Diagnosis and management of pulpal and periapical disease Flashcards
What mechanical tests are there to examine pulpal/periapical inflammation
Palpation
Percussion
Periodontal probing
Describe the palpation mechanical test for pulpal/periapical inflammation
- Compare with contra-lateral side
- Negative response does not indicate the absence of inflammation
Describe the percussion mechanical test for pulpal/periapical inflammation
Positive response may be due to:
- Infected pulp
- Occlusal trauma
- Sinusitis
- Cuspal fracture
- Periodontal disease
- Inflammation at the apex
Describe the periodontal probing mechanical test for pulpal/periapical inflammation
- Wide pocketing is more likely to be a periodontal problem
- Narrow pocket is either a sign of a fractured tooth or could be where the infection from the root canal is draining like a sinus tract but through the periodontal pocket
What do indirect sensibility tests rely on to indicate +ve to -ve responses
They rely on stimulation of A-delta nerve fibres to indicate blood circulation within the pulp
What kinds of indirect sensibility tests are there
Thermal - Cold, Heat
Electrical
What are the differential diagnoses of a sinus tract and periodontal disease with sensibility tests
Periodontal = within normal limits
Endodontic sinus tract disease = no response
What are the differential diagnoses of a sinus tract and periodontal disease with periodontal probing
Periodontal = Wide pockets
Endodontic sinus tract disease = narrow tract
What are the differential diagnoses of a sinus tract and periodontal disease with the clinical status of the tooth
Periodontal = minimal caries
Endodontic sinus tract disease = evidence of caries, restoration
What are the differential diagnoses of a sinus tract and periodontal disease with the general periodontal condition
Periodontal = poor
Endodontic sinus tract = within normal limits
What are the examination procedures required to make an endodontic diagnosis
- Medical/dental history: past/recent treatment, drugs
- Chief complaint: how long, symptoms, duration of pain, location, onset, stimuli, relief, medications
- Clinical exam: facial symmetry, soft tissue, periodontal status, caries, restorations
- Clinical testing: thermal, electrical
- Periapical tests: percussion, palpation
- Radiographic analysis: new periodicals (at least 2), bitewing
- Additional tests: transillumination, selective anaesthesia
Describe the progression of soft tissue changes with pulpal disease
- Reversible pulpitis
- Irreversible pulpitis
- Hyperplastic pulp
- Pulp necrosis
What can reversible pulpitis be caused by
Transient and maybe due to either dental caries, erosion, attrition, abrasion, trauma or operative procedures
What are the symptoms of reversible pulpitis
- Pain does not linger after stimulus is removed
- Pain is difficult to localise (pulp contains nociceptive fibres not proprioceptor fibres)
- Teeth not tender to percussion
AY BAWS CAN I HABE DE NOTE PLZ
Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of reversible pulpitis
How does reversible pulpitis appear radiographically
Normal periradicular appearance
Describe the treatment of reversible pulpitis
- Either cover exposed dentine
- Remove the stimulus
- Remove the stimulus and restoring the tooth
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Antibiotics therapy is not indicated for irreversible pulpitis
What are the symptoms of irreversible pulpitis
- Pain can develop spontaneously
- Severe pain
- Pain lingers after stimulus is removed
- Response lasts from minutes to hours
- Pain to hot liquids received by cold
- Sometimes the pain may be accentuated by postural changes such as lying down or bending over
- Over the counter analgesics are usually ineffective
Why might irreversible pulpitis be difficult to diagnose
As the inflammation has not yet reached the periapical tissues, which would result in no pain or discomfort to percussion
- So dental history and thermal testing are usually used to assess pulpal status
- When periodontal ligament is involved pain becomes localised
How does irreversible pulpitis present radiographically
- Normal peri-radicular appearance
- In later stages, a widened periodontal ligament
What are the treatment options for irreversible pulpitis
- Root canal treatment or extraction
What is hyperplastic pulp and what is it caused by
- Form of an irreversible pulpitis known as a pulp polyp
- Due to proliferation of a chronically inflamed young pulp tissue
What are the treatment options for hyperplastic pulp
- RCT
- Extraction
What is pulp necrosis and when does it happen
- Occurs at the end of an irreversible pulpitis
- Pulp becomes non-responsive to pulp testing and is asymptomatic
Why might some teeth be non-responsive to pulp testing
Due to calcification, recent history of trauma or simply the tooth doesn’t respond
- all testing must be comparative e.g. the patient may not respond to thermal testing on any teeth
What are the treatment options for pulp necrosis
Root Canal Treatment or Extraction
What hard tissue changes can occur with pulpal disease
- Pulp calcification
- Resorption
Describe physiological secondary dentine
- Formed continuously after tooth eruption and root formation
- Deposited on the floor and ceiling of pulp chamber rather than walls
- with time can result in occlusion of pulp chamber
When is tertiary dentine laid down
In response to environmental stimuli:
- reactionary dentine response to mild stimuli
- reparative dentine response to strong noxious stimuli
What is the link between pulp inflammation and resorption
Pulp inflammation occasionally caused resorption of the dentine by dentinoclast cells:
- clinically a pink spot can be seen
- a punched out lesion continuous with the rest of the pulp cavity can be seen
What are the treatment options for internal dentin resorption caused by pulp inflammation
RCT
If resorption is too advanced then XLA
What are the clinical features of cracked vital teeth
- Sharp pain on biting or release, occasional pain from cold
- Difficult to localise
- Tooth slooth, staining, transillumination (diagnosis?)
