2. Diagnosis of pulpal and periapical pathologies

Question 1

What causes irritation to the pulp?

Answer 1

-Dental caries (bacteria )

-Dental trauma >cracks, fractures> bacteria

-Cavity preparation

-Bacterial leakage at the interface between tooth and restorations

-Exposure of dentine > bacteria

Question 2

what is dentine hypersensitivity?

Answer 2

quite prevalent and triggered by cold and hot drink sweets.

It tends to happen when the gum has receded or you’ve lost a considerable amount of enamel.

for example, if a patient had an acidic diet or gastric reflux, the enamel is going to be eroded away over time and we’ll be exposing the dentine leading to sensitivity

Question 3

what is the prevalence of dentine hypersensitivey?

Answer 3

quite prevalent. 15% of the population suffers from dentine hypersensitivity

More frequent in women than in men

triggered by cold and hot drink sweets.

Question 4

How does dentine hypersensitivity develop?

Answer 4

-Direct Innervation (DI) Theory

-Odontoblast Receptor (OR) Theory

-Fluid Movement/Hydrodynamic Theory

Question 5

what is the hydrodynamic theory?

Answer 5

There are changes in the direction of the flux of dentinal fluid within the dentinal tubules.

The movement of dentinal fluid leads to mechanical deformation and activation of the sensory nerve terminals of Aδ fibreslocated in close contact withodontoblasts

Question 6

What are the symptoms of dentine hypersensitivity?

Answer 6

Short, sharp pain provoked by hot and cold (mostly cold), acidic foods and drinks, sweet foods

the pain starts as soon as the stimulus is applied and disappears as soon as the stimulus is removed (may last a couple of seconds)

no medication needed.

Question 7

What are the causes of dentine hypersensitivity?

Answer 7

-Periodontal disease
-Periodontal treatment
-Excessive brushing or flossing
-Leaking restorations
-Cracked teeth
-Abfractions
-Erosions

Question 8

how do you a Exposure of dentine in the cervical area due to periodontal disease?

Answer 8

gingival graft

look at slide 18

Question 9

what is the prevelance of patients suffering from peridontisits?

Answer 9

The prevalence among patients suffering from periodontal disease is above 75%.

Question 10

can occlusal problems exacerbate periodontal problems?

Answer 10

yes, You often find together periodontal disease and occlusal problems

Question 11

What are other causes of sensitivity?

Answer 11

bruxism and tooth wear in general (not frequent). the tooth wears down and tertiary dentine forms, the pulp has responded to the aggressions hence not a frequency cause.

Question 12

why are Fillings, crown preparations are a frequent cause of dentine sensitivity?

Answer 12

bacterial leakage
dentine and tubules exposed.
can all lead to sensitivity.

Question 13

how does a cracked tooth lead to sensitivity?

Question 14

what do you do if the cracked tooth is below the gumline?

Answer 14

extraction if not as deep filling or cuspal coverage

Question 15

how can you identify if a patient has a crack on their tooth?

Answer 15

tooth slooth

Question 16

what is the Treatment of tooth cracks?

Answer 16

-Use the microscope to see them

-Warn the patients regarding prognosis of the tooth

-Check their depth

-Remove them if possible

-Prevent extension of the crack by placing an orthodontic band

-Make a composite filling

-Monitor the tooth for 6 months-one year (including periapical radiographs)

-Place a crown

Question 17

what is a frequent cause of pulpal inflammation and tooth pain?

Answer 17

Caries is a frequent cause of pulpal inflammation and tooth pain

Question 18

what do you do when a patient has reversible pulpitis?

Answer 18

Reversible pulpitis (tooth needs filling, dentine protection, pulp capping) >

sharp non-spontaneous Pain and triggered by cold and sweets (symptoms very similar to the dentine hypersensitivity)

Question 19

what do you do when a patient has irreversible pulpitis?

Answer 19

Irreversible pulpitis( tooth needs root canal treatment)
Pain is spontaneous and lingering and hot temperature will trigger it.

Pulp necrosis (tooth needs root canal treatment)

A. Necrosis of the pulp with normal periapical tissues (tenderness on biting sometimes)

B. Chronic apical periodontitis (tenderness on biting sometimes)

C. Chronic apical periodontitis with associated sinus (tenderness on biting sometimes)

D Acute periapical abscess > Pain

Question 20

what happens during a clinical examination?

Answer 20

-Inspection
-Palpation
-Percussion
-Periodontal probing

Question 21

what is palpation?

Answer 21

Palpation is a method of feeling with the fingers or hands during a physical examination. checking for tenderness.

