Infection

Question 1

Symptoms of pulp hyperaemia/ reversible pulpitis

Answer 1

Pain lasting for seconds
Pain stimulated by cold or sweet foods
Pain resolves after stimulus
Reversible inflammation of the pulp

Question 2

Symptoms of irreversible pulpitis/ acute pulpitis

Answer 2

Constant Severe Pain
Likely to keep patient awake at night
Reacts to Thermal Stimuli
Poorly Localised Pain - referral of pain
No (or Minimal) Response to analgesics

Question 3

How may acute periodontitis show up on a radiograph?

Answer 3

No Big radiolucency because no bone loss.
Loss of clarity of lamina dura
Radiolucent shadow - may indicate and “old” lesion e.g. flare-up of apical granuloma.
Delay in changes at the apex of the tooth - widening of apical periodontal space.

Question 4

What is the cause of traumatic periodontitis?

Answer 4

Parafunction - tooth clenching or grinding.

Question 5

How to treat traumatic periodontitis?

Answer 5

Occlusal adjustment - tooth somewhere is too high
Therapy for parafunction

Question 6

What are symptoms of acute apical abscess?

Answer 6

Severe unremitting pain
Acute tenderness to percussionand mastication
Swelling

Question 7

What happens once acute apical abscess perforates through bone?

Answer 7

Pain often remits
Swelling, redness and heat in soft tissues become increasingly apparent.
As swelling increases pain returns
There is INITIAL reduction in tenderness to percussion o the tooth as pus escapes into soft tissues.

Question 8

Treatment for acute apical abscess?

Answer 8

Recommend optimal analgesia - NSAIDs
DO NOT PRESCRIBE ANTIBIOTICS unless signs of spreading systemic infection

Provide drainage
- Soft tissue incision intra/ extra-orally

Remove source/ cause of infection
- Extract tooth
- Pulp extirpation
- Periradicular surgery

Question 9

What are local factors that would indicate need for antibiotics after pulpal infection?

Answer 9

Airway compromised
Dysphagia
Trismus
Lymphadenopathy - enlargement of lymph nodes, usually due to infection
Location (e.g. FOM)

Question 10

What are some systemic medical conditions that may indicate need for antibiotics following a pulpal infection?

Answer 10

Immunocompromised patient - HIV, blood disorders, chemotherapy patients etc.
Previous infective endocarditis
Diabetes - poorly controlled
Elderly

Question 11

Describe periapical granuloma (chronic apical periodontitis)

Answer 11

Mass of chronically inflamed granulation tissue at apex of tooth (plasma cells, lymphocytes, and few histiocytes with fibroblasts and capillaries).

Question 12

What is the aetiology of a periapical (radicular) cyst?

Answer 12

Caries, trauma, periodontal disease
Death of dental pulp
Apical bone inflammation
Dental Granuloma
Stimulation of epitheilial rests of Malassez
Epithelial Proliferation
Periapical Cyst Formation

Question 13

What is a periapical (radicular) cyst?

Answer 13

It arises from epithelial residues in the periodontal ligament as a result of inflammation - generally from necrotic pulp

Question 14

Where does infection go if perforates ABOVE the insertion of mylohyoid muscle?

Answer 14

Sublingual space/ abscess

Question 15

What space will infection go if perforates the bone BELOW the insertion of the mylohyoid muscle?

Answer 15

Submandibular abscess.
More problematic than sublingual as can then progress to other areas.

Question 16

Where does the abscess go If a lower tooth perforates BELOW the lower insertion of a buccinator?

Answer 16

Into the mouth

Question 17

Where does the abscess go if a lower tooth perforates ABOVE the lower insertion of buccinator?

Answer 17

Into the buccal space.

Question 18

What abscess infections are more likely to go palatially?

Answer 18

Palatal root of molar or lateral incisors as their roots are placed more palatially.

Question 19

What happens if infection spreads into superficial temporal, deep temporal, masseteric or pterygomandibular space (masseteric spaces)?

Answer 19

1. Any of the surrounding masticatory muscles may go into spasm and cause severe trismus, not allowing the patient to open their mouth.
2. Then can develop to going into retro/ lateral pharyngeal spaces
3. Then pre-vertebral - very dangerous

Question 20

Where would an infection from upper anterior teeth spread?

Answer 20

Lip
Nasolabial region
Lower eyelid

Question 21

Where would infection from upper premolars and molars spread to?

Answer 21

Sinus
Cheek
Buccal
Infra-temporal region
Maxillary antrum (very rare)
Palate (less common)

Question 22

Where would infection from lower anteriors spread?

Answer 22

Mental and submental space
Labial - more likely because labial bone is thinner - easier to diffuse through

Question 23

Where would infection from lower premolars and molars gp?

Answer 23

Buccal space
Sub-masseteric space
Sublingual space
Submandibular space
Pterygomandibular
Lateral pharyngeal space
Retro-pharyngeal

Question 24

What is the aim of treatment for abscesses/ spread of infection?

Answer 24

Establishment of drainage
Removal of source of infection
Antibiotic therapy (not always needed)

Question 25

What is Ludwig’s Angina?

Answer 25

Bilateral cellulitis (inflammation) of the sublingual and submandibular spaces

Question 26

What are intra-oral features of Ludwig’s angina?

Answer 26

Raised tongue
Difficulty breathing
Difficulty swallowing
Drooling

Question 27

What are extra-oral and systemic features of Ludwig’s angina?

Answer 27

Diffuse redness and swelling bilaterally in submandibular region

Systemic - Increased; heart rate, breathing rate, temperature, white cell count - SIRS symptoms

Question 28

Where can infection from lateral/ retro pharyngeal spaces spread to?

Answer 28

Can go up into the skull or down into the mediastinum

Question 29

What are the 4 criteria for SIRS?

Answer 29

Temperature - >38 / <36
Heart rate - >90bpm
Respiratory rate - <20bpm
WBC count - >12000/mL OR <4000/mL

Question 30

How many of the 4 SIRS criteria do you need to have for sepsis diagnosis?

Answer 30

2/4

Question 31

What things (other than the site) would you note about an extra-oral swelling?

Answer 31

Is their airway compromised?
Temperature of lesion
Fluctuant/ indurated
Size
Colour
Presence of pus?
Fever
Malaise
Diffuse or clear borders
Rate of progression

Question 32

What should be written on a microbiology request form?

Answer 32

What treatment has been attempted/ given
Patient details - CHI, name, age, sex, address etc.
Site
Time sample taken
Have antibiotics been prescribed? - what type and if they worked

Question 33

What are the two ways of obtaining a pus sample and which is more effective?

Answer 33

Pus aspirate - better because less risk of contamination of oral flora

Incise and swab - higher risk of contamination from oral flora and more likely to dry out and die in an oxygenated environment