Expert: Mark Bornfeld DDS - 5/29/2007

Question


In March 2007  Tooth #30 presents with deep decay, close to nerve but possibly not  touching based on xray. Xray shows otherwise healthy intact tooth and nerve.  Previous work has been successful onlay a few years back and major 3+ surface amalgam restoration decades back.  Tooth has no pain and minor if at all sensitivity.  Tapping tooth does not cause pain.
Choices by various dentists are root canal or just excavate decay and hope not close to nerve, or if close to nerve perform direct pulp cap and hope for best.

Two months later, excavation of decay performed, dentist determines need for pulp cap and is performed. Acute pain, major sensitivity occurs. Ibuprofen takes care of pain but still persists after 5 days. Antibiotics (Clindamycin) and more pain killers prescribed. After full regimen of antibiotics taken, pain and sensitivity persists. Dental appt for evaluation and likely referral for endodontist for root canal to take place in a few days.


1. Nerve pain;  After my above history, could it be that nerve is still laying down new dentin below pulp cap and is the cause of pain, and will eventually subside? If so, is it reasonable to continue with pain meds and give nerve 4 or more weeks to see if abates?  Or is pain surely indicating that nerve is traumatized and will slowly die.
2. Could infection be present that was caused during procedure or “pushed” into nerve as a result of procedure.
3. Could this particular strain of antibiotic possibly not be effective?
4. What determines when a pulp cap fails when prior to the procedure, there was no indication of infection?

Thank you in advance
Dr Tim Radak


Answer
Dear Dr. Radak,

The current consensus is that pulp caps have a very uncertain future, and the majority eventually fail. The emergence of pain should be viewed as an unfavorable sign, and is evidence that a pulpitis has occurred. The use of antibiotics will not prevent a pulp cap from failing, and the fact that your dentist prescribed antibiotics suggests that your dentist feels it has already failed.

Pulp caps have a higher probability of success if:
1. they are performed on a child
2. the pulpal exposure is mechanical (i.e., caused by breakage) rather than carious (i.e., caused by tooth decay)
3. the pulpal exposure is small rather than large
4. the tooth is asymptomatic

It is likely that your situation does not fit any of the above conditions, so an expectation of a favorable outcome may be unrealistic.

A pulpitis may well eventually become asymptomatic, but this should not be interpreted to mean that the pulp cap was successful. At the very least, your tooth should be observed carefully for any signs of infection, regardless of the trend in the symptoms.

Hope this helps...

Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY