Tag Archives: hot tooth

Beware of the Cracks!

Imagine the following scenario:

A busy day in practice! A patient comes in with tooth #2-6 (upper left first maxillary molar) being extremely sensitive to cold (a.k.a. a “hot tooth”).  You notice a very old, large amalgam filling on the tooth which had been done over 2o years ago.  No recent restorative changes in the area  is reported by the patient.  Breathing in air, blowing air on this tooth with an air-water syringe or applying ice to the tooth sends the patient through the roof.  All other teeth in this quadrant are responding normally to cold test. Quickly and confidently, a pulpal diagnosis is reached (irreversible pulpitis), endodontic treatment is recommended, and the need for a full coverage crown is also emphasized after root canal treatment. Simple, right?

cracked tooth, split tooth

pre-op radiograph

 

Well, not so fast!

  • unless you stopped and thought about the reasons why the tooth became sensitive to begin with (i.e. thinking about the etiology for pulpitis and the possible pathways to the pulp),
  • unless you thoroughly examined the tooth clinically and looked for signs of cracks, leakage, caries, periodontal disease, parafunctional habits, etc.,
  • unless you grabbed a perio probe and actually noticed a 6-7mm probing defect on the distal aspect of the tooth,
  • unless you noticed on the pre-op radiograph a questionable area with respect to the quality of the crestal bone between teeth #2-6 and #2-7,
  • unless you removed the obscuring filling and gave yourself an adequate view of what lies beneath during the treatment (as opposed to those who still love to brag about their super conservative access and their beautiful final result through a tiny 2x2mm hole),

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You may miss a more serious issue with this innocent-looking tooth in need of JUST a root canal and a crown,  you may lose the opportunity to properly inform your patient of possible outcomes of your treatment and you may end up performing unnecessary treatments for a tooth with no hope.

Just imagine the final conversation with the patient after a quick exploratory/pulpectomy procedure:

Me –  “Ms. Black, unfortunately your tooth cannot be saved as I had suspected and warned you before we started the root canal procedure today.”

Ms. Black – “I am amazed Dr. E! [with a smile]  You knew exactly what was wrong with my tooth. You called it.”


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Too Hot to Handle!

One common question that many of my friends ask me is “How do you deal with a hot tooth?”

After giving adequate block injections and local infiltrations, I usually use intraligamental or intraosseous type of injections. My first choice for a few years has been using a syringe called Paroject. This syringe is used for intraligamental injections which is in a way intraosseous as well since the pressurized anesthetic solution in the PDL space will penetrate into the adjacent cancellous bone. I give 6-point intraligamental injection around the hot tooth using local anesthetic without epi and this usually does wonders.

Another effective method is using the intraosseous anesthesia with the Stabident and X-Tip systems. The details of the two systems can be reviewed in the article “Intraosseous Anesthesia” from the Endodontics: Colleagues for Excellence (Winter 2009) publication by the American Association of Endodontists (AAE).

Have I been 100% successful with all the hot teeth I have dealt with in the past few years? Absolutely not! If that happens, don’t forget there is always the good old practice-builder technique: the “Intrapulpal Injection“.