0099-2399/91/1700-0034/$02.00/0 JOURNAL OF ENDODONTICS Copyright 9 1990 by The American Association of Endodontists
Printed in U.S.A. VOL. 17, NO. 1, JANUARY1991
Radiographic Pulpal Calcifications: Normal or Abnormal--A Paradox Howard S. Selden, DDS
A survey was sent to all 525 (domestic) Diplomates of the American Board of Endodontics. It inquired as to the interpretation of the findings of radiographic pulpal calcifications (RPC) and how it might impact on treatment. The response to the question of pathological significance of RPC was divided equally between those who felt it was a sign of pathosis and those who did not. The remaining seven questions were overwhelmingly agreed upon: RPC are important findings included in differential diagnosis; nonsurgical root canal treatment was routinely attempted regardless of the extent of RPC; patients were informed prior to treatment of potential obstacles; and as a rule diplomates devote no more than 10% of their practice to surgical endodontics.
pulp. Apparently, correlation of the clinical and biological is lacking. The paradox of these contradictory views was the subject of a survey of Diplomates of the American Board of Endodontics. The attempt was to discover and quantitate their interpretation of the finding of RPC and how it might impact on treatment. SURVEY The survey (Fig. 1) was sent to all 525 Diplomates of the American Board of Endodontics (who were also members of the American Association of Endodontists) residing in the United States. In order to invoke as large a reply as possible, the questions were limited to eight, each requiring only the circling of one answer per question. A brief cover letter (Fig. 2) explained the purpose of the survey, emphasizing that a signature was not required. A self-addressed, stamped envelope was enclosed. The survey questions were grouped into three categories: Interpretation and significance (questions 1, 2, and 3); clinical bias toward nonsurgical or (by inference) surgical treatment with varying degrees of RPC (questions 4, 5, and 6); and significant related issues (questions 7 and 8). Questions 1 through 7 were short, concise statements requiting a yes or no answer. Question 8, though not directly related to RPC, was included so as to uncover the parallel issue of predominant character of practice, nonsurgical or surgical. It was hoped that prior reading of the survey before answering would tend to focus the respondent's thinking. For example, if one considered RPC as a sign of pulpal pathosis in question 1, it would seem to be inconsistent to answer no to question 2. A positive sign of disease would have to be logically construed as an important finding. If one were to answer yes to question 4, that RPC are a potential obstacle to nonsurgical treatment, then the expectation would be that the answer to question 7 would also be yes. Obviously, though a respondent might agree that RPC could interfere with root canal treatment, he/she might not customarily include discussion of the possibility during case presentation. It was felt in light of the current mandates of informed consent that the query was useful, if for no other reason than to provoke consideration of the issue. Questions 5 and 6 were the most challenging, claiming more time in their fabrication than all of the rest combined. It was eventually concluded that the final wording explicitly imply the assumption that root canal treatment was required.
One of the more common findings on diagnostic radiographs is varying types, shapes, densities, and locations of calcifications within the pulp chamber and root canals. The literature is abundantly clear that calcific changes are often responses to a wide range of stimulants: dental operative and impression procedures, restorative materials, caries, tooth abrasion, periodontal disease, pulp inflammation, pulp capping, trauma, and aging. Some may be idiopathic. Some authors have expressed caution in interpretation, since they believe that calcific findings should not be considered pathological but are normal manifestations of aging (1, 2). Older texts also concluded that calcifications of the pulp were without clinical significance (3, 4). The opinion, on the other hand, among many biologists is that increased pulpal calcification diminishes tissue vitality and capacity to survive, especially to subsequent injury (5-9). This view was clearly expressed by Langeland (9), "calcifications occur with such frequency that they are considered by some as a normal occurrence. However, "normal" in this respect may not be synonymous with healthy. These calcifications are pathologic entities that infringe on and adversely affect the pulp." Review of some endodontic texts (10-12) revealed that in the chapters dealing with clinical diagnosis of pulpal and periapical disease, little or no attention was given to the findings of radiographic pulpal calcifications (RPC). In the same texts detailed discussions of pulp biology extensively illuminated the pathological nature of calcific changes in the 34
Radiographic Pulpal Calcifications
Vol. 17, No. 1, Januaw 1991
CLINICAL P R A C T I C E S U R V E Y OF D I P L O M A T E S OF T H E A M E R I C A N B O A R D OF E N D O D O N T I C S Radiographic
Pulp~
CaiciRcationi
(RPC)
circle o n e a n s w e r per question 1.
