ENDO Pulpal and Periradicular Diseases Flashcards
what are the three components of the pulp?
nerves, blood vessels, and connective tissue
can the pulp respond to edema (i.e. expand)?
no because it is surrounded by dentin (hard tissue), which limits ability to expand
pulp lacks collateral circulation, which severely limits its ability to respond to what 3 things?
bacteria, necrotic tissue, and inflammation
what cells are contained in the pulp?
odontoblasts and mesenchymal cells (differentiate into osteoblasts)
which two nerve fibers are responsible for sensing pulpal pain?
A-delta and C fibers
which nerve fiber pain is sensed as quick, sharp, and dissipates quickly on removal of the stimulus?
A-delta
which nerve fiber is large and myelinated?
A-delta
what is the pulpodentinal complex?
A-delta fibers and odontoblast layer
which nerve fiber pain is sensed as a dull, throbbing ache?
C fibers
which nerve fiber is small and unmyelinated?
C fibers
are C fibers involved in the pulpodentinal complex?
no
T or F:
pain sensed from C fibers signifies irreversible tissue damage
true
___ fibers sense dentinal pain, whereas ___ fibers sense pulpitis pain
A-delta
C fibers
C fiber pain occurs with tissue injury and is mediated by ___, ___, and ___
inflammatory mediators, vascular changes in blood volume/flow, and increase in tissue pressure
C fiber pain eventually results in ___
tissue necrosis
___ can raise intrapulpal pressure to levels that excite C fibers
hot beverages and foods
pain from which fiber is diffuse and can be referred to a distant site or to other teeth?
C fiber
which pulpal disease is signified as asymptomatic, mild-moderate response to thermal/electrical stimuli?
within normal limits
which pulpal disease is signified by thermal (usually cold) stimulus that causes quick, sharp, hypersensitive response?
reversible pulpitis not actually a disease, but a symptom – goes away with removal of stimulus
what 3 things can reversible pulpitis be caused by?
early caries/rampant decay, SRP, deep restorations without a base
which 2 ways is reversible pulpitis distinguished from symptomatic irreversible pulpitis?
painful response to thermal stimulus is longer after removal in symptomatic irreversible pulpitis, and reversible pulpitis does not involve unprovoked (spontaneous) pain
which pulpal disease must involve penetration of bacteria into the pulp and is damaged beyond repair?
irreversible pulpitis
what is the end result of irreversible pulpitis?
pulpal necrosis (could be quick or take years), and is often asymptomatic
what are 2 consequences of asymptomatic irreversible pulpitis?
hyperplastic pulpitis and internal resorption
what are the histological findings of internal resorption?
chronic inflammatory cells, multinucleated giant cells, and necrotic pulp
postural changes can sometimes induce pain in which pulpal disease?
symptomatic irreversible pulpitis
T or F:
radiographs are sufficient to diagnose irreversible pulpitis
false
electric pulp tests are also of little value
pulpal necrosis is a pulpal disease described as the death of the pulp as a result of one of which 3 causes?
untreated irreversible pulpitis, traumatic injury, or long-term interruption of blood supply
T or F:
necrosis can be partial or total necrosis
true
for example, a tw-canaled tooth can have inflammation in one canal and necrosis in the other
what are the symptoms of pulpal necrosis?
tenderness to percussion/chewing with thickening of the PDL
what is the progression of inflammation/necrosis?
- inflammation progresses to liquefaction necrosis
- insufficient drainage due to dentinal walls and lack of collateral circulation
- causes increase in pressure and eventual necrotic pulp
- bacteria penetrate dentinal tubules (this is why we remove superficial layers during cleaning/shaping)
periradicular diseases of pulpal origin are a response from ___
irritants from the root canal system
what are the range of symptoms of periradicular diseases of pulpal origin?
range from asymptomatic to slight sensitivity to chewing, feeling of tooth elongation, intense pain, swelling, high fever, and malaise
what is the most indicative sign of a periradicular inflammatory lesion?
radiographic bone resorption, although periradicular lesions are frequently not seen radiographically
diagnosis of periradicular lesions is based on ___ and ___
clinical signs/symptoms and radiographic findings
what are the 5 periradicular disease diagnoses?
