Endo + Flashcards
Explain the 5 stage process of endodontic diagnosis?
- The patient tells the clinician the reasons for seeking advice.2. The clinician questions the patient about the symptoms and historythat led to the visit.3. The clinician performs objective clinical tests.4. The clinician correlates the objective findings with the subjectivedetails and creates a tentative list of differential diagnoses.5. The clinician formulates a definitive diagnosis.
What key symptoms will the patient complain of that may suggest pulp involvement?
PainSwellingNo sleepBroken toothDiscomfort from hot or coldTooth colour change
What questions should the clinician ask the patient about symptoms and history?
SOCRATESSite: quadrantOnset: when it started and does it get better/worseCharacter: describe the pain?Radiation:pain to other parts of body?Association:other signs and symptomsTiming: when pain worst?Exacerbate:what sets of the pain? does anything help reduce the pain?Severity:0-10 scale
Differential diagnosis for pulpal pain - referred pain?
Referred pain:muscle trigger point referred to tooth and mimicked endo involvementSinusitisAcute dental pain can be referred to opposite arc in same side
Name the 4 differential diagnoses for pulpal pain?
Referred painNeuropathic painCancer Other
Name the 3 causes for pulpitis?
Physical irritations from extensive decayTraumaAnachoresis (retrograde infections)
Name 5 key symptoms for pulpitis?
Pain on bitingPain when chewingSensitivity with hot or coldFacial swellingDiscolored tooth
What difficulties arise for pulpitis localisation?
Referred pain & the lack of proprioceptors in the pulplocalising the problem to the correct tooth can often be aconsiderable diagnostic challenge• Also of significance is the difficulty in relating the clinical status of atooth to histopathology of the pulp in concern• Unfortunately, no reliable symptoms or tests consistently correlatethe two.
Name the 7 classifications for pulpal disease?
1) Healthy pulp.2) Reversible Pulpitis.3) Symptomatic Irreversible4) Asymptomatic Irreversible5) Pulp Necrosis6) Previously Treated7) Previously Initiated Therapy
Name the 6 classifications for periapical disease?
1) Normal Apical Tissues2) Symptomatic Apical Periodontitis3) Asymptomatic Apical Periodontitis4) Chronic Apical Abscess5) Acute Apical Abscess6) Condensing Osteitis
What to do if the tooth is not restorable or periodontally unsavable?
EXTRACTION
Name 4 types of special investigations for pulpitis?
Tap the tooth – percussion test• Feel the surrounding hard tissue – palpation test• Testing movement of the tooth – mobility test• Shine a light through the tooth ‐ transillumination
Name and describe the categories for percussion?
None (-): tap on incisal edge of tooth with end of mirror causes no discomfortMild (+): tap on incisal edge of tooth with end of mirror causes little discomfortModerate (++): tap on incisal edge of tooth with end of mirror causes noticeable discomfort(painful)Severe (+++): tap on incisal edge of tooth with end of mirror causes definitive discomfort(very painful)
Name and describe the categories for palpation?
None (-): feeling buccal and lingual gingiva apical to a tooth with the oad of the finger causes no discomfort at allMild (+): feeling buccal and lingual gingiva apical to a tooth with the oad of the finger causes little discomfortModerate (++): feeling buccal and lingual gingiva apical to a tooth with the oad of the finger causes noticeable discomfort (painful)Severe (+++): feeling buccal and lingual gingiva apical to a tooth with the oad of the finger causes definitive discomfort (very painful)
Name and describe the categories for mobility?
Grade 0 – no apparent mobility• Grade 1 ‐ mobility less than 1mm buccolingually• Grade 2 ‐ mobility between 1 – 2 mm buccolingually• Grade 3 ‐ mobility greater than 2 mm buccolingually AND apicalmovement greater than 1 mm
What is the definition of sensibility testing?
e help to determine the pulpal status…alive or dead
What are the limitations for a sensibility test?
Can't differentiate between:“alive & healthy”“alive and diseased”“alive but just about to snuff it” or“in the process of dying
What is the definition of vitality, sensibility and sensitivity testing?
Vitality: blood supply present in tissueSensibility: ability to respond to a stimuliSensitivity: responsiveness to a stimuli
What is the true determinant for pulp vitality?
Vitality
Explain how the vitality test works?
The pulse oximeter sensor consists of two light‐emitting diodes,one to transmit red light (640 nm) and the otherto transmit infrared light (940 nm) anda photodetector on the opposite side of the vascular bed.The light‐emitting diode transmits red infrared lightthrough a vascular bed such as the finger or ear.Oxygenated hemoglobin and deoxygenated hemoglobinabsorb different amounts of red infrared light. Thepulsatile change in the blood volume causes periodicchanges in the amount of red infrared light absorbed bythe vascular bed before reaching the photodetector.The relationship between the pulsatile change in theabsorption of red light and the pulsatile change in theabsorption of infrared light is analyzed by the pulse oximeter to determine the saturation ofarterial blood.
Explain how the sensibility test works?
Thermal and electrical tests assess whether the pulp nerve fibres canrespond to a stimulus when applied to the tooth, hence they aresensibility tests
Explain how the sensitivity test works?
Thermal and electric pulp tests are NOT sensitivity tests, althoughthey can be used to test the sensitivity of a tooth
Name the 8 ideal characteristics for an ideal sensitivity pulp test?
SimpleObjectiveStandardisedReproducibleInexpensiveNon‐painfulNon‐injuriousAccurate
Why can pulpitis diagnosis be wrong sometimes?
Diagnosing pulpal and periradicular symptoms is extremely difficultbecause the histopathological condition of the pulp cannot bedetermined by clinical means
How can special investigations help with diagnosis?
Sensibility tests are used to try and reproduce the pain thepatient is having & so confirm the source and reason for thepainTooth localisation
What should be included during a sensibility test to look out for?
Use control teethUse the information from the history, clinical examinationand findings, other special tests/investigations
When is a sensibility test useful or indicated?
When a patient has unlocalised or referred dental painTo aid in diagnosis between odontogenic and non‐odontogenic painTo confirm apparent radiographic periradicular pathology in the absence of any clinical signs/symptomsTo confirm pulpal status when there are clinical signs/symptoms but no apparent radiographic changesperiradicularlyTo discern between a periodontal abscess and an endodontic abscess & help confirm when a perio‐endolesion is suspectedTo assess the pulpal status of a tooth prior to crowning.Monitoring the success of pulp caps/ pulpotomies (ensuring that the pulp has not become necrotic)Monitoring traumatised teeth/ revascularization cases(usually over several months).Monitoring teeth following orthognathic surgery/ OS procedures/ facial fractures/ tooth transplantationTo confirm profound pulpal anaesthesia.
When is a sensibility test not indicated?
Electric pulp testers DO NOT interfere with pacemakers
Name 2 types of sensibility tests?
Thermal| Electrical
Name and explain 5 types of cold sensibility tests?
Ice sticks (not could enough)Ethyl ChlorideEndoIce (TFE)EndoFrost (PBM)Dry Ice (very rapid sensory response)
What are the pros and cons for a cold sensibility test?
Superior to Hot testColder the test more reliableCold stim causes a rapid outward flow of dentinal fluid:- test a delta fibres, respond to fluid movement, info extrapolated to consider pulp is vital
Name and explain 5 types of hot sensibility tests?
Warm Gutta percha (place vaseline first)Warmed instrumentElectrical heat sourcesRubber prophy cup (frictional heat)
What are the pros and cons for a hot sensibility test?
Less useful than coldInitially stims A delta fibresProlonged heat stims C fibresExcessive heat can cause pulpal damageAn exaggerated and linegring response to heat is indicative of pulpitis
Explain how the electric pulp tester works?
A battery operated device passes a small electrical current along the enamel prisms & dentinal tubulesto pulp tissueCurrent causes an ionic shift across the neural membrane inciting an action potential at the nodes of Ranvierin myelinated nervesThis stimulates the A‐delta fibresEPTs have a rheostat showing the relative amount of current applied on various scales
How to explain and complete the cold test procedure on a patient?
Explain test and why it's necessaryPatient will feel coldIsolate and dry toothFind a control toothTweezers and cotton woolSpray cold stim onto wool and place onto tooth
Where should you place the cold sensibility test stimuli on the tooth?
On sound tooth structureIncisal edge or incisal 1/3 anteriorsMid third buccal surface premolarsMesio‐buccal cusp tip molarsHold pellet in place until the patient feels the stimuli or for a few seconds if no response
Describe a normal pulpal reaction to a cold stimuli?
A sharp, sharp cold/pain sensation which| immediately ceases when the stimuli removed
Describe a pulpitis reaction to a cold stimuli?
A severe, prolonged, exaggerated response to cold
Describe a non-responsive reaction to a cold stimulus?
Pulp necrosisPrevious pulpotomy or previous pulpectomyFalse negative
How to explain and complete the electric pulp test on a patient?
Explain procedure and why it is necessaryPatient may feel tinge or warm sensationDry and isolate tooth + control toothPlace interprox celluloid strip where requiredPlace conducting interface medium on toothPlace tip of EPT on conducting medium and patient completes circuit by earling the lip clip or touching the probeIncrease current slowlyLet patient respond at pre-pain sensation
Where should you place the electric pulp tester on the tooth?
On sound tooth structureIncisal edge or incisal 1/3 anteriorsMid third buccal surface premolarsMesio‐buccal cusp tip molars
Describe a normal pulpal reaction to an electric pulp tester?
Sharp warm/hot/tingle or throbbing sensation which immediately ceases when stimulus removed
Describe a pulpitis pulpal reaction to an electric pulp tester?
A severe prolonged exaggerated response
Describe a non-responsive pulpal reaction to an electric pulp tester?
Pulp necrosisPrevious pulpotomy or previous pulpectomyFalse negative
What are the 2 reasons for a false +ve result for a sensibility test?
Anxious or young patient| Multirooted tooth
What are the 8 reasons for a false -ve result for a sensibility test?
Incomplete root developmentTraumatised toothOrthodontic tooth movementHeavily restoredPulpal obliterationPeriodontal disease (decreased intensity of pain response to cold)Pre-medicationsPsychosis
Name 1 reason for a false -ve electric pulp test result?
Improper use/technique
Name 5 reason for a false +ve electric pulp test result?
Improper use/techniquePus in canal, as it can conduct to periapical tissuesMetal splintsBridgesOrtho arch wires
What is the definition of a periradicular lesion?
Develop near the tips of root (where canal communicates with periodontium via apical foramen)
Where is a inflammatory periodontal lesion usually found?
Emerge at other anatomical or iatrogenic openings:- lateral aspects of root- furcations of multirooted teeth
How does apical periodontitis develop?
Following pulp tissue breakdown and the emergence of root canal infectionCan be symptomatic or asymptomaticBone resorption part of process
Explain how an RCT can be used to treat apical periodontitis?
Eliminate bacteria via RCT:- active inflammatory lesion subsides- bone regeneration takes place
Name 3 microscopic level different structural frame-works of apical periodontitis?
Apical granulomaApical abscessApical cystClinically and radiographically these histopathological entities cannot be distinguished from each other or recognized
What is the definition of an apical granuloma?
Consists of an inflammatory lesion dominated by:- Lymphocytes,- Macrophages and- Plasma cellsNumerous fibroblasts and connective tissue fibres usually present- + many capillaries.Around the edge an encapsulation attempt may often be foundThe epithelium originates from the epithelial cell rests of MalassezInfluenced by cytokines & growth factors released in the inflammatory processthe normally resting cells divide and migrate.- They may form more or less continuous- Random course- May also become attached to the root surfacePolymorphonuclear leukocytes are found in varying numbersAbscess formation can be a transient or persistent event within anexisting apical granuloma
What is the definition of an apical abscess?
Pus within the lesionAbscess formation = cellular dynamics within apical granuloma or direct outcome of an acute primary infectionHigh influx of PMNs (with high phagocytic activity of PMNs)PMNs die and release tissue-destructive elementsCT are degradedTissue in centre of lesion liquefiedCOntinuum exists between apical abscesses and apical granulomas
What is the definition of an apical cyst?
Epithelium-lined cavityContains fluid or semi-solid materialSurrounded by CT:- infiltrated by mononuclear leukocytes and PMNs- cavity lined with stratified squamous epithelium- originates from epithelial rest of Malassez- can be lined with ciliary epitheliumLining can be be:- continuous- disrupted- completely missingSome cysts never become steady (consume bone or slowly expand)
Explain the nutritional deficiency theory for apical cyst formation?
Assumes that epithelial proliferationresults in an epithelial mass that is too large for nutrients to reach its core,resulting in necrosis and liquefaction of the cells in the center. PMNs areattracted by the necrotic material, which, together with tissue exudate,result in microcavities that eventually coalesce to form the cystic cavity
Explain the abscess theory for apical cyst formation?
Assumes that tissue liquefaction occurs first, at thecentral part of an abscess. The peripheral aspect of the cavity is later lined by proliferating epithelium, owing to the inherent nature of epithelial cells to cover exposed connective tissue surfaces
Why do the size of radicular cysts slowly increase?
Increased osmosis leading to passage of fluid from the surroundingtissue into the cyst lumen is likely to occur owing to breakdown ofepithelial and inflammatory cellsRelease of bone‐resorbing factors from mononuclear leukocytes present in the cyst wall,including interleukins, mast cell tryptase and prostaglandins.
What are the causes for apical periodontitis?