D o y o u c o n s i d e r RPC a s a s i g n of p u l p a l p a t h o s i s ?
Yes
No
Yes
No
D o y o u i n c l u d e RPC f i n d i n g s in m a k i n g a differential diagnosis.
Yes
No
4.
Do y o u c o n s i d e r RPC a s a p o t e n t i a l o b s t a c l e to n o n - s u r g i c a l root c a n a l t r e a t m e n t ?
Yes
No
5.
Do you routinely attempt non-surgical treatment in t h e p r e s e n c e of m i n o r R P C ?
Yes
No
Do you routinely attempt non-surgical treatment e v e n w h e n RPC a p p e a r s to t o t a l l y o b s c u r e t h e p u l p chamber?
Yes
No
D o y o u i n f o r m t h e p a t i e n t (prior to t r e a t m e n t ) t h a t n o n - s u r g i c a l root c a n a l t h e r a p y m i g h t n o t s u c c e e d because of the RPC?
Yes
No
35
totally obscured the pulp chamber. The anticipated answer to this question was open to much speculation and was considered of fundamental importance. If a sizable number o f diplomates did not routinely attempt nonsurgical treatment in the presence of significant RPC, then a problem in perception of the successful nonsurgical treatability of such teeth would exist (13). SURVEY R E S U L T S
:2. D o y o u view RPC a s a n i m p o r t a n t f i n d i n g in clinical examination? 3.
6.
7.
8.
C i r c l e t h e p e r c e n t a g e of s p e c i a l i t y p r a c t i c e d e v o t e d to s u r g i c a l e n d o d o n t i c s . (circle closest one)
10
40
60
90
FIG 1. Survey mailed to 525 (domestic) Diplomates of the American Board of Endodontics.
D ~ I ....dSSsU,o ~ACT,CE ~IM,rEO '0 eN~DONTPCS 701 W U N I ~ ~ V A R 0 NTNL[~E~ PA 11011
Dear
Fellow
Diplomats,
I m trying to discover and quant i tare tile prevailing interpretation, among endodontic dtplomates, of tile radiographic findings of pulp calcification, and how i t might Impact on t r e a t m e n t . 311e e n c l o s e d envelope, viii complete. Please
do n o t
mirvey, with only take a sign
will be avatlabs
its few
self-addressed, mintlteg of your
the survey. I anticipate for publication,
tiler
stamped time to
the
data
Of 525 surveys mailed, 413 (79%) were returned. The results of the survey (Table 1) are shown, providing numerical counts with percentages. Responses to question 1 resulted in almost equal division between yes and no. There were also seven unanswered replies to this question, implying sufficient ambivalence made it impossible to make a choice. There was no other question that had such a large number of unanswered responses. The answers to question 2, which required a judgment as to whether a finding of RPC was important, resulted in 293 (71%) saying yes. The answers to question 3 were divided similarly to question 2:302 (73%) said yes to RPC findings being included in differential diagnosis. It seems, therefore, that RPC are usually included along with routine pulp tests, history, other radiographic findings, and clinical symptoms in arriving at a diagnosis. Thus, question 3 raised a similar issue to question 1, but more indirectly. It was of interest to note that the number of positive responses to question 3 increased 24% as compared with question 1. The replies to question 4 were surprising, since it was expected that this was the one issue upon which universal agreement would be found. Nonetheless, 352 (85%) said yes they considered RPC as a potential obstacle to nonsurgical root canal treatment and 58 (14%) said no. There were even three who could not answer yes or no. The positive responses to both questions 5 and 6 were remarkably in agreement, 374 (91%) and 391 (95%), respectively. There was an overwhelming sentiment that nonsurgical
Fllndtng, In p a r t , } t a b l~en provided by tlte R e s e a r c h Department, The A l l e n t o w n l l o s p t t a l - l,ehigh V a l l e y lloapital Center. Than~ you for
your
participation
in
the
TABLE 1. Tabulation of survey responses*
study,
Hovard S. F,elden, D,D.S.
