I k a r Sir, I enjoyed reading I l r Tony Martln’s letter in the last Neitdetter

regarding changes to endodontic terminology. The science of endodontics is continually being refined, with old bcliefi being discarded as research “shows us the way”. This I-efineinent should also hold true for terminology, and, to that end, I support further efforts to fine tune our vocabulary.

My little contribution to the debate relates to the “pulp vitality” description. While I an1 not necessarily against the use of “pulpal stimulatory response”, I feel that a simpler approach may be better. Some years ago at an endodontic course, I heard

the term “pulp viability”. After all, is this not the purpose of pulp testing - to determine whether or not the pulp tissue is viiible; that is, able to survive?

The clinical decision that needs to be made is “does this tooth require l<CT?”, and the term “pulp viability testing” slots nicely into our diagnostic vocabulary.

Kind regards,

Dr Derek J. Lewis 6 Cinderella Drive,

Springwood, Qld. 4127

Reply to Drs Abbott and Lewis

Ilear Sir, Please be assured that my modest venture into the area of

endodontic terminology was never intended to shatter your editorial virginity with the bane (or delight) of any editor, controversy. My response is largely i n the context that pot- stirring beats empty pages, but hopefully in a way th:tt does not cast me as provoc.iteur. Maybe, like a symptomatic tooth it is over-responsiveness, but the following has turned somewhat into a position paper or a monograph and niy self-justification for being so indulgent is that what is being presented represents the essence of what distinguishes endodontics from endo- dontology. Thank goodness I could be comforted1 by some supportive sentiments from I l r Lewis to ameliorate the clob- bering of a score of one,‘tjury still out” and two,“thurnbs down” from I l r Abbott regarding my three proposals.

The ultimate answer one seeks in the set of diagnostic procedures traditionally identified as vitality testing, IS whether there is a viable vasculature within a tooth. If there is, the question then devolves to whether it is in such a disturbed and departed-from-normal st;ite that it cannot recover by us either providing appropriate help in the form of removal of a presumed cause of irritation (with or without subsequent sedative dressing), or doing nothing and simply giving (more) time for a pulp to make its own therapeutically unaided recovery?

Now one of the less applied but nevertheless trditionally listed pulp tests, but in my view the one with the most absolute authority, is the test cavity. I have always been a local anaesthesia mininialist, in th.it I never open into a tooth diagnosed (provisionally) as pulpally necrotic, or pulpless, and especially post trauma, that has been electively anaesthetised. It is salutary what percentage of teeth that have failed all conventional pulp tests, but will not tolerably allow further cutting onct- entry has reached subgingival levels. This particularly applies to teeth with calcifically obliterative or accelerated maturational changes within the coronal chamber space. Such teeth would be unlikely to pass even Laser Doppler flowmetry or Oximetry testing. Sometimes, for exaniple when post restoration is inescapable, an

injection is then given and when pulp is duly encountered and extirpated, it is pale pink in appearance and of intact rubbery texture. One does not need histological facilities to make, an admittedly crude, diagnosis of normal pulp. In the former situation howrver, this “hte in the event” report of sensation from the patient means one then has the opportunity, and I say the obligation, to re-think one’s diagnosis - hopefully before the integrity of the pulpal space has been macroscopically breached. At this juncture, a long shank explorer with a dob of etching gel on its tip, introduced to the deepest aspect of the access cavity. can relay an electric pulp test to a much receded pulp when the probe shaft is touched by the stimulating electrode. Usually one obtains a positive response in such teeth, whereupon one desists from further endodontic entry, restores the cavity in a suitable way and goes back to the diagnostic drawingboxd. I niust again stress that this ultimate monitor of the real necessity of .in intended KCT is lost if local anaesthetic is given either as ‘I

routine (regrettable in my view), or because the operator is not prepared to devote some time to educate the patient out of ‘1 preference for it on their part, a t least for the time being, until the definite need is established rather than presumed.

This above sort of scenario represents the dedicated and conservative end of the spectrum of vitality testing and I readily concede that it applies only to a small proportion of teeth. The vast majority just require a strongly suspected vitality (or lack of it) situation to be verified in support of a range of other adverse signs or symptoms, so that treatment can be got under way.

If Laser I l F or Oxinietry were to join the list of test modalities, “vitality” should arguably return to favour, as no stimulus is being applied. In criticism of niy own suggested PSI< expression, “responsiveness” automatically implies stimulus, so the “stimulatory” could be dropped. Then the debate devolves to a choice between the single words “responsiveness” or “sensibility” or as advanced by Dr Lewis,“viability”, which more than the first two may well be more appropriate in discerning between “reversible” and “non-reversible” pulpitis, as that latter term carries a certain inherent predictive element. Here our personal judgement should take second place to the tooth itself having every opportunity to make the verdict. So except i n those cases of severe non-short-term pain, an ideal approach IS

AUSTRALIAN ENI)OL)<)NTIC NEWSLETTERVOLUME 2 2 No. 2 JULY 1996 39

to be seeking ways to help a pulp by temporary dressing and elimination of cause. If a tooth is already full-crowned, there may not be much scope for this sort of help. In teeth less-restored, the physical encountering of pulp exposure will mean the situation virtually self-categorises for devitalisation and KCT. But it can be surprising the number of pulps, which at the time of the presenting pain-problem might be written off because of severity of chronicity (ie, time context) of the pain, that can make a comeback if we simply be kind to them - and in the non-exposure context here I see definite usefulness in Ledermix Cement (not paste).

