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pulpal and apical diagnosis Flashcards

1
Q

likely to be pruely pulpal?

A

no

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2
Q

• Each tooth needs 2 Diagnoses: what are they?

A

• Each tooth needs 2 Diagnoses:
– Pulpal
– Peri-Radicular (Maybe Perio &
Restorative also)

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3
Q

1st pt question

A

CC

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4
Q

local vs diffuse pain
diffuse pain likely what origin?

A

Can you point to the tooth that hurts?
Can you localize the source of your pain?If Purely PULPAL – probably NOT (diffuse pain = pulpal)

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5
Q

The Objective of Clinical Testing is to?

A

find and confirm the etiology of the patient’s CC.

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6
Q

percussion testing

A

tapping tooth to look for pain

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7
Q

types of clinical tests
performed based on?

A

performed (based on CC)
– Thermal: cold, heat (pulp vitality)
– EPT: (only if pulpal status is 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 & mobility (periodontal health)

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8
Q

radiographs of suspected areas

A

– Minimum 3 Diagnostic films:
• Straight-on PA film
• PA Shift Shot (20° change in horizontal angulation) M or D
• Bite-Wing (to determine Restorability & Bone level)

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9
Q

possible pulpal diagnosis

A

WNL
RP
SIP
AIP
N
PT
PIT

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10
Q

normal pulp (WNL)
CC?
clinical test used/ results?
radiographic?
damage?
testing adjacent teeth?

A

• CC: None (Asymptomatic Currently & Historically)

• Clinical Testing:
• Thermal testing (Hot-Cold WNL)
• EPT responsive (similar to other WNL teeth)
• Percussion Negative (WNL)

• No Radiographic Changes
• Another Clue: Minimal or No Apparent Damage
• No Axial cracks. Leave it ALONE

• VIP! Always test 2-3 adjacent teeth prior to the tooth in question-WHY? (Establish a
STANDARD BASE-LINE: 1st)

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11
Q

Reversible Pulpitis outcomes?

A
  1. If properly treated – may revert to normal
  2. May remain RP symptomatic for extended period
  3. May deteriorate to SIP or AIP (even if properly treated)
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12
Q

Reversible Pulpitis
CC?
clincal testing?
radiogrpahs?

A

Reversible Pulpitis
• CC: Cold Sensitive

• Clinical Testing:
– Cold sensitivity- pain relieved almost immediately once stimulus is removed-(does NOT linger)*
– Percussion Negative (all 3 teeth)
–Radiographic Changes?* NO PULP is VITAL

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13
Q

SIP
CC?
clincal testing?
radiographs?
early/late temps?
waking?

A

• CC: Cold Sensitive
• Clinical Testing:
– Cold Sensitivity –LINGERS*** 15-20 sec. after stimulus is removed.
– Percussion Negative
– Radiographic Changes: None at apex
– Look for etiology
1. Early SIP cold hurts, >10 and lingers
2. Late SIP hot hurts –cold helps
3. &/OR Pain might be spontaneous or awakens patient from sleep

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14
Q

teeth sensitivity to hot?

A

Normal Teeth are NOT sensitive to HOT. Gingiva are more sensitive to hot than teeth. HOT sensitivity usually indicates a deteriorating pulp = SIP Normal: HOT coffee hurts soft T. not
tooth !

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15
Q

deep caries and asymptomatic, what is indicated?

A

•Rarely, deep caries will not produce any symptoms, though clinically or radiographically, caries may extend well into the pulp.
RCT indicated

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16
Q

AIP
CC?
clincal testing?

A

•CC: May be currently asymptomatic –usual history of symptomatic previously)
•Clinical Testing:Cold Sensitivity: No Response to cold hot, or electric pulp tester.

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17
Q

PT

A

Obturated with final RC filling materials other than
medicaments which is not healing or requires remedial
treatment of some type. This becomes a Non-Surgical
retreatment or a surgical RETX or simply extraction &
replacement.

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18
Q

PIT

A

Tooth has been previously treated by partial endodontic therapy.
This could be a failed pulp cap or pulpotomy or it could be a pulpectomy.

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19
Q

WNL: (Normal Pulp) – Pulp and tests?

A

– Pulp is symptom free with normal response to pulp tests

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20
Q

RP : (Reversible Pulpitis) – pulp? findings?