Question
Yes
No
Unanswered
1
202t 49 293 71 302 73 352 85 374
204 49 118 29 109 27 58 14 39
7
391 95 384 93
22 5 28 7
2 3 4
5 6 ~,,l~ATIAMEm,CAN JO*ROO~EN~qCS
7
FIG 2. Cover letter included with survey to diplomates.
The questions asked were whether nonsurgical treatment was routinely attempted under the circumstances of the degree of calcification cited. The provision of only minor RPC in question 5 would lead one to expect almost universal selection of nonsurgical treatment. Question 6 specified RPC which
8
2 0 2 0 3 1 1
0 1
10%
40%
60%
90%
Unanswered
380 9--1
20 ~
0
9 2
4
9 Total surveys mailed equal 525. Total surveys returned equal 413 (79%). 1" Upper numbers are actual counts; lower numbers are percentages (all percentages rounded to closest whole number).
36
Selden
Journal of Endodontics
treatment should be attempted regardless of the extent of RPC (Fig. 3). The 384 (93%) who replied yes to question 7 was an 8% increase over the positive answers to question 4. It would suggest, therefore, that the positive responses to question 4 as to the potential for RPC obstructing treatment was possibly understated in the survey. The character of practice among diplomates was decisively revealed in question 8:380 (91%) devoted only 10% of their practice to surgery, 20 (5%) spent 40% on surgery, 9 (2%) 90% on surgery, and 4 (1%) left the question unanswered. An additional finding of interest was that the most common pattern of reply was to answer yes to questions 1 through 7. This remarkable concurrence, 113 (27%) of the surveys, was the only consistent pattern, all others were extremely random.
dontically treated, it can be suggested that the finding of RPC is objective evidence of a pulp at potential risk. Occasionally, endodontists are presented with patients who cannot localize their symptoms (Fig. 4). Experience may show that the finding of RPC when combined judiciously with other clinical and radiographic signs and symptoms (Fig. 5) is often a helpful clue as to the offending tooth. One might view the finding of RPC, after suitable pulp tests indicate pulpal disease, as visual confirmatory evidence of pulpal pathological change (Figs. 6 and 7). It might be thought that it was possible that three of the questions could have been misinterpreted. In question 2, RPC
DISCUSSION The most significant difference of opinion was whether RPC should be considered a sign of pulpal pathosis or not. It is understandable since many authors either ignore the finding altogether, understate its meaning, or caution that some calcifications are normal. In addition, the finding of RPC is almost ubiquitous and occurs in teeth otherwise free of radiographic pathosis or clinical symptoms. It seems that a combination of education and clinical experience has conditioned possibly 50% of the diplomates to downgrade evidence of RPC as a sign of pulp disease. It is probably noted on radiographs but not meaningfully incorporated in clinical diagnosis. This connection between calcific deposits and diminished health is not a unique finding in human tissues. The most highly publicized and potentially serious are the calcific deposits often found within the atherosclerotic plaques of coronary arteries (14). Even though millions of people with these plaques are probably free of symptoms and unaware of them, it does not mean the calcified plaques are benign and not a potential threat to their health. In regard to pulpal health, the same seems true of RPC. Although there is no basis for the position that all teeth with RPC should be aggressively endo-
FiG 3. Diagnostic radiograph of tooth 3 shows minor RPC and demonstrates symptoms of acute pulpal disease. To fully appreciate the extent of RPC in tooth 3, comparison with the significantly clear pulp chambers of adjacent teeth is helpful.
FIG 4. Diagnostic radiograph shows almost complete calcific obliteration of the pulp chamber of tooth 30. This finding, along with other positive tests for pulpal disease, helped determine source of severe pain unable to be localized by the patient. Subsequent root canal treatment of tooth 30 eliminated all symptoms.
