ICSII endo diagnosis

Question 1

case

Answer 1

1) 36 year old male
2) 10/10 pain in right side
3) patient awake all night
4) nonsignificant medical history
- no meds
- NKDA
5) filling fell out of #30 one year ago
6) no swelling
7) inflamed papilla
8) #31 sens to percussion
9) #30 cant even touch it, sensitive to percussion, normal to cold, tooth slooth painful
10) #29 sens to percussion, normal to cold

Question 2

pulp vitality

Answer 2

1) possibly all teeth are vital because they respond to cold
2) take CBCT
- nsf

Question 3

what about referred pain?

Answer 3

1) check for TMD, check for neuropathic pain
2) check for OPPOSING arch

Question 4

what about perio?

Answer 4

1) suspect #30 due to inflamed DB papilla and BOP
2) perio said it was ENDO

Question 5

if you don’t have a diagnosis, you cannot treat

Answer 5

1) you could wait for the infection to localize…

Question 6

why did we recommend RCT on #30 even though it was normal to cold and no lesion on CBCT and xray

Answer 6

1) test are only accurate up to 97%… you have to put pieces together
2) USUALLY the tooth most sensitive to percussion is the one
3) there is an etiology: there is caries on #30
4) the patient will not WANT to go home without treatment because 10/10 pain

Question 7

giving IA nerve block confirms…

Answer 7

1) that it is odontogenic and we have the right arch!
- anesthetic test
2) infiltration test doesn’t work on lower teeth because the thick mandible

Question 8

the resident did an MTA pulpotomy on #30

Answer 8

1) was this a good treatment?
- the tissue was “vital”
- age 36
2) nope this was inappropriate
- it was TOO sensitive to percussion
- inflammation has reached the PDL… so it probably reached the root
3) plus, this tooth needs a crown

Question 9

MTA is

Answer 9

1) hard like cement
2) a lot of mineralization occurs underneath

Question 10

what was the best option?

Answer 10

1) pulpectomy (not a full RCT)
2) then bring him back for full endo
3) then crown

Question 11

one month later… he comes back due to pain

Answer 11

1) percussion sensitivity and severe lingering pain to cold on #30
2) now RCT

Question 12

14 year old patient case

Answer 12

1) #7 and #8 slight sensitive to palpation and percussion
2) #7-10 normal to cold
3) radiograph shows…severe bone loss

Question 13

take a cbct and biopsy

Answer 13

1) bone loss around these teeth
2) biopsy done
- squamous cell carcinoma cancer found

Question 14

post treatment

Answer 14

1) big section of maxilla was removed
2) DO NOT ASSUME ONLY CANCER HAPPENS TO OLD PEOPLE

Question 15

normal pulp

Answer 15

1) little to no sensitivity to temperature
1) cold response disappears immediately

Question 16

reversible pulpitis

Answer 16

1) hx of restoration or shallow careis
2) sensitivity but not lingering
3) normal radiographic apex

Question 17

symptomatic irreversible pulpitis

Answer 17

1) positive to EPT cold
2) history spontaneous pain
3) lingering pain upon removal of cold and heat
4) radiating pain
5) may be percussion sensitive
6) WNL or widened PDL

Question 18

test the suspect tooth

Answer 18

1) LAST!
2) or it becomes hard to test the other teeth

Question 19

asymptomatic irreversible pulpitis

Answer 19

1) caries to the pulp but no pain
2) ex. hyperplastic pulpitis = pulp polyp

Question 20

pulp necrosis

Answer 20

1) may be asymptomatic
2) sinus tract may be present
3) usually has a radiolucency
4) casue symptoms when acutely infected
- percussion sensitive

Question 21

previously treated

Answer 21

1) has RCT before

Question 22

previously initiated

Answer 22

1) has started endo

Question 23

normal apical tissues (NAT)

Answer 23

• intact PDL and Lamina Dura
• not sensitive to percussion
• not sensitive to palpation

Question 24

asymptomatic apical periodontitis

Answer 24

1) not sensitive to percussion
2) PA radiolucency is present

Question 25

symptomatic apical periodontitis

Answer 25

1) sensitive to percussion
2) PA radiolucency may or may not be present

Question 26

acute apical abscess

Answer 26

1) fast onset
2) swelling
3) pain
4) may have trismus

Question 27

chronic apical abscess

Answer 27

1) sinus tract present
2) usually not much pain
3) intermittent drainage

Question 28

health history

Answer 28

1) TN
2) coronary artery disease
3) diabetes
4) artificial joints
5) rickets
6) history of cancer.. etc

Question 29

c-fibers

Answer 29

1) unmyelinated, slow
2) localed centrally in the pulp
3) small diameter

Question 30

diagnostic tests

Answer 30

1) percussion
2) bite test (qtip or tooth slooth)
3) cold
4) EPT
5) periodontal probing
6) palpation
7) heat (only if they report heat sensitivity)
8) mobility
9) transillumination

Question 31

how to do cold test

Answer 31

1) start with a brief touch, then go longer if they dont feel it
2) make sure tooth is dry so it doesn’t stick

Question 32

EPT

Answer 32

1) dry tooth
2) electrolyte and have the patient hold onto it
3) probe on tooth

Question 33

periodontal probing

Answer 33

1) must get to bottom of sulcus
2) sound for bone
3) isolated deep pockets can indicate a fracture

Question 34

tracing a sinus tract

Answer 34

1) put the GP cone size 30

Question 35

cracked tooth syndrome

Answer 35

1) cannot see fracture on radiograph
2) if pulp tests normally, try the crown
3) 80% do not need RCT
4) if symptoms persist, RCT since fracture into pulp
5) movement of fluid in dentinal tubules

