Chris J. Lampert, DMD Printer Friendly Version

Doctor, My Tooth Was Fine Until You Worked On It

The following is a letter I received from a referring doctor discussing a common clinical question.

Dear Dr. Lampert,

Recently, I prepared a tooth for a crown that was asymptomatic prior to treatment, asymptomatic during temporization, and then developed acute symptoms shortly after cementation of the final restoration.

From the patient’s perspective it appeared that my treatment caused the problem.  The tooth ultimately required endodontic treatment in your office to alleviate her symptoms.  In this particular case the tooth had an old, large, leaking amalgam restoration with recurrent decay prior to treatment.

This type of situation seems to happen to me more often than I would like to admit.  How should I explain this to the patient and what is the best way to prevent this from occurring?

This letter describes a situation that as an endodontist, I encounter on a routine basis. I receive a referral where the patient has a recently restored tooth that is now symptomatic, and the patient asks me if their dentist did anything wrong. I find that it is best to alleviate the patient’s concerns quickly by letting them know that this is an unavoidable and often unpredictable consequence of the restorative process. I also attempt to restore the patient’s confidence in their dentist by letting them know they are in very good hands with their general dentist and that everything was done correctly. I can say encouraging words about the restorative dentist that they can’t say about themselves.  Most patients are very appreciative of this reinforcement and second opinion. They leave with a better feeling about the situation than when they arrived.

From a clinical standpoint, whenever a crown is replaced with a new crown, a large restoration is replaced with a crown, or a deep restoration is placed, there is a chance that the pulp will not survive the restorative process. Teeth with signs of defensive biological processes such as pulp stones, calcified chambers, and condensing osteitis have been exposed to prior stress. The added stress of the next restorative procedure may push the pulp over the edge and lead to endodontic symptoms.

If the patient experiences any abnormal thermal sensitivity or chewing sensitivity during the time the tooth is in a temporary crown, the likelihood of symptoms increasing following the cementation of the permanent restoration is very high. The temporary phase is a good indicator of how the tooth will feel following cementation of the final restoration. Teeth that require a deep preparation in the cervical region, particularly on the buccal surface, are more prone to developing pulpal symptoms. This is a result of the anatomical position of the pulp chamber in this region, especially in premolars.

Another way to minimize post-operative endodontic symptoms is to conduct pre-treatment pulp testing before any restorative procedure that requires aggressive preparation. It takes 15 seconds to determine pulpal vitality on most teeth and is recommended before treatment is initiated.  Determining vitality will prevent the placement of a new restoration on a necrotic tooth. Placing a restoration on a necrotic tooth is a toothache in the making - it is just a matter of time before the tooth becomes symptomatic.  Another reason for determining pulpal vitality is to get a baseline on thermal sensitivity to use as a comparison if post-treatment symptoms arise. When a tooth is highly reactive to cold stimuli and requires a deep preparation, post-treatment cold sensitivity is very predictable.

From a patient management standpoint, before any invasive restorative procedure (anything other than a conservative preparation) the patient should be informed that future endodontic treatment is a possibility. The patient needs to be aware that most of the time a tooth will survive the restorative process just fine, however, at times a tooth may become symptomatic following the placement or replacement of a restoration. If endodontic treatment is subsequently needed, then they should not be surprised.

Although we cannot always prevent or predict post-restorative endodontic symptoms from occurring, we can prevent the misunderstanding from occurring by communicating well with the patient. Let the patient know that future endodontic treatment is not up to you or them, but is up to the tooth. I work with referring doctors that tell every patient following a crown preparation procedure that endodontic treatment might be needed if the tooth develops post-treatment sensitivity. Preparing patients for the least favorable outcome and delivering the best outcome is much better for creating patient satisfaction and patient loyalty to you and your office.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University.  He can be reached at drlampert@thedentistsnetwork.net.

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