A

RP : (Reversible Pulpitis) – Inflammation of the pulp based on subjective and objective
findings that should revolve and return the pulp to normal.

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21
Q

SIP (Symptomatic Irreversible Pulpitis) - Pulp? findings?

A

SIP (Symptomatic Irreversible Pulpitis) - Vital inflamed pulp that is incapable of healing. i.e.
lingering pain to cold, sensitivity to heat, spontaneous pain.

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22
Q

AIP (Asymptomatic Irreversible Pulpitis) – pulp? due to?

A

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)

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23
Q

Pulpal Necrosis (Necrosis) –

A

Pulpal Necrosis (Necrosis) – Death of the dental pulp (No Response to pulp tests)

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24
Q

PT: (Previously Treated) –

A

PT: (Previously Treated) – Tooth has been endodontically treated with canals obturated with
final root canal filling materials other than medicaments..

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25
Q

PIT (Previously Initiated Treatment)

A

PIT (Previously Initiated Treatment) – Tooth has been previously treated by partial
endodontic therapy, i.e. pulp cap, pulpotomy/pulpectomy. RCT NOT completed

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26
Q

continual changes of dx

A

Always remember everything in DX is continually CHANGING
A pain which is diffuse today may be localized tomorrow
A severe cold sensitivity may abate overnight
The same tooth may become newly sensitive to bite next day as pulp vitality
succumbs to challenge.

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27
Q

Both seriously Inflamed and Infected Pulpitis cases will ultimately lead to?

A

Both seriously Inflamed and Infected Pulpitis cases will ultimately lead to a Necrotic pulp if left untreated long enough.

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28
Q

Radio changes in purely pulpitis? why?

A

• RARELY do we see APICAL RADIOGRAPHIC CHANGES in cases of pure pulpitis or even
EARLY necrotic pulp ***
• Advanced pulpal disease or necrosis of the pulp is generally required to allow infection
to affect the apical tissues.

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29
Q

supporting our periapical dx

A

We must use EVIDENCE gained from CLINICAL EXAMINATION & CLINICAL TESTING along with our knowledge and experience:
1. Medical & Dental History
2. CC + Signs & Symptoms
3. Clinical examination
4. Clinical testing
5. Radiological indications

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30
Q

dx from radiographs alone?

A

• Never attempt to make a Dx fromradiographs alone **
• Many unrelated non-odontogenic entities can mimic “Lesions of Endodontic Origin” (LEO)s radiographically but in factbe something entirely different
• Don’tskip any steps*
• Document ALL TESTING andEXAMINATION DONE.

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31
Q

The radiolucency that we think we see near the apex may be***

A

must prove it is a LEO with testing

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32
Q

Looking for the DAMAGE?

A

• Do you see any damage to the tooth?
• Caries, Restoration, Fracture, Extreme/Rapid Wear?
• Trauma of any sort? Ask more than once!
Check 4 Crack
• Discoloration of the crown?

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33
Q

Following Pulpal Necrosis:
dx extends?
tooth tests? does radiographic evidence preceded pain?

A

• The disease process rapidly extends peri-apically.
• The tooth often will become percussion + &/or spontaneous pain may appear BEFORE radiographic evidence is clear.

34
Q

radiographic evidence of pulpal necrosis, time to develop? only visible when?

A

occurs but takes time to develop
– 100% OF THE MEDULLARY BONE CAN BE DESTROYED & no PARL may show on the
standard radiograph.
– A Visible PARL is ONLY VISABLE when 40% of the Cortical Bone has been destroyed.

35
Q

ALL PERI-RADICULAR INFLAMMATION IS SENSITIVE TO?

A

PERCUSSION.

36
Q

PURELY PULPAL PAIN IS NOT SENSITIVE TO?

A

PERCUSSION

37
Q

Can the Patient point to the tooth that hurts? Probably yes, but why?

A

• Mechanoreceptors (Proprioceptors) are present in PDL not in Pulp
• It means that inflammation/infection from the pulp has already reached the P/Apical tissues and we are dealing with an Apical DX of some type.
• The offending tooth will now be sensitive to percussion but a lesion may NOT yet show on XR*
• (Recent or chronic occlusal trauma –possible exception)

38
Q

apical diagnosis boxes?

A
39
Q

another possible PA dx

A

condesing osteitis

40
Q

WNL PA
percussion?
PDL/lamina dura

A

Teeth not sensitive to percussion or palpation.
Lamina dura is intact and the PDL is uniform and unbroken.

