Pulpal and Apical Diagnosis Flashcards
what two diagnoses are given to each tooth
-pulpal
- peri radicular
what type of pain is associated with pulpal pain
diffuse
what is the objective of clinical testing for
to find and confirm the etiology of the patients CC
what percentage of patients can actually point to the pain
37%
painful percussion on the causative tooth is more frequently reported in teeth diagnosed with ______
necrotic pulp
painful palpation is more frequently reported on teeth diagnosed with ______
previously initiated/treated teeth
what are the types of clinical testing
- thermal: cold, heat (pulp vitality)
- EPT: this test is not done routinely
- percussion: tapping with mirror (PDL sensitivity)
- palpatoin: digital touching of gingival (inflammation, redness, swelling, tenderness)
- periodontal probing and mobility (perio health)
what are the minimum 3 diagnostic radiographs
- straight on PA shot
- PA shift shot (20degree change in horizontal angulation mesial or distal)
- bite wing (to determine restorability and bone level)
what are the 3 basic conditions of pulpal status
- normal
- inflamed (could recover or get worse)
- infected (will go to necrosis)
what are the types of inflammed pulp
- reversible: no tx or symptomatic rx > recovery
- irreversible: pain lingering and often spontaneous. could be symptomatic or asymptomatic
what are the 5 pulpal diagnostic “boxes”
- WNL: normal pulp
- IP: irreversible pulpitis
- SIP: symptomatic irreversible pulpitis
- AIP: asymptomatic irreversible pulpitis
- N: necrotic pulp
why should you test 2-3 adjacent teeth prior to the tooth in question
establish a standard base line
what does a normal pulp look like
- CC: none
- clinical tests normal
- no radiograph changes
- minimal or no apparent damage
- no axial cracks
what are the 3 outcomes for reversible pulpitis
- if treated well - may revert to normal
- may remain RP symptomatic for extended period
- may deteriorate to SIP or AIP
what is the presentation of reversible pulpitis
- CC: cold sensitive
- cold sensitivity- pain does not linger
- pain is not spontaneous
- percussion negative
what is the presentation of irreversible symptomatic pulpitis
- CC: cold sensitive
- cold sensitivity lingers 15-20 sec in early SIP, in late SIP hot hurts and cold helps
- percussion negative
- pain might be spontaneous
what does hot sensitivity usually indicate
deteriorating pulp = SIP
how does necrosis of pulp present
- CC: may be asymptomatic currently but usually has history of symptoms
- no response to hot, or EPT
what is a previously treated tooth
- obturated with final RC filling materials other than medications which is not healing or requires remedial treatment
what is a previously initiated treatment
tooth has been previously treated by partial endodontic therapy
what is WNL
- normal pulp
- pulp is symptom free with normal response to pulp tests
what is RP
-reversible pulpitis
- inflammation of the pulp based on subjective and objective findings that should resolve and return the pulp to normal
what is SIP
- symptomatic irreversible pulpitis
- vital inflammed pulp that is incapable of healing
- lingering pain to cold, sensitive to heat, spontaneous pain
what is AIP
- asymptomatic irreversible pulpitis
- vital inflammed pulp incapable of healing
- no clinical symptoms
- inflamed due to caries (chronic hyperplastic pulpitis) , caries excavation (pulp exposure), trauma (fracture with exposed pulp tissue)
what is pulpal necrosis
death of the dental pulp
- no response to tests
what is PT
- previously treated
- tooth has been endodontically treated with canals obturated with final root canal filling materials other than medications
what is PIT
- previously initiated treatment
- tooth has been previously treated by partial endodontic therapy but not completed
why do we rarely see apical radiograph changes in cases of pure pulpitis or early necrotic pulp
advanced pulpal disease or necrosis of the pulp is gnerally required to allow infection to affect the apical tissues
how does the disease process of pulpal necrosis extend
peri apically
what happens following pulpal necrosis
the tooth with become positive to percussion and/or spontaneous pain may appear before radiographic evidence is clear
when is a PARL visible
only when 40% of the cortical bone has been destroyed
100% of the medullary bone can be destroyed but:
no PARL
what is the progression of RC system infections
- carious lesion of trauma opens tubules to bacterial invasion
- bacteria inflame pulp locally
- inflammation may overcome pulpal defenses and localized abscess may form in coronal pulp
- infection increases in pulp and necrosis begins
- infections use portals of exit to invade peri radicular tissues
- periradicular infection occurs beyond apex
all peri radicular inflammation is sensitive to:
percussion
purely pulpal pain is not sensitive to:
percussion
why can the patient point to the tooth that hurts
-mechanoreceptors (proprioceptors) present in PDL not in pulp
what does patient perception of pain mean
that the inflammation/infection from the pulp has already reached the P/apical tissues and we are dealing with an apical DX of some type
if the offending tooth is sensitive to percussion will a lesion show on XR
not necessarily
what can pain associated with peri radicular inflammation be confused for
recent or chronic occlusal trauma
what are the possible apical diagnoses and define each
- WNL
- SAP: symptomatic apical periodontitis
- AAP: asymptomatic apical periodontitis
- AAA: acute apical abscess
- CAA: chronic apical abscess
- CO: condensing osteitis
what are the basic characterisitc of WNL teeth
