Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-05-16, 11:45:19 | version 1.38.0
MANAGEMENT OF PULP CANAL OBLITERATION: TIPS AND TRICKS — A clinical case report Dr. Hugo Sousa Dias, Portugal — Dr. Hugo Sousa Dias Introduction Clinical management of calcified teeth provides an endodontic treatment chal- lenge and makes up a significant portion of current endodontic practice. People are living longer and want to maintain their natural dentition. There are several factors that might influence the development of varying degrees of moderate and severe calcification of the pulp chamber, as well as the root canal system, such as multiple restorations, trauma, vital pulp therapy and chronic irritation arising from deep resto- rations or cracks.1 Pulp stones in the pulp chamber, scle- rotic dentin usually in the pulp chamber, dystrophic calcification in the root canals, and pulp canal obliteration in the pulp chamber and the root canal are some of the clinical situations commonly encoun- tered by endodontists.1 Pulp canal oblit- eration, also called calcific metamor- phosis, is a sequelae of tooth trauma. It has been reported to develop more often in teeth with concussion and subluxation injuries.2–4 Calcific metamorphosis is defined by the American Association of Endodontists as “a pulpal response to trauma character- ized by rapid deposition of hard tissue within the canal space”.19 It is generally asymptomatic and patients present clini- cally with yellow discoloration of the af- fected tooth crown and apparent loss of the pulp space radiographically. This dis- coloration is due to a greater thickness of dentin deposition. The incidence of pulp canal obliteration after dental trauma has been reported to be approximately 4–24%. It is generally accepted that the frequen- cy of pulp canal obliteration is dependent on the extent of the luxation injury and the stage of root formation, and general- ly, obliteration of the pulp canal spaces advances in a corono-apical direction.4–6 The exact mechanism of canal obliteration is unknown, but is believed to be related to damage to the neurovascular supply of the pulp at the time of injury.5 The critical management decision is whether to treat these teeth endodonti- cally immediately, upon detection of the pulpal obliteration,7–9 or to wait until signs and symptoms of pulp or periapical dis- ease occur.10–15 Only 1–16% of teeth with pulp canal obliteration will develop pulpal necrosis and only 7–27% of them will develop radiographic signs of periapical disease.5 There is a progressive decrease in the response to thermal and electrical pulp testing as pulp canal obliteration becomes more pronounced. Furthermore, a signif- icant difference in electric pulp testing between partially obliterated and totally obliterated teeth has been reported. It is generally accepted that an absence of a positive response to the electric pulp test does not automatically imply pulpal necro- sis.2 It is also generally accepted that sen- sibility tests are unreliable.5 Teeth under- going pulpal obliteration are generally asymptomatic.2 Such teeth are often an incidental finding during clinical or radio- graphic investigation. The literature suggests that pulpal ne- crosis and periapical disease are not com- mon complications of pulp canal obliter- ation, and if root canal therapy is selected as a routine procedure, most treatments would be unnecessary, as the majority of teeth with pulp canal obliter- ation will never suffer pulpal necrosis or periapical disease. Smith recommends delaying treatment until there are symp- toms or radiographic signs of periapical disease, a view accepted by many.10-15 It is possible to differentiate two types of radiographic pulp canal space oblitera- tion: partial pulp canal obliteration (limited to the coronal part of the tooth) and total 50 — issue 2018 Endodontics Article