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Pulpal disease > Diagnosis of pulp and periapical disease and special investigations > Flashcards

Diagnosis of pulp and periapical disease and special investigations Flashcards

1
Q

Diagnosis of endodontic disease

A

Endodontic diagnosis like jigsaw, cannot be made from single piece of info
Careful history followed by thorough examination should lead to preliminary diagnosis
-in some cases this is inconclusive or give conflicting results –> no definitive diagnosis
Treatment should not be undertaken without diagnosis
-pxs may have to wait and be reassessed at later date

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2
Q

Pattern of diagnosis

A 
Px complaint
History of complaint
Medical history
Dental history
Clinical examination
Special investigations
Diagnosis
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3
Q

Patient complaint

A

Listen carefully to what px tell you

-often you have good idea of diagnosis before you look in mouth

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4
Q

History of complaint

A 
When did you first notice problem
Continuous or intermittent?
Are there any initiating or relieving factors?
Getting worse or staying same?
Where is problem?
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5
Q

History of complaint (specific to pain)

A 
Location
Initiating or relieving factors
Character
Duration
Severity
Spread/ radiation
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6
Q

Medical history

A

General medical history
Medical history relevant to complaint
-drug history (analgesics, antibiotics, bisphosphonates)
–>careful extracting pxs taking bisphosphonates, may get necrotic jaw

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7
Q

Dental history

A

Has any treatment been initiated?
Has any treatment provided given relief from symptoms?
What is time course for treatment provided?
Does px’s reported dental history match with clinical findings?

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8
Q

Examination

A 
Extra-oral
-TMJ
-Lymph nodes
-Any signs of extra-oral pathology?
Intra-oral
-Soft tissues
-Occlusion
-Periodontal examination (BPE, 6 point probing chart)
-Dental hard tissues
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9
Q

Intra-oral exam soft tissues

A 
General soft tissue exam
-tongue
-palate
-floor of mouth
-buccal mucosa/ sulci
Specific to tooth
-presence of swelling or sinus
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10
Q

If swelling is bony hard

A

Cyst or tumour

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11
Q

If swelling moves

A

Acute abscess

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12
Q

Occlusion

A

Are there any aspects of occlusion relevant to symptoms?
-check for fremitus (tooth movement in occlusion)
-check contacts in ICP
-check first contact in centric relation
-check excursions (lateral and protrusive)
Ideally, contacts should be even, without excessive forces on individual teeth

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13
Q

Occlusion with teeth with acute apical abscess

A

May become raised occlusally due to build up of p resulting in extreme tenderness on biting and high occlusal contact

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14
Q

Periodontal examination

A

General periodontal examination
-BPE
-6 point probing if indicated if codes 3 or 4
Specific periodontal examination
-walk probe around entire gingival margin of tooth in question
-assess level of attachment loss, if present
-check for isolated deep pocket - highly indicative of vertical root fracture
-mobility

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15
Q

Vertical root fracture

A

J shaped lesion

Hopeless prognosis - tooth requires extraction

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16
Q

Mobility

A

Mobility of tooth may indicate:
Periodontal bone loss
-loss of periodontal support may indicate generally poor prognosis for tooth
Presence of apical bone loss resulting in reduced bone support
-if periodontal support satisfactory, mobility should improve following resolution of apical pathology

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17
Q

Miller’s grading system

A 
Mobility
Grades 1, 2, 3
1: <1mm
2: in between
3: >2mm
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18
Q

Dental hard tissues

A 
Full dental examination
-caries
-restorations (failing, recently placed)
Specific tooth examination
-as above and check for tooth discolouration
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19
Q

Tooth discolouration

A

Can be split into 2 groups (from endodontic aetiology)

  • yellow/ cream discolouration: due to deposition of tertiary dentine resulting in thicker dentine tissue and reduced light transmission (tooth may be vital or non-vital)
  • grey/ black discolouration: due to pulpal blood products staining dentine (tooth generally non-vital)
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20
Q

Special investigations

A

Pulp tests
Periapical tests
Additional tests
Radiography

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21
Q

Pulp test definitions

A

Sensibility test
-tests ability to respond to stimulus
-assessment of pulp’s nerve supply
Vitality testing
-test whether pulp is vital i.e. has functional blood supply
Note: pulp tissue may have adequate vascular supply, but is not necessarily innervated

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22
Q

Pulp tests examples

A

Sensibility tests: cold, heat, electric
Vitality tests:
-pulse-oximetry
-laser Doppler flowmetry

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23
Q

Do nerves die with destruction of pulp tissue?

