Clinical Endodontics 1 Flashcards
1
Q
What is Endodontology?
A
Endodontology is concerned with the study of the form, function and health of injuries to and diseases of the dental pulp and periradicular region their prevention and treatment; the principal disease being apical periodontitis, caused by infection
2
Q
What is Endodontology?
A
A study of the continuum from the first changes in the pulp right through to development of a periodical abscesss
The study of how treatment intervention can influence this process
3
Q
Describe a normal healthy pulp
A
- Pulp horns are equal
2. Theres a good blood and nerve supply
4
Q
What happens when a carious lesion reaches the dentine ?
A
- You start getting inflammation in the pulp local to the lesion sight
- Pulp would start laying tertiary dentine
5
Q
Name the dentine that forms in response to an external stimulus
A
Tertiary dentine
6
Q
What effect does inflammation have on the pulp?
A
Pulp horns begin to shrink as dentine has been laid down
7
Q
Is the initial inflammation and formation of tertiary dentine irreversible or reversible?
A
Reversible
It can be cured if the caries is removed
8
Q
Describe dentinal tubules
A
Dentinal tubules are filled with fluid and this fluid moves creating a stimulus at the dentine pulp interface
9
Q
What happens to the pulp if the cause of the carious lesion isn’t removed?
A
Pulp chamber will get smaller as tertiary dentine is being laid down and Inflammation continues
10
Q
What happens to the pulp when it gets really inflamed?
A
As the pulp is encased in hard tissue so as the pulp gets more inflamed it expands increasing the pressure which causes pain
11
Q
What can happen if inflammation continues and isn’t cured?
A
The pulpal inflammation becomes irreversible and so whatever we do the pulp will die
12
Q
How so we establish the difference between reversible and irreversible pulpits in a patient?
A
Based on the patients symptoms
13
Q
What are the down falls of using symptoms to establish irreversible and reversible pulpitis
A
- Patients symptoms and the histology don’t always match
2. Not a precise science
14
Q
Give some symptoms of irreversible pulpitis
A
- Long duration, throbbing or aching pain
- Can be relieved by cold
- Very sensitive to hot
- Exacerbated by pressure
- Can be spontaneous
15
Q
Give some symptoms of reversible pulpitis
A
- Short duration
- sharp pain
- Sensitive to cold and sweet
- OK with hot
- Pain Only in response to stimulus
16
Q
How does inflammation cause damage to the pulp tissues?
A
As inflammation increases the pulp is also decreasing in size there’s less space for the inflamed tissue which causes damage
More pulp tissue is killed
17
Q
Which nerve fibres are the last to die in the pulp?
A
The C fibres
18
Q
Why do patients experience severe pain during irrevesible pulpitis?
A
A the C fibres are the last to die and they are the fibres that cause dull pain
19
Q
What does irreversible pulpitis ultimately lead to?
A
Pulpal necrosis
20
Q
What is interesting about multi rooted teeth having pulpitis?
A
One root canal may become necrotic but one may be completely viable
21
Q
One is it difficult to differentiate between irreversible and reversible pulpitis in must rooted teeth?
A
As patients may have one healthy and one infected pulp so the patient will present with confused symptoms
22
Q
What might patient feel when they are suffering from pulpal necrosis and why?
A
Patients may feel tenderness to being as sensitivity decreases as pulpal necrosis occurs
23
Q
Give examples of some sensitivity tests we can use to check pulp vitality
A
- EPT
2. Ethyl chloride
24
Q
What happens when pulpal necrosis occurs?
A
The tooth losses its blood and nerve supply and gives a negative response on an EPT
25
Can you regenerate the pulp after pulpal necrosis has occurred?
No as the pulp has no blood supply
26
When van pulpal recovery occur very rarely
Pulpal recovery can occur in paediatric cases where you can induce bleeding into the pulp releasing stem cells into the pulp chamber helping the pulp to reform
27
Is pulpal necrosis a quick process?
No it is a slow continuing process
28
What happens to bacteria once pulpal necrosis occurs?
Bacteria can thrive in the pulp as it is now dead so can't defend itself as no blood supply so no immune response
29
What is essential for periodical disease to progress?
Bacteria
30
What are the causes of periodical disease?
1. Bacteria
2. Viruses (rare)
3. Fungi (rare)
4. Archaea
31
Give examples of when pulpal exposure can occur without bacterial ingress
1. Trauma
| 2. Iatrogenic damage
32
How does periapical disease happen?
1. Starts off when the dead root is filled with bacteria and they produce toxins
2. Toxins leave the root via the apical foramen
3. Inflammation occurs at the end of the tooth (similar feeling as a bruise)
33
What is the first sign of apical inflammation?