acute periradicular periodontitis, acute periradicular abscess (acute apical abscess), chronic periradicular periodontitis, suppurative periradicular periodontitis (chronic periradicular abscess), and chronic focal sclerosing osteomyelitis (condensing osteitis)
which periradicular disease is described as a painful localized inflammation of the PDL around the apex?
acute periradicular periodontitis
what are 3 possible causes of acute periradicular periodontitis?
extension of the pulpal disease into periradicular tissue, canal overinstrumentation or overfill, or occlusal trauma
what is the only way to determine the need for RCT in cases of acute periradicular periodontitis?
pulp tests
T or F:
acute periradicular periodontitis only occurs around nonvital teeth
false, can be both
what is the histology of acute periradicular periodontitis?
localized inflammatory infiltrate within the PDL
which periradicular disease is a painful, purulent exudate around the apex?
acute periradicular abscess (acute apical abscess)
acute periradicular abscess is a result of the exacerbation of ___ from ___
acute apical periodontitis from necrotic pulp
what might you find radiographically on tooth with acute periradicular abscess?
possible slight thickening of the lamina dura
what is always present in acute periradicular abscess?
swelling
what is a phoenix abscess, and how does it differ from an acute periradicular abscess?
phoenix abscess has the same symptoms as an acute periradicular abscess (acute apical abscess) but with an obvious radiographic perirapical radiolucency
what is the histopathology of acute periradicular abscess?
central area of liquefaction necrosis containing neutrophils and cellular debris, surrounded by macrophages, lymphocytes, and plasma cells
T or F:
bacteria are always found in the apical tissues or within the abscess in acute periradicular abscesses
false, bacteria is not always found in these areas
what are the 4 signs and symptoms of an acute periradicular abscess?
rapid onset swelling, mod-severe pain, pain w/percussion and palpation, and slight increase in tooth mobility
describe the swelling associated with acute periradicular abscess
usually remains localized, but is determined by the location of the apex and muscle attachments. may become diffuse and spread (cellulitis)
how is an acute periradicular abscess differentiated from a lateral periodontal abscess?
pulp vitality testing and sometimes periodontal probing
which periradicular disease is a long-standing, asymptomatic or mildly-symptomatic lesion?
chronic periradicular periodontitis
what is the radiographic presentation of chronic periradicular periodontitis?
visible apical bone resorption that results from extensive demineralization of cancellous and cortical bone due to bacteria and endotoxins
is tenderness to percussion and palpation indicative of chronic periradicular periodontitis
slight tenderness is possible
what is the diagnosis of chronic periradicular periodontitis confirmed by?
general absence of symptoms, radiographic presence of periradicular radiolucency, and confirmation of pulpal necrosis
a totally necrotic pulp primarily has aerobic or anaerobic microorganisms?
anaerobic (no vascularity, no defense cells)
chronic periradicular periodontitis has been classified histologically as ___ or ___. how do you distinguish between the two classifications?
periradicular granuloma or periradicular cyst
distinguished via histopathological examination
which periradicular disease is associated with either a continuously or intermittently draining sinus tract without discomfort?
suppurative periradicular periodontitis (chronic periradicular abscess)
how can suppurative periradicular periodontitis (chronic periradicular abscess) mimic a periodontal lesion with a pocket?
the exudate from the abscess can sometimes drain though the gingival sulcus
what are the pulp test results of suppurative periradicular periodontitis?
negative because the pulp is necrotic
what is the radiographic presentation of suppurative periradicular periodontitis?
presence of bone loss at the periradicular area
what is the treatment for suppurative periradicular periodontitis?
the sinus tract sresolve spontaneously with nonsurgical endodontic treatment
which periradicular disease has excessive bone mineralization around the apex of an asymptomatic, vital tooth?
chronic focal osteomyelitis (condensing osteitis)
how does chronic focal osteomyelitis present radiographically?
radiopacity around the apex
the radiopacity around the apex of a tooth with chronic focal osteomyelitis may be due to ___
low grade pulp irritation
what is the treatment for chronic focal osteomyelitis?
it is asymptomatic and benign, and therefore does not require endodontic therapy
why do numerous orofacial diseases mimic endodontic pain?
sensory misperception is produced as a result of overlapping between sensory fibers of the trigeminal nerve
what are the 6 characteristics of orofacial pain that is of nonodontogenic involvement
- episodic pain with pain free remissions
- trigger points
- pain travel crosses the midline of the face
- pain that surfaces with increasing mental stress
- pain that is season or cyclic
- paresthesia
what are the only systemic contraindications to endodontic therapy?
uncontrolled diabetes or a very recent myocardial infarction (within 6 months)
what are the 7 pieces of information that need to be collected on the patient’s dental history when assessing pain?
