STRESSED PULP CONDITION

The stressed pulp condition: An endodontic-restorative diagnostic concept

M a r w a n Abou-Rass, D.D.S., M.D.S., Ph.D.*

1 Unlverstty of Southern Californta, School of Denttstry, Los Angeles, Callf

T H E A L T H Y PULP

r RECOVERY - L i STRESSED PULP HEALTHY PULP AND PRIMARY TRAUMA 1

I D I S E A S E D PULP

I NO RECOVERY - I I The term *nressed pulp" describes a vital dental to stimulation is dependent on many variables, such as Fig. 1. Possible reactio pulp that has been subjected to repeated damage, tooth age, type, systemic condition, previous trau- including operative trauma, accidents, or other patho- ma and pathology, and patient threshold to noxious iogic changes, he stressed pulp condition is a clinical stimuli. effective methods for thermal testing is the use of

connpt and not a histologic entity. Pulp-testing methods can be improved if the dentist carbon dioxide ice at -79' C to elicit a response, ~h~

T~~ itressed pulp condition should be considered incorporates the results of pulp tests with a careful provoked response should be evaluated in t e r n of

prior to any extensive restorative dentistry or other review of past and present conditions of the pulp. duration and intensity. The stressed pulp is a vital pulp

dental procedures. Although a stressed pulp is usually Clinical methods to evaluate live pulpal tissue diren- with diminished responses and should not be mistaken

asymptomatic clinically, it may deteriorate rapidly to a ly are not available. Therefore, pulp tests should for a healthy pulp or a nonvital pulp (Table I).

diseased or necroticcondition. Crown preparations, pin include a combination of all available clinical methods Stimulation of a control contralateral tooth is usually

buildups, restorative failures, tooth structure cracks, or findings, such as: (1) patient report on tooth history; needed for purposes of comparison.

and poor systemic conditions can transform the pulp (2) radiographic evaluation of the pulp cavity outline; The pulp response should always be analyzed with a

fro% a state of asymptomatic stress to a state of pulpal (3) tooth and tissue examination; and (4) tooth thorough understanding of the limitations of thermal, response to thermal or physical stimulation. physical, and electric stimuli. T h e information

Patient report on tooth history. In most instances the obtained from the patient report on tooth history, D I A G ~ ~ ~ ~ ~ O F A STRESSED PULP patient does not have a history of pain or discomfort. clinical examination, radiographic evaluation, and CONDITION The tooth has been functioning well, but its his- stimulus-response tests is compared to develop a &ag-

~ ~ ~ ~ ~ i ~ i ~ ~ pulpal vitality is of utmost importance tory is lengthy and indicates evidence of cumulative nostic trend. This trend is then considered in the future

to the restorative dentist. Pulpal complications follow- injury to the pulp, including past trauma, onhodon- treatment plan.

ing restorative dentisvy can be caused by (1) new tic treatment, multiple restorations, or poor systemic trauma, (2) exacerbation of undiagnosed health.

S O M E ASPECTS O F PULPAL INJURY

pulpal disease, and (3) transformation of stressed pulp Tooth and tissue examination. The clinical crown The dental pulp is a unique anatomic and physiolog-

to a state of disease. usually contains multiple restorations. In addition, ic organ. I t can mover from primary injury. However, such recovery is dependent on many factors that can

Radiographic evaluation. Pulp chambers of stressed

Application of topical medications on cavity pwparationrl Continuous air-drying of preparation Cement with high acidity D i m pulp capping D ~ P tmth preparation (where less than 2 mm of mainiq

dentin coven he pulp) High-speed tooth ~ t t i n g without molant

palpation produce no response. One of the most Unbared restoration allowing for thermal mnduaivity

264 SEPTEMBER 1982 VOLUME 46 NUMBER 3 0022-3913/82/O¶l264 + 04SW.40/00 1982 The C. V. Mmby Cc. THE JOURNAL OF PROSTHETIC DENTISTRY

LNECROTIC PULP

ns of pulp to hauma.

Raising pulp tmperatuw up to 10" F by imp-ion materials, polishing of casting, or cutting dentin without molant

Orthodontic tooth movement of heavily mtored adult teeth Periodontal surgical exposure of mmentum and lateral canals

The following diseases, conditions, and treatment cause pulpal injury and may lead to pulpal smess:

Chmnic bruxirm Chronic caries Chmnic periodontal diwaa' Chmnic trauma fmm occlusion' Chronic occlusal attrition and erosion Cracks in tooth nrunuw Radiation therapy Syaemic diseases or oral manifestation Diabetes, vitamin C deficiency, leukcmia, endocrine dirtur-

banm

The ability of the pulp to recover from pathologic and operative trauma is related to:

Type of injury. Mild injury is believed to be of no significance, and repair can be expected.

Duration of injury. A primary injury of short duration provides the best chance for recovery.

ntickness of remaining denfin. Remaining dentin between the cavity floor or crown preparation and the pulp is necessary to protect the pulp. If the remaining dentin is less than 2 mm thick,' trauma to the pulp becomes more damaging and the recovery chances are reduced.

Physiolo~~c age oflhe tooth. The pulp chamber and apical foramen size should be large enough to allow adequate vascular flow to the tooth. A receded pulp chamber or pulp chamber filled with calcification stones or reparative dentin may not have a good reparative potential due to its deprivation of vascular and cellular element^.^'

Host factors. Patient age and systemic health play an important role in pulp recovery potentials. Young, healthy patients have better healing responses.

