Pulp and periapical diagnosis

Question 1

Symptoms vs Signs?

Answer 1

Symptoms –> things pt tell you

Signs –> things you observe on the basis of your investigation

Question 2

What are some symptoms of pulpitis/periapical tissues?

Answer 2

Pain
Sensitivity to hot and cold
Cannot bite or chew
Swelling
Bad taste

Question 3

List 4 unique skills a dentist must have to diagnose conditions of the pulp?

Answer 3

Diagnose the problem
Diagnose where the problems
Discuss findings with pt
Agree best management

Question 4

If a person has toothache, the initial process should be:

a) catered to individual
b) erratic
c) orderly

Answer 4

Orderly

Question 5

What are the 6 sections of the orderly process used to diagnose conditions of the pulp?

Answer 5

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

Question 6

Describe the classic progress of dental disease following caries?

Answer 6

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)

Question 7

How does a chronic diseased state form?

Answer 7

When host defences develop equilibrium with microbial toxins and live in a chronic diseased state

Question 8

List the conditions of the pulp and periapical tissues that are chronic diseases

Answer 8

Pulp necrosis, asymptomatic and apical periodontitis (necrotic pulp), chronic apical abscess

Question 9

How does an acute apical abscess form?

Answer 9

A shift in host/microbe balance may cause acute exacerbation

Question 10

What fibres supply sensory innervation to the pulp?

Answer 10

Peripherally - A delta
Central - C fibres
Both of V

Question 11

What kind of sensory innervation is supplied to the pulp?

Answer 11

Pain and nociception only. No proprioception

Question 12

Where are A delta fibres concentrated?

Answer 12

Pulp horns

Question 13

What kind of feelings do A delta fibres transmit?

Answer 13

Well-localised, sharp, transient pain

Question 14

When are A delta fibres stimulated?

Answer 14

When dentine is uncovered or pulp superficially damaged

Question 15

A delta fibres have a:

a) high stimulation threshold
b) low stimulation threshold

Answer 15

B - low stimulation threshold

Question 16

What kind of feelings do C fibres transmit?

Answer 16

Poorly localised, dull throbbing pain

Question 17

C fibre pain is associated with what kind of inflammation?

Answer 17

Irreversible, deep tissue

Question 18

C fibres have a:

a) high stimulation threshold
b) low stimulation threshold

Answer 18

A - high threshold stimulation

Question 19

How can the character of dental pain help diagnosis?

Answer 19

Pain history

How the pain is provoked/reproduced

Question 20

Why do pt with irreversible pulpitis complain about pain at night in bed?

Answer 20

Increase of BP in the pulp, whilst laying down

Question 21

How does exposed dentine cause pain?

Answer 21

Fluid movement through exposed tubules

Question 22

Why is irreversible pulpitis particularly poorly localised by pt’s?

Answer 22

C fibres

Question 23

What is referred pain?

Answer 23

Convergence of innervation from several teeth/related structures

Question 24

Pulpal pain is made worse by moving or biting not he tooth.

True or false?

Answer 24

If inflammation is confined to the pulp space, moving the tooth or putting pressure on it will cause little or no pain
FALSE

Question 25

List list characteristics of pulpal pain

Answer 25

Stimulated by hot/cold/sweet Poorly localised (especially irreversible pulpitis) Not influenced by tooth movement

Question 26

How can the pulp condition be classified? (5)

Answer 26

``` Normal Reversible pulpitis Irreversible pulpitis (symptomatic and asymptomatic) Pulp necrosis Previously treated ```

Question 27

List the 3 types of pulp sensibility tests?

Answer 27

Thermal Electronic Test cavity

Question 28

Function of electronic sensibility tests?

Answer 28

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

Question 29

Describe the test cavity sensibility test

Answer 29

Cut into dentine without LA to confirm pulp status. If it hurts = vital pulp Only used as last resort

Question 30

What is the purpose of a cusp flexure test?

Answer 30

Identify cracked cusp

Question 31

Describe how you do a cold thermal sensibility test

Answer 31

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

Question 32

Describe how you do a heat thermal sensibility test

Answer 32

Warm gutta percha sticks

Question 33

Disadvantage of electronic pulp tester?

Answer 33

Gives no quantitative information on the pulp condition, just presence or absence of functioning nerve fibres

Question 34

Advantage of thermal tests compared to electronic pulp tester?

Answer 34

Thermal tests give qualitative diagnostic information on pulp condition

Question 35

How do you prevent current crossing to other teeth e.g. connected amalgams whilst electronically testing the pulp?

Answer 35

Slip of rubber dam between the teeth

Question 36

What can cause a reduced response during pulp sensibility tests? (3)

Answer 36

Old teeth with mineralised pulps Recently traumatised teeth where pulp sensory nerves are concussed Teeth under LA

Question 37

What can cause an exaggerated response during pulp sensibility tests?

Answer 37

Anxious, fearful, young patients

Question 38

What should you bear in mind when testing multi-rooted teeth?

Answer 38

Each root may be in a different state

Question 39

When should you use a cusp flexure test?

Answer 39

When the pt has pain when biting

Question 40

What type of pulpal condition can cracked teeth mimic?

Answer 40

Pulpitis or apical periodontitis

Question 41

How are cusp flexure tests carried out?

Answer 41

By biting down on the individual cusp with a tooth sloth

Question 42

How does the innervation of the periodontium differ to pulp?

Answer 42

Rich proprioception

Question 43

Characteristics of periodontal pain?

Answer 43

Stimulated by tooth movement not hot/cold/sweet | Well localised by pt

Question 44

Classification of periapical condition (5)

Answer 44

``` Normal Apical periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis ```

Question 45

Name 2 tests of special value in periapical diagnosis

Answer 45

Biting, percussion and palpitation tenderness Radiographs

Question 46

Describe the biting, percussion and palpation tenderness test

Answer 46

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

Question 47

Positive result radiographically for periapical inflammation

Answer 47

Inflammation causes bone resorption or condensation = radiolucency (thin bone) If it is chronic = radio density

Question 48

List 3 periapical diagnostic tests

Answer 48

TTP - tap tooth with fingertip Biting tenderness - tooth sloth allows you to distinguish periapical inflammation from cracked cusps Radiographs - show bony periapical changes

Question 49

Why should you use your fingertip when testing for ttp?

Answer 49

Mirror handle would hurt a sensitive tooth

Question 50

What kind of bony periapical changes can be seen on radiographs?

Answer 50

Symptomatic apical periodontitis - classica widening of apical periodontal membrane space after trauma Chronic apical abscess - painless radiolucency at apex of tooth

Question 51

What type of questions should be asked about pain history?

Answer 51

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

Question 52

Describe an extra-oral examination

Answer 52

Look at your patient as they talk e.g. swellings, facial expressions showing pain, enlarged lymph nodes Palpate swelling snad lymph nodes

Question 53

What are you looking for in an intra-oral examination?

Answer 53

``` Oral cleanlisness Caries/periodontal status Heavily restored teeth Fractures/restorations Swellings associated with teeth Sinus tracts associated with teeth Darkened teeth ```

Question 54

What is the purpose of special tests?

Answer 54

Reproduce the patient-reported pain

Question 55

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

Answer 55

Normal or reversible pulpitis (a delta pain) No exposed dentine well localised