CC, location, chronology, quality of pain, intensity and severity of symptoms, affecting factors (stimulated or simultaneous), and supplemental history
when collecting information about location of pain, it is important to realized that the accuracy of the patient’s description of pain depends on ___
- whether the inflammatory state is limited to the pulp tissue only
- if inflammation has not reached the PDL, it may be more difficult to localize because the pulp contains sensory fibers that transmit only pain, not location
- if inflammation extends beyond the apex, it will be easier for the patient to identify the source of pain because the PDL contains proprioceptive sensory fibers (percussion tests can be used)
with respect to referred pain, describe crossing the midline, pain from posterior teeth, and maxillary and mandibular molars
- it is rare for odontogenic pain to cross the midline
- pain from posterior teeth may be referred to the preauricular area, down the neck, or up to the temple, on the ipsilateral side
- pain from posterior molars can often be referred to the opposing quadrant or to other teeth in the same quadrant
- maxillary molars often refer pain to the zygomatic, parietal, and occipital regions of the head, whereas mandibular molars frequently refer pain to the ear, angle of the jaw, or posterior regions of the neck
what are important pieces of information to know about the chronology of a patient’s pain?
- inception (when pt first noticed pain)
- mode (spontaneous or provoked symptoms, immediate or delayed)
- periodicity (sporadic or occasional pattern)
- frequency (persistent or intermittent, how often)
- duration (momentary or lingering)
with respect to the quality of the dental pain, what can be inferred if a patient describes a dull, drawing, or aching pain?
bony origin
with respect to the quality of the dental pain, what can be inferred if a patient describes a throbbing, pounding, or pulsating pain?
vascular response to tissue inflammation
with respect to the quality of the dental pain, what can be inferred if a patient describes a sharp, electric, recurrent, or stabbing pain?
pathosis of nerve root complexes, sensory ganglia, or peripheral innervation (irreversible pulpitis or trigeminal neuralgia)
with respect to the quality of the dental pain, what can be inferred if a patient describes an aching, pulsing, throbbing, dull, gnawing, radiating, flashing, stabbing, or jolting pain?
pulpa and periradicular pathoses
what are the major points to consider when asking your patient about affecting factors of their dental pain?
- provoking factors (heat, cold, biting, or chewing, or bending over)
- attenuating factors (pain relief, lying down or sitting up, warm or cold liquids)
what supplemental history information might you want to obtain from your patient regarding their dental pain?
- past facts and current symptoms that characterize the diagnosis
- sometimes need to wait a while for vague symptoms to localize, which is often a necessary approach in pulpal pathosis confined to the root canal space, which can refer pain to other teeth or to nondental sites
intraoral diagnostic tests enable the clinician to do what 3 things?
- define pain by evoking reproducible symptoms that characterize the CC
- provide an assessment of normal responses for comparison with abnormal responses
- use controls for testing - adjacent, opposing, and contralateral teeth should be tested before the tooth in question to establish the patient’s normal range of response
describe palpation as a diagnostic test
- when periradicular inflammation develops after pulp necrosis, the inflammatory process may burrow its way through the facial cortical bone and begin to affect the overlying mucoperiosteum
- before incipient swelling becomes clinically evident, ti may feel tender during shaving or applying makeup
does percussion testing indicate health of the pulp?
no, but the sensitivity of the proprioceptive fibers reveals information of the apical periodontal ligament
what does a positive response to percussion test indicate?
the presence of inflammation of the PDL, and the extent of the inflammatory process (degree of response correlates with degree of inflammation)
what 3 other factors can inflame the periodontal ligament and yield a percussion positive test result?
- rapid orthodontic movement of teeth
- a recently placed restoration in hyperocclusion
- a lateral periodontal abscess
how should a percussion test be performed?
