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Medical Forum / General / Dentistry / December 2005Help needed with treatment progression
I did an examination on a patient. I took a radiograph and it revealed a DO cavity on UR 7 and MO on UR 8. Both showed quite large radiolucencies. I decided to tackle UR7, which had an existing occlusal amalgam. When I went in with a bur the caries was more on the palatal wall, and I chased this going down towards the palatal pulp horn. I was getting concerned at this point, but my tutor told me to keep going. Thoughts that were going through my mind were 1) strange path of caries 2) How am I going to restore the tooth, because ultimately I did not have direct vision as my handpiece was masking where I was drilling. This resulted in a carious exposure and during the drilling process the patient complained of sensitivity. I proceeded to give a palatal infiltration. I was just about to put rubber dam on when the patient's mobile phone rang and he had to go off unexpectedly. My tutor told me to put ledermix + dycal and a ZOE temp. I managed to remove 95% of the caries. I want to hear your guys opinions on what I should do next. I will need to listen to what problems the person has been having if any. He hasn't phoned the clinic with raging tooth ache so that's a good sign ...I hope. However if he has been asymptomatic, I would want to test vitality. He is in his fifties, so bearing in mind that pulp tests aren't always conclusive with ethyl chloride. I am thinking of when he next comes in, to give buccal and palatal infiltrations to UR7, then put rubber dam on. Remove the temp, and the pledgett of cotton wool and clean/ irrigate with clorahexadine. Carefully hand excavate remaining caries. Place dycal down over the exposed area. Then a layer of GIC and restore with amalgam or RMGIC and wait about a month and see what happens. If asymptomatic, revome RMGIC except a small area over the pulp which will serve as a liner thus insulating from thermal stimuli and restore with amalgam. What do you guys rekon? When the pulp was exposed there was a fair bit of bleeding. I think the exposure was 1.5-2mm, however the patient was asymptomatic before commencing treatment. Thanks for your help. >What do you guys rekon? When the pulp was exposed there was a fair bit >of bleeding. I think the exposure was 1.5-2mm, however the patient was >asymptomatic before commencing treatment. > >Thanks for your help. Carious exposures need RCT. Everytime. (except when EXT is indicated) -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com Extraction or endo will most likely be the ultimate cure. Fart around with it until you're both comfortable with the idea. ;-) Dartos > What do you guys rekon? When the pulp was exposed there was a fair bit > of bleeding. I think the exposure was 1.5-2mm, however the patient was > asymptomatic before commencing treatment. > > Thanks for your help. NEVER, EVER let a patient answer a cell phone during treatment ! If they have an important call coming in, let them leave the phone with your receptionist who will answer the call for the patient. They don't need blood and spit all over their phone, you don't need them sitting up and hunting through pockets to get the phone. Be firm. There is NO NEED to talk on a phone during dental treatment. Your patient probably spread lots of blood droplets and saliva all over the treatment area when they got up in the middle of treatment to talk on the phone. Bring the patient back and do the RCT.  Signature/ Amatus / > > I did an examination on a patient. I took a radiograph and it revealed [quoted text clipped - 45 lines] > > Thanks for your help. > 1) strange path of caries Yes, but that's the path of least resistance in this case > 2) How am I going to restore the tooth, because ultimately I did not > have direct vision as my handpiece was masking where I was drilling. If you find that you can't see, then you STOP, put long shank round burs on your handpiece, and go carefully. The long shank (surgical) burs will put the head of the latch type handpiece farther away, so you can see. This tooth will be best served by Endo, regardless of the patient's symptoms. JMO SP SignatureTake out the TRAASH to reply > 2) How am I going to restore the tooth, because ultimately I did not > have direct vision as my handpiece was masking where I was drilling. Direct vision ? What is that ? The handpiece is in the way of direct vision at least half of the time. You just learn to work around it. Signature/ Amatus / > >> 1) strange path of caries [quoted text clipped - 13 lines] > JMO > SP > > 2) How am I going to restore the tooth, because ultimately I did not > > have direct vision as my handpiece was masking where I was drilling. > > Direct vision ? What is that ? The handpiece is in the way of direct > vision at least half of the time. You just learn to work around it. Still say long shank burs will help. SP SignatureTake out the TRAASH to reply > Still say long shank burs will help. Some of the