn't you rather use a
non-analgesic temporizing material to know for sure if the temporary
you placed actually helps reduce the pain?  If you cover up the pain
with an analgesic, then the patient has no symptoms, maybe the cause of
the symptoms are there but the analgesic is just covering them up.
When you remove the ZOE and replace the filling, the pain may return
back again since the analgesic is no longer there.  I would guess in
this case the eugenol in the ZOE had nothing to do with the resolving
of the causes of the pain symptoms.  You may have removed any occlusal
prematurities in the #5 MO when you took it out, and this resolved the
pain.  Or the cause of the pain on #5 may have been the deep decay on
#4, in which case ZOE on #5 does nothing to fix the cause of the pain.
Because the #5 filling was too shallow to be affecting the pulp.
Another possibility: maybe #4 had an infection, and the toxins from #4
infection were making #5 sensitive, while #4 was not sensitive since
the pulp was dead.  ZOE on #5 covers up the symptoms on #5, but doesn't
solve the problem because the true solution to the problem was to
extirpate pulp on #4 to stop sensitivity on #5.

Note: never assume that you should go straight in and extirpate a pulp
just because a cavity is big on the X-ray.  Use a #8 or #6 slow-speed
round bur to excavate decayed material and verify that there actually
is caries into the pulp.  This may remove all the decayed material
without causing a pulp exposure.  Take an explorer to verify tactically
that there is no more soft carious material left.  If there is no
exposure, fill as usual.  If you have a carious exposure during
slow-speed excavation, then root canal is probably warranted, although
you may get away with direct pulp cap with composite.  In theory,
caries close to the pulp can cause symptoms of an irreversible pulpitis
by conducting toxins into the pulp via dentinal tubules between the
infection and the pulp, which could in theory make a neighboring tooth
also sensitive.  But the pulp itself may be sterile.  It may not
contain bacteria, just the toxins of the bacteria moving into it via
dentinal tubules.  So if you remove the bacteria, and fill the tooth,
you may remove the source of the toxins.  The body clears away those
toxins that remain within a short time, and everything is normal.
Granted, in this case, #4 showed possible evidense of sclerosed canals
on the X-ray, according to you, although there is a lot of ambiguity in
interpreting sclerosis or bone loss or demineralization on X-rays.

The correct answer: adjust occlusion on #5, if there is any occlusal
prematurity.  Then use slow-speed #6 or #8 to excavate decay on #4.  If
no exposure during slow-speed excavation and you know that the decay is
all out, then just fill.  Make sure #4 has no occlusal prematurities,
since this may result in pain.  If there is exposure during slow-speed
excavation, then perform pulpotomy and RCT.  Chances are, the RCT on #4
was justified, but you cannot know this for sure unless you know you
have a carious pulp exposure occurring during slow-speed excavation, or
you have another, obvious, "slam-dunk diagnosis" of irreversible
pulpitis or pulpal necrosis.  Often, you cannot diagnose the need for a
root canal just by looking at an X-ray and you shouldn't assume based
on an X-ray that the tooth needs an RCT.  You have to go in and
excavate with a slow speed.

Also, you will not "induce a pulpitis" by "operating" on a tooth.  This
is not a rationale for RCT.  A pulptis is caused by the gradual
progression of bacteria, or toxins from bacteria, into the pulp.  A
procedure to remove decay around the pulp can only contribute to the
preservation and comfort of the pulp, and will not make a pulp "act up"
into an irreversible pulpitis, absent a pulp exposure during
excavation.  The only rationale for RCT is clear evidense of pulpal
health being compromised, such as caries into the pulp or necrosis.  Or
you need to do RCT in order to prepare a tooth prosthodontically, such
as making an overdenture out of it or to make a post space for a
post/core for a crown.

--Johhny

Yes, RCT was necessary, you exhibited good clinical judgement.

--

W_B
Take out the G'RBAGE
wubbabubbazG@RBAGEyahoo.com