Most AP is due to microorganisms within the RC. Other occasionalcauses include trauma, occlusal trauma, foreign body reactionBacteria in infected necrotic pulps predominately obligate anaerobes.Different microorganisms display differing abilityto survive in the root canal systemMore likely thata community of microbes existsBiofilms form in RCs. Biofilms protect bacteria from being destroyed
Name 6 microbial causes of primary apical periodontitis?
Carious lesionsCracksTraumatic exposureAccessory canalsExposed dentinal tubulesPeriodontal pockets to the apical foramen
Name 3 factors of selective pressures for microbial invasion of apical periodontitis?
NutritionOxygenMicrobial interactions
Name 6 types of bacteria present in primary root canal infections?
- Spirochetes• Fusobacteria• Actinobacteria• Firmicutes• Proteobacteria• BacteriodetesNo more than 10 per canal and more are negative and are mostly anaerobic
What is a reason for persistent Apical periodontitis?
Microbes remaining within the canal system
What are the survivability characteristics for E. faecalis?
Possesses a “proton pump” which allows it to survive in high pH (i.e. can survive calcium hydroxide)• Can survive in mono‐infection• can survive long periods of low/no nutrition
Explain the root canal response to canal instrumentation cutting BVs in the PDL or bone?
This activates intrinsic and extrinsic coagulation pathways.• Contact between the Hageman factor and:• collagen of basement membranes,• enzymes such as kallikrein or plasmin,• endotoxins from inflamed root canalscan activate the clotting cascade and the fibrinolytic system.• Fibrinogen molecules and fibrin degradation products are released during fibrin proteolysis by plasminthese release fibrinopeptides• Trauma to the periapical tissues during RCT can also activate the kinin system• This will then activate the complement system.• C3 complement fragments found in periradicular lesions.• Products released from the activated systems contribute to the inflammatory process and causeswelling, pain, and tissue destruction.
Name the 7 factors needed for a tooth to be healthy?
comfortable to the patient• not tender to percussion or occlusal pressure• not sensitive to palpation.• Free from sinus tracts• Free from swelling• Has no painful symptoms.• Has normal pocket‐probing depths:• pocketing may also imply a sinus tract drainage along the periodontalligament space.
Name the 5 different types of root canal infections?
asymptomatic apical periodontitis (chronic apical/periradicular periodontitis),• symptomatic apical periodontitis (acute apical/periradicular peri‐ odontitis),• acute apical abscess (acute periradicular abscess),• chronic apical abscess (chronic periradicular abscess, suppurative apical/periradicularperiodontitis),• condensing osteitis (focal sclerosing osteomyelitis, periradicular osteosclerosis, sclerosingosteitis, sclerotic bone).
What are the radiographic findings for a normal periapical condition?
unbroken lamina dura• distinct periodontal ligament space of normal width,comparable to adjacent and contralateral teeth.
What is the definition of an asymptomatic apical periodontitis?
is longstanding periapical inflammatory• Has radiographically visible periapical bone resorption• has no clinical signs and symptoms.• Is associated with a tooth with a non‐vital pulp (untreated or treated).It might be suspected from a carefully taken disease history in cases when patient hasexperienced a prior painful event.
What is the definition of an symptomatic apical periodontitis?
Symptomatic apical periodontitis may develop as a direct consequence of thebreakdown and infection of the pulp within a previously healthy periapical region.• It reflects a response to an initial exposure of the periapical periodontium to bacteria• or their products emerging from the infected root canal.• may also appear in a tooth with previous asymptomatic apical periodontitis.• Can be a natural shift in the balance previously established between the bacteria andthe host or occur in response to endodontic treatment (endodontic flare‐up).• The typical symptoms include:• pain (aching)• may become severe or even unbearable.• usually tender to percussion• mucosa and bone overlying the apical area sensitive to palpation.• premature occlusion
What is the definition of an acute apical abscess?
Characterized by:• rapid onset,• spontaneous pain,• tenderness of the tooth to pressure,• pus formation• swelling of associated tissues.• Initially, may be extremely painful, (pressure builds up in bone or periodontal space).• Cortical plate may perforate and pus will accumulate under the periosteum producing a most severe painful condition.• Only with the perforation of the periosteum will the pus be able to drain and allow pain to subside.• Then a tender local swelling will appear.• Sometimes, natural drainage will be established within a few days by perforation of the covering tissue.• In other cases, the swelling will remain for some time before it gradually subsides.• Drainage of an apical abscess will take the “path of least resistance”• thickness of overlying bone• Following penetration of the bone and periosteum, drainage will often be visible:• in the oral cavity but it may also occur• into perioral tissues or• into the maxillary sinus.