Tender tooth
34
What happens at the apex of the tooth if inflammation continues
Starts to cause damage to the periodontal ligament
| Periodontal ligament tissue delves into inflammatory tissue
35
Name the 4 zones of inflammation of the periodontal ligament
1. Infected zone
2. Contaminated zone
3. Irritated zone (Established inflammation)
4. Simulated zone (starting to get inflammation)
36
What is the disadvantage of having a strong inflammatory response in reaction to bacterial toxins coming out of the apical foramen?
This inflammatory responses damage bacteria AND the host which can lead to bone loss around the end of the tooth
37
Other than bacteria what is a significant cause of peri apical disease
The bodies host response to bacterial toxins
| The bodies host response damages the periodontal ligament causing bone loss
38
How do we treat reversible pulpitis?
Remove caries to help the pulp recover
39
If we remove caries will the pulp heal itself if the patient suffers from irrevesible pulpitis?
no
40
Which mnemonic can e ruse to HELP us diagnose pulpitis?
SOCRATES
| BUT you need to listen to the patient and probe further and process the information they give you
41
What does SOCRATES stand for?
```
Site
Onset
Character
Radiation
Alleviation
Time course
Exacerbation
Severity
```
42
Give some pulpal Endodontics diagnoses we can come to
1. Dentine hypersensitivity
2. Reversible pulpitis
3. Irreversible pulpitis
4. Pulpal necrosis (Partial or total)
43
What is the biggest problem associated with Endodontic diagnosis
You can't see the tissue so we have to rely on patient symptoms
44
Name some periapical Endodontics diagnoses we can come to
1. Acute apical periodontitis
2. Chronic apical periodontitis
3. Acute exacerbation of chronic apical periodontitis
4. Chronic periapical periodontitis with suppuration
5. Periapical abscess
45
Give some clinical signs and symptoms of dentine hypersensitivity
1. Short very sharp pain on exposure to cold
2. Gingival recession
3. Exposed dentine
46
What results will a patient with dentine Hypersensitivity have to special tests?
Patient will be acutely sensitive to cold air and fluids
47
How do we manage dentine Hypersensitivity?
```
immediate:
OHI
Topical desensitising agents
Long term:
Monitor and restore if necessary
```
48
Give some clinical signs and symptoms of reversible pulpitis
1. Sensitive to hot and cold (cold usually worse)
2. Short duration
3. Sharp pain
49
What results will a patient with reversible pulpitis have to special tests?
Positive to sensitivity testing
| Exaggerated response to cold
50
How do we manage reversible pulpitis?
```
Immediate:
1. Temporary restoration
2. Desensitising agents
Long term:
Permanent restoration
```
51
Give some clinical signs and symptoms of irreversible pulpitis
1. Throbbing pain elicited by hot
2. Pain last minutes-hrs
3. Poorly localised initially
3. Pain can be spontaneous
52
What results will a patient with irreversible pulpitis have to special tests?
Positive response to thermal testing and EPT
Exaggerated response to heat
Some widening of PDL space seen on a radiograph
53
How do we manage irreversible pulpitis?
```
Immediate:
Pulp extirpation
Good analgesic advice
extraction
Long term:
Root Canal Treatment
Extraction
```
54
Give some clinical signs and symptoms of pulpal necrosis
Likely symptom free
| May be some discolouration
55
What results will a patient with pulpal necrosis have to special tests?
Negative response to sensitivity testing
| Widening of PDL may be present on a radiograph
56
How do we manage pulp necrosis?
In the long term:
Monitor
Root canal treatment
Extraction
57
Give some clinical signs and symptoms of Acute apical periodontitis
1. Acutely tender to bite on
2. Highly tender to percussion
3. May be high in occlusion
58
What results will a patient with Acute apical periodontitis have to special tests?
Negative to sensitivity testing
| Widening of PDL space may be visible on a radiograph
59
How do we manage Acute apical periodontitis?
```
Immediate:
Adjust occlusion
Access tooth and dress with Ca(OH)2
Long term:
Root canal treatment
Extraction
```
60
Give some clinical signs and symptoms of Chronic apical periodontitis
Symptom free but patient may suffer from occasional mild ache
61
What results will a patient with Chronic apical periodontitis have to special tests?
Negative to sensitivity tests
| Periapical radiolucency may be evident on a radiograph
62
How do we manage Chronic apical periodontitis?
In the long term:
Monitor
Root canal treatment Extraction
63
Give some clinical signs and symptoms of Chronic apical periodontitis with acute exacerbation
1. Dull throbbing pain
2. Tender to percuss
3 .Tender to palpate
64
What results will a patient with Chronic apical periodontitis with acute exacerbation ave to special tests?
Negative to sensitivity tests
| Periapical radiolucency evident on a radiograph
65
How do we manage Chronic apical periodontitis with acute exacerbation
```
Immediate:
Access the tooth and dress with Ca(OH)2
Long term:
Root canal treatment
Extraction
```
66
Give some clinical signs and symptoms of a Periapical abscess
Well circumscribed swelling
| Throbbing pain
67
What results will a patient with an Periapical abscess have to special tests?
