Hmm… vital and necrotic at the same time?
Jon Richards DDS MS
Back in training, we were always taught something like “necrotic teeth don’t feel temperature.” This is a clear example that making such definitive generalized statements during endodontic diagnosis can expose our biases and reveal just how little we know (but wont admit it).
The patient’s complaint was “pain to biting pressure, and sensitivity to cold and especially hot.” The periapical radiograph was highly suggestive of advanced periapical pathosis with the DB root. Testing confirmed tooth #19 was moderately percussion tender, slightly palpation tender, and responded delayed to cold, and hot. Tooth #18 (full gold crown) responded WNL to testing.
Upon access, the pulp contents were found to be necrotic. Instrumentation of the MB canal produced some bleeding – suggestive of at least an in tact blood supply. After patency with the D root, profuse suppurative exudate filled the D canals and pulp chamber space. This drainage continued for at least the next 20 minutes.
After 3 weeks of Ca(OH)2 paste in the canals, the patient returned for re-evaluation. He was asymptomatic. The sensitivity to temperature and biting pain resolved. No antibiotics were prescribed or became necessary. At this appontment the canals were reinstrumented, irrigated, and dried, and obturated. Tooth #19 was restored with a bonded amalgam core while it was still isolated under a rubber dam.
I thought this was interesting and a great example not to let your previous biases affect diagnosis and decision-making. It was possible that the temperature sensitivity was coming from an adjacent tooth, and had treatment been initated on #18 based on prior understanding that “teeth with infections cant feel cold or hot,” the treatment would have been innappropriate.