- first with the clinicians finger, and then the blunt handle of a mouth mirror
- having the patient chew on a cotton roll, a cotton swab, or the reverse end of a low-speed suction straw may help
thermal tests are especially valuable when the patient describes the pain as ___
- diffuse
- thermal testing of vital pulps often helps to pinpoint the source
- the sensory response of teeth is refractory to repeated thermal stimulation, so the dentist should wait an appropriate amount of time for tested teeth to respond and recover to avoid misinterpretation
what are the options for cold testing?
cold water baths, ice sticks, ethyl chloride (-5* C), dichlorodifluoromethane (DDM: endo ice -30* C), and carbon dioxide ice sticks (-77.7* C)
describe how to use endo ice
- spray a cotton pellet liberally with the endo ice (ethyl chloride)
- immediately applied the chilled cotton pellet to the middle third of the facial aspect of the crown
- keep the pellet in contact with the tooth for 5 seconds or until the patient begins to feel pain
what are the options for heat testing?
- warm sticks of temporary stopping and rotating a dry prophy cup to create frictional heat
- hot water bath with rubber dam isolation (yields the most accurate patient response)
what are the four possible responses to thermal tests, and what does each indicate?
- no response (nonvital pulp is indicated, or false negative due to excessive calcification, an immature apex, or recent trauma)
- mild-moderate pain that subsides in 1-2 seconds (WNL)
- strong, momentary painful response that subsides in 1-2 seconds (reversible pulpitis)
- moderate-strong painful response that lingers for several seconds or longer after stimulus has been removed (irreversible pulpitis)
what does electric pulp testing indicate?
- indicates there are vital sensory fibers present within the pulp
- does not suggest the health or integrity of the pulp
what is the true determinant of pulp vitality?
vascular supply to the pulp
does electric pulp testing provide information about vascular supply to the pulp?
no
do electric pulp tests correlate with the relative histologic health or disease status of the pulp?
no
several conditions can cause false responses to electric pulp testing, so it is essential that ___ tests be performed before a final diagnosis is made
thermal
describe the electric pulp testing technique
- teeth must be isolated and dried
- electrode of the pulp tester should be coated with a viscous conductor (toothpaste)
- the electrode is applied to the dry enamel on the middle third of the facial surface of the crown
- the current flow should be adjusted to increase slowly
why should you avoid placing the electrode on a restoration when performing an electric pulp test?
it can cause a false reading
which teeth typically have quicker responses to electric pulp tests and why?
anterior teeth because the enamel is thinner
what is a contraindication to electric pulp testing?
a patient with a cardiac pacemaker that has been implanted
what are the causes of positive false readings of electric pulp tests?
- electrode or conductor contact with a metal restoration or on the gingiva
- patient anxiety
- liquefaction necrosis may conduct current to the attachment apparatus
- failure to isolate and dry the teeth before testing
what are the causes of negative false readings of electric pulp tests?
- patient has been heavily premedicated with analgesics, narcotics, alcohol, or tranquilizers
- excessive alcohol consumption
- inadequate contact between the electrode or conductor and the enamel
- a recently traumatized tooth
- excessive calcification of the canal
- recently erupted tooth with immature apex
- partial necrosis
if a significant isolated pocket is discovered in the absence of periodontal disease, it increases the probability of ___
a vertical root fracture
what two things are essential to distinguish disease of periodontal origin from disease of pulpal origin?
pulp vitality testing and periodontal probing
tooth mobility is directly proportional to the ___ or to the ___
integrity of the attachment apparatus or to the extent of inflammation of the PDL
what are some causes of tooth mobility?
- acute apical abscess (pressure exerted by the purulent exudate may cause transient tooth mobility)
- horizontal root fracture in the coronal half of the tooth
- very recent trauma
- chronic bruxism
- overzealous orthodontic treatment
describe selective anesthesia testing
typically only used when the clinician has not determined through prior testing which tooth is the source of pain. because the diffusion of the local anesthetic is not limited to a single tooth, the clinician cannot make a conclusive diagnosis on the basis of pain relief
describe the test cavity as a form of pulp testing
- completed without anesthetic and analyzed based on presence or absence of painful response once dentin is invaded
- it is only done in cases where a strong suspicion of pulp necrosis is present and corroborate with other tests and radiographic findings, but a definitive test is required
- can result in iatrogenic damage
why should clinicians not rely exclusively on radiographs in an attempt to arrive and a diagnosis?