41
Q

SAP: (Symptomatic Apical Periodontitis)
percussion?

A

Inflammation of the periodontium producing a painful response to biting/percussion/maybe palpation.

42
Q

AAP (Asymptomatic Apical Periodontitis)

A

Inflammation and destruction of the periodontium that is of pulpal origin appearing as a radiolucent area with no clinical symptoms.

43
Q

AAA (Acute Apical Abscess)

A

Inflammatory reaction to pulpal infection with rapid onset, spontaneous pain, tooth tender to pressure, pus formation and SWELLING & FEVER

44
Q

CAA: (Chronic Apical Abscess)

A

Inflammatory reaction to pulpal infection with gradual onset, little or no discomfort and
DRAINING SINUS TRACT.

45
Q

CO: (Condensing Osteitis)

A

Diffuse radiopaque lesion representing a localized boney reaction to a low-grade
inflammatory stimulus.

46
Q

PA dx: radio findings and pain?

A
47
Q

WNL PA
percussion?
lamina dura?
PDL?
symptoms?
pulp tests?
injury?

A
48
Q

SAP PA
percussion? palpation?
swelling/DST?
pulp testing?
radiographs?
similar situations?

A
49
Q

AAP (Asymptomatic Apical Periodontitis)
sensitivity?
pulp?
PDL?
swelling?

A
50
Q

AAA (Acute Apical Abscess)
pulp?
pain to?
radio?
mobile?
DST?
infection?

A
51
Q

cellulitis

A

Rapid Development Swelling (often Severe) Elevated Temp./Fever
can occur with AAA, requires I and D

52
Q

CAA (Chronic Apical Abscess)
emergency?
pulp?
pain?
percussion? palpation?
swelling?
fever?
drainage?

A
53
Q

CAA extraoral swelling/ pain

A

usually not, typically no pain

54
Q

tracing DST

A

Always trace out a Draining Sinus Tract (DST) with Gutta Percha cone & Radiograph … sometimes you can be fooled!!!!

55
Q

CO (Condensing Osteitis)
radio?
symptoms?
tx?
response to?
differential diagnosis?

A

CO (Condensing Osteitis)
➢ Radio-opaque formative or reactive bone
➢ Asymptomatic and no apparent pathology = NO TREATMENT (Continue to monitor)
➢ Treatment of CO is based upon symptoms
➢ Develops in response to a mild or “sub clinical” inflammation or infection where bone is actually formed instead of being resorbed or destroyed
Differential DX: Sclerotic Bone which is a non-pathology & requires no TX. (no DAMAGE

56
Q

Why is an ACCURATE DX Important?

A

• Everything that follows an inaccurate DX is . . . WRONG !
• You cannot do ANY Treatment for the patient until you have a supported DX*
• If you cannot make a definitive DX today, support the patient with appropriate supportive medications and follow up or…refer

57
Q

Common Types of Longitudinal (Vertical) Fractures (in increasing order of severity)

A

• Craze Lines (Confined to enamel)
• Fractured Cusp (Oblique shearing FX ) Facial-Lingual
• Cracked Tooth (Incomplete “Greenstick” FX)
• Split Tooth
• Vertical Root Fracture***

58
Q

craze lines

A

Common & Generally Unimportant (don’t stop light)

59
Q

fractured cusps

A

Often involves undermined cusp, may be restorable

60
Q

cracked tooth “greenstick”
direction?
pulp involved?
confined to crown?

A

– M-D FX involving 1 or both marginal ridges
– May or may Not involve the pulp
– May be confined to crown or extend to root

61
Q

split tooth
involves what structures?
must remove? determine?

A

– Involves Crown, Root & generally Pulp
– Must remove FX segment & determine restorability

62
Q

vertical root fractures
begins where?
planes of occurrence?
often in teeth with what prior tx?

A

Begins INTERNALLY (at root apex or from crown)
– Primarily in axial plane may be F-L or M-D*
– Often occur in RCT teeth

63
Q

horizontal fractures

A

Horizontal Fractures are also important but are generally easily seen and are usually associated with known traumatic events.

64
Q

fractured cusps first step

A

always do all necessary DX testing.
Determine condition of pulp. If vital and restorable, anesthetize and remove the fractured portion and restore if possible.

