Diagnosis Flashcards
Describe signs and symptoms of clinically normal pulp
Asymptomatic
Produces mild and transient response to various stimuli
True nature and severity of response caries according to age and state of tooth
Cold test
* mild pain that last no more than 1-2 minutes (provided no calcification).
Percussion
* NTTP
Palpation
* NTTpal
Radiograph
* normal appearance
Describe histology of clinically normal pulp by Ricucci et al 2014
- No changes to dentin, predentin or odontoblastic process.
- Dentinal tubules runs parallel to each other through and dentin and predentin with no reduction in numbers
- No reduction in odontoblastic layer or odontoblastic cell size
- Tertiary dentin or other calcification absent
- No inflammatory cells, dilated blood vessels of bacteria present.
Describe signs and symptoms of dentine hypersensitivity
- Pain to thermal, chemical, tactile or osmotic stimuli on exposed dentine.
- Exaggerated response
- Severe and sharp pain on application of stimulus to exposed dentine
- Not lingering
Describe signs and symptoms of reversible pulpitis
- Mild inflammation
- Capable of healing once stimulus removed
- Sensibility test
- Pain when stimulus placed on tooth.
- Pain ceases within a few seconds or immediately upon removal of stimulus
- Short and sharp pain. Not spontaneous and not lingering
- Radiograph
- no significant radiographic changes to periapical region
cause of problem (caries, deep resto) may be evident. - Pain to biting suggest possibility of crack
- REVERSIBLE PULPITIS IS USUALLY A “PROVISIONAL DIAGNOSIS” AS IT IS IMPOSSIBLE TO BE COMPLETELY CERTAIN OF THE PULP’S ABILITY TO RECOVER. PREVIOUS PROBLEMS, PREVIOUS INFLAMMATION, DEGREE OF FIBROSIS, TRUE STATUS OF PULP. ETC CAN AFFECT ABILITY OF PULP TO RECOVER.
PROVISIONAL DIAGNOSIS CAN BE REVIEWED IN 3 MONTHS (HEALING MAY TAKE TIME OR NECROSIS TAKES TIME TO BE EVIDENT)
Describe histology of reversible pulpitis by Ricucci et al 2014
• Specimens with uninflamed and atrophic pulp present
• Atrophic pulp appears less cellular than in young healthy pulp with fewer fibroblast but greater amount of collagen bundles
• Odontoblastic layer may be flattened and reduced
• Islands of calcification maybe seen throughout the pulp tissue, with thick layer of tertiary dentin reducing the volume of pulp space.
• Evidence of moderate chronic inflammation in the coronal confined to the coronal pulp space
• Lymphocytes and plasma cells are seen to gather in moderate concentration in the deepest areas of caries penetration but does not obscure the normal architecture.
NO AREA OF LIQUEFACTION OF COAGULATION NECROSIS AND BACTERIAS ABSENT
Describe signs and symptoms of irreversible pulpitis
- Lingering pain induced by thermal stimuli. Only mild temperature changes required to induce pain.
- Very sharp pain to hot or cold stimuli
- Lingering pain for minutes to hours
- Dull or throbbing pain
- Spontaneous (unprovoked) pain
- Wake pt up at night, worsen when lying down.
- Difficulty in locating precise tooth that is the source of pain. This is due to extensive branching of dental nerve and fewer proprioceptive fibres in the pulp
ACUTE
- Sudden onset, wakes pt up at night
- Spontaneous pain with moderate to severe intensity
- Lingering pain in response to temperature change
- Intensified by posture change
- Analgesics rarely effective
- Tooth may be tender to bite pressure or percussion (indication of spread of inflammatory process to periapical tissues). Also possibility of crack
- Radiograph
- not very useful in diagnosis.
- useful for identifying cause
CHRONIC
- Similar signs and symptoms byt much less severe
- Pts complain of moderate pain, which is more intermittent than continuous
- Controlled by analgesics
Initially difficult to diagnose as no radiographic changes, as disease progresses to involve the periapical tissues, changes become more evident radiographically and clinically.
Describe histology of irreversible pulpitis by Ricucci et al 2014
- Either partial or total necrosis of coronal pulp.
- At least one area undergone liquefaction or coagulation necrosis surrounded by masses of live or dead polymorphonucler neutrophils (PMN)
- Concentration of chronic inflammatory cells (Plasma cells, lymphocytes and macrophages) forms a dense halo around the central zone of these abscess
- Bacterial aggregations/biofilms are observed colonizing the necrotic pulp tissue or the adjacent dentin walls.
Absence/presence of direct communication between caries cavity and pulp chamber was recorded.
Describe signs and symptoms of necrobiosis
- Has both inflamed and necrotic (usually infected) pulp tissue
- Presence of bacteria within the necrotic part of the pulp causes it to spread.
