Pulpal and Apical Diagnosis Flashcards
Each tooth needs what two diagnoses?
– Pulpal
– Peri-Radicular
(Maybe Perio & Restorative also)
It is _____ to present as purely pulpal dx
unlikely
If patient cannot localize the source of pain it is probably..
purely pulpal (diffuse pain=pulpal)
What is the first question to ask the patient in pain?
What is your chief complaint?
What is the objective of clinical testing?
find and confirm the etiology of the pts CC
What clinical tests are performed base on the clinical complaint?
– Thermal: cold, heat (pulp vitality)
– EPT: only if pulpal status is in doubt
– Percussion: tapping with mirror (PDL sensitivity)
– Palpation: digital touching of gingival (inflammation, redness, swelling, tenderness)
– Periodontal probing & mobility (periodontal health)
What clinical test is not done routinely?
EPT
A minimum of how many radiographs are required for diagnosis of a suspected area?
- Straight-on PA film
- PA Shift Shot (20° change in horizontal angulation)
- Bite-Wing (to determine restorability and bone level)
Can you do thermal testing on crowns?
Yes
What are the 3 basic conditions of the pulp?
- Normal
- Inflamed (could recover or deteriorate)
- Reversible (always symptomatic)
- Irreversible (Pain Lingering & often Spontaneous)
a) Symptomatic
b) Asymptomatic - Infected (infected pulp will proceed to necrosis)
What are the 5 pulpal diagnostics?
- “NORMAL” PULP
- REVERSIBLE PULPITIS
- SYMPTOMATIC IRREVERSIBLE PULPITIS
- ASYMPTOMATIC IRREVERSIBLE PULPITIS
- NECROTIC PULP
(we also have PT and PIT but these are easily seen on xray and reported in recent dental history of area)
What are the symptoms of normal pulp?
CC: None (Asymptomatic Currently & Historically)
Clinical Testing:
* Thermal testing (Cold WNL)
* EPT responsive (similar to other WNL teeth)
* Percussion Negative (WNL)
* Palpation Negative (WNL)
* No Radiographic Changes
Another Clue: Minimal or No Apparent Damage
* No Axial cracks. Leave it ALONE
Always test 2-3 adjacent teeth prior to the tooth in question-WHY?
Establish a STANDARD BASE-LINE
What are the symptoms of reversible pulpitis?
CC: Cold Sensitive (does not linger)
Clinical Testing:
– Cold sensitivity - pain relieved almost immediately once stimulus is removed-(does NOT linger)
- Percussion Negative
- Palpation also negative
- NO Radiographic Changes
Does reversible pulpitis have cold sensitivity?
Yes but it does not linger
Does reversible pulpitis have percussion sensivity?
No
Does reversible pulpitis have radiographic changes?
No
Reversible pulpitis may have 3 different outcomes…
- If properly treated – may revert to normal
- May remain RP symptomatic for extended period
- May deteriorate to SIP or AIP (even if properly treated)
Percussion and palpation are considered periapical issues or pulpal issues?
periapical
What are the symptoms of irreversible pulpitis symptomatic?
CC: Cold Sensitive (or spontaneous pain that wakes them up or pain to heat)
Clinical Testing:
– Cold Sensitivity – LINGERS*** more than 30 sec. after stimulus is removed.
– Percussion Negative
– Palpation Negative
– Radiographic Changes: None at apex
- Cold hurts, and lingers
- Hot hurts – pathognomonic to SIP
- Pain might be spontaneous or awakens patient from sleep
Normal Teeth are NOT sensitive to HOT. HOT sensitivity usually indicates a deteriorating pulp and is what diagnosis?
Symptomatic irreversible pulpitis
If a patient has to take medication for pain for a tooth what diagnosis is it most likely?
Symptomatic irreversible pulpitis
How do you usually treat symptomatic irreversible pulpitis?
root canal most likely
Does symptomatic irreversible pulpitis have cold sensitivity?
Yes and it does linger for more than 30 seconds
Does symptomatic irreversible pulpitis have percussion sensitivity?
No
Does symptomatic irreversible pulpitis have palpation sensitivity?
No
Does symptomatic irreversible pulpitis have radiographic changes?
No changes at apex
Does symptomatic irreversible pulpitis have hot sensitivity?
Yes
If a patient wakes up in the middle of the night with spontaneous pain what is the diagnosis?
symptomatic irreversible pulpitis
If you are drilling a tooth for caries and have pulp exposure what is the immediate pulpal diagnosis?
asymptomatic irreversible pulpitis
What is a pulpal polyp diagnosis?
asymptomatic irreversible pulpitis
If you have deep caries that extend into the pulp with no symptoms what is this?
asymptomatic irreversible pulpitis
If you have deep caries that extend into the pulp with no symptoms what is the treatment?
RCT
Does asymptomatic irreversible pulpitis have percussion/ palpation sensistivity?
no
Does asymptomatic irreversible pulpitis have radiographic changes?
no changes at apex
What are the symptoms of a necrotic pulp?