FtG 5. Diagnostic radiograph of tooth 30 with symptoms of acute pulpitis. Extensive RPC seen in tooth 30 was very likely a pulpal response to both deep prior restoration and new carious lesion. Similar RPC in asymptomatic tooth 31 was initially considered "idiopathic,"--no caries, no restorations, and no history of trauma. Reexamination of tooth 31 with microscope-enhanced fiberoptic illumination revealed a crack, otherwise undetectable, in the buccal aspect of the mesiobuccal cusp, crossing diagonally. This crack could have provided the pulpal irritation leading to RPC formation. Since the pulp responded within a normal range to thermal and electrical tests, no treatment was recommended.
Voh 17, No. 1, January 1991
F~G 6. Diagnostic radiographs of teeth 2, 3, 30, and 31, of one patient, showing significant RPC and old amalgam restorations. For many years all teeth evidenced the same distressing symptoms: marked tenderness to percussion and elevated response to cold. Conclusion based on pulp test responses, clinical symptoms, and RPC findings was pulpitis in all four teeth. Root canal treatment w a s performed.
seems capable of being important for more than one reason. I r a respondent felt positively about one reason and negatively about another, he/she would be unable to honestly select yes or no 1o the question. It now seems obvious that the question could have been better worded. Questions 5 and 6 also seemed to have been cause for confusion. Some apparently understood the question to have asked whether RPC were "indications" to treat endodontically, and not, as intended, whether nonsurgical treatment was routinely attempted under the circumstances stated. Nonetheless, it seems possible to accept all yes responses as valid, since regardless of interpretation of the question a positive answer does accept the desirability of nonsurgical treatment. On the other hand, negative answers could have a double meaning: either nonsurgical treatment is not routinely attempted with a finding of RPC, or RPC are not an indication for root canal treatment. In this event the negative replies were few. Despite the flaws in these three questions, the survey did uncover a basic difference of opinion about the interpretation of RPC and revealed information about endodontic speciality practice. The astonishingly high percentage of returns would indicate that the survey technique among Diplomates of the American Board of Endodontics was a fruitful method to poll opinions and gather data. The ready willingness of large numbers to share their opinions should encourage further development of this technique.
Radiographic Pulpal Calcifications
37
Fie 7. Reexamination radiographs 7 months after root canal treatment and cast restorations. Patient reported elimination of all symptoms and restitution of comfortable function. Funding, in part, has been provided by the Research Department, The Allentown Hospital-Lehigh Valley Hospital Center. Dr. Selden is a former clinical assistant professor, Department of Endodontology, Temple University School of Dentistry, is former chief, Dental Department, Allentown Hospital, Allentown, PA, and is a staff member, Dental Department, Muhlenberg Hospital, Bethlehem, PA.
References 1. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:10. 2. Ingle JI, Beveridge EE. Endodontics. 2nd ed. Philadelphia: Lea & Febiger, 1976:456. 3. Stafne EC. Oral roentgenographic diagnosis. Philadelphia: WB Saunders, 1958:63-5. 4. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 2nd ed. Philadelphia: WB Saunders, 1963:247. 5. Weine FS. Endodontic therapy. St. Louis: CV Mosby, 1972:83, 97-8. 6. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:291. 7. Ingle JI, Beveridge EE. Endodontics. 2rid ed. Philadelphia: Lea & Febiger, 1976:373-8. 8. Seltzer S, Bender IB. The dental pulp. Philadelphia: JB Lippincott, 1965:230-2. 9. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:275-81. 10. Weine FS. Endodontic therapy. St. Louis: CV Mosby, 1972:2t-56. 11. Ingle JI, Beveridge EE. Endodontics. 2rid ed. Philadelphia: Lea & Febiger, 1976:440-559. 12. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:3-27. 13. Selden HS. The role of a dental operating microscope in improved nonsurgical treatment of "calcified" canals. Oral Surg 1989;66:93-8. 14. Cecil R. Textbook of medicine. 15th ed. Philadelphia: WB Saunders, 1979:1218.
