lecture 5 Flashcards
it is unlikely to often present as purely ______
pulpal
each two needs 2 diagnsoses:
pulpal and
peri-radicular (maybe perio and restorative also)
1st question to ask the patient in pain
what is your chief complaint
if purely pulpa=
diffuse pain=
=probably not
diffuse pain= pulpal
-this indicates where to begin you Problem Focused Exam and Testing
(hard to tell where pain is when affects just pulp)
this is what brought the patient here
and the objective of clinical testing is to find and comfirm the etiology of this
cc
this is performed based on cc
clinical testing
clinical tests:
- thermal
- ept
- percussion
- palpatation
- periodontal probing and mobility
thermal:
cold and heat (pulp vitality)
EPT
only if pulpal status in in doubt- this test is NOT done routinely
percussion
tapping with mirror (PDL sensitivity)
palpation
digital touching of gingival (inflammation, redness, swelling, tenderness)
periodontal probing and mobility
periodontal health
minimum 3 diagnostic films for oral exam:
- straight on PA film
- PA Shift Shot (20 degree change in horizontal angulation) M or D
- bite-wing (to determine restorability and bone level)
after oral exam (clinical testing and radiographs) now:
examine collected data
-reason for pulpal condition
answering the question of ____usually leads to an accurate diagnosis and a more successful treatment outcome
why
when evaluating the pulpal status, there are 3 basic conditions:
- normal (should remain normal and healthy)
- inflamed (could recover or deteriorate
A. reversible (no tx or symptomatic TX
->recovery)
B. Irreversible (pain lingering and often spontaneous)
-symptomatic (pain)
-asymptomatic (no pain) - infected (infected pulp with proceed to necrosis)
normal pulp=within normal limits (WNL) do what
leave it alone
reversible pulpitis
CC:
clinical testing:
CC: cold sensitivity
-pain relieved almost immediately when stimulus is removed (DOESNT LINGER)
-percussion: negative(on all tested teeth)
no radiographic changes
reversible pulpitis may follow 1 of 3 outcomes
- if properly treated- may revert to normal
- may remain RP symptomatic for extended period
- may deteriorate to SIP(symptomatic) or AIP(asymptomatic)
irreversible pulpitis (symptomatic)
CC
clinical testing results:
CC: cold sensitive
1. cold sensitivity hurts and lingers more than 30 seconds!!
2. everything is negative and NO radiographic changes at the apex
3. hot hurts (pathognomic for SIP)
4. pain maight be spontaneous or awakens patient from sleep
are normal teeth sens to hot?
NO
hot sens usually indicates a deteriorating pulp=SIP
rarely, deep caries (will/will not) produce any symptoms, though clinically or radiographically, caries may extend well into the pulp
-in such cases, what is definitely indicated in order to prevent a later exacerbation
will not
RCT
(this is example of AIP- asymptomatic irreversible pulpitis)
(polyp- found in young kinds- way of pulp defending itself)
cc: may be currently asymptomatic (usual history of symptomatic previously)
clinicial testing: cold sens. has no response and no response with EPT
necrotic pulp
obturated with final RC filling materials other than medicaments which is not healing or requires remedial treatment of some type.
previously treated
previously treated becomes
This becomes a non-surgical retreatment or a surgical retreatment or simply extraction and replacement
tooth has been previously treated by partial endodontic therapy
previously initiated treatment
a previously initiated treatment could be from a failed
failed pulp cap or pulpotomy or it could be pulpectomy
basic characteristics of the various PULPAL diagnosis “boxes”:
- WNL
- RP
- SIP*
- AIP*
- pulpal necrosis
- PT (previously treated)
- PIT (previously initiated treatment
pulp is symptom free with normal response to pulp test
wnl: normal pulp
inflammation of the pulp based on subjective and objective findings that should resolve and return the pulp to normal
RP: reversible pulpitis
vital inflamed pulp that is incapable of healing; lingering pain to cold, sensitivity to heat, spontaneous pain
SIP (symptomatic irreversible pulpitis)
vital inflamed pulp incapable of healing. no clinical symptoms.
-inflamed due to caries (chronic hyperplastic pulpitis) caries excavation (pulp exposure), trauma (fracture with exposed pulp tissue)
Asymptomatic irreversible pulpitis AIP
death of the dental pulp (no response to pulp tests)
pulpal necrosis
tooth has been endodontically treated with canals obturated with final root canal filling materials other than medicaments
previously treated
tooth has been previously treated by partial endodontic therapy (pulp calp, pulpotomy/pulpectomy) RCT NOT completed
previously initiated treatment PIT
always remember everything in ___is continually changing
diagnostic
both seriously inflamed and infected pulpitis cases will ultimately lead to a ______ if left untreated long enough
necrotic pulp
if you cannot arrive at a supportable Dx, you cannot
do any treatment
rarely do we see _____in cases of pure pulpitis or even EARLY necrotic pulp.
why?
apical radiograph changes
why: advanced pulpal disease or necrosis of the pulp is generally required to allow infection to affect the apical tissues
is there a correlation between clinical symptoms and histo/pathological reality?
no not really
DX must be supported and documented by clinical examination and testing before
any treatment planning can be done
how do we support our peri-apical Dx?
we must use evidence gained from clinical examination and clinical testing along with our knowledge and experience:
1. medical and dental history
2. CC and signs and symptoms
3. clinical examination
4. clinical testing
5. radiological indications
____which are generally of limited use in Dx of purely pulpal disease may come to some value in Apical Dx .
radiographs
never attempt to make a Dx from this alone:
why?