a radiolucency will not begin to manifest until demineralization of bone extends through the cortical plate of the bone
since radiographs are only 2-dimensional, what should your radiographic strategy include?
exposure of two films at the same vertical angulation but with a 10-15 degree change in horizontal angulation
T or F:
the status of the health and integrity of the pulp cannot be determined by radiographic images alone
true
radiographically, a single root canal should appear ___
tapering from crown to apex
radiographically, a sudden change in appearance of the canal from dark to light indicates ___
the canal has bifurcated or trifurcated
a necrotic pulp will not cause radiographic changes until ___
demineralization of the cortical plate (significant medullary bone destruction may occur before any radiographic signs start to appear)
why should attending dentists be cautioned in accepting prior diagnostic radiographs from the patient or another dentist, no matter how recent they were made?
prior iatrogenic mishaps such as ledge formation, perforation, or instrument separation are critical for a newly treating dentist to uncover
what is the SLOB rule?
- same lingual, opposite buccal
- the object closest to the buccal surface appears to move in the direction opposite the movement of the tube head/cone up or down or side to side when compared with a second radiograph
- objects closest to the lingual surface appear to move in the same direction of the cone
proper application of the SLOB technique allows the dentist to accomplish what 6 things?
- locate additional canals or roots
- distinguish between superimposed objects
- differentiate various types of resorptions
- determine buccal lingual positions of fractures and perforative defects
- locate foreign bodies
- locate anatomic landmarks in relation to the root apex
what is the differential diagnosis (11) based on radiographic periradicular radiolucencies?
- vertical root fracture
- lateral periodontal cyst
- osteomyelitis
- developmental cysts
- traumatic bone cyst
- ameloblastoma
- cemental dysplasia
- cementoblastoma
- central giant cell granuloma
- systemic disease
- nonanatomic radiolucency
- anatomic radiolucency
a long-standing vertical root fracture may be viewed radiographically as a variant of ___
apical periodontitis
what establishes the diagnosis of a lateral periodontal cyst?
tracing of the lamina dura and normal responses to pulp vitality testing
the incisive canal cyst (nasopalatine duct cyst) may exhibit radiographic features similar to ___
apical periodontitis
when do ameloblastomas typically occur? what do aggressive lesions look like radiographically? what do they cause radiographically?
- 4th and 5th decades of life
- aggressive lesions occur as multilocular radiolucencies
- frequently cause extensive resorption of roots in the area
describe radiographic presentation of cemental dysplasia and which teeth it commonly affects
- varies in radiographic presentation from initially radiolucent to later more radiopaque
- more commonly associated with vital mandibular anterior teeth
what is the radiographic presentation of cementoblastoma?
- well-circumscribed, dense, radiopaque mass often surrounded by a thin, uniform, radiolucent outline
- severe hypercementosis or chronic focal sclerosing osteomyelitis (condensing osteitis) has a similar radiographic appearance
what is the radiographic presentation of central giant cell granuloma?
- produces a radiolucent area with either a relatively smooth or ragged border showing faint trabeculae
- associated teeth are usually vital
which systemic disease gives rise to a general radiolucent appearance of bone and may later give rise to well-defined oval or round radiolucencies?
giant cell lesion of primary hyperparathyroidism
what are some odontogenic nonanatomic radiolucencies?
dental papilla, dentigerous cyst, odontogenic keratocyst, residual (apical) cyst, odontoma (early stage)
what are some nonodontogenic nonanatomic radiolucencies?
fibro-osseous lesions, osteoblastoma, cementifying fibroma, ossifying fibroma, malignant tumor, multiple myeloma
what are the anatomic radiolucencies found in the mandible only?
mental foramen, mandibular canal, submandibular fossa, mental fossa
what are the anatomic radiolucencies found in the maxilla only?
maxillary sinus, incisive foramen, greater (major) palatine foramen, nasal cavity
what are the anatomic radiolucencies found in both jaws?
marrow spaces and nutrient canals
what are the clinical features of cracked tooth syndrome?