- Necrotic tissue may in the coronal portion of the pulp with inflamed tissue apically
- Mixture of signs and symptoms. Difficult to diagnose
- Symptoms may be mild with intermittent painful episodes over many weeks or months
- Sensibility test
mixed and frequently inconclusive or inconsistent - Radiograph
may have AP with evidence of widening PDL space which may be unexpected as pt reported sensitivity to hot and cold.
Describe signs and symptoms of pulpal necrosis
- No response to pulp sensibility test.
- History of past trauma, previous episodes of pain or history of restorations and caries important to assist with investigation.
- Radiograph
- may have signs (untreated caries, extensive restorations, previous pulp cap) and may not have signs (trauma)
- Trauma may cause pulp necrosis as a result of severing the apical blood supply if the tooth has been displaced from its normal position or if there has been significant damage and inflammation to the apical periodontal ligament.
- Radiograph
- no significant radiographic changes are evident unless periapical involvement, and this only occurs once the necrotic tissue becomes infected.
- Necrotic pulp per se does not cause apical periodontitis unless it is infected.
- Pain does not present unless PDL is affected.
- Pt may complain of occasional dull continuous ache, exacerbated by heat but relieved by cold. Reason is unknown but speculated that micro-organisms producing gases may infect the necrotic pulp and these gases contract with applications of cold water which relieves pressure on the nerve endings (nerve ending may be functioning in the apical portion)
- Relief from cold is usually temporary and pain returns soon.
Necrotic pulp acts as a source of nutrients for the bacteria to infect the necrotic tissue and render the tooth pulpless. This may occur within 1-2 months of the initial invasion by bacteria
Describe signs and symptoms of Pulpless and infected root canals
- Always infected
- Usually asymptomatic, although pts may give history of occasional vague discomfort over time.
- Pain may arise from periradicular tissues that becomes inflamed because of the presence of bacterial in the pulp space.
- Only clinical sign us the lack of response from pulp sensibility testing.
- Radiograph
- no changes in early stage, but within 2-10 months there will be radiolucency suggesting PA involvement.
- Radiographic periapical changes (bone resorption) usually takes 2-10 months to be evident even though necrotic pulp remnant is removed by bacteria within 1-3 months after invasion.
Describe Atrophy
- Normal physiologic process that occurs with age and is asymptomatic.
- Pulp sensibility test responses may be normal or delayed.
- Radiograph
- no obvious changes. Size of pulp chamber may be reduced.
Describe pulp canal calcification
- no symptoms if pulp tissue is normal, AP will develop if the canal is pulpless and infected.
- Usually no response to thermal test but EPT may elicit a normal or delayed response.
- Radiograph
- no evidence of the usual pulp chamber outline, root canal may appear narrow or may not be evident at all.
Describe hyperplasia
- Occurs almost exclusively in young teeth with abundant blood supply and a large carious lesion
- It is essentially an overgrowth of granulation tissue and may result in the development of a pulp polyp.
- Mild discomfort during mastication.
- Response to cold sensibility test but often with an exaggerated response to cold test.
- No significant radiographic changes unless AP present.
Describe internal resorption
SURFACE RESORPTION
- minor areas of resorption of the surface of the root canal wall.
- no clinical/radiographic signs
- no tx required
INFLAMMATORY INTERNAL RESORPTION
- can occur any point along the length of the pulp space
- Probably due to a metaplastic change or activation of dentinoclasts within the inflamed pulp tissue that is in contact with the coronal pulp which is necrotic and infected.
- usually asymptomatic and incidental radiographic finding
if symptoms are present, it is usually due to acute AP
apical portion usually vital and response normally to sensibility test
- as lesion progresses, pulp becomes necrotic and infected, and overtime pulpless and infected.
Radiograph
– oval shape, sometimes AP
INTERNAL REPLACEMENT RESORPTION
- uncommon condition where the pulp undergoes metaplastic changes and the dentine is resorbed and replaced by bone-like hard tissue
- usually asymptomatic and incidental radiographic finding
cause is unknown, NOT DUE TO BACTERIA
radiograph- irregular enlargement of pulp space filled with bone like tissue
- periapical changes usually do not occur with internal replacement resorption
Discuss treatment of inflammatory internal resorption
- Endodontic treatment
- Removal of blood supply to resorbing cells through the apical foramina
- Several caoh dressing required if lesion is active to ensure complete removal of all dentinoclasts and to encourage hard tissue repair on the external surface of the root if there has been a perforation.
Describe endodontically treated teeth
- Previously vital endo treatment (pulp cap, pulpotomy) assess if remaining pulp is healthy
- Previous endo treatment
- development of AP
- PA lesion could be true cyst, extra-radicular infection, foreign body reaction or periapical scar.
- PA lesion can take 2-5 years to heal (bystrom et al 1987)
- Root filling can be commented on over/under fill, over/under extension, mechanical problems such as fractured file, perforation should be noted.