teeth not sensitive to percussion or palpation. lamina dura is intact and the PDL is uniform and unbroken
what are the basic characterisitcs of SAP
inflammation of the periodontium producing a painful response to biting/percussion/maybe palpation
- may or may not show on radiograph
- most important symptom is presence of pain
- pulp may be vital or non vital
describe the basic characterisitcs of AAP
-inflammation and destruction of the periodontium that is of pulpal origin appearing as a radiolucent area with no clinical symptoms
- pulp non vital
- thickened PDL
- no swelling
describe the basic characterisistics of AAA
inflammatory reaction to pulpal infection with rapid onset, spontaneous pain, tooth tender to pressure, pus formation and swelling and fever
- dont need to have PARL
- might not have a fever
- No DST
describe the basic characteristics of CAA
inflammatory reaction to pulpal infection with gradual onset, little or no discomfort and draining sinus tract
- need radiograph
- not an emergency
- swelling generally minimal or none
- sensitivity to palpation and percussion is little to none
- no Rx analgesic or AB required
describe the basic characterisitcs of CO
- diffuse radiopaque lesion representing a localized boney reaction to a low grade inflammatory stimulus
which peri apical diagnoses are associated with pain
-SAP
- AAA
what can a thickened PDL be caused by
occlusal trauma
- PARL
- new, high restoration
what does diagnosis depend on
the sum of patient history, symptoms, clinical exam, signs and testing and radiographic interpretation
what is condensing osteitis
-radio opaque formative or reactive bone
- treatment based on symptoms
- develops in response to a mild or sub clinical inflammation or infection where bone is actually formed instead of being resorbed or destroyed
- aysymptomatic and no pathology = no treatment
what is the differential dx for CO
sclerotic bone which is a non pathology and requires no treatment
why is an accurate dx important
- you cant do any treatment for the pt until you have a supported dx
- if cant make definitive dx today, support patient with appropriate supportive medications
the teeth may suffer many types of injuries and possible fractures following:
internal or external trauma
what is the range of longitudinal tooth fractures
Craze lines to vertical root fracture
what are the common types of longitudinal fractures
-craze lines
- fractured cusp
- cracked tooth
- split tooth
- vertical root fracture
describe craze lines
- confined to enamel
- common and generally unimportant
- dont stop light
- asymptomatic and not a concern for endo
- can stain and become an esthetic issue
describe a fractured cusp
- oblique shearing fracture
- facial - lingual
- often involves undetermined cusp may be restorable
describe a cracked tooth
- incomplete “greenstick” fracture
- M-D Fx involving 1 or both marginal ridges
- may or may not involve pulp
- may be confined to crown or extended to root
describe a split tooth
- crack extends to a surface in all areas
- involves crown, root and generally pulp
- must remove fx segment and determine restorability
describe vertical root fracture
- begins internally at root apex or from crown
- primarily in axial plane may be F-L or M-D
- often occur in RCT teeth
what is the protocol for a fractured cusp
- always do dx testing to determine condition of pulp
- if vital and restorable, anesthetize and remove the fractured portion and restore if possible
removal of the FX cusp will reveal either:
- a fx too far below the attached gingiva to maintain periodontically (crown lengthening may help)
- little tooth structure remains that RCT and post, build up and crown will be needed
what is the most common site of cracked teeth
mandibular 2nd or 1st molar followed by maxillary premolars
what can cracked tooth be caused by
clenching habit or other trauma
how do you diagnose cracked tooth
trans illumination
how do you diagnose fractured tooth
trans illumination
what is the common patient compliant with a cracked tooth
-acute, sharp, momentary pain upon biting or release of biting pressure
describe the pulp in cracked teeth
generally vital in early stages
- if left alone the pulp can become necrotic and the previous pain stops because the pulp is necrotic and can no longer respond
- SAP will develop as infection invades the peri radicular tissues
what is the cause of pain in cracked teeth when the pulp is still vital
biting in a manner that wedges open the crack and air and saliva enter the defect. when biting pressure is released the wedged crack moves rapidly towards closure forcing a change in the fluid gradient in the dentinal tubules producing the characteristic acute, sharp and momentary pulp pain
when will a RCT not be successful in a cracked tooth
if the crack extends to the pulpal floor or a canal
is a cracked tooth sensitive to percussion when the pulp is vital
no
what are the clinical testing devices for cracked teeth
- transillumination
-staining - P probing
- B/W XR - restorability
- angular crestal
- bite stick
what is a drop off pocket a tip off for
that a longitudinal (axial) crack may extend into the root and therefore create a hopeless prognosis
- non restorable tooth
what is a drop off pocket
- when you measure 3-3-3-3-8-3
- a narrow pocket and often indicates the extension of a crown fracture into the root
what does a vertical root fracture on a previously treated RCT case after success show
a J shaped lesion
what is a J shaped lesion
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
what is the only way to determine a VRF
to expose it surgically and use a stain and a microscope and wait for it to separate
