ADC Communication Task

Dr Mohamed Soliman
BDS, ADC Certified

[email protected]

1- Irreversible pulpitis
2- Amalgam Replacement
3- Cracked Cusp
4- Vertical Root Fracture (VRF)

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 Irreversible pulpitis Scenario

- 30 yrs. old
- Pain in lower right posterior side
- Now spontaneous pain, not relieved by
Panadeine
- #46 is TTP, large carious lesion and small
Periapical R.L

Diagnosis:
Irreversible pulpitis
How to be told to the pt?
I’m really afraid to tell you that this tooth ‘bottom back right tooth’ has got a dead nerve
Or u can say inflamed nerve
The cause is large decay approaching the nerve inside the tooth causing u that pain
U can ask for a pen and paper to draw if pt can’t understand, draw a tooth to show the pt
the position of the nerve and decay

TTT Options:
1- No ttt
The 1st option ‘which I believe u need to know anyway’ is to do nothing HOWEVER, u
need to know that this is actually not good because it may cause more damage, pain and
infection which may spread more and involve adjacent structures.
2- Root Canal ttt
The 2nd option is a procedure we call it root canal treatment which means we have to go
inside the tooth and remove the nerves causing u your pain and by this we can save this
tooth
‘Don’t use the appreviation RCT with the pt’
In general we usually do rct in 3 stages, today we will do the first visit to take the nerves
out to take ur pain away then u will come later to clean the root canals which occupied
by the nerves and shape them well to receive the filling in the final stage.

** Consequences RCT:

 Blocked canals: refer to specialist or exo

Referring to a specialist will incur extra costs

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 3- Extraction
To take the tooth out however I know that u don’t want to lose the tooth but it’s one of
ur options and it’s my duty of care to tell u all the available options and u choose one of
them

Post-operative instructions:

We expect ur pain to completely disappear or sometimes it may become little sensitive to touch or
bite so try to avoid eating on it and if u take the pain killers I’m going to prescribe everything should
be alright, if not please give us a call.

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 Amalgam Replacement Scenario

Fillings are 20 yrs old, no cracks, no secondary caries, pt is a smoker and wants to replace silver
fillings with white fillings.

Pt may change fillings for reasons such as:

 Fear of mercury/ mercury concerns

Only use words like silver fillings (amalgam is a jargon term).

Reason why we don’t recommend replacing silver fillings here:

1- As such Silver fillings are one of the most reliable and strong filling materials and in some
cases are chosen over the white fillings where stresses of chewing are high.
2- Your teeth and your fillings are in good condition and have no decay or cracks in them. Had
there been any decay beneath the existing filling or if the margins of the filling were
compromised then there was reason to remove the fillings but given that fillings are in
sound condition we should leave them.
3- Removal of existing filling will lead to loss of tooth structure which will weaken existing
tooth structure that can lead to nerve damage and hence it may need Root canal treatment
and also the tooth will not be strong enough, In this case, a filling or a cap may need to be
fabricated in the lab to prevent the tooth from breaking.
4- White fillings may discolour with time due to smoking and food stains.

 Fear of mercury/ mercury concerns

Research conducted so far has failed to prove that the mercury in the silver fillings has no adverse
effects on human health. The adverse effects only come into effect when the mercury in the filling is

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in vapour form such as when being inserted or removed but in the current state it is in the bound
form.

If Aesthetics is a concern, then request to see pt’s smile and try to reach a compromise where you
replace those that are visible in a smile line. (for example only premolars)

 Friend’s/ naturopath advice:

Refer to the reasons of why we don’t recommend replacing them

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 Cracked Cusp Scenario

- 45 yrs. Old
- Routine dental check-up
- Silver filling are 20 yrs. Old
- Pain on chewing on lower right side
- #46 is TTP and responds +ve to FracFinder or Tooth Sleuth

Diagnosis: Cracked Cusp

Tell the pt:

After my examination, reviewing the x-rays and the test that we have done, the tooth was found to
be cracked

I know that u may not see this crack but it’s actually evident from the examination and the tests that
we did & If left, the crack may propagate and split the tooth.

Cause:

This is not very uncommon to happen with this kind of filling in ur tooth

Those silver fillings usually we used them as perfect filling in the past but by time we discovered that
they can weaken the tooth structure because we have to cut a lot for them to be retained so we
found that it wasn’t conservative (in other pts it could be due to teeth clenching and grinding)

Rx options:

We don’t know exactly the extension of this crack it may be deep or shallow so we need to do more
investigations, so we need to remove the filling and investigate more.

Three options:

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1- remove filling and if we find, if crack is shallow, then replace with another filling that is best
scenario
2- If after the filling is removed and the tooth structure is not enough, then we prefer doing an
indirect filling which is done in the lab, we will take measurement of ur tooth after its
preparation, send it to the lab then wait for mostly 1 or 2 weeks before receiving it and then
glue it to ur tooth (Price: $1000-$1300) (inlay/ onlay)
3- If crack is deep approaching the nerve of the tooth then we have to do a procedure we
called Root Canal Treatment

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 Vertical Root Fracture (VRF) Scenario

- 45 yrs. Old
- Discomfort in #25, restored with amalgam for 15 yrs
- After filling removal, a fracture line running mesio-distally across tooth was found

Diagnosis: VRF

I’m sorry to tell u that the tooth has split into two halves. The only option here is to pull the tooth
out.

If pt becomes upset, empathise with them and support them. Explain to them that if left as it’s, it
might become more painful or infected or lead to a serious complication.

Rx options for exo:

Generally teeth with vertical root fracture are not straight fwd exos. Initially it started as a crack and
propagated to split the tooth.

 The first scenario may happen: Able to take the tooth out in one piece or piece after
another.
 The second scenario: while trying to extract the tooth, the tooth may break and as a result
we may need to cut into the gums or into the gums and jaw bone to retrieve the broken
piece.
 If that piece cannot be retrieved then referral to specialist.
 If pt is apprehensive you can also let them know they can be referred to the specialist from
the beginning. But also explain all the procedure (step 1-3)

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Consequences:

 How close is this tooth to Maxillary sinus (hollow space in upper jaw bone, next to nose, location
of this space very close to the roots of this tooth). Because of this close proximity a
communication may develop b/w the sinus and mouth. However it’s not common to happen but
I thought you may need to know that before we start.
Please rest assured that this a treatable condition and usually resolve by itself within few weeks.
If it happen we will need to refer you to a specialist who will assess and manage the condition,
mostly he will stitch the wound and review it again for few weeks.

 Intrusion of root or broken root into the sinus, this is more uncommon to happen. Very small
percentage to happen but just in case it happens, a specialist referral will be deemed necessary.

 A condition we call it ‘Dry socket’ which is experienced by pain, foal smell and inflamed gums
around the socket usually happening after 3-5 day after tooth removal, Although more common
in bottom back teeth. If it happens, plz call us, we will simply redress tooth and prescribe you
some stronger pain killers.

THANK YOU