- More common in mandibular molars, especially 2nd molars
What are the treatment options for cracked vital teeth
RX Ortho band/Cu band/temp crown then progress to cusps coverage restoration
What are the clinical features of cracked non-vital teeth
- Dull ache on biting
- Teeth not tender to percussion (TTP), narrow perio pocket adjacent to fracture
- Radiographically halo, J shaped diffuse lesion surrounding the root
What are the treatment options for cracked non-vital teeth
RX
XLA/consider hemisection
What are the clinical classifications of peri-apical disease
- Acute apical periodontitis
- Chronic apical periodontitis (+/- acute exacerbation)
- Apical periodontitis with and abscess (chronic/acute)
- Apical periodontitis with a sinus tract (Acute/chronic)
What is acute apical periodontitis and what is it caused by
Periapical inflammation caused by:
- Traumatic occlusion
- Bacteria/toxins from infected/necrotic pulps
- Overinstrumentation
- Extrusion of irrigants or materials during RCT
What are the clinical features of acute apical periodontitis
- The tooth is tender to biting
- Tooth sensibility tests +ve/-ve
- Can be tender to palpation
What does acute apical periodontitis show radiographically
No change or could have widening of the PDL
What is the treatment for acute apical periodontitis
- RCT
- XLA
What is the presenting complaint (PC) of chronic apical periodontitis
Nil or moderate/severe pain (acute exacerbation)
What is the common History of Presenting Complaint in patients with chronic apical periodontitis
- Previous pain
- Recent restoration in the tooth
- RCT been carried out
What are the diagnostic tests for chronic apical periodontitis
-ve to tooth sensibility tests
May be TTP (teeth not tender to percussion) and/or tender to palpation
What are the radiographic findings for chronic apical periodontitis
Widening to an apical radiolucency
What are the treatment options for chronic apical periodontitis
- RCT
- XLA
How does the trabecular bone respond to irritation radiographically
Shows concentric radiopaque around the root
If a patient comes in with what symptoms do they need to go to A&E
- Patient is pyrexic
- Limited opening
- Difficulty swallowing
- Large swelling such as surrounding near the eye and crossing midline under the chin like for instance signs of ludwigs angina
- Patient needs to go to A&E and be admitted to max fax for IV antibiotics and their care and management
Give examples of things that can cause pain that mimic acute odontogenic pain
- Trigeminal neuralgia, MS
- Cancer, osteoarthritis
- Rheumatoid arthritis
- Facial arthromyalgia
- Migraine
- Tension headache
- Bruxism
- Allergic/bacterial sinusitis
- SCA
- Herpes zoster
Where else might you see radiographic lesions that you may mistake to be of endodontic origin and how can you avoid making this mistake
- Mental foramen
- Nasopalatine foramen
- Maxillary sinus
Normal vitality tests and radiographs at different angles will reveal lesion is not so closely associated with the root
Name some materials that are used to maintain pulp vitality
- Calcium hydroxide
- MTA
What is the mode of action of calcium hydroxide when used to maintain pulp vitality
- Antibacterial on wound surface
- High pH
- low grade irritation from the coagulation necrosis produces hard tissue barrier
- Releases growth factors from dentine matrix to signal cellular response for pulpal repair and dentine bridge formation
What is Mineral Trioxide Aggregate (MTA) composed of
- Portland cement (75%)
- Bismuth Oxide (20%)
- Calcium sulphate (5%)
What does Mineral trioxide aggregate (MTA) do to help maintain pulp vitality
- Antimicrobial and biocompatible
- Releases growth factors from dentine matrix to signal cellular response for pulpal repair and dentine bridge formation
- Good seal
What are the treatment options for reversible pulp damage
- Indirect pulp capping
- Direct pulp capping
Describe indirect pulp capping treatment for reversible pulp damage
Where infected softened carious dentine removed and leave a layer of leathery type non infected dentine over the pulp:
- Wash dry cavity
- Calcium hydroxide (setting)/MTA placed
- Restore and review
Describe direct pulp capping treatment for reversible pulp damage
Where pulp is exposed through non-infected dentine and has no recent history of spontaneous pain:
- Wash area with sterile water and arrest bleeding
- Place calcium hydroxide/MTA
- Restore with a bacteria tight seal
- 1 year later check radiographically and also tooth sensibility tests
Name some treatments for irreversible pulp damage
- Pulp amputation
- Pulpectomy
Describe a pulp amputation (pulpotomy)
Part of exposed inflamed pulp removed and preserves remaining pulp e.g. incomplete root formation is exposed.
