Pulp and periapical diagnosis Flashcards
Symptoms vs Signs?
Symptoms –> things pt tell you
Signs –> things you observe on the basis of your investigation
What are some symptoms of pulpitis/periapical tissues?
Pain Sensitivity to hot and cold Cannot bite or chew Swelling Bad taste
List 4 unique skills a dentist must have to diagnose conditions of the pulp?
Diagnose the problem
Diagnose where the problems
Discuss findings with pt
Agree best management
If a person has toothache, the initial process should be:
a) catered to individual
b) erratic
c) orderly
Orderly
What are the 6 sections of the orderly process used to diagnose conditions of the pulp?
History - listen to what the patients tells you
Clinical examination - look at the teeth and surrounding tissues
Special test - appropriate special tests, reproducing the pain
Diagnosis -review all the information and diagnose (which tooth, condition)
Discussion and treatment plan - what are the options? What action is likely to help the problem?
Treatment
Describe the classic progress of dental disease following caries?
Normal pulp becomes reversibly inflamed by microbial infection (reversible pulpitis, normal periapical tissues) - short sharp pain
Inflammation spreads deeper into the pulp as micro-organisms invades and becomes irreversibly inflamed (irreversible pulpitis) - the pain is more prolonged and can come spontaneously
Pulp completely necroses, microbial and pulp breakdown products seep into apical tissues and cause profound inflammation, host responses with inflammatory cells causes pus to collect (pulp necrosis, acute apical abscess = symptomatic apical periodontitis)
How does a chronic diseased state form?
When host defences develop equilibrium with microbial toxins and live in a chronic diseased state
List the conditions of the pulp and periapical tissues that are chronic diseases
Pulp necrosis, asymptomatic and apical periodontitis (necrotic pulp), chronic apical abscess
How does an acute apical abscess form?
A shift in host/microbe balance may cause acute exacerbation
What fibres supply sensory innervation to the pulp?
Peripherally - A delta
Central - C fibres
Both of V
What kind of sensory innervation is supplied to the pulp?
Pain and nociception only. No proprioception
Where are A delta fibres concentrated?
Pulp horns
What kind of feelings do A delta fibres transmit?
Well-localised, sharp, transient pain
When are A delta fibres stimulated?
When dentine is uncovered or pulp superficially damaged
A delta fibres have a:
a) high stimulation threshold
b) low stimulation threshold
B - low stimulation threshold
What kind of feelings do C fibres transmit?
Poorly localised, dull throbbing pain
C fibre pain is associated with what kind of inflammation?
Irreversible, deep tissue
C fibres have a:
a) high stimulation threshold
b) low stimulation threshold
A - high threshold stimulation
How can the character of dental pain help diagnosis?
Pain history
How the pain is provoked/reproduced
Why do pt with irreversible pulpitis complain about pain at night in bed?
Increase of BP in the pulp, whilst laying down
How does exposed dentine cause pain?
Fluid movement through exposed tubules
Why is irreversible pulpitis particularly poorly localised by pt’s?
C fibres
What is referred pain?
Convergence of innervation from several teeth/related structures
Pulpal pain is made worse by moving or biting not he tooth.
True or false?
If inflammation is confined to the pulp space, moving the tooth or putting pressure on it will cause little or no pain
FALSE
List list characteristics of pulpal pain
Stimulated by hot/cold/sweet
Poorly localised (especially irreversible pulpitis)
Not influenced by tooth movement
How can the pulp condition be classified? (5)
Normal Reversible pulpitis Irreversible pulpitis (symptomatic and asymptomatic) Pulp necrosis Previously treated
List the 3 types of pulp sensibility tests?
Thermal
Electronic
Test cavity
Function of electronic sensibility tests?
To see if there is any functioning sensory nerve tissue in the tooth - decides whether pulp is necrotic or not, does not show the state of the pulp
Describe the test cavity sensibility test
Cut into dentine without LA to confirm pulp status.