Printed in U.S.A. VOL. 17, NO. 1, JANUARY1991
Radiographic Pulpal Calcifications: Normal or Abnormal--A Paradox Howard S. Selden, DDS
A survey was sent to all 525 (domestic) Diplomates of the American Board of Endodontics. It inquired as to the interpretation of the findings of radiographic pulpal calcifications (RPC) and how it might impact on treatment. The response to the question of pathological significance of RPC was divided equally between those who felt it was a sign of pathosis and those who did not. The remaining seven questions were overwhelmingly agreed upon: RPC are important findings included in differential diagnosis; nonsurgical root canal treatment was routinely attempted regardless of the extent of RPC; patients were informed prior to treatment of potential obstacles; and as a rule diplomates devote no more than 10% of their practice to surgical endodontics.
pulp. Apparently, correlation of the clinical and biological is lacking. The paradox of these contradictory views was the subject of a survey of Diplomates of the American Board of Endodontics. The attempt was to discover and quantitate their interpretation of the finding of RPC and how it might impact on treatment. SURVEY The survey (Fig. 1) was sent to all 525 Diplomates of the American Board of Endodontics (who were also members of the American Association of Endodontists) residing in the United States. In order to invoke as large a reply as possible, the questions were limited to eight, each requiring only the circling of one answer per question. A brief cover letter (Fig. 2) explained the purpose of the survey, emphasizing that a signature was not required. A self-addressed, stamped envelope was enclosed. The survey questions were grouped into three categories: Interpretation and significance (questions 1, 2, and 3); clinical bias toward nonsurgical or (by inference) surgical treatment with varying degrees of RPC (questions 4, 5, and 6); and significant related issues (questions 7 and 8). Questions 1 through 7 were short, concise statements requiting a yes or no answer. Question 8, though not directly related to RPC, was included so as to uncover the parallel issue of predominant character of practice, nonsurgical or surgical. It was hoped that prior reading of the survey before answering would tend to focus the respondent's thinking. For example, if one considered RPC as a sign of pulpal pathosis in question 1, it would seem to be inconsistent to answer no to question 2. A positive sign of disease would have to be logically construed as an important finding. If one were to answer yes to question 4, that RPC are a potential obstacle to nonsurgical treatment, then the expectation would be that the answer to question 7 would also be yes. Obviously, though a respondent might agree that RPC could interfere with root canal treatment, he/she might not customarily include discussion of the possibility during case presentation. It was felt in light of the current mandates of informed consent that the query was useful, if for no other reason than to provoke consideration of the issue. Questions 5 and 6 were the most challenging, claiming more time in their fabrication than all of the rest combined. It was eventually concluded that the final wording explicitly imply the assumption that root canal treatment was required.
One of the more common findings on diagnostic radiographs is varying types, shapes, densities, and locations of calcifications within the pulp chamber and root canals. The literature is abundantly clear that calcific changes are often responses to a wide range of stimulants: dental operative and impression procedures, restorative materials, caries, tooth abrasion, periodontal disease, pulp inflammation, pulp capping, trauma, and aging. Some may be idiopathic. Some authors have expressed caution in interpretation, since they believe that calcific findings should not be considered pathological but are normal manifestations of aging (1, 2). Older texts also concluded that calcifications of the pulp were without clinical significance (3, 4). The opinion, on the other hand, among many biologists is that increased pulpal calcification diminishes tissue vitality and capacity to survive, especially to subsequent injury (5-9). This view was clearly expressed by Langeland (9), "calcifications occur with such frequency that they are considered by some as a normal occurrence. However, "normal" in this respect may not be synonymous with healthy. These calcifications are pathologic entities that infringe on and adversely affect the pulp." Review of some endodontic texts (10-12) revealed that in the chapters dealing with clinical diagnosis of pulpal and periapical disease, little or no attention was given to the findings of radiographic pulpal calcifications (RPC). In the same texts detailed discussions of pulp biology extensively illuminated the pathological nature of calcific changes in the 34
Radiographic Pulpal Calcifications
Vol. 17, No. 1, Januaw 1991
CLINICAL P R A C T I C E S U R V E Y OF D I P L O M A T E S OF T H E A M E R I C A N B O A R D OF E N D O D O N T I C S Radiographic
Pulp~
CaiciRcationi
(RPC)
circle o n e a n s w e r per question 1.