65
Q

fractured cusps pulp WNL

A

Normal procedure is to remove the fractured cusp and see if the remaining tooth structure will support a restoration (intra-coronal or extra-coronal).

66
Q

variability of fractured cusps tx

A

Anything from simple intracoronal restoration to endodontic intervention to extraction of the tooth may ensue in this highly variable injury.

67
Q

Fx below the attached gingiva: restoration?

A

crown lengthening may help
so little tooth structure remains that RCT + post, build-up and crown will be necessary to properly restore.

68
Q

cracked teeth most common on?

A

Most common site of cracked
tooth is mandibular 2nd or 1st molar
followed by maxillary premolars.

69
Q

cracked teeth and caries? bruxism?

A

Often seen in teeth without caries or restoration.
May follow bruxism or clenching habit or other trauma

70
Q

diagnosing cracked teeth with restorations

A

Difficult to see if covered by MOD
amalgam or even composite. May
need to remove restorations, stain
& trans-illuminate to diagnose.

71
Q

cracked teeth symptoms

A

A Cracked Tooth is most often discovered following patient complaint of acute, sharp, momentary pain upon biting or release of biting pressure. An old crack may often be seen as stained.

72
Q

cracked teeth pulp

A

Generally pulp is vital in early stages & may remain so for some time.

73
Q

cracked teeth and avoidance of biting? soon leads to?

A

Often, the untreated patient may learn to avoid biting on the tooth and the pulp may survive for a time in this manner before eventually succumbing to the bacterial challenge &/or extension of the crack at which point the pulp becomes necrotic & the previous pain stops because the pulp is now necrotic and can no longer respond. Later SAP will develop as infection invades the peri-radicular tissues.

74
Q

production of sharp pain in a cracked tooth

A

When a cracked tooth with a vital pulp is bitten upon in a manner to wedge open
the crack, air & saliva enter the defect. When biting pressure is released, typically
the wedged crack moves rapidly toward closure forcing a change in the fluid
gradient in the dentinal tubules producing the characteristic acute & sharp,
momentary pulpal pain as long as the pulp remains vital.

75
Q

cracked teeth and percussion early? pulp?
possible to protect? how?
succumbing? RCT?

A

At this point, the tooth is generally NOT sensitive to percussion and if the crack is confined to the crown & the pulp remains healthy, it may be possible to protect & preserve the pulp and stabilize the crack by extra-coronal restoration to achieve stability of the crack.

RCT may become necessary nevertheless if pain continues or the pulp succumbs. It is important to note that the crack may extend to the root even with the stabilization. RCT or Extraction may become necessary depending upon the extent of extension of the crack ( if the crack extends to the pulpal floor or a canal, RCT will not be successful).

76
Q

Clinical Testing Devices for Cracked tooth:

A

-Transillumination
-Staining (Sable Seek)
-P. Probing (drop-off Pocket)
-B/W XR why? (restorability)
-Angular crestal
-Bite Stick: “Frac Finder” and “Tooth Slooth”

77
Q

Drop-Off” Pockets

A

A “Drop-Off” Periodontal Pocket in an otherwise healthy periodontal mouth may be a tip-off that a longitudinal (axial) crack may extend into the root and therefore create a guarded or hopeless prognosis.

A drop-off pocket is when you measure 3-3-3-3-8-3. It is a NARROW pocket and often indicate the extension of a crown fracture into the root. May signal a non-restorable tooth

A VRF on a PT RCT case after success for several years now shows a “J” Shaped Lesion
Chances are good that a VRF fracture may have occurred.

78
Q

finding Vertical Root Fractures
look for?
radiographic confirmation?

A

Look for J-Shaped (HALO) apical boney lesion
Probe for Drop-off Pocket
VRF difficult to confirm radiographically –UNLESS . . .
separation of segments occurs

79
Q

Classic “J” endo lesion always a VRF?

A

This is simply a drainage path of a CAA along the PDL as evidenced by the sealer extrusion from the lateral accessory canals along this path. No angular crestal bone loss, no drop-off pocket, unable to transilluminate due to crown.

80
Q

The only absolutely certain way to
determine a VRF is?

A

expose it surgically and demonstrate the fracture using stain and a possibly
a microscope* or wait for it to separate?

81
Q

why check occlusion with thickened PDL present?

A

thickened PDL can be caused by occlusal trauma with high restoratiosn

endo (22 decks)

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