If it hurts = vital pulp
Only used as last resort
What is the purpose of a cusp flexure test?
Identify cracked cusp
Describe how you do a cold thermal sensibility test
Ethyl chloride/endo-frost sprayed onto cotton wool, touch the suspect and adjacent teeth where the pulp horns are concentrated, record the response.
Start on a tooth on the other side of the mouth as a control
Describe how you do a heat thermal sensibility test
Warm gutta percha sticks
Disadvantage of electronic pulp tester?
Gives no quantitative information on the pulp condition, just presence or absence of functioning nerve fibres
Advantage of thermal tests compared to electronic pulp tester?
Thermal tests give qualitative diagnostic information on pulp condition
How do you prevent current crossing to other teeth e.g. connected amalgams whilst electronically testing the pulp?
Slip of rubber dam between the teeth
What can cause a reduced response during pulp sensibility tests? (3)
Old teeth with mineralised pulps
Recently traumatised teeth where pulp sensory nerves are concussed
Teeth under LA
What can cause an exaggerated response during pulp sensibility tests?
Anxious, fearful, young patients
What should you bear in mind when testing multi-rooted teeth?
Each root may be in a different state
When should you use a cusp flexure test?
When the pt has pain when biting
What type of pulpal condition can cracked teeth mimic?
Pulpitis or apical periodontitis
How are cusp flexure tests carried out?
By biting down on the individual cusp with a tooth sloth
How does the innervation of the periodontium differ to pulp?
Rich proprioception
Characteristics of periodontal pain?
Stimulated by tooth movement not hot/cold/sweet
Well localised by pt
Classification of periapical condition (5)
Normal Apical periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis
Name 2 tests of special value in periapical diagnosis
Biting, percussion and palpitation tenderness
Radiographs
Describe the biting, percussion and palpation tenderness test
Biting on a cotton wool roll of tooth sloth
Percussion of teeth with finger (not mirror handle) = ttp
Palpation of tissues over the apex of the tooth
Positive result radiographically for periapical inflammation
Inflammation causes bone resorption or condensation = radiolucency (thin bone)
If it is chronic = radio density
List 3 periapical diagnostic tests
TTP - tap tooth with fingertip
Biting tenderness - tooth sloth allows you to distinguish periapical inflammation from cracked cusps
Radiographs - show bony periapical changes
Why should you use your fingertip when testing for ttp?
Mirror handle would hurt a sensitive tooth
What kind of bony periapical changes can be seen on radiographs?
Symptomatic apical periodontitis - classica widening of apical periodontal membrane space after trauma
Chronic apical abscess - painless radiolucency at apex of tooth
What type of questions should be asked about pain history?
Nature - what does it feel like (sharp/dull throbbing)
Site - where is it (well or poorly localised)
Periodicity - when and how often doe sit hurt
Precipitants - what makes it start (hot/cold/sweet/chewing)
Reliving factors - analgesics, cold, warm, biting, nothing
Duration - how long does it last
Describe an extra-oral examination
Look at your patient as they talk e.g. swellings, facial expressions showing pain, enlarged lymph nodes
Palpate swelling snad lymph nodes
What are you looking for in an intra-oral examination?
Oral cleanlisness Caries/periodontal status Heavily restored teeth Fractures/restorations Swellings associated with teeth Sinus tracts associated with teeth Darkened teeth
What is the purpose of special tests?
Reproduce the patient-reported pain
Mike - 45
History - localised, sharp, transient pain. Brought about by eating and drinking cold and sweet things - in the UL1
Hurts during early morning jogs in cold air
Extra-oral - nil of note
Intra-oral - clean, healthy mouth
UR3-UL3 - good colour, no caries/fractures, normal mobility, no swelling etc
Drying UL1 with air provokes transient, sharp pain
Diagnose
Normal or reversible pulpitis (a delta pain)
No exposed dentine
well localised