time Signature/ Amatus / > >> > 2) How am I going to restore the tooth, because ultimately I did [quoted text clipped - 6 lines] > Still say long shank burs will help. > SP > > Still say long shank burs will help. > > Some of the time True... but in the cases where they don't work, I arrange for the patient to be thrown down the elevator shaft. Cheers SP SignatureTake out the TRAASH to reply >> > Still say long shank burs will help. >> [quoted text clipped - 5 lines] > Cheers > SP The patient came back today. The tooth was sensitive to hot and cold, which lingered for a minute. I guess had I not used ledermix then things would have gotten a whole lot worse. I wanted to take a periapical at this stage, but my tutor told me that there was no justifiable reason at this stage, and just explore the tooth. I proceeded under rubber dam after giving palatal and buccal infiltrations to UR7. Removed the kalzinol temp and cotton wool which was coated in ledermix. There was a pulpal exposure in 2 places, which at that point extraction or RCT were going through my mind. During the first visit, I actually thought about an extraction when I looked at the path of caries, and saw the pulp chamber on the bitwing radiograph, which was quite obbliterated. The guy is 55 yrs old. I could only find the distal canal, so I got my tutor to have a look, and he couldnt make anymore headway either. At that point we decided to temporise with ledermix and kalzinol taking the tooth slightly out of occlusion. A periapical was taken which revealed twisted roots in the distal direction, and sclerosed canals. I told the patient that RCT would be difficult and that there is no guarantee of sucesss. From his part it would require long time committments. I advised him to go an think about it over the Christmas period, and to see him in January and we will proceed from there. Given that he lives about 25 miles from the dental school, and that he is quite nervous, I think he will go with the extraction...but I shall wait and see. Now you know why most of us here said that you had enough information on the first visit to make an accurate diagnosis. This wasn't a case where it might have gone the other way. Next time skip all of the extra appointments and play-time. ;-) Dartos > The patient came back today. The tooth was sensitive to hot and cold, which > lingered for a minute. [quoted text clipped - 30 lines] > quite nervous, I think he will go with the extraction...but I shall wait and > see. > Now you know why most of us here said that you had enough information > on the first visit to make an accurate diagnosis. This wasn't a case [quoted text clipped - 3 lines] > ;-) > Dartos Yes... but at dental school they still make you do things to the book. I told the patient what might happen, and I was feeling smug when what I initially suggested to my tutor turned out to be correct. Thanks for your help! Been there, done that, had to pay through the nose for the T-shirt. It's not wrong to learn more than they teach you, but you do need to be careful that you make them believe they are always right. Yes sir, I understand sir, thank you sir. School won't last forever, and then you can expand a little. Top three things that dental school did not teach me? 1. How to do a decent root canal & find MB-2. 2. Clenching is a *major* problem. 3. Exposures like you describe need endo or extraction 'now'. ;-) Dartos > Yes... but at dental school they still make you do things to the book. I > told the patient what might happen, and I was feeling smug when what I > initially suggested to my tutor turned out to be correct. > > Thanks for your help! > A periapical was taken which revealed twisted roots in the distal direction, > and sclerosed canals. > I told the patient that RCT would be difficult and that there is no > guarantee of sucesss. From his part it would require long time committments. > I advised him to go an think about it over the Christmas period, and to see > him in January and we will proceed from there. This is perhaps the one type of tooth where I will keep the Biocaylex (Endocaylex) as a viable treatment option. You pulpotomize whatever you can and rebuild the tooth with that stuff in the pulp chamber. About every three months or so, you go back in and replace it. If it works, the tooth will become 'mommified' and you may get 5 years of life out of it, maybe more. The advantage is that the Biocaylex stuff is just CaO which becomes Ca(OH)2 in the tooth. There is no arsenic or other poisons as in N2. SP SignatureTake out the TRAASH to reply I proceeded to give a palatal infiltration. I was just about to put rubber dam on when the patient's mobile phone rang and he had to go off unexpectedly. ____________________________ Tell him that he should have his mobile phone fix his tooth, as obviously his mobile phone is more important than the doctor's treatment. I'd like to see what he would do if his phone rang in the middle of a colonoscopy. - dentaldoc |
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