radiographs
-many unrelated non-dontogenic entities can mimic “lesions of endodontic origin” LEOs radiographically but in fact be something entirely different
form example in powerpoint, the radiolucency that we think we see near the apex may be:
- artifact
- non-odontogenic lesion
3 oral manifestation of systemic disease - normal anatomical landmark
must prove what it is!
look for damage:
caries, restorations, fracture, extreme/rapid wear?
trauma?
check for crack
discoloration of crown
-the disease process rapidly extends peri-apically
-tooth often become percussion and/or spontaneous pain may appear before radiographic evidence is clear
pulp necrosis
for this dx, radiographic evidence will develop. but takes time
10% of the medullary bone can be destroyed and no PARL may show on the standard radiograph
pulpal necrosis
a visible PARL is only visible when
40% of the cortical bone has been destroyed
progression of RC system infections in 7 steps:
- carious lesion or trauma opens tubules to bacterial invasion
- bacteria inflame pulp locally
- inflammation may overcome pulpal defenses and localized abscesses may form in coronal pulp
- infection increases in pulp and necrosis begins
- necrosis involves entire RC system
- infection uses “portals of exit” (apical foramen and lateral canals) to invade peri-radicular tissues (apical periodonitis)
- periradicular infection occurs beyond apex (apical abscess)
all peri-radicular inflammation is sensitive to:
why is this important?
percussion
-purely pulpal pain is not sensitive to percussion
can the patient point to the tooth that hurts? probably yes, but why?
- mechanoreceptors(proprioceptors) are present in ____and not_____.
- it means that inflammation/infection from the pulp has:
- the offending tooth will now be sensitive to percussion but a lesion may not yet:
- what would be an exception:
- PDL
not in pulp - already reached the P/Apical tissues and we are dealing with an apical Dx of some type.
- show on x-ray
- exception: recent or chronic occlusal trauma
APICAL diagnostic “boxes”
- WNL: normal
- SAP: symptomatic apical Periodontitis
- AAP: asymptomatic apical periodontitis
- AAA: acute apical abscess (swelling + fever)
- CAA: chronic abscess (PAR +Draining sinus tract)
- CO: condensing osteitis
-radiopaque on xray
-treatment is determined by symptoms
-teeth not sensitive to percussion or palpation
-lamina dura intact
-PDL uniform and unbroken
WNL-normal and do nothing
-inflammation of the periodontium-> producing painful response to biting/percussion/maybe palpation
(peri-apical diagnostic “boxes”)
SAP
inflammation and destruction of the periodontium that is of pulpal origin appearing as a radiolucent area with no clinical symptoms
(peri-apical diagnostic “boxes”)
AAP
inflammatory reaction to pulpal infection with rapid onset, spontaneous pain, tooth tender to pressure, pus formation and swelling and fever!
AAA
acute apical abscess
inflammatory reaction to pulpal infection with gradual onset, little or no discomfort and draining sinus tract!
CAA
chronic apical abscess
diffuse radiopaque lesion representing a localized boney reaction to a low-grade inflammatory stimulus
CO
condensing osteitis
SAP Dx:
(symptomatic apical periodontitis)
- tooth sens to percussion and biting pressure**
- palpation variable
- no swelling, no DST
- pulp vitality variable (vital to NV)
- radiographic appearance variable: minor or no significant apical radiographic changes or thickened PDL space to frank PARL(early on)
beware with apical dx,
other situations may result in similar symptoms like
recent restorations (high)
occlusal habits (bruxism)
trauma
a thickened PDL can be caused by:
so check occlusion especially if new/high restoration
occlusal trauma or PARL
AAP Dx (acute apical periodontitis)
- no sens. to percussion, palpation, biting
- pulp non-vital
- thickened pdl
- no swelling- No DST
AAA dx (acute apical abscess)
- pulp necrotic
- severe pain to: biting, percussion or palpation
- apical radiograph changes, thickened PDL space or PA radiolucency
- often mobile due to active infection
- rapidly developing infection-usually swelling (intra and extra -oral and fever)
AAA with severe cellulitis :
incision and drainage needed, oral surgeon if extra-oral, patient often needs to be admitted, elevated temp/fever, rapid development swelling(often severe)
is CAA an emergency
no
CAA dx
(chronic apical abscess)
- pulp necrotic
- pain minimal or none
- sensitivity to percussion minimal or none
- sensitivity to palpation minimal or none
- swelling minimal or none
- NO fever
- may have been present for extended periods of time (how it got big)
- usually drainage via DST or gingival sulcus via narrow periodontal pocket
always trace out a DST with _____and ____ bc sometimes you can be fooled
gutta percha cone and radiograph
what if the ostium of the DST in CAA doesn’t point to a PARL?
always trace and xray
- usually no extraoral swelling
- pain minimal/none
- generally intra-oral DST
- no facial swelling
- generally fairly comfortable
- generally no Rx analgesic and no antibiotics required
CAA
this depends on the sum of patient history and symptoms, clinical exam, signs and testing and radiograph interpretation
diagnosis depends on
radio-opaque formative or reactive bone
-treatment based on symptoms
CO (condensing osteitis)
CO develops in response to a mild or _______ or infection where bone is actually formed instead of being resorbed or destroyed
-asymptomatic and no apparent pathology which means what with treatment?
“sub clinical” inflammation
no treatment(continue to monitor)