In Dr Abbott’s second paragraph he claims that my proposed (PSR) term “more accurately describes the test procedures”. Not so; my suggestion is procedurally non-specific. I was and am only concerned with terminology focusing our interpretive faculties in diagnostically beneficial ways. H e points out that “pulp sensibility” has been in use for eight years. I submit that a more correct statement would be availablefor use; its adoption has by my reckoning been minimal, and my belief as to why is basically as per my original letter.

As for l l r Abbott’s contention that “vital” and “non-vital” should be expunged, I would hope that the clinical approach outlined above would make at least somewhat of a case for them to be spared. To use such a dualistic distinction to exclusively determine intervention is too simplistic, but in my view these expressions are not useless, much less are they harmful. He goes on to berate the historic use of “hyperaemia” because it is intrinsically describing something that cannot be assessed, namely increased blood supply. Whilst I agree with this position at the pre-entry diagnostic level, it is a good descriptive word for that pulp which when entered bleeds profusely and can often constitute quite a haemorrhage-control problem. To discard “hyperaeniia” for reasons often advanced (but not in this instance by I l r Abbott) of it being a histologic term and then replace it with a range of “pulpitis” conditions is a fundanient- ally flawed philosophy. So if we’re to be so pure as to avoid “hyperaeniia”, would not consistency dictate that the various types of pulpitis should go out the window with it?

O f the five other ternis that Dr Abbott advises have officially replaced “non-vital”, none are in conflict with my preference for “pulpal stiniulatory responsiveness” as the characteristic we seek to be informed of to help establish a tooth’s internal good- or ill-health.

1 suppose in the final analysis the intention of gaining proof of vascular activity by neural information might never be absolutely fulfilled. But let’s face it, the two go hand in hand in the vast majority of cases. I t therefore boils down to dentist- interpretation, where error can be kept to a minimum firstly by adopting the broadest range of tests and not just depending on one or even two; and secondly by operator open-mindedness. The rare example of a tooth with pulpal necrosis giving a false positive response is perhaps the main reason for abandonment of the term “pulp vitality”, but substitution of other labels won’t

overcome that. But if it must go, Dr Lewis’s “pulp viability” is in my view better than “vitality”, except that both have a degree of prognostic content, which could be erroneously presumptive. “Sensibility” and “responsiveness” however are both stimulation- reportive, and Dr Abbott and I concur on this being the prime purpose of the term. So we’re left with a choice of the single word “sensibility” or the double word “stimulatory respon- siveness”, which as Dr Abbott points out are by Webster’s definition fairly synonomous. Does it not therefore boil down to a question of semantic preference on the one hand versus expression being more intrinsically descriptive on the other? Whilst conceding the closeness of the contest, I remain marginally in favour of the PSR (now reduced to PR); but if turning back the clock of progress by eight years is the price that would be paid, I defer to l l r Abbott’s defence of “pulp sensibility” and Dr Lewis can perhaps commiserate with me that our respective flags are at half-mast, but not totally down.

In Dr Abbott’s objection to “periapicitis” - even if the other five modalities of testing apart from percussion, are utilised, one still cannot state that inflammation exists at a periapex. But the probability for diagnostic purposes would surely have to be conceded as strong, and of the several tests and signs that one might take notice of in arriving at that (presumed) conclusion, tenderness to percussion surely dominates the field. So I hold to my contention that if that characterisitic of percussive tenderness is the most relevant yardstick for indicating a likely inflammatory condition at or near the apex, why resile from using my suggested expression? I t is a no more impure use of an “itis” expression when we don’t have a stained tissue section under a microscope, than is “pulpitis”, which Dr Abbott is able to condone.

Finally with “trabecular obliterative osteosis”, I think that I l r Abbott had dug himself into such a mode of objection with my first two expressions that it simply spilled over onto this third one! His point of TOB being unacceptably close to another Frances Andreasen term TAB is unarguably correct, but fortunately the acronym for my expression is “TOO’; it was a printing (on my part) error that caused the TOB notation and I formally hereby declare it corrected. In pointing out that “osteosis” is a general term implying some form of pathology of bone, he is precisely outlining niy main reason for proposing its adoption. The condition is vague, and just how “diseased” the bone actually happens to be, whilst debatable, is certainly on the minor scale of the pathology spectrum.

I thank Drs Abbott and Lewis for their interest and preparedness to respond and hope that this area of discussion has at least advanced endodontologic consciousness, even though it may not (yet) have rewritten part of the dental dictionary.

Dr A.P. Martin 183 Macquarie Street,

Sydney, NSW 2000

40 AUSTRALIAN ENDODONTIC NEWSLETTERVOLUME 22 No. 2 JULY 1996