Damaged tissue is removed using a high speed bur under cooling with sterile water/saline
Bleeding is arrested and covered with calcium hydroxide and restored and tooth monitored
What types of pulp amputations (pulpotomy) are there and why are they different
Superficial damage - partial pulpotomy
Involves coronal pulp - coronal pulpotomy
Describe a pulpectomy
Total pulp removal which is followed by root canal treatment
When pulp is irreversible damaged or when pulp cavity is needed for retention of a restoration
Describe the sequence treatments that lead to endodontic treatment
- Emergency treatment to deal with symptoms
- Extraction of unsalvageable teeth
- Dental caries stabilised
- Preventive regime including periodontal therapy
- Then endodontic treatment can be carried out as the patient is more stabilised
What are the indications for RCT
- Planned on teeth that are functionally and aesthetically important and have a reasonable prognosis
- Irreversibly damaged/necrotic pulp with or without clinical and or radiological finding of apical periodontitis
- Elective devitalisation
What are some contraindications for RCTs
- Teeth that cannot be made functional or restored with limited ferrule effect
- Teeth with insufficient periodontal support
- Teeth with poor prognosis like with extensive external/internal resorption, extensive vertical fractures
- Patient is unable to tolerate rubber dam
- Complex anatomy
- Uncooperative patients or patients where dental procedure cannot be undertaken (limited opening/rubber dam cannot be placed)
- Teeth of patients with poor oral condition that cannot be improved within a reasonable time
What treatment routes need to be evaluated when considering an RCT
Endodontic
Restorative
Periodontal
How do you assess the restorability prior to endodontic treatment
Ferrule Effect:
- 2mm dentine axial wall height
- Parallel axial walls
- Metal must totally encircle tooth
- Must be on solid tooth structure
- Must not invade biological width
- Need approx 5mm height of supra bony tooth structure
What do you do if there isn’t enough tooth left
Consider:
- crown lengthening
- XLA - accept the space with denture, bridgework or dental implants
Why are root filled teeth weaker
- Loss of tooth structure
- Wider the isthmus, loss of marginal ridge
- Loss of roof of pulp, more cusp flexure more prone to fracture
Altered physical properties: - Moisture loss, difference in collagen
Loss of proprioception: - Randow and Glantz 86, load root filled teeth x2 than vital teeth
What non vital teeth are most likely to fracture
Maxillary teeth more than mandibular teeth
Second molars > premolars
How do we make sure anterior root filled teeth don’t fracture
They don’t necessarily need crowning and should be ok, better that teeth with posts there so fook it really
What requirements are there for post placement
- Minimum length of 4-5mm of Gutta Percha
- No space between post and GP
Other considerations: - Post length = to length of crown or 2/3 root length
- Ideally at least an equal amount of post below and above the alveolar crest
What is the function of posts
Retention - they don’t strengthen the roots
What factors of a post will provide more retention
If the post is :
- Longer
- Parallel sided rather than tapered
- Roughen surface
- Threaded post more than other surface
Self threading posts should be avoided
What kinds of posts are there
Direct/Indirect
Metal/Fibre
What kinds of fibre posts are there
- Composite - C-fibre, silica fibre, light transmitting posts, ribbon fibre materials
- Ceramic (zirconium oxide)
What is a nayyar core for root filled teeth
When amalgam is used to fill the root chamber i think hmmmmmm
If marginal ridge is missing after RCT what should be done
On posterior teeth will need cusp coverage if the marginal ridge is missing