- sustained pain during biting pressures
- pain only upon release of biting pressures
- occasional, momentary, sharp, poorly localized pain during mastication, very difficult to reproduce
- sensitivity to thermal changes
- sensitivity to mild stimuli, such as sweet or acidic foods
when are radiographics not useful in identifying cracked tooth syndrome?
a mesiodistal crack is impossible to reveal, since the line of fracture is not in the plane of the radiograph
which teeth are most commonly affected by cracked tooth syndrome?
a strong majority are lower molars, with a slight preference for the first molar over the second
what are the diagnostic tools for cracked tooth syndrome?
- transillumination
- tooth slooth or cotton-tip applicator, noting which cusps occlude when the pain occurs aids in the location of the fracture site
- stain
- use a stream of air to detect pain from the crack that reaches exposed surface of tooth
how do you treat cracked tooth syndrome if the tooth has a healthy pulp or has reversible pulpitis?
splint with an orthodontic band and observe or prepare for crown (place a sound, temporary crown and observe before placing a permanent crown)
how do you treat cracked tooth syndrome if the tooth has irreversible pulpitis or necrosis with acute periradicular periodontitis?
- endodontic treatment (minimize removal of tooth structure and condensation force)
- restoration (if sufficient tooth structure remains, place a glass ionomer or acid-etched, dentin bonded core without a post and restore with a permanent crown; core material can be placed 2-3mm into the canal orifice. if insufficient tooth structure remains, consider a passively placed post along with an acid-etched, dentin bonded core and a permanent crown)
what is the prognosis of a tooth with cracked tooth syndrome?
generally guarded prognosis unless the fracture is traceable all the way from the mesial to distal, which indicates a poor prognosis
what direction does a vertical root fracture progress?
starts apically and progresses coronally
vertical root fractures are usually in which plane?
buccal lingual
in most cases of vertical root fractures, there is an isolated ___ defect at the site of the fracture
probing
what are important diagnostic signs of vertical root fractures?
radiolucency from the apical region to the middle of the root (J-shaped or teardrop shaped)
vertical root fractures may mimic other entities such as ___ or ___
periodontal disease or failed root canal treatment
predisposing factors of vertical root fractures are a weakening of the root structure in what 3 ways?
heavy enlargement of the canal, mechanical stress from obturation, or unfavorable placement of posts
how is the diagnosis of a vertical root fracture confirmed?
visualizing the fracture with an exploratory surgical flap
what is the goal of treatment for a vertical root fracture?
to eliminate the fracture space
what is the treatment for vertical root fracture of single rooted teeth?
extraction
what is the treatment for vertical root fracture of multi rooted teeth?
- hemisection with removal of only the affected root
- extraction
what is the prognosis of a tooth with a vertical root fracture?
hopeless
how do the pulp and periodontium communicate?
tubules, lateral accessory canals, furcation canals, and apical foramen
T or F:
endodontic disease can cause periodontal disease, but periodontal disease usually doesn’t cause endodontic problems
true, unless the periodontal disease involves the apex of the tooth
how can periodontal treatment affect pulpal health?
periodontal treatment (root planing) can result in bacterial penetration into exposed dentinal tubules, which can cause thermal sensitivity and subsequent pulpitis
what is the clinical presentation of primary endodontic lesions? is the tooth vital?
- inflammatory processes may or may not be localized at the apex. they may appear along the lateral aspects of the root or in the furcation, or may have a sinus tract along the periodontal ligament space appearing like a narrow, deep pocket
- tooth tests nonvital
describe how periodontal disease is progressive
it starts in the sulcus and migrates to the apex as deposits of plaque and calculus produce inflammation that causes loss of surrounding alveolar bone and soft tissues
manifestation of a periodontal abscess occurs during the ___ phase of inflammation
acute
what is the treatment of primary periodontal lesions?
periodontal therapy
what is the clinical presentation of primary periodontal lesions with endodontic involvement?
deep pocketing with history of periodontal disease and possible past treatment history
what is the treatment of primary periodontal lesions with endodontic involvement?
endodontic therapy followed by periodontal treatment
what is the clinical presentation of true combined perio-endo lesions?
once the endo lesions and perio lesions coalesce, they may be clinically indistinguishable
what is the treatment of true combined perio-endo lesions?
- requires treatment of both the endodontic and periodontal problem
- progression depends on whether or not the periodontal component actually caused the destruction