ABOU-RASS STRESSED PULP CONDITION

Table I. Classification of cl inical pulp cond i t ions and the i r differential diagnosis

Clinical evaluation Healthy pulp Diseased pulp Stressed pulp Necrotic pulp

Patient report No significant dental Pain complaint No complaint History of history Long history of dental Previous complex spontaneous pain or

Tooth use in procedures. disease, dental history no pain mastication or trauma Tooth used in

Recent dental work mastication Pain with hot food

injury and survived with diminished responses and

lessened repair potentials. Before performing restorative dentistry the dentist

should conduct a comprehensive pulpal health evalua- tion on teeth to be restored. Th i s evaluation should include (1) traditional pulp-testing methods and (2) a

review of the pasl, presenr, and planned future lreat- menl of the tooth. Th i s analysis will usually identify

teeth with stressed pulp conditions.

Teeth with stressed pulps should be treated before complex restorative dentistry.

REFERENCES

3. Landay, M. A., Nazirnov, H., and Selum, S.: The eKmr excessive occlusal fom on the pulp. J Pcriodontol 41:3, 1970.

4. Kawahara, H., and Yagami, A.: In vim studia of cellular responsc to heat and vibration in cavity pmparation. J Dent Res 49:829, 1970.

5. Langcland, K.. Dowdcn, W. E., Tmnnad, L., and Langcland, L. K.: Human pulp changes of iatrogenicorigin. In Sirkin, M., editor: Biology of the Human Dental Pulp. St. Louis, 1973, The C. V. Mmby Co., pp 122-159.

6. Langeland, K.. and Langeland, L. K.: Pulp reaaion to cavity and crown preparation. Aust Dent J 15:261, 1970.

7. Saygh, F. S.. and Reed. A. J.: Calcification in thedental pulp. Oral Surg 25873, 1968.

Radiographic Well-defined pulp Deep restorations or Pulp chamber Variable and may evaluation chamber and canals caries recession show any of the

Mintmal restoration Pulp cavity outline Narrow pulp canal findings distance from pulp altered by Partial calcification Present with healthy,

No calcification or calcification or Deep restorations diseased, or stressed resorption

No osseous changes Normal root

resorption

internal resorption Root resorption Osseous changes

~ o r k a l apical area Periodontal lesion

I. Seltzer, S., Bender, I. B., and Kaulman, I. I.: HiaoloPie R-,,&,,, ," .'YY".> L".

chaqes in dental pulp or dogs and monkeys following DR. M A ~ \ v A ~ ABOU-hss application of pressure, drugs, and micrmrganirms on prc- UN~VERS~N OF S O ~ H E R N C A ~ ~ ~ ~ ~ ~ I A pared avitia. Pans I and 11. Oral Surg 14:327,856, 1961. SCHWLOF DENT~SIRY

2. Selucr. S., Bender, I. B., and Ziontz, M.: T h e interrelationship Los ANGELES, CA NW7 of pulp and periodontal discasc. Oral Surg 16:1474, 1963.

Tooth and tissue Minimal caries or examination restorations

Normal color of tissue and tooth

Disease or defects in dentin

Normal surrounding tissue or symptomatic supporting tissue

Defective restorations Dental disease or

defects with multiple restorations

Evidence of trauma Occlusal trauma

Variable and may show any of the ' . findings

Present with healthy, diseased, or stressed pulp

Pulp response to Immediate, severe Very rapid and severe stimuli' transient pain, or very late

mostly provoked response Provoked andlor

spontaneous linger-on

Similar to patient's chief complaint

Late, weak, sluggish, inconsistent response requiring high degree of stimulation and longer time to produce

No response to stimuli or to heat, pain

*Stimuli = Cold, hcat, permssian, cavity test (electric pulp tester, optional)

Part trauma. Dental diseases and operative trau-

ma may produce residual damage to the pulp. Al- though the pulp may recover and survivc the primary

trauma, it will have less chance of su~viving future

trauma. These factors are closely interrelated and should be

considered together. T h e analysis of past and present treatment on a tooth, combined with the results of pulp

testing, can produce a more reliable evaluation and differential diagnosis of the pulp for the future.

dentist should perform endodontic therapy before the

new restorative effort. Placing pulp caps, deep exten- sive restorations, o r composite pin-buildups in teeth

with stressed pulps are common causes for endodontic complications following restorative therapy. Orthodon-

tic movement of pulpally stressed teeth can also neces-

sitate endodontic therapy later.

When dental caries and defective restorations are removed from the tooth crown, endodontic pr&dures

are simple, straightforward, and uneventful. However,

CLINICAL MANAGEMENT OF TEETH WITH STRESSED PULPS

when a tooth is built u p with pins and restored with

crowns, endodontia can be complex and the possibility

of perforations and other procedural errors leading to pain and complications is increased. Endodontics

should be considered strongly before beginning restor- ative therapy, orthodontics, o r other traumatic proce- dures on teeth with stressed pulps.

SUMMARY

T h e stressed pulp condition is a clinical concept that describes p u l p that have received repeated previous

Extra text pages added to the JOURNAL I T h e concept of the stressed pulp is a concept dcvelopcd to describe pulps that are neither

healthy nor obviously diseased. Many patients have one o r more teeth with stressed

pulp conditions that do not require treatment. Howev- er, patients should be advised that the teeth may become symptomatic in the future. If restorative treat-

ment is indicated on teeth with stressed pulps, the

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SEPTEMBER 1982 VOLUME 48 . NUMBER 3 THE JOURNAL OF PROSTHFTIC DENTISTRY