Clinical classification and presentation of pulp and periapical disease

Question 1

Apical constriction in apical vessels

Answer 1

Maintains pulpal vitality

Question 2

What gives rise to pulpal inflammation?

Answer 2

Bacteria and their by-products

Question 3

Signs and symptoms

Answer 3

Signs: what you can observe as a clinician
Symptom: what px complains about

Question 4

Diagnosing pulp and periapical disease

Answer 4

Px complaint
History of complaint
Clinical examination
Special investigations
-pulp tests
-periapical tests
-additional tests
-radiography

Question 5

Anatomical features unique to dental pulp

Answer 5

Unyielding walls: limited volume to accomodate pulpal swelling
Constricted blood source: intra-pulpal pressure increases, intereferes with blood and lymph flow
Tooth surrounded by bone: bone infection invariably results

Question 6

Pulpal diagnoses

Answer 6

Normal pulp
Reversible pulpitis
Symptomatic irreversible pulpitis
Asymptomatic irreversible pulpitis
Pulp necrosis

Question 7

Normal pulp

Answer 7

Pulp symptom free

‘Normal’ response to pulp testing e.g. cold testing results in mild or transient response of no more than 1 or 2 seconds

Question 8

Microbial products react with pulp

Answer 8

Caries involves dentine in a microbiological attack

Inflammatory response in pulp leads to focal pulpitis

Question 9

Causes of pulpitis

Answer 9

Caries (primary/ secondary)
Restorative intervention e.g.restorations, crowns etc.
Trauma
Tooth surface loss

Question 10

Pulpal inflammation and pain

Answer 10

Results in lower threshold to nerve pathway firing, resulting in pain to otherwise non-painful stimuli

Question 11

Reversible pulpitis

Answer 11

Reversibly inflamed pulp tissue
Discomfort to stimuli such as cold or sweet lasting a few s after removal of stimulus
Subjective diagnosis based on clinical findings and not related to histological status

Question 12

Symptomatic irreversible pulpitis

Answer 12

Irreversibly inflamed pulp tissue with associated symptoms
Subjective diagnosis that pulp is incapable of healing and endodontic treatment is required
Pain may be difficult to localise as inflammation has not reached periapical tissues

Question 13

Pain characteristics of symptomatic irreversible pulpitis

Answer 13

Lingering pain after removal of stimulus
Spontaneous
Keep px awake at night
Pain may be referred

Question 14

Asymptomatic irreversible pulpitis

Answer 14

Irreversibly inflamed pulp tissue without associated symptoms
Subjective diagnosis that pulp is incapable of healing and endodontic treatment required

Question 15

Microbial products react with pulp

Answer 15

If untreated, inflammation leads to pulp necrosis and invasion into resulting pulp space of microbes will lead to periapical pathology

Question 16

Pulp necrosis

Answer 16

Dental pulp necrotic & endodontic treatment indicated
Tooth is non-responsive to pulp testing and asymptomatic
Pulp necrosis by itself does not cause periapical periodontitis without presence of bacteria

Question 17

Events following pulp necrosis

Answer 17

Invasion of pulp chamber space by microbes
Development of ecosystem and formation of biofilm within root canal system –> infection!
Microbial toxins out; tissue fluids, inflammatory exudate, immune cells in

Question 18

Apical periodontitis =

Answer 18

Peri-apical periodontitis

Peri-radicular periodontitis

Question 19

Chronic =

Answer 19

Asymptomatic

Question 20

Acute =

Answer 20

Symptomatic

Question 21

Great majority of periapical periodontitis lesions are

Answer 21

Asymptomatic

Question 22

Periapical diagnoses

Answer 22

Normal apical tissues
Symptomatic periapical periodontitis
Asymptomatic periapical periodontitis
Acute periapical abscess
Chronic periapical abscess
Condensing osteitis

Question 23

Normal apical tissues

Answer 23

Tissues not sensitive to clinical testing

Radiographs show normal periapical tissues

Question 24

Acute periapical periodontitis

Answer 24

Inflammation spread to periapical tissues resulting in tenderness to p
Px able to localise source of pain to specific tooth
Radiographic changes may or may not be visible

Question 25

Chronic periapical periodontitis

Answer 25

Inflammation spread to periapical tissues, however, inflammation is low grade, presents with no symptoms
Radiographic changes appear as periapical radiolucency

Question 26

Acute periapical abscess

Answer 26

Inflammation of periapical tissues with pus formation and swelling
Rapid onset, spontaneous pain with extreme tenderness of tooth to p
Px may experience malaise, fever and lymphadenopathy
Radiographic changes may or may not be visible

Question 27

Chronic periapical abscess

Answer 27

Inflammation of periapical tissues with intermittent discharge of pus through associated sinus tract
Usually little or no discomfort
Radiographic changes usually appear as periapical radiolucency

Question 28

Condensing osteitis

Answer 28

Diffuse radiopaque lesion representing localised bony reaction to low-grade inflammatory stimulus usually seen at apex of tooth