CC: May be currently asymptomatic – usual history of symptomatic previously
Clinical Testing:
- Cold Sensitivity: No Response to cold, or electric pulp tester
Does necrotic pulp have cold sensitivity?
NO
Does necrotic pulp have a response from electric pulp tester?
NO
Does necrotic pulp have radiographic changes?
NO- radiographs are liars
What is a previously treated tooth?
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.
What is a previously initiated treatment tooth?
- Tooth has been previously treated by partial endodontic therapy.
- This could be a failed pulp cap or pulpotomy or it could be a pulpectomy
- No gutta percha or obturation in canals
If a tooth already has root canal treatment (previously treated) should you cold test it?
No it won’t have a cold response
- only test for cold if the patient complains about it
If a tooth already has previously initiated treated should you cold test it?
Yes you can do tests depending on the chief complaint
PT or PIT?
Previously Treated or Previously Initiated Treatment
PT
PT or PIT?
Previously Treated or Previously Initiated Treatment
PT
PT or PIT?
Previously Treated or Previously Initiated Treatment
PIT
PT or PIT?
Previously Treated or Previously Initiated Treatment
PIT
If a root canal was done but they missed a canal is it PT or PIT?
PT but write it in the note
What is normal pulp?
Pulp is symptom free with normal response to pulp tests
What is reversible pulpitis (RP)?
Inflammation of the pulp based on subjective and objective findings that should revolve and return the pulp to normal
What is symptomatic irreversible pulpitis (SIP)?
Vital inflamed pulp that is incapable of healing. i.e. lingering pain to cold, sensitivity to heat, spontaneous pain.
What is asymptomatic irreversible pulpitis (AIP)?
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)
What is pulpal necrosis?
Death of the dental pulp (No Response to pulp tests)
What is previously treated (PT)?
Tooth has been endodontically treated with canals obturated with final root canal filling materials other than medicaments..
What is previously initiated treatment (PIT)?
Tooth has been previously treated by partial endodontic therapy, i.e. pulp cap, pulpotomy/pulpectomy. RCT NOT completed
Both seriously Inflamed and Infected Pulpitis cases will ultimately lead to a _______ pulp if left untreated long enough
Necrotic
If you cannot arrive at a supportable DX what do you do?
you cannot do any treatment
- have the patient come back a few days later and have them take pain medication
Why do we RARELY 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
What are the 5 elements of clinical examination and testing?
- Medical & Dental History
- CC + Signs & Symptoms
- Clinical examination
- Clinical testing
- Radiological indications
Radiographs which are generally of limited use in DX of purely pulpal disease may become of some value in…
Apical DX
Can you make a diagnosis from radiograph alone?
NO
If a radiograph indicates P/A rarefaction which appears to be associated with a root apex and:
-Pulp Testing is WNL
-Patient is Asymptomatic
-No CC
-No Damage to the tooth is apparent
-No Trauma is reported
Apical periodontitis
The radiolucency that we think we
see near the apex may be…
- Artifact(3 X-Rays minimum)
- Non-odontogenic lesion
- Oral manifestation of systemic disease
- Normal anatomical landmark
How does the lamina dura appear on radiograph?
radiopaque line
(radiolucency appears if it is broken- meaning PDL disrupted)
Following pulpal necrosis the disease rapidly extends peri-apically and has what symptoms?
- Purcussion +
- spontaneous pain may appear before radiogaphic evidence is clear
- ultimately, radiographic evidence will develop but TAKES TIME
A Visible periapical radiolucency is ONLY VISABLE when ____% of the Cortical Bone has been destroyed
40%
_____% OF THE MEDULLARY BONE CAN BE DESTROYED & no periapical radiolucency may show on the standard radiograph
100%
What is the progression of root canal system infections?
- Carious Lesion or Trauma opens tubules to bacterial invasion
- Bacteria inflame pulp locally
- Inflammation may overcome pulpal defenses and localized abscesses may form in coronal pulp
- Infection increases in pulp and necrosis begins
- Necrosis involves entire RC System
- Infection uses “portals of exit” (apical foramen and lateral canals) to invade peri-radicular tissues (apical periodontitis)
- Periradicular infection occurs beyond apex (apical abscess)
ALL PERI-RADICULAR INFLAMMATION IS SENSITIVE TO…
percussion
Purely pulpal pain is not sensitive to…
percussion
Mechanoreceptors (Proprioceptors) are present in the PDL or the pulp?
PDL
What percent of patients know what tooth hurts?
37%
If a tooth is sensitive to percussion what does this mean?
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
What are the types of apical diagnostics?
- WNL (normal)
- SAP (symptomatic apical periodontitis)
- AAP (asymptomatic apical periodontitis)
- AAA (acute apical abscess with swelling and fever)
- CAA (chronic apical abscess + DST)
- CO (condensing osteitis)
If a patient is in pain and has swelling what is the automatic apical diagnosis?