What is the definition of an chronic apical abscess?
Typical feature = sinus tract.• Drains into:• mouth or• extraorally through the skin• A sinus tract may establish exit with drainage• into the gingival sulcus,• in a periodontal pocket or• in a furcation area• MUST be differentiated from periodontal disease and from a pocket associated with avertical root fracture.• A sinus tract may also lead into the maxillary sinus and cause unilateral chronic sinusitis!• Most commonly associated with an apical radiolucency (but not always)• It is asymptomatic (or only slightly symptomatic)• patient often unaware of its presence.• This may last as long as the sinus tract is not obstructed.
What is the definition of cellulitis?
symptomatic edematous inflammation• associated with diffuse spreading of invasive micro‐organisms through connective tissue and fascial planes.• Its main clinical feature is diffuse swelling of facial or cervical tissues.• Cellulitis usually follows an apical abscess that penetrated the bone,• allows the spread of pus along paths of least resistance.• Spreading infection may or may not be associated with systemic symptoms such as fever and malaise.• Since cellulitis is usually a sequela of an uncontrolled apical abscess, other clinical features typical of anapical abscess are also expected.• Spreading of an infection into adjacent and more remote connective tissue compartments may, rarely, resultin serious or even life‐threatening complications.• Cases of Ludwig’s angina• orbital cellulitis• cavernous sinus thrombosis• and even death from a brain abscess• originating from a spreading dental infection have been reported.
What is the definition of condensing osteitis?
diffuse radiopaque lesion• believed to represent a localized bone reaction to a low‐ grade inflammatorystimulus• usually seen at an apex of a tooth (or its extraction site) in which there has been alongstanding pulp disease.• It is characterized by overproduction of bone in the periapical area, mostly aroundthe apices of mandibular molars and premolars that had long standing chronic pulpitis.• The pulp of the involved tooth may be vital and chronically inflamed or may havebecome necrotic with time, leaving the radiopaque area.• Normally the condition does not prompt treatment• unless the pulp necrosis.• The radiopacity may or may not disappear after endodontic treatment or toothextraction
How are the periodontium and pulp connected?
Natural communications| Pathological and iatrogenic communications
As the periodontium and teeth develop, name the 3 natural avenues communication between pulp and periodontium?
Dentinal tubulesApical foramenAccessory canals
What can cause the dentinal tubules to become exposed?
DevelopmentalDiseasePeriodontal surgeryTraumatic injury
Describe the 4 types of CEJ morphology?
I: cementum over enamelII: edge edge cementum and enamelIII: gap between cementum and enamelIV: enamel over cementum
What is the definition of the apical foramen?
Principle route of communication between pulp and periodontiumPulpal inflamm can cause a localised inflammatory reactionMay be exposed due to severe loss of attachment
What is the definition of lateral canals?
Found apicallyCOntains CT and BVsDon’t extend full width of dentine
What is the definition of a furcal canal?
All teeth with furcation involvement can potentially have exposed furcal canalsLesions suggested radiographically may be due to infectious products from a necrotic pulp diffusing down a furcal or lateral canal
What teeth to test for exposed furcal canals?
Sensitivity test:- Lower 46,36 (DL root)Upper and lower premolars (1-3 roots)Canines (2 roots)
What is the definition of a developmental malformation?
Palatogingival grooveUsually maxillary lateral incisorsIf epithelial attachment is breached, grooves becomes contaminatedSelf-sustaining infrabony pocket developsLoss of attachment can quickly extend to apical foramenDifficult to treat as scaling and RSI does not work
How to drain an endodontic abscess?
Insert a GP cine and radiograph| Can drain through the PDL space to the sulcus
What is the classification system for perio and endo lesions?
2017 World Workshop| Periodontitis associated with endodontic lesions
Explain the clinical examination for a possible endo or perio lesion?
PalpationPercussionpocket probingMobilitySinus or pus draining through PDLIf sinus is present, palpate to see if dischargingIf so, insert gutta percha cone and radiograph
Explain the diagnosis procedure for a possible endo or perio lesion?
Special testsTo differentiate between perio and endoSensitivity testHigher false positives in teeth with advanced periodontitisIf perio only tooth will respond to sensitivity testingUse 2 tests to increase reliabilityTest cavities to differentiate between perio and endodontic pathosisBoth perio and endo affecting tooth form a perio-endo lesionCharacterised by CAL, bone loss and periradicular pathology
What symptoms should I suspect with a perio-endo lesion?
Hisotry of symptomsHistory of surgerydeep pockets (average root lengths)furcationPus exuding from deep pockets or swellings