Question 36

case III

Answer 36

1) spontaneous pain, submandibular swelling
2) pulp test #31: percussion positive and bite, #30 slightly percussion positive
3) ALL teeth in LRQ no response to cold
4) ALL teeth in LRQ viral to EPT

Question 37

case III do a CBCT

Answer 37

1) you can see lesions on CBCT much better
2) cracked teeth usually runs MD, then can go down the root of the tooth
- as a result, can see vertical bony defect
- deeper probing, loss of cortical plate

Question 38

fracture necrosis

Answer 38

1) M or D pocket >5 mm (41%)
2) CAP, SAP, AAA (69%)
3) cracked Distal marginal ridge (84%)
4) <5 mm and no distal marginal ridge crack (93%)

Question 39

signs of vertical root fracture

Answer 39

1) previously treated
2) J shaped or halo radiolucency
3) sinus tract/multiple sinus tracts
4) isolated deep periodontal pocket
5) absence of buccal cortical plate
6)radiolucency at terminus of a post
7) loss of bone in mid root area with intact bone coronal and apical to the defect
8) direct visualization
9) etc

Question 40

cavity test

Answer 40

1) only do it on a tooth with a crown
2) only when a necrotic pulp is suspected
3) cut a hole into the crown and into the dentin and use EPT
4) or without anesthetic, start cutting the access and into the pulp

Question 41

non carious pathways into pulpal degeneration

Answer 41

1) trauma
2) periodontal disease
3) ortho movement
4) dens evaginatus and invaginatus
5) surgical sequelae

Question 42

trigeminal neuralgia

Answer 42

1) electric shock pain
2) has a trigger pain
3) no dental etiology
4) can be treated with carbamazepine

Question 43

pain symptoms of non dental origin

Answer 43

1) travel across the midline of face
2) cyclical with day or season
3) trigger sites in head and neck
4) paresthesia without inflammation

Question 44

chronic pain syndromes of the jaws

Answer 44

1) TMD
2) facial myalgia
3) atypical facial pain
4) allergic sinusitis

Question 45

if symptoms cannot be reproduced

Answer 45

1) and there is not radiographic evidence
2) do not do RCT

Question 46

case 4

Answer 46

1) 11 year old
2) non significant medical history
2) bony swelling between 29 and 30
4) #29 sensitive to percussion, negative to cold and EPT
5) #30 slight sensitive to percussion, normal to cold
6) what could be the cause of pulp necrosis of #29?
- fracture
- dens evaginatus (common in children)

Question 47

differential diagnosis

Answer 47

1) GIANT radiolucency
2) myxoma
3) take a CBCT
- mixed lesion of radiolucency and radiopacity
- diagnosis: traumatic bone cyst

Question 48

traumatic bone cyst

Answer 48

1) empty cavity
2) just air
3) stimulate bleeding to stimulate healing
4) unknown etiology

Question 49

case 5

Answer 49

1) 47M
2) hypertension, epilepsy, hypothyroid, hyperlipidemia
3) RCT on #19 2 years ago
4) DL cusp fracture
5) sinus tract present
- trace it
6) probe it!!!
- 12 mm pocket

Question 50

case 6

Answer 50

1) 48F
2) sinus tract on gum buccal to #5
3) negative to cold
4 )trace sinus tract
5) etiology?
- shallow restoration on tooth

Question 51

case 7

Answer 51

1) 57F
2) NSMH
3) sinus tract on lingual
4) viral pulp, chronic apical abscess
5) how can it be vital pulp??? if there is an abscess… usually pulp necrosis or previously treated
- diagnosis - trauma to tori
- osteomyelitis from piece of bone exfoliating (necrotic bone)
- this is how you know it is something ELSE, not pulpal

Question 52

case 8

Answer 52

1) 42F
2) ASA II
3) diagnosis pulpal necrosis / SAP
4) case assessment
- CBCT : C shaped anatomy, lesion is continuous with the IAN
- resident case

Question 53

case 9

Answer 53

1) 76M
2) pain for 5 days on LRQ
3) HIV, high cholesterol
4) verpamil, biktarvy, crestor
5) Pt went to the ER the week before and given IB, clindamycin, oxycodone
6) swelling buccal #28
7) cold test: #10,12,23,27,28, all NR to cold
8) is there a lesion on #28
- CBCT shows the lesion
9) see anything else?

Question 54

case 10

Answer 54

1) 51M
2) HIC and HTN
3) PrEP,losartan
4) #20 pain and swelling, sensitive to percussion
- previously treated
- symptomatic apical periodontitis
5) CBCT root fracture

Question 55

coronal leakage

Answer 55

1) only takes a month for bacterial to make it to the botton
2) CBCT shows there was one untreated root canal in #21
- any tooth that starts with a 2 can have multiple canals

Question 56

case 11

Answer 56

1) #30 negative to cold, sensitive to percussion, 12mm pocket on Buccal
2) pulp necrosis, symptomatic apical periodontitis
3) vertical root fracture?
- nope, it isn’t previously treated
- no sinus tract
- this is an endo-perio lesion

Question 57

case #12

Answer 57

1) #12 negative to cold, sensitive to percussion
2) previously treated, symptomatic apical periodontitis
3) CBCT shows a buccal split with a lateral canal

Question 58

case 13

Answer 58

1) #13 I have a bump on my gum
2) lateral canal present
3) apical surgery was done?

Question 59

how long does it take an endo lesion to heal?

Answer 59

1) 4 years
2) so a recent RCT may still be healing