Question 22

what is a Percussion test?

Answer 22

In the percussion test, the dentist is looking to replicate your pain on biting down. They will apply pressure the occlusal, or chewing, surface of the teeth, first with their finger and then with the handle end of an instrument.

Question 23

what are other special tests that can be done by dentists?

Answer 23

Thermal Test:
-Cold test: ethylchloride, dichlorodifluoromethane (DDM)
-Heat test: (heated gutta-percha)

Electric pulp test:

Periapical radiograph

CBCT radiographic images

LDF and Pulse Oximetry: Assessment of pulpal blood flow (unavailable in most surgeries and more often used only for scientific purposes)

Cavity test: Cavity preparation without anaesthesia

Question 24

are these clinical tests reliable?

Answer 24

None of these tests is totally reliable so the diagnosis of tooth pain is always an educated guess.

All of these tests make sense if you compare the response of the suspected tooth with the adjacent teeth and with the corresponding tooth on the other side.

Pain killers modify significantly the response to hot and cold tests (non steroid and steroid)

Question 25

what are the clinical symptoms and pain history of Reversible pulpitis?

Answer 25

Reversible pulpitis :
-The patients says that has pain

The pain is caused by cold, hot food or drinks, sweet food, fresh air.

The pain does not last for more than a few sec.

The patient never took pain killers for this

The pain has been there for a few weeks, even months sometimes.

The patient is often capable of identifying the tooth (or the teeth) that are the cause of the pain

Question 26

if the patient has Reversible pulpitis what will the clinical tests show?

Answer 26

Hot and cold test:
The pain appears as soon as the stimulus is applied and disappears as soon as the stimulus is removed (may last a few sec)

Electric test:
Lower levels of electric current elicit the response compared to contra lateral teeth

Percussion and Palpation: No tenderness

Examination of radiograph: caries or big filling close to the pulp. ( no periapical radiolucency)

Cavity preparation without anaesthesia:
the patient feels pain as soon as you reach the dentine and the pain disappear as soon as you stop drilling

Question 27

what are the clinical symptoms and pain history of irreversible pulpitis?

Answer 27

Irreversible pulpitis
The patients says that has pain
The pain is caused by cold, hot food, sweet food, fresh air and last for longer time.
Cold drinks may relieve the pain
The pain is often not provoked by any stimulus
The pain lasts for minutes, sometimes hours.
The patient took pain killers for this and they had some effect
The pain has been there for a few days
The patient is often not capable of identifying the tooth (or the teeth) that are the cause of the pain or indicate a tooth that is obviously not the cause of the pain, or indicate as the cause of the pain an area on the opposing arch.
The patient was awake at night with pain
The pain starts with some delay from the stimulus

Question 28

if the patient has irreversible pulpitis what will the clinical tests show?

Answer 28

Hot and cold test:
the pain appears often with some delay and stays there for 2-3 min or longer (hot test very painful please have anaesthetic ready)

Electric test:
lower levels of electric current elicit the response compared to contra lateral teeth

Percussion and Palpation:
little tenderness sometimes

Examination of radiograph:
caries or big filling close to the pulp.( but also widening of PDL and periapical radiolucency sometimes)

Cavity preparation without anaesthesia:
the patient feels pain as soon as you reach the dentine and the pain continues after stopping drilling (2-3 min or more

Question 29

what are the clinical symptoms and pain history of acute Periapical abscess?

Answer 29

acute Periapical abscess:
The patients says that has pain
The pain is caused by biting, swallowing, touching the tooth with the tongue
Cold drinks and hot drinks do not affect the pain
The pain is often not provoked by any stimulus
The pain lasts for hours
The patient took pain killers for this and they were not very effective
The pain has been there for a few days
The patient is perfectly capable of identifying the tooth that is the cause of the pain.
The patient was awake at night with pain

Question 30

if the patient has Acute periapical abscess what will the clinical tests show?

Answer 30

Hot and cold test:
no response

Electric test:
no response or response with very high levels

Percussion and Palpation
very tender

Examination of radiograph:
caries or big filling close to the pulp plus periapical radiolucency (but not always)

Cavity preparation without anaesthesia
not needed

Question 31

Apart from pulpal problems what are the other causes of tenderness to percussion of a tooth?

Answer 31

Periodontal disease (abscess)

Trauma from occlusion (radiographic aspect?)

Sinusitis

First or second molar may be tender when the third molar is erupting

Food impaction

Question 32

look at slide 70 and 71

Answer 32

summaries pulpitis