A

Nerve fibres can maintain structural identity even in advanced stages of pulpitis where there is considerable destruction of other components of pulp tissue
-may give +ve response to pulp testing

24
Q

Aδ fibres

A

Pain, temperature, touch

25
Q

C dorsal root

A

Pain

26
Q

Character of pain

A

In dental pain the sharp, rapid pain is probably reaction of Aδ fibres, which extend into dentine, to external stimuli
Achy, dull pain probably associated with deeper slow-reacting and high threshold unmyelinated C-fibres
-indicative of pulpal inflammation

27
Q

Sensibility tests: cold

A 
Ethyl chloride
Ice
-least cold
Frozen CO2
Propane/ butane spray
-coldest
28
Q

Sensibility test: heat

A

Heated wax
Heated gutta percha
Hot liquid

29
Q

Ethyl chloride test

A
  • explain procedure to px
  • spray ethyl chloride onto cotton wool pellet and wait few s for ice crystal to form
  • ideally isolate tooth in qu
  • test adjacent tooth, buccal and palatal
  • wait at least 30s
  • test tooth in qu buccal and palatal
  • if no response, wait one min, then test again
30
Q

Cold thermal test

A

-theoretically, only sensation from tooth can be pain
-sensation may be mild or severe pain
-intensity of sensation gives indication of level of pulpal inflammation
-+ve response likely to indicate functioning nerve tissue but false +ves possible
–ve response likely to indicate no functioning nerve tissue, false -ve possible
First test will give best and most accurate response

31
Q

General principles of cold testing

A

Pain can refer from one arch to other
Never crosses midline
Pain will always start in arch where source of problem is

32
Q

Heat test

A 
Generally used much less commonly than cold testing
Possible methods
-heated wax
-heated gutta percha
-hot liquid
33
Q

Electric pulp test

A

Tests function of nerve tissue in tooth

Stimulates nerves directly

34
Q

Electric pulp test method

A

Explain procedure to px
Identify tooth in qu
Use toothpaste to form good contact with tooth
Test adjacent tooth, buccal surface
Wait at least 30s
Test tooth in qu buccal surface
If no response, wait one min, then test again

35
Q

Factors affecting reliability of sensibility testing

A

Varying thickness of enamel/ dentine
Restorations, notably crowns
Teeth with open apices
Px response factors

36
Q

Reproducibility of sensibility tests

A

Pxs respond differently to pulp tests on different days, and at different hours of same day
Reproducibility of pulp testing area of concern and may relate to variable state of mind of px as well as lack of intrinsic accuracy

37
Q

Sensitivity (true positive)

A

Measures proportion of actual +ves which are correctly identified as such

38
Q

Specificity (true negative)

A

Measures proportion of -ves which are correctly identified as such

39
Q

Pulse-oximetry

A

Passes wavelengths of light to photo sensor to detect pulsing arterial blood
Equipment expensive
Not proven to be as reliable as current, cheap methods of sensibility testing

40
Q

Laser doppler flowmetry

A

Light transmitted through pulp
If blood flow present the light will be scattered, which is detected by sensor
Equipment expensive
Not proven to be as reliable as current, cheap methods of sensibility testing

41
Q

Perapical tests

A

Percussion
Palpation
Tooth slooth

42
Q

Percussion/ palpation

A

Not true vitality tests
Indicates presence of inflammation in periodontium
TTP more frequent where partial or total necrosis present

43
Q

Palpation

A

Palpate over apices tocheck for apical inflammation and pus production

44
Q

Tooth slooth

A

Allows p testing of individual cusps
Pain on biting usually indication of periapical inflammation
Pain on release of p usually indication of crack

45
Q

Test for cracks

A

Tongue spatula if you can’t afford tooth slooth

46
Q

Additional tests

A

Transillumination
Selective anaesthesia
Test cavity

47
Q

Transillumination

A

Direct light through tooth to detect pathology, especially crack and fractures which cannot be seen under dental light

48
Q

Selective anaesthesia

A

When having difficulty locating source of pain (e.g. upper or lower), anaesthetise selected teeth to find source
Also useful when ruling out non-peripheral source for pain

49
Q

Test cavity

A

Last resort!
Begin access cavity prep
No local anaesthesia
If px feels sensation then tooth is vital
If no sensation, proceed with endodontic treatment

50
Q

When to take x-rays

A

X-rays taken after you have arrived at provisional diagnosis

-they help to confirm diagnosis

51
Q

Radiographs

A

Bitewings or periapicals

OPT and occlusal views less commonly used for pulp and periapical disease diagnosis

52
Q

Bitewings

A

Refer to clinical guidelines regarding frequency of bitewings
Use bitewings to screen for caries/ pathology at appropriate intervals
Also use to confirm suspected pathology following an examination

53
Q

Periapicals

A

Take as indicated following clinical examination

Used to detect apical pathology, periodontal bone loss, root fractures etc.

54
Q

Diagnostic warning signs

A 
Pulp chamber constriction
-inflamed pulp
Pulp stones possibly indicate
-previous trauma
-occlusal parafunction
55
Q

Diagnostic aids for radiographs

A

If sinus present insert gutta percha point into sinus tract

-the point will appear on radiograph and ‘point’ to source of infection

56
Q

CBCT?

A

Cone beam CT scans
Can be used in specific circumstances to aid diagnosis
3D image of teeth in qu
Extra radiation dose to px, must justify

Pulpal disease (11 decks)

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