AAA (acute apical abscess)
If a patient has a DST (draining sinus tract) what is the automatic apical diagnosis?
CAA (chronic apical abscess)
What are the characteristics of condensing osteitis (CO)?
- Radiopaque appearance on
the XR. - Treatment is determined
by symptoms
What is a normal apical diagnosis?
Teeth not sensitive to percussion or palpation. Lamina dura is intact and the PDL is uniform and unbroken.
What is a SAP (symptomatic apical periodontitis)?
Inflammation of the periodontium producing a painful response to biting/percussion/maybe palpation.
What is an AAP (asymptomatic apical periodontitis)?
Inflammation and destruction of the periodontium that is of pulpal origin appearing as a radiolucent area with no clinical symptom
What is an AAA (acute apical abscess)?
Inflammatory reaction to pulpal infection with rapid onset, spontaneous pain, tooth tender to pressure, pus formation and SWELLING & FEVER
What is a CAA (chronic apical abscess)?
Inflammatory reaction to pulpal infection with gradual onset, little or no discomfort and DRAINING SINUS TRACT.
What is a CO (condensing osteitis)?
Diffuse radiopaque lesion representing a localized boney reaction to a low-grade inflammatory stimulus
What kind of radiographic finding does a condensing osteitis (CO) have?
radiopaque lesion
What apical diagnostics have pain?
- SAP (symptomatic apical periodontitis)
- AAA (acute apical abscess)
What apical diagnostics always have radiolucencies?
- AAP (asymptomatic apical periodontitis)
- CAA (chronic apical abscess)
What is the apical DX for this tooth?
WNL - normal
What is the apical DX for this tooth?
SAP (symptomatic apicla periodontitis)
What other situations may have similar symptoms as a SAP (symptomatic apicla periodontitis)?
- recent restorations (high)
- occlusal habits (bruxism)
- trauma
A THICKENED PDL can be caused by…
Occlusal trauma or periapical radiolucency
What is the apical DX for this tooth?
AAP (asymptomatic apical periodontitis)
What is the apical DX for this tooth?
AAA (acute apical abscess)
What is cellulitis?
- Rapid Development
- Swelling (often Severe)
- Elevated Temp./Fever
What is the apical DX for this tooth?
CAA (chronic apical abscess)
Always trace out a Draining Sinus Tract (DST) with…
Gutta Percha cone & Radiograph
What is the apical DX for this tooth?
CAA (chronic apical abscess)
DST (draining sinus tract) is pathognomonic for…
CAA (chronic apical abscess)
It is often inaccurate and always unacceptable and unethical to attempt to diagnose from _________ alone
Radiographs
How does CO (condensing osteitis) develop?
Develops in response to a mild or “sub clinical” inflammation or infection where bone is actually formed instead of being resorbed or destroyed
What is a differential diagnosis for CO (condensing osteitis)?
Sclerotic Bone which is a non-pathology & requires no TX
What are common types of longitudinal (vertical) fractures?
- craze lines
- fractured cusp
- cracked tooth
- split tooth
- vertical root fracture
What are craze lines?
- Vertical lines in the enamel of your teeth are called Craze Lines
confined to enamel - This is common and generally asymptomatic and not a concern for endodontics but when the craze lines stain, an esthetic issue may develop and can be treated by several restorative techniques
What is the first step when you see a fractured cusp?
Always do all necessary DX testing. Determine condition of pulp. If vital and restorable, anesthetize and remove the fractured portion and restore if possible
If a tooth with a fractured cusp tests WNL what do you do?
if the pulp tested WNL, the normal procedure is to remove the fractured cusp and see if the remaining tooth structure will support a restoration
What can happen when you remove a fracture cusp?
removal of the FX cusp will reveal either a FX too far below the attached gingiva to maintain periodontally (crown lengthening may help) or so little tooth structure remains that RCT + post, build-up and crown will be necessary to properly restore
What is the most common site of a cracked tooth?
mandibular 2nd or 1st molar followed by maxillary premolars
A Cracked Tooth is most often discovered following patient complaint of…
acute, sharp, momentary pain upon biting or release of biting pressure
In early stages of a cracked tooth what is the pulp status?
vital pulp
If a patient avoids biting on the cracked tooth and ignores it what can happen to the pulp?
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
What does biting on a cracked tooth hurt?
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
What are the clinical testing devices for a cracked tooth?
-Transillumination
-Staining (Sable Seek)
-P. Probing (drop-off Pocket)
-B/W XR (restorability)
-Angular crestal
-Bite Stick (tooth slooth)
What is a drop off pocket?
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.
What is a good tip-off that a longitudinal crack may extend into the root?
- drop-off pocket
- J shaped (HALO) apical boney lesion
What is a classic J endo lesion?
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
VRF difficult to confirm radiographically UNLESS…
separation of segments occurs
What is the only certain way to determine if there is a vertical root fracture?
expose it surgically and demonstrate a fracture using stain or microscope