D o y o u c o n s i d e r RPC a s a s i g n of p u l p a l p a t h o s i s ?
Yes
No
Yes
No
D o y o u i n c l u d e RPC f i n d i n g s in m a k i n g a differential diagnosis.
Yes
No
4.
Do y o u c o n s i d e r RPC a s a p o t e n t i a l o b s t a c l e to n o n - s u r g i c a l root c a n a l t r e a t m e n t ?
Yes
No
5.
Do you routinely attempt non-surgical treatment in t h e p r e s e n c e of m i n o r R P C ?
Yes
No
Do you routinely attempt non-surgical treatment e v e n w h e n RPC a p p e a r s to t o t a l l y o b s c u r e t h e p u l p chamber?
Yes
No
D o y o u i n f o r m t h e p a t i e n t (prior to t r e a t m e n t ) t h a t n o n - s u r g i c a l root c a n a l t h e r a p y m i g h t n o t s u c c e e d because of the RPC?
Yes
No
35
totally obscured the pulp chamber. The anticipated answer to this question was open to much speculation and was considered of fundamental importance. If a sizable number o f diplomates did not routinely attempt nonsurgical treatment in the presence of significant RPC, then a problem in perception of the successful nonsurgical treatability of such teeth would exist (13). SURVEY R E S U L T S
:2. D o y o u view RPC a s a n i m p o r t a n t f i n d i n g in clinical examination? 3.
6.
7.
8.
C i r c l e t h e p e r c e n t a g e of s p e c i a l i t y p r a c t i c e d e v o t e d to s u r g i c a l e n d o d o n t i c s . (circle closest one)
10
40
60
90
FIG 1. Survey mailed to 525 (domestic) Diplomates of the American Board of Endodontics.
D ~ I ....dSSsU,o ~ACT,CE ~IM,rEO '0 eN~DONTPCS 701 W U N I ~ ~ V A R 0 NTNL[~E~ PA 11011
Dear
Fellow
Diplomats,
I m trying to discover and quant i tare tile prevailing interpretation, among endodontic dtplomates, of tile radiographic findings of pulp calcification, and how i t might Impact on t r e a t m e n t . 311e e n c l o s e d envelope, viii complete. Please
do n o t
mirvey, with only take a sign
will be avatlabs
its few
self-addressed, mintlteg of your
the survey. I anticipate for publication,
tiler
stamped time to
the
data
Of 525 surveys mailed, 413 (79%) were returned. The results of the survey (Table 1) are shown, providing numerical counts with percentages. Responses to question 1 resulted in almost equal division between yes and no. There were also seven unanswered replies to this question, implying sufficient ambivalence made it impossible to make a choice. There was no other question that had such a large number of unanswered responses. The answers to question 2, which required a judgment as to whether a finding of RPC was important, resulted in 293 (71%) saying yes. The answers to question 3 were divided similarly to question 2:302 (73%) said yes to RPC findings being included in differential diagnosis. It seems, therefore, that RPC are usually included along with routine pulp tests, history, other radiographic findings, and clinical symptoms in arriving at a diagnosis. Thus, question 3 raised a similar issue to question 1, but more indirectly. It was of interest to note that the number of positive responses to question 3 increased 24% as compared with question 1. The replies to question 4 were surprising, since it was expected that this was the one issue upon which universal agreement would be found. Nonetheless, 352 (85%) said yes they considered RPC as a potential obstacle to nonsurgical root canal treatment and 58 (14%) said no. There were even three who could not answer yes or no. The positive responses to both questions 5 and 6 were remarkably in agreement, 374 (91%) and 391 (95%), respectively. There was an overwhelming sentiment that nonsurgical
Fllndtng, In p a r t , } t a b l~en provided by tlte R e s e a r c h Department, The A l l e n t o w n l l o s p t t a l - l,ehigh V a l l e y lloapital Center. Than~ you for
your
participation
in
the
TABLE 1. Tabulation of survey responses*
study,
Hovard S. F,elden, D,D.S.