Negative to sensitivity test
| May have a periapical radiolucency evident on a radiograph
68
How do we manage Periapical abscess
Immediate:
1. Access the tooth and dress with Ca(OH)2
Incise and drain
Long term:
Root canal treatment
Extraction
69
Define a normal pulp?
A clinical diagnostic category in which the pulp is symptom free and normally response to pulp treating
70
Define reversible pulpitis?
A clinical diagnosis based on subjective and objective finding indicating that the inflammation should resolve and the pulp return to normal
71
Define symptomatic irreversible pulpitis
A clinical diagnosis based on subjective and objective finding indicating that the inflamed pulp is incapable of healing
Lingering thermal pain, spontaneous pain and referred pain
72
Define asymptomatic irreversible pulpitis
A clinical diagnosis based on subjective and objective finding indicating that the inflamed pulp is incapable of healing
No clinical symptoms but inflammation produced by caries, caries excavation or trauma
73
Define pulpal necrosis
A clinical diagnostic category indicating death of the dental pulp
The pulp is usually nonrepsonsive to pulp testing
74
Define a previously treated tooth
A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obdurated with various fillings materials other than intracanal medicaments
75
Define a previously initiated therapy tooth
A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic treatment
76
Define what not apical tissue is
Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing
The lamina dura surrounding the root is intact and the periodontal ligament space is uniform
77
Define symptomatic apical periodontitis
Inflammation usually of the apical periodontium producing clinical symptoms including a painful response to biting and or percussion or palpation
It might to might not be associated with an apical radiolucent area
78
Define asymptomatic apical periodontitis
Inflammation and destruction of apical periodontal that is of pulpal origin appears as an apical radiolucent area and does not produce clinical symptoms
79
Define acute apical absces
An inflammatory reaction to pulpal infection and necrosis characterised by rapid of spontaneous pain tenderness of the tooth to press pus formation and swelling of associated tissues
80
Define chronic apical absces
An inflammatory reaction to pulpal infection and necrosis characterised by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract
81
Define condensing osteitis
Diffuse radiopaque lesion representing a localised bony reaction to a low grade inflammatory stimulus usually seen at apex of tooth
82
What is the purpose of root canal treatment?
To either maintain asepsis of the root canal system or to disinfect adequately by removing bacteria disinfecting the canal and then sealing it.
83
Why is root canal treatment difficult?
1. Canals are difficult to clean as they are very curved
2. Accessory canals
3. Multiple canals
84
When undertaking root canal treatment what should you make sure?
1. Make sure you have the correct diagnosis
2. Obtain appropriate consent and discuss with the patient (98% success rate)
3. Take a realistic assessment of restorability and longevity
85
Before starting your RCT treatment what must you do?
PLACE A RUBBER DAM
Use oraseal if require
Ensure the air way is protected
86
Why is rubber dam important for RCT?
1. To protect the airway
2. To prevent contamination of the canal by saliva
3. Protects patient against irritants being swallowed
87
Name the 4 main stages of RCT
1. Access
2. Chemo mechanical preparation
3. Obturation
4. Restoration
88
If you are carrying gout your RCT over several appointments what should you do?
Need to medicate the canal with calcium hydroxide or steroid based dressing
89
What is the aim of the access cavity?
Need to get reality to the canal without destroying the tooth
90
Before starting your access cavity what should you do?
You need to estimate the distance to the root of the pulp chamber and the the floor of the pulp
91
What do you need to remember in regards to the crown of the tooth and the roots?
They are not always aligned so make sure you line up your but to the largest part of the pulp chamber to avoid drilling out the side of the tooth
92
Go through the steps of forming an access cavity
1. With a high speed go through the roof of the pulp chamber
2. Then use an Endo Z burr and make sure you've removes all of the pulp chamber roof until you see all of the pulp chamber floor
3.
93
What is an Endo Z burr?
A safe ended burr
94
How would you access an incisor tooth?
1. Use a long tapered diamond burr and initially go through the cingulum into the dentine
2. Gradually change the angel of the bu more in line with the long axis of the tooth
3. When the pulp chamber is found extend the access cavity to remove the roof BUT maintain tas much of the tooth structure as possible incisally
95
Summarise what you need to do BEFORE starting your access cavity
1. Good isolation
2. Good magnification
3. Good pre op assessment
4. Knowledge of the anatomy
96
Summarise what you do when you are creating an access cavity
1. Remove the restoration to check restorability
2. Break through the roof of the pulp chamber
3. Remove the roof of he pulp chamber using a safe ended bur
4. Ensure that you can see all of the pulp chamber floor
97
How do we know we have been successful in creating your access cavity
We have removed a minimal amount of dentine to see the whole of the pulp chamber floor
Files are able to reach the root apex without bending beyond their limits
