LETTERS
procedure to be done on an outpa tien t basis; m any patients require close supervision and a m ed ically alert team to hand le p ossible opera tive and postoperative co m p lica tions. RON A LD JO H N SO N , D D S PH ILA D ELPH IA
Indirect pulp-capping □ Jordon, Suzu ki, and Sk in n er (The Jou rnal, July) have failed to take into accou nt a num ber of factors co n cern ing the alleged “ su cce ss” of “In d irect pulp-capping of carious teeth w ith periapical le sio n s.” T h ese points de serve further consid eration; — A “rad iographically d iscernible carious exposure” can not be co n sid ered as evidence of exposure in a s m uch as a judgm ent of a three-d im ension al ob ject cannot be m ade on the b asis of a tw o-d im ensional radiograph. — U nless the caries is first re m oved, it is not p ossible to know if you are in “ clo se proxim ity to the p u lp .” A sound layer of d en tin may be present betw een the caries and the pulp. — V itality testing on m u ltican al teeth is not d efinitive; one canal may have n ecro tic tissu e w hereas others can be at any stage from “ n o rm al” to degenerative. — Q uestionable preoperative rad iolu cent areas w ere evident in m any in stan ces in the radiographs il lustrating the article. T h is fact is further clouded by a lack o f radiographic standardization. G oldm an has show n that varying the angu la tion of the radiograph can lead to “reappearance of the lam ina d ura” and resolution of lesions. — “ S u cc e ss” in th is study is based entirely on the absence of pain. T h is is not a reasonable criterion in view of the in cid en ce of asym ptom atic necrotic pulps. — F ailu res were noted in all single-rooted teeth; “ su cce ss” was reported only w ith m andibular m o lars (w here cortical bone is thickest). Erosion of cortical bone is necessary before a rad iolu cen t lesion can be de tected.
— To say that “ conservative treat m ent (ind irect pulp capping of teeth w ith radiographic lesions) rem ains an im portant clin ical con sid eratio n ” seem s m islead ing w hen the authors dem onstrate “ su cce ss” in only 11 of 24 teeth (46% ). — O nly one of nin e teeth w ith sen sitiv ity to percu ssion was deem ed “ su cce ssfu l.” T h is criterion may be a better ind icator o f periapical in volvem ent than the radiograph. JE R R Y F . T A IN T O R , D D S, M S B R Y C E W. B O N N E S S , DDS G A RTH A. JA M E S , DDS LINCOLN , N EB
A u th o rs’ c o m m e n t : If it is true that judgm ent of a three-d im ensional ob je c t cannot be m ade by a tw o-d im en sional radiograph, then all of us in c lin ica l d entistry are in serious trou b le indeed, for there is n ’t a single c lin ica l d iscip lin e that does not rely heavily on ju d iciou s rad iographic in terpretation in arriving at a proper diagnosis. A lso, if it is true that the carious lesion s d escribed were not at least in clo se proxim ity to the pulp, then the associated p eriap ical lesions were nothing m ore than coin cid en tal arti facts— a d ifficu lt hypothesis to a c cept in view of the substantial num ber of cases observed. In fact, the sim ultaneous coex isten ce of deep carious lesion s in association w ith w ell-d efined periapical areas in sub stantial num bers is m ore than am ple
TO
THE
E D IT O R
evidence to support the con clu sion of a cause-and-effect relation sh ip. In any event, the fact rem ains that in 11 of 24 cases, the periapical lesions disappeared soon after conservative treatm ent and the teeth have re m ained c lin ica lly and rad iographi cally norm al for as long as nine years postoperatively. V itality testing of m u lticanal teeth m ay w ell be m islead ing becau se of the p ossibility that partially n ecrotic pulps w ill respond positively. T h is is why long-term observations m ust be m ade. It is con ceivab le that m any of our conservatively treated cases were involved in undetected partial n e crosis, but it is hig h ly u n lik ely that healing w ould occur in such cases. Consequently, the problem would probably m anifest itself clin ic a lly in tim e. T h is actu ally occurred in 13 of the 24 cases w ithin one year of co n servative treatm ent. In the other 11 cases, now follow ed up for as long as nine years, th e periapical lesions have disappeared. W e do not believe this w ould have occurred w ith par tially n ecro tic pulps. Regarding the preoperative ra d iolu cent areas, we in tentionally selected for p u blication the cases that illustrated the range of p eriap ical in volvem ent we actu ally observed, from slig h t (Fig 5 A) to m ore e xten sive (Fig 3A). Furtherm ore, the periapical lesions consisted of three w ell-d efined zones that inclu ded loss o f d efinition of the lam ina dura, a rad iolu cent area, and a surrounding area of osteosclerosis; all teeth illu s trated in the article clearly show this precise definition. M oreover, there was radiographic standardization. In all cases, a m inim um of three rad io graphs were taken at varied angu lations at all recall intervals as w ell as preoperatively. T h e ch an ces of a m istaken im pression of resolution were rem ote. S u ccess in our study w as clearly based not only on absence of painful sym ptom s, but also on a norm al c lin ical and radiographic assessm ent as evaluated over a long period. . . . W hen one consid ers the treatm ent al ternatives to the conservative ap proach, that is, eith er end od ontic therapy or extraction, the ch an ces of JADA, Vol. 97, October 1978 ■ 591