Question
Yes
No
Unanswered
1
202t 49 293 71 302 73 352 85 374
204 49 118 29 109 27 58 14 39
7
391 95 384 93
22 5 28 7
2 3 4
5 6 ~,,l~ATIAMEm,CAN JO*ROO~EN~qCS
7
FIG 2. Cover letter included with survey to diplomates.
The questions asked were whether nonsurgical treatment was routinely attempted under the circumstances of the degree of calcification cited. The provision of only minor RPC in question 5 would lead one to expect almost universal selection of nonsurgical treatment. Question 6 specified RPC which
8
2 0 2 0 3 1 1
0 1
10%
40%
60%
90%
Unanswered
380 9--1
20 ~
0
9 2
4
9 Total surveys mailed equal 525. Total surveys returned equal 413 (79%). 1" Upper numbers are actual counts; lower numbers are percentages (all percentages rounded to closest whole number).
36
Selden
Journal of Endodontics
treatment should be attempted regardless of the extent of RPC (Fig. 3). The 384 (93%) who replied yes to question 7 was an 8% increase over the positive answers to question 4. It would suggest, therefore, that the positive responses to question 4 as to the potential for RPC obstructing treatment was possibly understated in the survey. The character of practice among diplomates was decisively revealed in question 8:380 (91%) devoted only 10% of their practice to surgery, 20 (5%) spent 40% on surgery, 9 (2%) 90% on surgery, and 4 (1%) left the question unanswered. An additional finding of interest was that the most common pattern of reply was to answer yes to questions 1 through 7. This remarkable concurrence, 113 (27%) of the surveys, was the only consistent pattern, all others were extremely random.
dontically treated, it can be suggested that the finding of RPC is objective evidence of a pulp at potential risk. Occasionally, endodontists are presented with patients who cannot localize their symptoms (Fig. 4). Experience may show that the finding of RPC when combined judiciously with other clinical and radiographic signs and symptoms (Fig. 5) is often a helpful clue as to the offending tooth. One might view the finding of RPC, after suitable pulp tests indicate pulpal disease, as visual confirmatory evidence of pulpal pathological change (Figs. 6 and 7). It might be thought that it was possible that three of the questions could have been misinterpreted. In question 2, RPC
DISCUSSION The most significant difference of opinion was whether RPC should be considered a sign of pulpal pathosis or not. It is understandable since many authors either ignore the finding altogether, understate its meaning, or caution that some calcifications are normal. In addition, the finding of RPC is almost ubiquitous and occurs in teeth otherwise free of radiographic pathosis or clinical symptoms. It seems that a combination of education and clinical experience has conditioned possibly 50% of the diplomates to downgrade evidence of RPC as a sign of pulp disease. It is probably noted on radiographs but not meaningfully incorporated in clinical diagnosis. This connection between calcific deposits and diminished health is not a unique finding in human tissues. The most highly publicized and potentially serious are the calcific deposits often found within the atherosclerotic plaques of coronary arteries (14). Even though millions of people with these plaques are probably free of symptoms and unaware of them, it does not mean the calcified plaques are benign and not a potential threat to their health. In regard to pulpal health, the same seems true of RPC. Although there is no basis for the position that all teeth with RPC should be aggressively endo-
FiG 3. Diagnostic radiograph of tooth 3 shows minor RPC and demonstrates symptoms of acute pulpal disease. To fully appreciate the extent of RPC in tooth 3, comparison with the significantly clear pulp chambers of adjacent teeth is helpful.
FIG 4. Diagnostic radiograph shows almost complete calcific obliteration of the pulp chamber of tooth 30. This finding, along with other positive tests for pulpal disease, helped determine source of severe pain unable to be localized by the patient. Subsequent root canal treatment of tooth 30 eliminated all symptoms.
