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Endo I > Pulpal and Apical Diagnosis > Flashcards

Pulpal and Apical Diagnosis Flashcards

1
Q

what two diagnoses are given to each tooth

A

-pulpal
- peri radicular

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2
Q

what type of pain is associated with pulpal pain

A

diffuse

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3
Q

what is the objective of clinical testing for

A

to find and confirm the etiology of the patients CC

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4
Q

what percentage of patients can actually point to the pain

A

37%

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5
Q

painful percussion on the causative tooth is more frequently reported in teeth diagnosed with ______

A

necrotic pulp

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6
Q

painful palpation is more frequently reported on teeth diagnosed with ______

A

previously initiated/treated teeth

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7
Q

what are the types of clinical testing

A
  • 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)
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8
Q

what are the minimum 3 diagnostic radiographs

A
  • straight on PA shot
  • PA shift shot (20degree change in horizontal angulation mesial or distal)
  • bite wing (to determine restorability and bone level)
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9
Q

what are the 3 basic conditions of pulpal status

A
  • normal
  • inflamed (could recover or get worse)
  • infected (will go to necrosis)
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10
Q

what are the types of inflammed pulp

A
  • reversible: no tx or symptomatic rx > recovery
  • irreversible: pain lingering and often spontaneous. could be symptomatic or asymptomatic
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11
Q

what are the 5 pulpal diagnostic “boxes”

A
  • WNL: normal pulp
  • IP: irreversible pulpitis
  • SIP: symptomatic irreversible pulpitis
  • AIP: asymptomatic irreversible pulpitis
  • N: necrotic pulp
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12
Q

why should you test 2-3 adjacent teeth prior to the tooth in question

A

establish a standard base line

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13
Q

what does a normal pulp look like

A
  • CC: none
  • clinical tests normal
  • no radiograph changes
  • minimal or no apparent damage
  • no axial cracks
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14
Q

what are the 3 outcomes for reversible pulpitis

A
  • if treated well - may revert to normal
  • may remain RP symptomatic for extended period
  • may deteriorate to SIP or AIP
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15
Q

what is the presentation of reversible pulpitis

A
  • CC: cold sensitive
  • cold sensitivity- pain does not linger
  • pain is not spontaneous
  • percussion negative
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16
Q

what is the presentation of irreversible symptomatic pulpitis

A
  • 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
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17
Q

what does hot sensitivity usually indicate

A

deteriorating pulp = SIP

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18
Q

how does necrosis of pulp present

A
  • CC: may be asymptomatic currently but usually has history of symptoms
  • no response to hot, or EPT
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19
Q

what is a previously treated tooth

A
  • obturated with final RC filling materials other than medications which is not healing or requires remedial treatment
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20
Q

what is a previously initiated treatment

A

tooth has been previously treated by partial endodontic therapy

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21
Q

what is WNL

A
  • normal pulp
  • pulp is symptom free with normal response to pulp tests
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22
Q

what is RP

A

-reversible pulpitis
- inflammation of the pulp based on subjective and objective findings that should resolve and return the pulp to normal

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23
Q

what is SIP

A
  • symptomatic irreversible pulpitis
  • vital inflammed pulp that is incapable of healing
  • lingering pain to cold, sensitive to heat, spontaneous pain
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24
Q

what is AIP

A
  • 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)
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25
Q

what is pulpal necrosis

A

death of the dental pulp
- no response to tests

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26
Q

what is PT

A
  • previously treated
  • tooth has been endodontically treated with canals obturated with final root canal filling materials other than medications
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27
Q

what is PIT

A
  • previously initiated treatment
  • tooth has been previously treated by partial endodontic therapy but not completed
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28
Q

why do we rarely see apical radiograph changes in cases of pure pulpitis or early necrotic pulp

A

advanced pulpal disease or necrosis of the pulp is gnerally required to allow infection to affect the apical tissues

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29
Q

how does the disease process of pulpal necrosis extend

A

peri apically

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30
Q

what happens following pulpal necrosis

A

the tooth with become positive to percussion and/or spontaneous pain may appear before radiographic evidence is clear

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31
Q

when is a PARL visible

A

only when 40% of the cortical bone has been destroyed

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32
Q

100% of the medullary bone can be destroyed but:

A

no PARL

33
Q

what is the progression of RC system infections

A
  • 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
34
Q

all peri radicular inflammation is sensitive to:

A

percussion

35
Q

purely pulpal pain is not sensitive to:

A

percussion

36
Q

why can the patient point to the tooth that hurts

A

-mechanoreceptors (proprioceptors) present in PDL not in pulp

37
Q

what does patient perception of pain mean

A

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

38
Q

if the offending tooth is sensitive to percussion will a lesion show on XR

A

not necessarily

39
Q

what can pain associated with peri radicular inflammation be confused for

A

recent or chronic occlusal trauma

40
Q

what are the possible apical diagnoses and define each

A
  • WNL
  • SAP: symptomatic apical periodontitis
  • AAP: asymptomatic apical periodontitis
  • AAA: acute apical abscess
  • CAA: chronic apical abscess
  • CO: condensing osteitis
41
Q

what are the basic characterisitc of WNL teeth

A

teeth not sensitive to percussion or palpation. lamina dura is intact and the PDL is uniform and unbroken

42
Q

what are the basic characterisitcs of SAP

A

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

43
Q

describe the basic characterisitcs of AAP

A

-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

44
Q

describe the basic characterisistics of AAA

A

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

45
Q

describe the basic characteristics of CAA

A

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

46
Q

describe the basic characterisitcs of CO

A
  • diffuse radiopaque lesion representing a localized boney reaction to a low grade inflammatory stimulus
47
Q

which peri apical diagnoses are associated with pain

A

-SAP
- AAA

48
Q

what can a thickened PDL be caused by

A

occlusal trauma
- PARL
- new, high restoration

49
Q

what does diagnosis depend on

A

the sum of patient history, symptoms, clinical exam, signs and testing and radiographic interpretation

50
Q

what is condensing osteitis

A

-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

51
Q

what is the differential dx for CO

A

sclerotic bone which is a non pathology and requires no treatment

52
Q

why is an accurate dx important

A
  • 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
53
Q

the teeth may suffer many types of injuries and possible fractures following:

A

internal or external trauma

54
Q

what is the range of longitudinal tooth fractures

A

Craze lines to vertical root fracture

55
Q

what are the common types of longitudinal fractures

A

-craze lines
- fractured cusp
- cracked tooth
- split tooth
- vertical root fracture

56
Q

describe craze lines

A
  • confined to enamel
  • common and generally unimportant
  • dont stop light
  • asymptomatic and not a concern for endo
  • can stain and become an esthetic issue
57
Q

describe a fractured cusp

A
  • oblique shearing fracture
  • facial - lingual
  • often involves undetermined cusp may be restorable
58
Q

describe a cracked tooth

A
  • 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
59
Q

describe a split tooth

A
  • crack extends to a surface in all areas
  • involves crown, root and generally pulp
  • must remove fx segment and determine restorability
60
Q

describe vertical root fracture

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
61
Q

what is the protocol for a fractured cusp

A
  • always do dx testing to determine condition of pulp
  • if vital and restorable, anesthetize and remove the fractured portion and restore if possible
62
Q

removal of the FX cusp will reveal either:

A
  • 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
63
Q

what is the most common site of cracked teeth

A

mandibular 2nd or 1st molar followed by maxillary premolars

64
Q

what can cracked tooth be caused by

A

clenching habit or other trauma

65
Q

how do you diagnose cracked tooth

A

trans illumination

66
Q

how do you diagnose fractured tooth

A

trans illumination

67
Q

what is the common patient compliant with a cracked tooth

A

-acute, sharp, momentary pain upon biting or release of biting pressure

68
Q

describe the pulp in cracked teeth

A

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

69
Q

what is the cause of pain in cracked teeth when the pulp is still vital

A

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

70
Q

when will a RCT not be successful in a cracked tooth

A

if the crack extends to the pulpal floor or a canal

71
Q

is a cracked tooth sensitive to percussion when the pulp is vital

A

no

72
Q

what are the clinical testing devices for cracked teeth

A
  • transillumination
    -staining
  • P probing
  • B/W XR - restorability
  • angular crestal
  • bite stick
73
Q

what is a drop off pocket a tip off for

A

that a longitudinal (axial) crack may extend into the root and therefore create a hopeless prognosis
- non restorable tooth

74
Q

what is a drop off pocket

A
  • when you measure 3-3-3-3-8-3
  • a narrow pocket and often indicates the extension of a crown fracture into the root
75
Q

what does a vertical root fracture on a previously treated RCT case after success show

A

a J shaped lesion

76
Q

what is a J shaped lesion

A

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

77
Q

what is the only way to determine a VRF

A

to expose it surgically and use a stain and a microscope and wait for it to separate

78
Q
A

Endo I (13 decks)

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