procedure to be done on an outpa tien t basis; m any patients require close supervision and a m ed ically alert team to hand le p ossible opera tive and postoperative co m p lica tions. RON A LD JO H N SO N , D D S PH ILA D ELPH IA
Indirect pulp-capping □ Jordon, Suzu ki, and Sk in n er (The Jou rnal, July) have failed to take into accou nt a num ber of factors co n cern ing the alleged “ su cce ss” of “In d irect pulp-capping of carious teeth w ith periapical le sio n s.” T h ese points de serve further consid eration; — A “rad iographically d iscernible carious exposure” can not be co n sid ered as evidence of exposure in a s m uch as a judgm ent of a three-d im ension al ob ject cannot be m ade on the b asis of a tw o-d im ensional radiograph. — U nless the caries is first re m oved, it is not p ossible to know if you are in “ clo se proxim ity to the p u lp .” A sound layer of d en tin may be present betw een the caries and the pulp. — V itality testing on m u ltican al teeth is not d efinitive; one canal may have n ecro tic tissu e w hereas others can be at any stage from “ n o rm al” to degenerative. — Q uestionable preoperative rad iolu cent areas w ere evident in m any in stan ces in the radiographs il lustrating the article. T h is fact is further clouded by a lack o f radiographic standardization. G oldm an has show n that varying the angu la tion of the radiograph can lead to “reappearance of the lam ina d ura” and resolution of lesions. — “ S u cc e ss” in th is study is based entirely on the absence of pain. T h is is not a reasonable criterion in view of the in cid en ce of asym ptom atic necrotic pulps. — F ailu res were noted in all single-rooted teeth; “ su cce ss” was reported only w ith m andibular m o lars (w here cortical bone is thickest). Erosion of cortical bone is necessary before a rad iolu cen t lesion can be de tected.
— To say that “ conservative treat m ent (ind irect pulp capping of teeth w ith radiographic lesions) rem ains an im portant clin ical con sid eratio n ” seem s m islead ing w hen the authors dem onstrate “ su cce ss” in only 11 of 24 teeth (46% ). — O nly one of nin e teeth w ith sen sitiv ity to percu ssion was deem ed “ su cce ssfu l.” T h is criterion may be a better ind icator o f periapical in volvem ent than the radiograph. JE R R Y F . T A IN T O R , D D S, M S B R Y C E W. B O N N E S S , DDS G A RTH A. JA M E S , DDS LINCOLN , N EB
A u th o rs’ c o m m e n t : If it is true that judgm ent of a three-d im ensional ob je c t cannot be m ade by a tw o-d im en sional radiograph, then all of us in c lin ica l d entistry are in serious trou b le indeed, for there is n ’t a single c lin ica l d iscip lin e that does not rely heavily on ju d iciou s rad iographic in terpretation in arriving at a proper diagnosis. A lso, if it is true that the carious lesion s d escribed were not at least in clo se proxim ity to the pulp, then the associated p eriap ical lesions were nothing m ore than coin cid en tal arti facts— a d ifficu lt hypothesis to a c cept in view of the substantial num ber of cases observed. In fact, the sim ultaneous coex isten ce of deep carious lesion s in association w ith w ell-d efined periapical areas in sub stantial num bers is m ore than am ple
TO
THE
E D IT O R
evidence to support the con clu sion of a cause-and-effect relation sh ip. In any event, the fact rem ains that in 11 of 24 cases, the periapical lesions disappeared soon after conservative treatm ent and the teeth have re m ained c lin ica lly and rad iographi cally norm al for as long as nine years postoperatively. V itality testing of m u lticanal teeth m ay w ell be m islead ing becau se of the p ossibility that partially n ecrotic pulps w ill respond positively. T h is is why long-term observations m ust be m ade. It is con ceivab le that m any of our conservatively treated cases were involved in undetected partial n e crosis, but it is hig h ly u n lik ely that healing w ould occur in such cases. Consequently, the problem would probably m anifest itself clin ic a lly in tim e. T h is actu ally occurred in 13 of the 24 cases w ithin one year of co n servative treatm ent. In the other 11 cases, now follow ed up for as long as nine years, th e periapical lesions have disappeared. W e do not believe this w ould have occurred w ith par tially n ecro tic pulps. Regarding the preoperative ra d iolu cent areas, we in tentionally selected for p u blication the cases that illustrated the range of p eriap ical in volvem ent we actu ally observed, from slig h t (Fig 5 A) to m ore e xten sive (Fig 3A). Furtherm ore, the periapical lesions consisted of three w ell-d efined zones that inclu ded loss o f d efinition of the lam ina dura, a rad iolu cent area, and a surrounding area of osteosclerosis; all teeth illu s trated in the article clearly show this precise definition. M oreover, there was radiographic standardization. In all cases, a m inim um of three rad io graphs were taken at varied angu lations at all recall intervals as w ell as preoperatively. T h e ch an ces of a m istaken im pression of resolution were rem ote. S u ccess in our study w as clearly based not only on absence of painful sym ptom s, but also on a norm al c lin ical and radiographic assessm ent as evaluated over a long period. . . . W hen one consid ers the treatm ent al ternatives to the conservative ap proach, that is, eith er end od ontic therapy or extraction, the ch an ces of JADA, Vol. 97, October 1978 ■ 591