FtG 5. Diagnostic radiograph of tooth 30 with symptoms of acute pulpitis. Extensive RPC seen in tooth 30 was very likely a pulpal response to both deep prior restoration and new carious lesion. Similar RPC in asymptomatic tooth 31 was initially considered "idiopathic,"--no caries, no restorations, and no history of trauma. Reexamination of tooth 31 with microscope-enhanced fiberoptic illumination revealed a crack, otherwise undetectable, in the buccal aspect of the mesiobuccal cusp, crossing diagonally. This crack could have provided the pulpal irritation leading to RPC formation. Since the pulp responded within a normal range to thermal and electrical tests, no treatment was recommended.
Voh 17, No. 1, January 1991
F~G 6. Diagnostic radiographs of teeth 2, 3, 30, and 31, of one patient, showing significant RPC and old amalgam restorations. For many years all teeth evidenced the same distressing symptoms: marked tenderness to percussion and elevated response to cold. Conclusion based on pulp test responses, clinical symptoms, and RPC findings was pulpitis in all four teeth. Root canal treatment w a s performed.
seems capable of being important for more than one reason. I r a respondent felt positively about one reason and negatively about another, he/she would be unable to honestly select yes or no 1o the question. It now seems obvious that the question could have been better worded. Questions 5 and 6 also seemed to have been cause for confusion. Some apparently understood the question to have asked whether RPC were "indications" to treat endodontically, and not, as intended, whether nonsurgical treatment was routinely attempted under the circumstances stated. Nonetheless, it seems possible to accept all yes responses as valid, since regardless of interpretation of the question a positive answer does accept the desirability of nonsurgical treatment. On the other hand, negative answers could have a double meaning: either nonsurgical treatment is not routinely attempted with a finding of RPC, or RPC are not an indication for root canal treatment. In this event the negative replies were few. Despite the flaws in these three questions, the survey did uncover a basic difference of opinion about the interpretation of RPC and revealed information about endodontic speciality practice. The astonishingly high percentage of returns would indicate that the survey technique among Diplomates of the American Board of Endodontics was a fruitful method to poll opinions and gather data. The ready willingness of large numbers to share their opinions should encourage further development of this technique.
Radiographic Pulpal Calcifications
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Fie 7. Reexamination radiographs 7 months after root canal treatment and cast restorations. Patient reported elimination of all symptoms and restitution of comfortable function. Funding, in part, has been provided by the Research Department, The Allentown Hospital-Lehigh Valley Hospital Center. Dr. Selden is a former clinical assistant professor, Department of Endodontology, Temple University School of Dentistry, is former chief, Dental Department, Allentown Hospital, Allentown, PA, and is a staff member, Dental Department, Muhlenberg Hospital, Bethlehem, PA.
References 1. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:10. 2. Ingle JI, Beveridge EE. Endodontics. 2nd ed. Philadelphia: Lea & Febiger, 1976:456. 3. Stafne EC. Oral roentgenographic diagnosis. Philadelphia: WB Saunders, 1958:63-5. 4. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 2nd ed. Philadelphia: WB Saunders, 1963:247. 5. Weine FS. Endodontic therapy. St. Louis: CV Mosby, 1972:83, 97-8. 6. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:291. 7. Ingle JI, Beveridge EE. Endodontics. 2rid ed. Philadelphia: Lea & Febiger, 1976:373-8. 8. Seltzer S, Bender IB. The dental pulp. Philadelphia: JB Lippincott, 1965:230-2. 9. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:275-81. 10. Weine FS. Endodontic therapy. St. Louis: CV Mosby, 1972:2t-56. 11. Ingle JI, Beveridge EE. Endodontics. 2rid ed. Philadelphia: Lea & Febiger, 1976:440-559. 12. Cohen S, Burns RC. Pathways of the pulp. St. Louis: CV Mosby, 1976:3-27. 13. Selden HS. The role of a dental operating microscope in improved nonsurgical treatment of "calcified" canals. Oral Surg 1989;66:93-8. 14. Cecil R. Textbook of medicine. 15th ed. Philadelphia: WB Saunders, 1979:1218.
